Obesity as a risk factor for sedation-related complications during propofol-mediated sedation for advanced endoscopic procedures

Abstract

Background There is limited data on the safety of anesthesia-assisted endoscopy using propofol-mediated sedation in obese individuals undergoing advanced endoscopic procedures (AEPs). Objective To study the association between obesity [as measured by body mass index (BMI)] and the frequency of sedation-related complications (SRCs) in patients undergoing AEPs. Design Prospective cohort study. Setting Tertiary referral center. Patients 1016 consecutive patients undergoing AEPs [BMI<30: 730(72%), 30-35:159(16%), >35:127(12%)]. Intervention Monitored anesthesia sedation with propofol alone or in combination with benzodiazepines and/or opioids. Main Outcome Measures SRCs: airway modifications (AMs), hypoxemia, hypotension requiring vasopressors, and early procedure termination were compared across three groups. Results There were 203 AMs in 13.9% patients, hypoxemia in 7.3%, need for vasopressors in 0.8% and premature termination in 0.6% of patients. Increasing BMI was associated with an increased frequency of AMs (BMI:<30–10.5%, 30-35–18.9%, >35–26.8%, p<0.001) and hypoxemia (<30–5.3%, 30-35–9.4%, >35–13.4%, p=0.001); there was no difference in the frequency of need for vasopressors (p=0.254) and premature termination of procedures (p=0.401). On multivariable analysis, BMI [OR 2.0 (95% CI 1.3-3.1)], age [OR 1.1 (95% CI 1.0-1.1)] and ASA class ≥ 3 [OR 2.4 (95% CI 1.1-5.0)] were independent predictors of SRCs. In obese individuals (n=286), there was no difference in the frequency of SRCs in patients receiving propofol alone or in combination (p=0.48). Limitations Single tertiary center study. Conclusions Although obesity was associated with an increased frequency of SRCs, propofol sedation can be used safely in obese patients undergoing AEPs when administered by trained professionals.

Controversies in Perioperative Anesthetic Management of the Morbidly Obese: I Am a Surgeon, Why Should I Care?

“…Most studies suggest that the comorbidities indirectly associated with obesity, rather than obesity itself, increases the risks in same day surgeries. Clinical trials report a statistically significant higher incidence in respiratory events (oxygen desaturation, bronchospasm, stridor/laryngospasm, airway obstruction) and need for oxygen supplementation in obese patients [60,61]. However, these studies did not report an increase in unanticipated admission rates in obese patients, suggesting that the respiratory events which are a direct consequence of obesity may not be clinically significant [58].…”

Optimizing care for the obese patient in interventional radiology

“…The net effect of these physiologic changes can increase or decrease the required dose of sedatives (22). A prospective study of over 1000 obese patients found that high BMI and low anesthesiologist expertise were strong predictors of propofol sedation-related complications, highlighting the fact that the increased risk of sedation in obese patients can be managed by experienced providers (28). Dosing sedatives in obese patients by ideal body weight will result in subtherapeutic doses, whereas using total body weight (TBW) will result in overdoses (29).…”

Sedation, anesthesia, and medications

“…Subjects with an elevated STOP-BANG score were also found to be at increased risk for apnea (OR: 1.63; 95% CI: 1.19, 2.25). Similarly, obesity defined as a BMI > 30 kg/m 2 was associated with an increased risk of sedation-related complications during anesthesiologist-directed propofolmediated sedation for advanced endoscopic procedures [8].…”

“…Important prerequisites for this type of approach include a dedicated anesthesia staff who engage in active airway management throughout the case as well as the use of monitoring including pulse oximetry, electrocardiogram, blood pressure, and either capnography or visual inspection to detect apnea. Many case series have found this approach to be quite effective [6][7][8]18]. It also appears to have a very high safety profile but comparative numbers to propofol-mediated sedation with endotracheal intubation are not available to definitively answer the safety issue.…”