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What’s New in the
Patient Safety World
November
2020
·
Telemedicine Here to Stay But Use It Safely
·
The Costs of Inappropriate Medications
·
Prevention of Complications in the Cardiac
Intensive Care Unit
·
Targeted Propofol Sedation for GI Procedures: Is
It Safe?
Telemedicine Here to Stay But Use It Safely
One of the few
positive things to come out of the COVID-19 pandemic (yes, there are some
positives!) is that telemedicine has flourished. As shutdowns and restrictions and
fear led to significant drop-offs in office/clinic visits, telehealth and
“virtual” visits began to fill the gaps and both patients and clinicians have
begun to see the benefits of such visits. Since CMS (Centers for Medicare &
Medicaid Services) issued emergency waivers in April 2020 to allow payment for
telehealth services and many other insurers followed suit, such visits have
skyrocketed. A report from McKinsey & Co. in June concluded that 46% of
consumers in the U.S. were using telemedicine, up from 11% a year earlier, and
estimated that with changes such as replacing 20% of emergency room visits and
25% of health-care office visits, telemedicine eventually could account for a
fifth of all Medicare, Medicaid and commercial insurance spending on
outpatient, office and home health care (Cortez 2020).
But not all patients are ready for or able to participate in telehealth visits. And for many, clinicians must be aware of barriers they will encounter during such visits. Lam 2020
Nieman and Oh (Nieman 2020) have very practical
recommendations for connecting with older adults via telemedicine:
- Assume the patient has some degree of hearing loss
- Ask them if they have on their hearing aids and are in a
quiet room
- Ask them to wear a headphones or a headset
- Put on a headset yourself
- Use video and have the camera focused on your face
- Use captioning when available
- Provide a written summary of key points and instructions
- Pay attention to cues, such as nodding along or looking to a
loved one, which suggest a patient may not be following the conversation
- Have a backup plan (eg. audio by landline phone)
- Ask a loved one or care partner to join
in, if necessary
Practical recommendations for telehealth visits have also been made by the AMA AMA 2020, Canadian Patient Safety Institute and Canadian Medical Association CPSI 2020, and the British Medical Journal Car 2020. TRC 2020
The Joint Commission (Joint Commission 2020) acknowledged some additional benefits of
telehealth during the COVID-19 pandemic:
- Promoting social distancing
- Aiding in monitoring the progression of home-quarantined
COVID-19 patients
- Enabling providers who are quarantined but asymptomatic to
provide care remotely from their homes, thus mitigating the loss of highly
needed resources
- Reducing the use of personal protective equipment (PPE)
- Helping patients with transportation barriers connect
with their care providers
It stressed that
your telehealth visits, of course, must be done on secure systems and are
subject to HIPAA and all other security and confidentiality concerns.
It’s also critical
to recognize that not all conditions can be appropriately or safely managed via
telehealth. Patients must be informed that certain symptoms (like chest pain,
or even “indigestion” which might be a sign of an MI) merit immediate attention
and should not be attempted via telemedicine.
Joint Commission
stresses that organizations should develop protocols for virtual care and standards
for which symptoms and conditions can be managed virtually They should also pay
attention to regulations on scope of practice, noting that limitations
regarding different health care disciplines can vary by state. It also has
recommendations regarding training, supervision, workflow, and feedback.
Some types of
interaction are ideal for telehealth visits. The annual “wellness visit”, where
the focus is on managing risk factors, can often be fully accomplished using
telemedicine. And the annual “brown bag” medication review that is so important
in geriatrics is actually easier to do via telemedicine. The patient doesn’t
have to bring in their “brown bag” of medications but can simply show
everything in their medicine cabinet to you via these communication links. It
saves all time and still allows for face-to-face interaction. For years we have
recommended that clinicians provide a phone call to most patients 24-48 hours
after discharge from hospitals. Better yet, do that via a telemedicine visit!
One of the drawbacks
of the telehealth visit is lack of a physical exam. But that is not always the
case. Back in the early 1990’s we developed one of the first telemedicine
systems at the Erie County Medical Center, SUNY Buffalo’s major teaching
facility. We had contracts to deliver medical care for inmates at Attica Prison
and other New York State prisons. It was very costly for the prison system to
send inmates for clinic visits (they had to send at least 2 guards with each
prisoner and this led to substantial overtime costs). So, we began using
telemedicine visits. A nurse practitioner or physician assistant at the prison
would be able to place a stethoscope so we could audibly appreciate heart
sounds, lung sounds, bowel sounds, etc. The views of the tympanic membrane we’d
see from their otoscope made us all envious. We even had a special glove lined
with sensors that allowed us to examine the abdomen as the on-site clinician
palpated the patient’s abdomen. Of course, your typical patient does not have
access to all these items in his/her home. But, someday, patients with certain
conditions will be supplied with stethoscopes or otoscopes or other tools that
will allow parts of the physical exam to become part of the telehealth visit.
Some smartphones already allow transmission of reasonable fundoscopic views.
Much of the neurological exam can be appreciated by watching the patient walk
and talk (it’s difficult for some patients to set up their webcam to allow
viewing of their gait but it’s easy to transmit video of their gait by their
spouse or other using a smartphone).
Telemedicine has had
a substantial impact on stroke care, particularly in rural areas. Physicians in
rural ED’s who were previously reluctant to diagnose strokes and begin
thrombolytic therapy can now interact with a neurologist via telemedicine and
be better positioned to make such decisions.
Telehealth can be a
godsend for certain populations. Those with significant physical disabilities
that limit their ability to travel to an office or clinic are likely to
benefit. Patients in rural areas may avoid long trips to get access to
specialists. There is a nationwide shortage of psychiatrists, particularly
child and adolescent psychiatrists, and telehealth can improve access to these.
Telehealth could also reduce the long wait times patients have to see another
specialist in short supply, the dermatologist (though not all dermatological
problems can be diagnosed in telemedicine visits). Followups from surgery may
be facilitated by telemedicine by allowing visualization of healing wounds. Our
April 7, 2020 Patient Safety Tip of the Week “From
Preoperative Assessment to Preoperative Optimization” discussed how prehabilitation may help
reduce complications prior to surgery. That included an opinion piece (Silver
2020) in the British
Medical Journal that suggested we should use prehabilitation to prepare
patients for COVID-19 infections and that these interventions can be delivered
while patients are practicing social distancing or are sheltering in place and
can be easily delivered via telemedicine.
There is also a
“good news, bad news” feature of telehealth – death of the waiting room. The
good news is that patients won’t be exposed to transmissible diseases in a
waiting room. The bad news is that many patients actually like the social
interactions that occur in a waiting room. But there is also an important point
we make over and over regarding practice management – some of the most
important people in your practice are your front line staff. Patients will
often confide to them things they are reluctant to reveal to the clinicians
(such as that they are not taking their medications because they cannot afford
them).
One nuance of
telemedicine that we consider extremely important is that it forces the
clinician to actually look at his/her patient! All too often in today’s more
typical “face-to-face” office visits, the clinician is looking at a computer
screen rather than at the patient. Body language and facial expression often
convey much more meaning than the spoken word. By carefully observing those in
your patient, you may recognize when they are having difficulty comprehending
something. Those of you who give talks or chair meetings have probably begun to
appreciate that same nuance as we’ve moved from the “old” webcast format to the
new zoom format. If we see our audience fidgeting, we know it’s time for a
break. Similarly, if we see some of the yawning, we know it’s time to move on
to something else or deliver whatever ploys you use to wake up your audience.
Telehealth and
“virtual” visits are clearly here to stay. But every hospital, office, clinic,
or other healthcare organization must ensure that they deliver such services
securely and safely as well as conveniently.
Cortez M. Telemedicine, Washington Post 2020;
September 14, 2020
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2768772?resultClick=3
Nieman CL, Oh ES. Connecting With Older
Adults via Telemedicine. Annals of Internal Medicine 2020; Epub ahead of print
11 August 2020
https://www.acpjournals.org/doi/10.7326/M20-1322
https://edhub.ama-assn.org/steps-forward/module/2702689
https://www.patientsafetyinstitute.ca/en/Events/Conquer-Silence/Pages/default.aspx
https://www.bmj.com/content/371/bmj.m3945
https://www.telehealthresourcecenter.org/evidence/
The Joint Commission. The optimal use of
telehealth to deliver safe patient care. Quick Alert 2020; Issue55:| October
7,2020
https://www.jointcommission.org/-/media/tjc/newsletters/quick-safety-55-telehealth-9-25-20-final.pdf
https://www.medscape.com/viewarticle/936664
Silver JK. Prehabilitation could save lives
in a pandemic BMJ 2020; 369 :m1386
https://www.bmj.com/content/369/bmj.m1386
https://jamanetwork.com/journals/jama/fullarticle/2771681
Print “November 2020 Telemedicine Here to Stay But
Use It Safely”
The Costs of Inappropriate
Medications
Most of our columns on PIM’s (Potentially
Inappropriate Medications) in the elderly have focused on the safety issues.
But there is also a fiscal downside of such prescribing. Two recent articles in
the Journal of the American Geriatrics Society have highlighted those costs.
Clark et al. (Clark
2020) used data from the 2011–2015 Medical
Expenditure Panel Survey (MEPS) to estimate the prevalence of PIM prescribing
in community‐dwelling U.S. adults aged 65 and older. According to the
press release for this study (UB
2020), “among the 218 million-plus older adults
surveyed, more than 34% were prescribed at least one potentially
inappropriate medication. Those patients were, on average, prescribed twice
as many drugs, were nearly twice as likely to be hospitalized or visit the
emergency department, and were more likely to visit a primary care physician
compared to older adults who were not prescribed potentially inappropriate
medication.
Patients who received these medications also
spent an additional $458 on health care, including an extra $128 on
prescription drugs.”
In that study the crude rate of hospitalizations
was higher in those prescribed PIM’s at 35.6 per 100 persons versus 19.3 per
100 persons in the non-PIM group. The rate of ED visits was 41.1 per 100
persons in the PIM group compared with 23.6 per 100 persons in the non-PIM
group. In the crude data, the difference in average total expenditures was
higher for those on PIM’s within the inpatient ($1,767), ED ($141), and
outpatient ($1,568) settings. Prescription drug expenditures were also higher
in those prescribed PIM’s ($2,263). Totaling expenditures across all types resulted
in a difference of $5,168 for those exposed to PIM’s as compared with the
non-PIM group.
The authors did note a small but significant
decrease over the period studied in the use of specific inappropriate
medications including antispasmodics, antidepressants, digoxin, non-benzodiazepine
hypnotics, androgens, estrogens, and metoclopramide. But, notably, some of the
agents most commonly targeted for deprescribing in older adults (eg, first generation
antihistamines, antipsychotics, benzodiazepines, nonsteroidal anti-inflammatory
drugs, PPI’s, and long-acting sulfonylureas) did not change over this time
period.
They conclude that PIM’s continue to be
prescribed at high rates among older adults and are associated with increased
healthcare utilization and costs across the healthcare continuum. They note
that deprescribing is “currently in its infancy” in the United States, and that
further interventions are needed to target unnecessary and inappropriate medications
in older adults and reduce unnecessary healthcare utilization.
In the other study, Fralick
et al. (Fralick 2020) analyzed data from the Medicare Part D
Prescription Drug Program data set (2014–2018). They found that, from 2014 to
2018, 43 billion doses of potentially inappropriate medications were dispensed,
with a reported spending of $25.2 billion. In 2018, 7.3 billion doses of
potentially inappropriate medications were dispensed. The most common medications
by number of doses dispensed were proton pump inhibitors, benzodiazepines, and
tricyclic antidepressants, and the top five unique medications by reported
spending were dexlansoprazole, esomeprazole, omeprazole, dronedarone, and
conjugated estrogens.
Speaking of proton pump inhibitors, another
recent study (Patel
2020) confirmed a point we have made over and
over – PPI’s (and other acid suppressing medications) are often inappropriately
continued after patients are discharged from or transferred from the ICU. The
researchers analyzed data on patients admitted to ICU’s from 13 hospitals
within a health system over a 6-month period. The highest incidence of
inappropriate medication continuation after ICU transfer or discharge occurred
in patients receiving a PPI (26.78%), followed by H2 blockers (8.39%) They also
found frequent inappropriate continuation of bronchodilators (5.9%). They
conclude that inappropriate discharge of patients on these medications not only
poses risk for long term effects on a patient’s body but also costs the
patients money for a medication they may not require.
Those authors note
that studies have shown no benefits of adding PPI/H2RA medications in
decreasing morbidity and mortality in the ICU and that many studies on
long-term PPI usage have shown adverse effects. That is in keeping with a
just-released scientific statement from the American Heart Association “Prevention
of Complications in the Cardiac Intensive Care Unit” (Fordyce 2020) noted in our November 2020 What's New in
the Patient Safety World column “Prevention of Complications in the Cardiac
Intensive Care Unit”.
That statement says “Newer evidence suggests that stress ulcer prophylaxis may be
associated with reduced gastrointestinal bleeding in high-risk patients but
overall has no demonstrated mortality benefit, and the number needed to treat
is high.” It goes on to say “Routine use of stress ulcer prophylaxis is not
necessary for low-risk patients in the CICU (cardiac ICU), including all
patients receiving MV (mechanical ventilation). Stress ulcer prophylaxis is reasonable
for patients in the CICU with multiple risk factors for gastrointestinal
bleeding (including patients with shock, acute kidney injury requiring renal replacement
therapy, MV, liver disease, use of anticoagulants, and ongoing coagulopathy as
defined by platelet count <50 000/m3, an international normalized ratio
>1.5, or a partial thromboplastin time >2 times the control value or on
dual antiplatelet therapy), although the data supporting this approach are weak.”
Based on their findings of inappropriate
continuation of these categories of drugs, Patel et al. believe that a
multidisciplinary approach to medication reconciliation during ICU downgrade
would prove beneficial in preventing such occurrences.
Bottom line: Far too many patients continue
to take medications that are likely to be inappropriate. This leads not only to
adverse effects on the patients but also increases healthcare utilization and
costs. Careful medication reconciliation is needed at all transitions of care
and, for most older adults, the annual “brown bag” medication review is
important. Evidence-based deprescribing is critical in reducing hazards to
patients and costs to the healthcare system. It’s also worth noting our
previous warnings that sometimes the drug you thought you discontinued is still
being taken by your patients.
Some of our past columns on Beers’ List and Inappropriate Prescribing
in the Elderly:
- January 15, 2008 “Managing Dangerous
Medications in the Elderly
- June 2008 “Potentially
Inappropriate Medication Use in Elderly Hospitalized Patients”
- October 19, 2010 “Optimizing Medications
in the Elderly”
- September 22, 2009 “Psychotropic Drugs and
Falls in the SNF”
- September 2010 “Beers List and CPOE”
- June 21, 2011 “STOPP Using Beers’ List?”
- December 2011 “Beers’ Criteria Update in the Works”
- May 7, 2013 “Drug Errors in the Home”
- November 12, 2013 “More on Inappropriate Meds in the Elderly”
- January 28, 2014 “Is Polypharmacy Always Bad?”
- March 4, 2014 “Evidence-Based Prescribing and Deprescribing in the Elderly”
- September 30, 2014 “More on Deprescribing”
- February 10, 2015 “The Anticholinergic Burden and Dementia”
- May 2015 “Hospitalization: Missed Opportunity to Deprescribe”
- July 2015 “Tools for Deprescribing”
- November 2015 “Medications Most Likely to Harm the Elderly Are…”
- August 2, 2016 “Drugs in the Elderly:
The Goldilocks Story”
- October 31, 2017 “Target Drugs for
Deprescribing”
- January 2018 “What Happens After
Delirium?”
- May 2018 “Antipsychotic Use in
Nursing Homes: Progress or Not?”
- June 2018 “Deprescribing
Benzodiazepine Receptor Agonists”
- October 2018 “STOPP/START/STRIP”
- November 27, 2018 “Focus on Deprescribing”
- March 19, 2019 “Updated Beers Criteria”
- March 10, 2020 “Medication Harm in the
Elderly”
- June 2020 “The Antipsychotics in
Dementia Conundrum”
Some of our past columns on deprescribing:
- March 4, 2014 “Evidence-Based Prescribing and Deprescribing in the Elderly”
- September 30, 2014 “More on Deprescribing”
- May 2015 “Hospitalization: Missed Opportunity to Deprescribe”
- July 2015 “Tools for Deprescribing”
- April 4, 2017 “Deprescribing in
Long-Term Care”
- October 31, 2017 “Target Drugs for
Deprescribing”
- January 2018 “What Happens After
Delirium?”
- June 2018 “Deprescribing Benzodiazepine
Receptor Agonists”
- November 27, 2018 “Focus on Deprescribing”
- March 19, 2019 “Updated Beers Criteria”
- March 10, 2020 “Medication Harm in the
Elderly”
- June 2020 “The Antipsychotics in
Dementia Conundrum”
Some of our previous columns on medication
reconciliation:
October 23, 2007 “Medication Reconciliation
Tools”
December 30, 2008 “Unintended
Consequences: Is Medication Reconciliation Next?”
May 13, 2008 “Medication
Reconciliation: Topical and Compounded Medications”
September 8, 2009 “Barriers
to Medication Reconciliation”
August 2011 “The
Amazon.com Approach to Medication Reconciliation”
January 2012 “AHRQ’s
New Medication Reconciliation Tool Kit”
September 2012 “Good
News on Medication Reconciliation”
October 1, 2019 “Electronic Medication
Reconciliation: Glass Half Full or Half Empty?”
July 2020 “Not Following Medication
Changes after Hospitalization?”
Some
of our other columns on failed discontinuation of medications:
May
27, 2014 “A
Gap in ePrescribing:
Stopping Medications”
March
2017 “Yes!
Another Voice for Medication e-Discontinuation!”
February
2018 “10
Years on the Wrong Medication”
August
28, 2018 “Thought
You Discontinued That Medication? Think Again”
December
18, 2018 “Great
Recommendations for e-Prescribing”
August 2019 “Including
Indications for Medications: We Are Failing”
August 6, 2019 “Repeat
Adverse Drug Events”
References:
Clark CM, Shaver AL, Aurelio LA, et al.
Potentially Inappropriate Medications Are Associated with Increased Healthcare
Utilization and Costs. J Am Geriatr Soc 2020; Published online 05 August 2020
https://onlinelibrary.wiley.com/doi/abs/10.1111/jgs.16743
UB (University at Buffalo). Study: 34% of
older adults in the U.S. are prescribed potentially inappropriate drugs,
raising health care costs by hundreds. (Press Release). Newswise 2020; October
21, 2020
Fralick, M., Bartsch, E., Ritchie, C.S. and
Sacks, C.A. (2020), Estimating the Use of Potentially Inappropriate Medications
Among Older Adults in the United States. J Am Geriatr Soc 2020; Early View
https://onlinelibrary.wiley.com/doi/10.1111/jgs.16779
https://journal.chestnet.org/action/showPdf?pii=S0012-3692%2820%2934409-3
Fordyce CB, Katz JN, Alviar CL, et al. Prevention
of Complications in the Cardiac Intensive Care Unit: A Scientific Statement
From the American Heart Association. Circulation 2020; Published online 29
October 2020
https://www.ahajournals.org/doi/10.1161/CIR.0000000000000909
Print “November 2020 The Costs of Inappropriate
Medications”
Prevention of Complications
in the Cardiac Intensive Care Unit
The American Heart Association has just
released a scientific statement “Prevention of Complications in the Cardiac
Intensive Care Unit” (Fordyce
2020). The suggested practices for cardiac
intensive care units (CICU’s) are based primarily on evidence generated from
patients admitted to general medical or surgical ICU’s but take into account
the special circumstances and underlying conditions that CICU patients have.
They recognize there has been “substantial heterogeneity in care of critically
ill cardiac patients” and note that this document aims to provide standardized approaches
to preventive care using the best available evidence. It suggests the use of a
bedside checklist to inform best practices in the prevention of complications in
this unique population.
Details of the topics in this comprehensive
28-page document are beyond the scope of today’s column. The topics are arranged
under the following categories:
PREVENTION OF CICU-ACQUIRED INFECTIONS
- Prevention of Percutaneous MCS (mechanical
circulatory support)
- Device–Related Infections
- Prevention of CLABSI
- Prevention of VAP
- Prevention of CAUTI
- Prevention of Other HAI’s
- Antibiotic Stewardship and Prevention of
Antibiotic Resistance
APPROACH TO ANALGESIA AND SEDATION AND THE
DIAGNOSIS AND PREVENTION OF DELIRIUM
- General Approach: ABCDEF Bundle
- Pain and Analgesia
- Delirium
- Anxiety and Agitation
- Sedative Agent Selection
- Ventilatory Dyssynchrony and Shivering: Neuromuscular
Blocker Use
PREVENTION OF VENTILATOR COMPLICATIONS
- Tidal Volume
- Positive End-Expiratory Pressure
- Oxygen Supplementation
- Daily SBT’s (spontaneous breathing
trials) and Other Strategies for Successful Extubation
- Appropriate Use of Noninvasive PPV
- Intubation/PPV-Associated Hemodynamic Compromise
BENEFITS OF EARLY MOBILIZATION
- Defining Mobilization
- Potential Benefits of Early Mobilization
- Safety and Risks of Early Mobilization
- Patient Eligibility for Early Mobilization
and Criteria for Termination of Therapy
PREVENTION OF GASTROINTESTINAL COMPLICATIONS
- Feeding
- Gastrointestinal Bleeding Prophylaxis
- Hyperglycemia Management and Prevention
of Hypoglycemia
PREVENTION AND RECOGNITION OF MEDICATION
COMPLICATIONS AND ERRORS
- Anticoagulation
- Antiarrhythmic Therapy
- Vasoactive Medications
COMPLICATIONS OF INVASIVE CARDIAC PROCEDURES
AND DEVICES
TRANSITIONS OF CARE BEST PRACTICES
- Multidisciplinary Rounding
- Palliative Care
- Role of Cardiac Intensivists
The document also provides a sample “Daily Bedside
Checklist” to encourage best practices and to prevent complications for
patients admitted to the cardiac intensive care unit (CICU). It has reminders
sorted into the major categories noted above.
This is a very useful and timely document and
comes with 150 references. We hope you’ll read the details of each topic and
implement their suggested best practices.
References:
Fordyce CB, Katz JN, Alviar CL, et al. Prevention
of Complications in the Cardiac Intensive Care Unit: A Scientific Statement
From the American Heart Association. Circulation 2020; Published online 29
October 2020
https://www.ahajournals.org/doi/10.1161/CIR.0000000000000909
Print “November 2020 Prevention of Complications
in the Cardiac Intensive Care Unit”
Targeted Propofol Sedation
for GI Procedures: Is It Safe?
The
fact that most gastrointestinal endoscopy procedures require some level of
sedation raises patient safety concerns. Most sedation for such procedures
involves use of benzodiazepines with or without an opioid. Propofol has also been
used in some circumstances. Propofol has the advantage of rapid onset of action
and predictable depth of sedation but it has a relatively narrow therapeutic
window. Moreover, it lacks a reversal agent. Therefore, use of propofol usually
requires administration by an anesthetist or anesthesiologist.
The emergence
of propofol target-controlled infusion (TCI) systems is felt by some to provide
a potential alternative to anesthetist-managed sedation. Propofol TCI systems
are pre-programmed with pharmacokinetic models and some adjust for patient
weight and age.
A recent study from a tertiary medical center
in Argentina analyzed the experience of patients who had undergone
elective gastrointestinal endoscopy under propofol target-controlled infusion
sedation (García Guzzo 2020). 823 outpatients, age 18 and older with ASA
scores I–III (85% were actually score I-II) who underwent diagnostic and therapeutic EGD, colonoscopy, or
both were included in the analysis. 48% had colonoscopy alone and 37%
had combined EGD and colonoscopy. Patients who had endoscopic retrograde
cholangiopancreatography, enteroscopy, and procedures performed under planned
tracheal intubation were excluded from the study. The propofol target-controlled infusions (TCI’s) were administered and
monitored by anesthetists. Conventional monitoring included blood pressure,
EKG, and oxygen saturation by pulse oximetry. Capnography apparently was not
used.
A strong dose-effect relationship was found between
hypoxia and obesity; patients with body mass index ≥40 were nine times
(odds ratio 10.22) more likely to experience oxygen desaturation < 90%
events.
The authors conclude that propofol sedation
using target-controlled infusion appears to be a safe and effective anesthetic
technique for gastrointestinal endoscopic procedures with acceptable rates of
adverse events and could be more widely adopted in clinical practice.
Overall, this was a low-risk population and
the procedures were relatively low-risk, So the results cannot be extrapolated
to patients with higher ASA scores. These results are comparable or better than
most results reported for use of other sedation regimens for such
gastrointestinal endoscopic procedures.
Though the overall safety profile looks very
good, we are concerned about use of propofol in patients with obesity. In fact,
the researchers found a strong dose–effect relationship between obesity and
episodes of oxygen desaturation to SaO2 < 90%. Compared to patients with a
normal BMI, the risk of those with BMI 30–35 was almost double (OR 1,68), for
those with BMI 35–40 three times (OR 2.85) and for those with BMI ≥40
nine times (OR 10.22) more likely to experience episodes of oxygen desaturation
to SaO2 < 90%.
Of course, we would not be surprised if those
same rates of desaturation are seen in obese patients undergoing these
procedures using alternative sedation protocols. Obese patients have a high
incidence of obstructive sleep apnea (OSA) and apneic episodes are probably as
likely triggered by sedation with benzodiazepines, opioids, or propofol. Also
keep in mind that 87% of the patients in this study received not only propofol
but also received the opioid fentanyl.
The authors note that use of a high-flow
nasal cannula or continuous positive airway pressure via nasal mask (SuperN2va)
have been proposed to reduce oxygen desaturation events for spontaneously breathing
obese patients.
We remain cautious
about the use of propofol with or without an opioid for GI endoscopic
procedures in obese patients (or others who are at risk for obstructive sleep
apnea). We’d probably like to see use of capnographic monitoring for that
population. But the jury is still out on the value of capnography in the GI
suite. Our March 2018 What's New in the Patient Safety World column “Capnography in the GI Suite” discussed that issue. The ASGE guidelines
for sedation and anesthesia in GI endoscopy (Early 2018) state “capnography has been demonstrated to
detect depressed respiratory activity before transient hypoxemia, but a clear
link between transient hypoxemia and serious cardiopulmonary unplanned events
during sedated endoscopy has not been established. Integrating capnography into
patient monitoring protocols for endoscopic procedures with moderate sedation
has not been shown to improve patient safety; however, there is evidence
supporting its use in procedures targeting deep sedation.” However, under its
recommendations for propofol use during endoscopy, it does state “Capnography
should be considered because it may decrease the risks during deep sedation.”
And under their summary recommendations they “suggest that capnography
monitoring be considered for patients undergoing endoscopy targeting deep
sedation.”
Most of the studies looking at the added
value of capnography in GI procedures have concluded that, while capnography
may reduce the number of hypoxic events, it has not changed the overall risk of
serious events (Kim
2018, Veazie
2020, Saunders 2017).
A recent study at a high-volume university
hospital GI department (Bisschops
2019) found that the relative
risks of experiencing both adverse events and interventions during recovery
were reduced significantly in patients monitored by capnography compared to a
control group. There were 1,044 patients in the capnography arm and 1,092 patients
in the control arm. The primary endpoint (change in total incidence of mild
oxygen desaturation, severe oxygen desaturation, bradycardia, and tachycardia) occurred
on average 11.45 times per 100 procedures in the control group, compared to 5.08
times per 100 procedures in the group monitored by capnography, a 55.69%
reduction. There were nine escalations of care in the control group and none in
the capnography group.
Jopling and Qiu (Jopling 2017) performed a retrospective analysis of a
huge number of inpatients and outpatients undergoing gastrointestinal
endoscopic procedures with sedation. They found the use of capnography was
associated with and a 61% estimated reduction in the odds of a pharmacological
rescue event compared to the matched outpatient population. (And note that, for
the inpatient population, use of capnography was associated with a reduction in
both mortality and pharmacologic rescue rates.)
But most studies have not stratified the
patients by obesity or OSA risk. One study (Prathanvanich
2015) used capnography during
upper endoscopy in morbidly obese patients and found it very useful in
detecting early respiratory depression and no clinically significant
cardiorespiratory complications occurred. However, there was no control group
for comparison.
References:
García Guzzo ME, Fernandez MS, Sanchez Novas
D, et al. Deep sedation using propofol target-controlled infusion for
gastrointestinal endoscopic procedures: a retrospective cohort study. BMC Anesthesiology2020;
20(1): 195
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