背景:常规门诊内窥镜检查在各种门诊环境中进行。在中度镇静下进行内窥镜检查的已知风险是过度镇静的可能性,需要使用逆转剂。需要报告更多关于不同门诊设置的逆转率。我们的学术三级护理中心利用分诊工具,将高风险患者引导到医院内门诊手术中心(APC)进行手术。这里,我们报告了在使用分诊工具进行风险分层后,在院内APC与在独立式动态内镜消化健康中心(AEC-DHC)进行内镜检查的门诊镇静逆转率的数据.
目的:为了观察使用分诊工具进行风险分层对患者预后的影响,主要是镇静逆转事件。
方法:我们观察了2013年4月至2019年9月在AEC-DHC和APC进行的所有门诊内窥镜检查程序。使用分诊工具将程序分层到各自的部位。我们评估了记录了氟马西尼和纳洛酮镇静逆转的每个程序。记录的人口统计学和特征包括患者年龄,性别,体重指数(BMI),美国麻醉医师协会(ASA)分类,程序类型,以及镇静逆转的原因。
结果:在研究期间,在AEC-DHC和22494在APC进行了97366次内窥镜手术。其中,AEC-DHC的17例患者和APC的9例患者进行了镇静逆转(0.017%vs0.04%;P=0.06)。AEC-DHCvsAPC需要逆转的人口统计包括平均年龄(53.5±21vs60.4±17.42岁;P=0.23),ASA等级(1.66±0.48vs2.22±0.83;P=0.20),BMI(27.7±6.7kg/m2vs23.7±4.03kg/m2;P=0.06),女性(64.7%vs22%;P=0.04)。AEC-DHC和APC使用的镇静剂和逆转药物的平均剂量为咪达唑仑(5.9±1.7mgvs8.9±3.5mg;P=0.01),芬太尼(147.1±49.9μgvs188.9±74.1μg;P=0.10),氟马西尼(0.3±0.18μgvs0.17±0.17μg;P=0.13)和纳洛酮(0.32±0.10mgvs0.28±0.12mg;P=0.35)。AEC-DHC需要镇静逆转的程序包括结肠镜检查(n=6),食管胃十二指肠镜(EGD)(n=9)和EGD/结肠镜(n=2),而APC程序包括EGD(n=2),EGD与胃造口管放置(n=1),内镜逆行胰胆管造影术(n=2)和内镜超声(n=4)。AEC-DHC镇静逆转的适应症包括缺氧(n=13;76%),过度嗜睡(n=3;18%),低血压(n=1;6%),然而,在APC,其中包括缺氧(n=7;78%)和低血压(n=2;22%)。任一地点均未发生镇静相关死亡或长期镇静逆转后不良结局。
结论:我们的研究强调了在我们的三级护理医院使用的风险分层分诊工具在减少门诊内窥镜检查过程中镇静逆转事件的有效性。使用分类工具进行风险分层,在EGD和结肠镜检查的门诊设置中,可以实现较低的镇静逆转率.
BACKGROUND: Routine outpatient endoscopy is performed across a variety of outpatient settings. A known risk of performing endoscopy under moderate sedation is the potential for over-sedation, requiring the use of reversal agents. More needs to be reported on rates of reversal across different outpatient settings. Our academic tertiary care center utilizes a triage tool that directs higher-risk patients to the in-hospital ambulatory procedure center (APC) for their procedure. Here, we report data on outpatient sedation reversal rates for endoscopy performed at an in-hospital APC vs at a free-standing ambulatory endoscopy digestive health center (AEC-DHC) following risk stratification with a triage tool.
OBJECTIVE: To observe the effect of risk stratification using a triage tool on patient outcomes, primarily sedation reversal events.
METHODS: We observed all outpatient endoscopy procedures performed at AEC-DHC and APC from April 2013 to September 2019. Procedures were stratified to their respective sites using a triage tool. We evaluated each procedure for which sedation reversal with flumazenil and naloxone was recorded. Demographics and characteristics recorded include patient age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, procedure type, and reason for sedation reversal.
RESULTS: There were 97366 endoscopic procedures performed at AEC-DHC and 22494 at the APC during the study period. Of these, 17 patients at AEC-DHC and 9 at the APC underwent sedation reversals (0.017% vs 0.04%; P = 0.06). Demographics recorded for those requiring reversal at AEC-DHC vs APC included mean age (53.5 ± 21 vs 60.4 ± 17.42 years; P = 0.23), ASA class (1.66 ± 0.48 vs 2.22 ± 0.83; P = 0.20), BMI (27.7 ± 6.7 kg/m2 vs 23.7 ± 4.03 kg/m2; P = 0.06), and female gender (64.7% vs 22%; P = 0.04). The mean doses of sedative agents and reversal drugs used at AEC-DHC vs APC were midazolam (5.9 ± 1.7 mg vs 8.9 ± 3.5 mg; P = 0.01), fentanyl (147.1 ± 49.9 μg vs 188.9 ± 74.1 μg; P = 0.10), flumazenil (0.3 ± 0.18 μg vs 0.17 ± 0.17 μg; P = 0.13) and naloxone (0.32 ± 0.10 mg vs 0.28 ± 0.12 mg; P = 0.35). Procedures at AEC-DHC requiring sedation reversal included colonoscopies (n = 6), esophagogastroduodenoscopy (EGD) (n = 9) and EGD/colonoscopies (n = 2), whereas APC procedures included EGDs (n = 2), EGD with gastrostomy tube placement (n = 1), endoscopic retrograde cholangiopancreatography (n = 2) and endoscopic ultrasound\'s (n = 4). The indications for sedation reversal at AEC-DHC included hypoxia (n = 13; 76%), excessive somnolence (n = 3; 18%), and hypotension (n = 1; 6%), whereas, at APC, these included hypoxia (n = 7; 78%) and hypotension (n = 2; 22%). No sedation-related deaths or long-term post-sedation reversal adverse outcomes occurred at either site.
CONCLUSIONS: Our study highlights the effectiveness of a triage tool used at our tertiary care hospital for risk stratification in minimizing sedation reversal events during outpatient endoscopy procedures. Using a triage tool for risk stratification, low rates of sedation reversal can be achieved in the ambulatory settings for EGD and colonoscopy.