Sedation Trends for Conscious Sedation: A 20-Year Perspective

Introduction: Sedation for endoscopy continues to evolve. When endoscopy was introduced most patients were not sedated, which remains the practice in much of the world. In the United States, endoscopies are done with either gastroenterologist provided “conscious” sedation or with anesthesia provided “deep” sedation. The later is more expensive and has not been proven to be safer. Others and we have found that conscious sedation provides adequate sedation in the majority of outpatients. We sought to determine how conscious sedation patterns have changed over the past 20 years in an ambulatory surgery center. Methods: The first 100 colonoscopies performed in an outpatient, ambulatory center in 1996 were compared to the first 100 performed in the same center in 2016. Double procedures were excluded. Age, sex, and sedation total (narcotic dose and benzodiazepam dose) were compared between the groups. The narcotics used were either meperidine or fentanyl. Doses were converted to fentanyl equivalency by using an accepted narcotic equivalency factor of 1.33 (50 mg meperidine=66.6 ug fentanyl). We also compared those requiring higher doses of sedation defined as ≥100 ug fentanyl or ≥5 mg midazolam. Finally we looked at those requiring what we define as the maximal safe (MAX) dose (≥200ug fentanyl or ≥10 mg midazolam).Table. ResultsResults: The 2016 patients were younger (mean 59.0 v 68.9 years, p< 0.0001) but of similar sex (% female 42 v 46, NS). Meperidine was used in 1996 (100%) but Fentanyl was more common in 2016 (86%)(p< 0.0001). The mean Fentanyl equivalent dose increased from 84.9 to 129.1 ug (p < 0.0001) as did the mean Midazolam dose (3.48 to 6.26 mg, p < 0.0001). The percent requiring high dose increased from 19 to 61% while the percent using MAX dose increased from 0 to 13% (both p < 0.0001). Conclusion: In these patients collected 20 years apart; the narcotic requirement increased 52% and the benzodiazepam requirement increased 80%. There was a marked increase in patients requiring high or MAX dose sedation. Finally, while the percent female was similar, the more recent cohort of patients were almost a decade younger than those undergoing colonoscopy in 1996. There were no anesthesia related complications in this cohort and our overall complication rate has been consistently very low and our patient satisfaction consistently high. Further studies are needed to better understand the underlying factors and clinical significance of this change in practice.