Patients with comorbidities involving major organ systems or who had a recent history of mechanical ventilation or previous critical care involvement were found to be more likely to need critical care again after endoscopy, according to a new study presented at Canadian Digestive Disease Week 2023.
The research, which examined patients who had an inpatient endoscopy while admitted to ward-level care at the Toronto General Hospital, also found that most patients who required critical care after gastrointestinal endoscopy (GIE) had complications unrelated to the endoscopy itself.
The single-center, retrospective case-control study, which included adults treated from 2015 to 2019, is “the largest to date to examine risk factors associated with critical care requirements post-[GIE] in the tertiary care in-patient setting,” according to the investigators.
They sought to find factors associated with the need for critical care and post-GIE adverse events to help determine which inpatients may benefit from anesthesia consultation and support during an endoscopic procedures (abstract A67).
The researchers identified 275 cases and 2,069 controls. Cases were inpatients who required critical care response team involvement and/or critical care admission within seven days of a gastrointestinal endoscopy, whereas the control group was patients who did not need this care.
“The majority of adverse events among cases were not found to be complications directly related to GIE,” the authors wrote. “Patients with a history of pulmonary hypertension and ASA [American Society of Anesthesiologists] score III/IV had the highest odds of probable or definite endoscopy-related adverse events.”
David Wan, MD, a GI hospitalist and an associate professor of clinical medicine at Weill Cornell Medicine, in New York City, who specializes in inpatient gastroenterology and was not involved in the study, said when patients with respiratory, cardiac, renal or liver issues require an endoscopy, it often is performed in the ICU. “If you’re the sickest of the sick and go through an endoscopy, you’ll be more likely to have a complication or adverse effect,” Dr. Wan said. “One needs a higher threshold to scope these patients, and if scoped, [they] may need closer monitoring and anesthesiology assistance.”
Speaking to Gastroenterology & Endoscopy News about the Toronto General’s endoscopy program, co-investigator Kristel Leung, MD, said such concerns are weighed carefully. “Oftentimes, these are patients who, in the balance of their health, may benefit from their endoscopy, and recognizing the risks of undergoing such a procedure, we will then proceed with the patient’s, or substitute decision maker’s, consent,” said Dr. Leung, a hepatology fellow in the Division of Gastroenterology and Hepatology at the Toronto Center for Liver Disease. “There have certainly been situations where we say we cannot do the endoscopy because the up-front risks greatly outweigh the benefits.”
Dr. Leung explained that it wasn’t always possible to predict a complication, such as ICU care or team involvement, after endoscopy.
Involving Anesthesiology Early
According to Dr. Wan, the findings suggest that the involvement of anesthesiology services for these high-risk cases is appropriate and necessary. In many U.S. hospitals, anesthesiology routinely evaluates all inpatient cases. If a patient is deemed too sick for the endoscopy suite, then the procedure is performed in the ICU. But, in other countries, anesthesia services may not be available for all cases. The findings “would help in a hospital where you have to be selective,” Dr. Wan said. “Who do you want to be more careful about or who do you want to ensure gets anesthesia?”
He also noted that he hasn’t seen a study that aimed to formally study the topic.
Dr. Leung explained that in their procedures, the majority of patients who are undergoing endoscopy in the ambulatory unit are sedated with medications not limited to anesthesiologists. In her institution, the majority of patients undergoing endoscopy in the ambulatory unit are given small doses of fentanyl and midazolam and “are highly monitored by the physicians and nurses of the endoscopy unit throughout their procedure and afterwards,” she said. “Those who are identified to have high-risk comorbidties—such as heart disease or lung disease—are referred to an anesthesiologist ... to mitigate the risk of cardiovascular and respiratory complications.”
Dr. Leung and her co-investigators hope that the findings of this soon-to-be-published study can make it clearer which patients would benefit from inclusion of anesthesia services. “We look forward to reporting the findings of this study and hope that it will help us better characterize the high-risk patient to determine the safest care pathway for them.”
—Natalie Schachar
The sources reported no relevant financial disclosures.
This article is from the July 2023 print issue.