Abstract
Standard monitoring of heart rate, blood pressure and arterial oxygen saturation during endoscopy is recommended by current guidelines on procedural sedation. A number of studies indicated a reduction of hypoxic (art. oxygenation < 90% for > 15 s) and severe hypoxic events (art. oxygenation < 85%) by additional use of capnography. Therefore, U.S. and the European guidelines comment that additional capnography monitoring can be considered in long or deep sedation. Integrated Pulmonary Index® (IPI) is an algorithm-based monitoring parameter that combines oxygenation measured by pulse oximetry (art. oxygenation, heart rate) and ventilation measured by capnography (respiratory rate, apnea > 10 s, partial pressure of end-tidal carbon dioxide [PetCO2]). The aim of this paper was to analyze the value of IPI as parameter to monitor the respiratory status in patients receiving propofol sedation during PEG-procedure. Patients reporting for PEG-placement under sedation were randomized 1:1 in either standard monitoring group (SM) or capnography monitoring group including IPI (IM). Heart rate, blood pressure and arterial oxygen saturation were monitored in SM. In IM additional monitoring was performed measuring PetCO2, respiratory rate and IPI. Capnography and IPI values were recorded for all patients but were only visible to the endoscopic team for the IM-group. IPI values range between 1 and 10 (10 = normal; 8–9 = within normal range; 7 = close to normal range, requires attention; 5–6 = requires attention and may require intervention; 3–4 = requires intervention; 1–2 requires immediate intervention). Results on capnography versus standard monitoring of the same study population was published previously. A total of 147 patients (74 in SM and 73 in IM) were included in the present study. Hypoxic events occurred in 62 patients (42%) and severe hypoxic events in 44 patients (29%), respectively. Baseline characteristics were equally distributed in both groups. IPI = 1, IPI < 7 as well as the parameters PetCO2 = 0 mmHg and apnea > 10 s had a high sensitivity for hypoxic and severe hypoxic events, respectively (IPI = 1: 81%/81% [hypoxic/severe hypoxic event], IPI < 7: 82%/88%, PetCO2: 69%/68%, apnea > 10 s: 84%/84%). All four parameters had a low specificity for both hypoxic and severe hypoxic events (IPI = 1: 13%/12%, IPI < 7: 7%/7%, PetCO2: 29%/27%, apnea > 10 s: 7%/7%). In multivariate analysis, only SM and PetCO2 = 0 mmHg were independent risk factors for hypoxia. IPI (IPI = 1 and IPI < 7) as well as the individual parameters PetCO2 = 0 mmHg and apnea > 10 s allow a fast and convenient conclusion on patients’ respiratory status in a morbid patient population. Sensitivity is good for most parameters, but specificity is poor. In conclusion, IPI can be a useful metric to assess respiratory status during propofol-sedation in PEG-placement. However, IPI was not superior to PetCO2 and apnea > 10 s.
Highlights
Percutaneous endoscopic gastrostomy (PEG) is the procedure of choice for patients who are expected to experience qualitative or quantitative inadequate oral nutrition for a period of a couple of weeks to years
Integrated Pulmonary Index® (IPI) is an algorithm-based monitoring parameter that combines oxygenation measured by pulse oximetry and ventilation measured by capnography
Capnography is not part of the recommended standard monitoring during sedation for endoscopy, even though it is known that apnea episodes, which may lead to hypoxia, cannot be detected by the current standard monitoring
Summary
Percutaneous endoscopic gastrostomy (PEG) is the procedure of choice for patients who are expected to experience qualitative or quantitative inadequate oral nutrition for a period of a couple of weeks to years. Cardiopulmonary complications are a common problem in GIT endoscopy with an incidence of hypoxemia of up to 69% [6]. Additional electrocardiogram (ECG) is recommended in patients with known severe heart disease or expected arrhythmic problems. Capnography is not part of the recommended standard monitoring during sedation for endoscopy, even though it is known that apnea episodes, which may lead to hypoxia, cannot be detected by the current standard monitoring. The European and the U.S endoscopy guidelines comment that capnography should be considered in long or deep sedated patients [7, 8]. A 2012 statement paper by the American Society for Gastrointestinal Endoscopy (ASGE), the American Collage of Gastroenterology (ACG) and The American Gastroentrology Association (AGA) claims that capnography increases costs by the additional device and by a prolonged duration of procedure time triggered by false alarms [9]
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