Safer sedation practice may not translate into improvements in endoscopic outcomes

Although the literature surrounding sedation practice and endoscopic outcomes remains sparse and controversial, there have been a number of stringent guidelines issued regarding sedation use in endoscopy.

To assess the impact of changes to enhance safer sedation practice on endoscopic outcomes.

Sedation practice was audited in 7234 consecutive gastrointestinal endoscopic procedures in 2004 and protocols for enhancing safer sedation practice were introduced. These included; introduction of a unit sedation policy, exchange of midazolam 10 mg vials to 5 mg repacked syringes, adverse events recording of midazolam use of greater than 5 mg and reversal agents, more stringent patient monitoring procedures and endoscopists education and feedback. A reaudit of 7071 procedures was performed in 2006. Outcomes audited the included midazolam doses, patient intolerance, 30-day postprocedure mortality, reversal agent use and total adverse events.

Sedation doses were reduced substantially after intervention [mean midazolam dose (SD): 4.9 mg (2.5) in 2004 vs. 2.9 mg (1.2) in 2006; P<0.0001] with no endoscopist using a mean greater than 5 mg in 2006 compared with 19% in 2004 (P=0.005). The use of reversal agents (0.6 vs. 0.7% for 2004 and 2006, respectively; P=0.74), mortality (1.0 vs. 1.3%; P=0.23) and the adverse events (1.7 vs. 2%; P=0.44) were similar. Unsuccessful procedures because of patient intolerance increased from 0.1 to 1.9% (P<0.0001).

Although protocols to enhance safer sedation practice substantially reduced sedation doses used; this did not, however, translate into improved endoscopic outcomes. Moreover, incomplete procedures because of poor tolerance increased.