An Instrument To Guide Sedation Method and Improve Tolerance to Endoscopic Procedures

Abstract

Purpose: Despite conscious sedation, up to a quarter of patients may be dissatisfied with sedation during endoscopy. Our group has developed a questionnaire that aims to reliably identify patients who will experience endoscopy adversely. The major predictors of poor tolerance are the level of nervousness before the procedure and chronic use of alcohol, SSRIs and benzodiazepines. The aim of this study is to report the preliminary results of a randomized controlled study that tested the developed questionnaire in guiding sedation method. Methods: Subjects presenting for routine endoscopy were recruited and randomized to receive either conventional conscious sedation with Versed and Fentanyl (control group) or to undergo an evaluation based on the instrument we developed and then assigned to either conscious sedation or sedation using propofol based on the risk of dissatisfaction assessed by the questionnaire. Tolerance was measured using a post-procedure questionnaire. Variables assessed included: nervousness, pain and distress during procedure, the extent to which physical and emotional needs were met and overall satisfaction. A visual analogue scale was used with higher scores corresponding to worse outcomes. Mann Whitney U test was used to assess the differences in scores. Results: 298 subjects (112 males and 186 females) completed the study. 46 subjects (16%) were younger than 40 year old, 196 (66%) were 41–60 year old and 54 (18%) were older than 60 year old. Females had higher levels of nervousness (4.1 vs 3.2; p = 0.007). Nervousness levels were higher among patients younger than 60 years old and among patients with educational level of high school or less (3.9 vs. 2.7; p = 0.012 & 4.5 vs 3.4; p = 0.015). Furthermore, chronic narcotic use was associated with higher level of nervousness before procedure (3.3 vs 2.6; p = .023). Fear of pain during procedure as reflected by higher levels of expected pain strongly correlated with nervousness before procedure (r = 0.59, p = 000.1). Conclusions: The preliminary results of our study suggest that the instrument we developed is useful in identifying subjects at risk to experience aversive experience during endoscopy. These subjects are candidate for propofol-based sedation with improved outcomes.