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Safety Analysis of Bariatric Patients Undergoing Outpatient Upper Endoscopy With Nurse Administered Propofol Sedation
Tyler R. McVay*1, John C. Fang1, Linda J. Taylor1, Alexander Au2, Wesley Williams2, Angela Presson3, Ragheed Al-Dulaimi3, Anna Ibele4
1Division of Gastroenterology, Hepatology, and Nutrition, University of Utah School of Medicine, Salt Lake City, UT; 2University of Utah School of Medicine, Salt Lake City, UT; 3Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT; 4Division of General Surgery, University of Utah School of Medicine, Salt Lake City, UT
Introduction
Nurse administered propofol sedation (NAPS) has been shown to be a safe and effective method of providing sedation for patients undergoing gastrointestinal endoscopy. Bariatric surgery patients are potentially at higher risk for sedation related complications due to comorbidities including obstructive sleep apnea (OSA). However, the outcomes of NAPS in bariatric patients have not been previously reported. We performed a retrospective analysis of the safety and efficacy of NAPS in bariatric patients undergoing pre-surgical outpatient upper endoscopy.
Methods
Consecutive bariatric patients undergoing pre-surgical outpatient EGD were compared to non-obese patients (BMI ≤25 kg/m2) undergoing diagnostic EGD at our institution from March 2011 - September 2015 using our endoscopy database and medical charts. Patients’ demographics, STOP-Bang questionnaire (sleep apnea screening tool) results, procedural and recovery data, including any airway interventions were recorded. Bariatric and non-obese group differences in procedure details, complications, and airway interventions were assessed using a t-test or Wilcoxon rank test for continuous variables and chi-squared or Fisher’s exact test for categorical variables. Statistical significance was assessed at the 0.05 level.
Results
130 consecutive preoperative bariatric surgical patients and 265 control patients were analyzed. All procedures were successfully completed using NAPS. When compared to the control group, the bariatric group was on average younger (43.9 vs 54.3 years; p<0.001), had a greater number of females (76% vs 55%; p<0.001), higher prevalence of sleep apnea (62% vs 8%; p<0.001), and higher BMI (45.8 vs 21.9kg/m2; p<0.001). The bariatric group received larger doses of propofol and fentanyl (p<0.001), had longer procedure times (p<0.001) but shorter recovery times (p=0.0038). The control group experienced more bradycardia (p<0.001). The bariatric group experienced significantly more oxygen desaturations (22% vs 7%; p<0.001) and required more chin lift/jaw thrust maneuvers (20% vs 6%; p<0.001). Advanced airway interventions were very rarely required in either group and there was no difference in the use of oral/nasal airways or bag-valve mask ventilation (2 patients in bariatric group and 1 in control group). No patients in either group required intubation.
Conclusions
Compared to non-obese patients, we found that bariatric patients experienced significantly more oxygen desaturations and required more chin lifts/jaw thrusts while undergoing outpatient upper endoscopy utilizing NAPS. However, their need for advanced airway interventions was very rare and similar to non-obese patients. Morbidly obese bariatric surgery patients can safely undergo preoperative EGD using nurse-administered propofol sedation.
Table 1. Patient Characteristics and Procedural Details of EGDs in Bariatric Surgery Patients and Normal Weight Controls
| | Control Group (N=265) | Bariatric Group (N=130) | P-value | | Age (years) - mean | 54.3 | 43.9 | <0.001 | | Sex - % female | 55 | 76 | <0.001 | | BMI (kg/m2) - mean | 21.9 | 45.8 | <0.001 | | History of Sleep Apnea | 20 (8%) | 80 (62%) | <0.001 | | Propofol Dose (mg) - mean | 162.8 | 301.1 | <0.001 | | Procedure Time (min) - mean | 9.1 | 12.3 | <0.001 | | Recovery Time (min) - mean | 29.2 | 26.9 | 0.038 |
Table 2. Complications and Airway Interventions during EGDs in Bariatric Surgery Patients and Normal Weight Controls | | Control Group (N=265) | Bariatric Group (N=130) | P-value | | Desaturations (SpO2 <90%) | 19 (7%) | 29 (22%) | <0.001 | | Hypotension (Systolic Blood Pressure <90mmHg) | 50 (19%) | 16 (12%) | 0.1 | | Bradycardia (Heart Rate <60bpm) | 75 (28%) | 17 (13%) | <0.001 | | Chin Lift/Jaw Thrust | 17 (6%) | 26 (20%) | <0.001 | | Nasal/Oral Airway | 0 (0%) | 1 (1%) | 0.33 | | Bag-Valve Mask Ventilation | 1 (0%) | 1 (1%) | 0.55 | | Intubation | 0 (0%) | 0 (0%) | - |
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