Retrospective Study
Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. Dec 16, 2016; 8(20): 770-776
Published online Dec 16, 2016. doi: 10.4253/wjge.v8.i20.770
Identification of factors associated with sedation tolerance in 5000 patients undergoing outpatient colonoscopy: Canadian tertiary center experience
Alexandra Shingina, George Ou, Oliver Takach, Sigrid Svarta, Ricky Kwok, Jessica Tong, Kieran Donaldson, Eric Lam, Robert Enns
Alexandra Shingina, Department of Gastroenterology, Faculty of Medicine, University of Toronto, Toronto General Hospital, Ontario M5G 2C4, Canada
George Ou, Sigrid Svarta, Department of Gastroenterology, Faculty of Medicine, University of British Columbia, Vancouver V5Z 1M9, Canada
Oliver Takach, Ricky Kwok, Jessica Tong, Kieran Donaldson, Eric Lam, Robert Enns, Division of Gastroenterology, Saint Paul Hospital, Vancouver V6Z 2K5, Canada
Author contributions: Shingina A and Enns R designed the project; Shingina A and Svarta S designed ethics proposal; Shingina A, Ou G, Svarta S, Kwok R, Donaldson K collected the data; Takach O and Lam E analyzed the data; Shingina A, Ou G, Svarta S, Lam E and Enns R wrote the manuscript.
Institutional review board statement: This study was reviewed and approved by the University of British Columbia - Providence Health Care Research Institute.
Informed consent statement: The informed consent is not applicable since this study is a retrospective review. All clinical data collected was dissociated from patient identifiers using a combination of alphanumeric characters in accordance to ethics board’s requirements.
Conflict-of-interest statement: All authors of this paper have no relevant conflicts of interest to declare.
Data sharing statement: No data were created so no data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Robert Enns, MD, Division of Gastroenterology, Saint Paul Hospital, 770-1190 Hornby Street, Vancouver V6Z 2K5, Canada. rob.enns@ubc.ca
Telephone: +1-604-6886332
Received: April 20, 2016
Peer-review started: April 20, 2016
First decision: June 12, 2016
Revised: July 25, 2016
Accepted: September 6, 2016
Article in press: September 8, 2016
Published online: December 16, 2016
Processing time: 238 Days and 8.6 Hours
Abstract
AIM

To develop a prediction model aimed at identifying patients that may require higher than usual sedation doses during colonoscopy.

METHODS

A retrospective chart review on 5000 patients who underwent an outpatient colonoscopy at St. Paul’s Hospital from 2009 to 2010 was conducted in order to develop a model for identifying patients who will require increased doses of sedatives. Potential predictor variables including age, gender, endoscopy indication, high sedation requirements during previous endoscopies, difficulty of the procedure, bowel preparation quality, interventions, findings as well as current use of benzodiazepines, opioids and alcohol were analyzed. The outcome of study was the use of high dose of sedation agents for the procedure. In particular, the high dose of sedation was defined as fentanyl greater than 50 mcg and midazolam greater than 3 mg.

RESULTS

Analysis of 5282 patients (mean age 57 ± 12, 49% female) was performed. Most common indication for the procedure was screening colonoscopy (57%). Almost half of our patients received doses exceeding Fentanyl 50 mcg and Midazolam 3 mg. Logistic regression models identified the following variables associated with high sedation: Younger age (OR = 0.95 95%CI: 0.94-0.95; P < 0.0001); abdominal pain (OR = 1.45, 95%CI: 1.08-1.96); P = 0.01) and Inflammatory Bowel Disease (OR = 1.45, 95%CI: 1.04-2.03; P = 0.02) as indications for the procedure; difficult procedure as defined by gastroenterologist (OR = 1.73, 95%CI: 1.48-2.03; P < 0.0001); past history of abdominal surgery (OR = 1.33, 95%CI: 1.17-1.52; P <0.0001) and previous colonoscopy (OR = 1.39, 95%CI: 1.21-1.60; P = 0.0001) and alcohol use (OR = 1.26, 95%CI: 1.03-1.54; P = 0.02). Age and gender adjusted analysis yielded inflammatory bowel disease as an indication (OR = 3.17, 95%CI: 1.58-6.37; P = 0.002); difficult procedure as defined by an endoscopist (OR = 5.13 95%CI: 2.97-8.85; P = 0.0001) and current use of opioids, benzodiazepines or antidepressants (OR = 2.88, 95%CI: 1.74-4.77; P = 0.001) having the highest predictive value of high sedation requirements. Our prediction model using the following pre-procedural variables including age, gender, indication for the procedure, medication/substance use, previous surgeries, previous high sedation requirements for colonoscopy yielded an area under the curve of 0.76 for Fentanyl ≥ 100 mcg and Midazolam ≥ 3 mg.

CONCLUSION

Pre-procedural planning is the key in conducting successful, efficient colonoscopy. Logistic regression analysis of 5000 patients who underwent out-patient colonoscopy revealed the following factors associated with increased sedation requirement: Younger age, female gender, difficult endoscopy, specific indications as well as cardiopulmonary complications and current use of opioids/benzodiazepines. Age and gender adjusted analysis yielded similar results. These patients are more likely to need a longer recovery periods post-endoscopy, which could result in additional time and personnel requirements. The final predictive model has good predictive ability for Fentanyl ≥ 100 mcg and Midazolam ≥ 3 mg and fair predictive ability for Fentanyl ≥ 50 mcg and Midazolam ≥ 2 mg. The external validity of this model is planned to be tested in another center.

Keywords: Colonoscopy; Sedation; Sedation tolerance; Fentanyl; Midazolam; Predictive model

Core tip: This manuscript explores patient specific characteristics that are associated with increased sedation tolerance based on retrospective review of 5000 patients that underwent outpatient colonoscopies. Using a logistic regression analysis, we developed a predictive model that can identify patients requiring higher than usual sedation doses using pre-procedurally available patient parameters. The final prediction model that includes age, indication for the procedure, medication/substance use, previous surgeries yielded an area under the curve of 0.76 for Fentanyl ≥ 100 mcg and Midazolam ≥ 3 mg. This modelling could help optimize periprocedural planning and potentially identify patients who would benefit from alternative sedation methods, e.g., propofol.