Assessing respiratory complications in patients with obesity and obstructive sleep apnea undergoing a screening colonoscopy with moderate and deep sedation
Kaur R, Morales IMC, Ashraf T, Bhatti S, Nimri FM, and Kutait A. Assessing respiratory complications in patients with obesity and obstructive sleep apnea undergoing a screening colonoscopy with moderate and deep sedation. Gastrointestinal Endoscopy 2020; 91(6):AB530.
Introduction: Millions of screening colonoscopies are performed annually which means there is a substantial health cost for insurances. There has been more utilization of deep sedation requiring costly anesthesia services compared to moderate sedation given severity of systemic diseases, increased comfort, satisfaction, and ease of scoping for the endoscopist. Typically, obese patients with obstructive sleep apnea (OSA) have required deep sedation, however many are able to utilize moderate more safely. Here we assess respiratory complications in deep and moderate sedation in high risk patients who have obesity and OSA undergoing a screening colonoscopy. Methods: A retrospective cohort study was done in patients with obesity and OSA who have undergone a screening colonoscopy between 2014 and 2018 with either moderate or deep sedation. Background history included age, sex, race, BMI, alcohol, tobacco and marijuana use. Complexity and airway was measured by ASA and Mallampati score (MS). OSA severity was assessed by the AHI score. Moderate sedation was supervised by the endoscopist using midazolam with fentanyl or meperidine. Deep sedation was done with anesthesia staff using propofol. Intra-procedure respiratory complications were assessed by apneic episodes as determined by the end tidal CO2. Results: 458 patients with OSA and obesity, with 49.1% undergoing moderate sedation, were analyzed. There were no major background differences in sex, age or BMI (table 1). A significant race difference was noted between the two groups with majority African American (59.6%) for deep and Caucasian (59.1%) for moderate sedation (p<.001, table 1). Overall, the mean diagnostic AHI was 48.0 and recent AHI 5.3. The majority ASA class in moderate sedation was ASA II compared to ASA III in deep sedation (p<.001, table 1). MS II was most prevalent in both sedation groups with more MS III in deep sedation compared to moderate sedation (p<.001, table 1). Intra-procedural respiratory depression was significantly noted in deep sedation (5.2% vs 0.9%, p=0.008). Interventions solely for deep sedation included 1 oral airway insertion and 3.4% needing intubation (p=0.007, table 2). Discussion: There is a notable increased respiratory risk in deep sedation. Patient’s requiring intra-procedural intubation can go on to have further post-procedure complications. Traditionally, ASA III and MS III are done with anesthesia, however this study showed that patients with similar ASA and MS were able to undergo moderate sedation with little to no complications. These findings go on to advocate that while close airway monitoring with anesthesia is common in obese patients with OSA, moderate sedation carries much less risk and should be the preferred modality. It is also certainly more cost effective without the need for anesthesia services cutting down a sizeable amount of healthcare costs.