|Year : 2020 | Volume
| Issue : 4 | Page : 198-202
Arterial desaturation during upper gastrointestinal endoscopy in nonsedated patients
Ashis K Saha
Department of Medicine, Mata Gujri Memorial Medical College & Lions Seva Kendra Hospital, Kishanganj, Bihar, India
|Date of Submission||17-Jun-2020|
|Date of Decision||06-Aug-2020|
|Date of Acceptance||06-Aug-2020|
|Date of Web Publication||09-Dec-2020|
Dr. Ashis K Saha
Department of Medicine, Mata Gujri Memorial Medical College & Lions Seva Kendra Hospital, PurabPalli Road, Kishanganj 855107, Bihar.
Source of Support: None, Conflict of Interest: None
Introduction: Upper gastrointestinal endoscopy is the first and basic diagnostic procedure to diagnose mucosal disease of the esophagus, stomach, and duodenum, but arterial desaturation is a common occurrence during insertion of the scope and this can be detected by using pulse oximeter attaching with the finger during the procedure. Materials and Methods: In this prospective cross-sectional study done in MGM Medical College and LSK Hospital, Kishanganj, Bihar, India, 1814 patients underwent this procedure for diagnosis only in nonsedated condition only by oral anesthesia by xylocaine spray and pulse oximeter probe in the finger to monitor arterial oxygen saturation, pulse, and automated blood pressure monitor blood pressure. All the variables were measured before the procedure, at the insertion of the scope, during the procedure, and after the extubation of the scope. Results: Among 1814 patients aged under 50 years were 1137 (females = 494 and males = 643) and above 50 years were 677 (females = 307 and males = 370) with average hemoglobin of 11.9 gm%. During the insertion of the endoscope, there was sudden dipping of oxygen saturation in both the age groups more significantly in the case of the above 50 years of age group (P < 0.05) as compared to others. Systolic blood pressure also increased significantly during insertion (P > 0.05) in both the age groups as compared to baseline. But the pulse rate did not significantly increase as compared to the baseline rate prior to insertion in both groups. With the progress of endoscopy oxygen saturation both blood pressure came to normal but the pulse rate increased as compared to baseline. Conclusion: Common complication, arterial desaturation during endoscopy procedure can be recognized by pulse oximetry in nonsedated patient and this will prevent serious consequences. So monitoring with pulse oximetry is of prime importance in this routine procedure.
Keywords: Arterial oxygen desaturation, high blood pressure, pulse oximetry, upper gastrointestinal endoscopy
|How to cite this article:|
Saha AK. Arterial desaturation during upper gastrointestinal endoscopy in nonsedated patients. MGM J Med Sci 2020;7:198-202
| Introduction|| |
Upper gastrointestinal endoscopy (UGIE) is the most common and available technique in the world to diagnose any type of mucosal abnormality extending from small erosion to large ulcer and cancer or to treat the disease by various technical methods in the form of banding varices, injection of a sclerosant solution into the varices or administration of hemoclips to block the bleeding or removal of foreign body from the upper gastrointestinal tract., Though it is a safe procedure, it has been documented as a cause of mortality in 0.43 to 0.8 per 10,000 procedures.,,, Previously this procedure was done after sedating the patient and many of these patients suffered from arterial desaturation during this procedure leading to cardio-pulmonary as well as noncardiac events.,,,,,, Reduction in the partial pressure of oxygen leads to the development of arterial desaturation during UGIE. There is a great debate about whether the performance of UGIE in nonsedated patients reduces the incidence of arterial desaturation-induced complications as compared to sedated patients. In comorbid patients with chronic obstructive pulmonary disease, cardiovascular disease and smoking UGIE can produce undetected hypoxemia, which may be detrimental to the patients. But with the advent of a pulse oximeter, it is possible to measure accurately arterial oxygen desaturation, pulse rate, and automated blood pressure but cannot detect ventilation in ventilated patients. There are many studies available regarding UGIE in the case of sedated patients but very few studies are available in nonsedated patients. With the pulse oximetry, it was possible to show that there was no effect of the diameter of the endoscope in the desaturation of oxygen during the procedure as a whole. So, in the case of the elderly, this measurement is very much essential, as at this age undetected hypoxemia results dreaded cardiopulmonary complications. In the case of sedated patients, aspiration of saliva and gastric content, under-ventilation, and vasovagal events due to over-sedation may occur. So, in view of these complications, the British Society of Gastroenterology recommended in 2003 the use of pulse oximetry in sedated and in nonsedated patients during UGIE. The study was designed to show the effects of UGIE on cardiovascular systems, like pulse, blood pressure.
| Materials and methods|| |
This was a cross-sectional observational study done at MGM Medical College and LSK Hospital in Kishanganj, Bihar after obtaining permission from the local ethics committee. In this study total, 1814 of patients were referred for UGIE. According to the declaration of Helsinki, informed consent was taken from the patients prior to this study. Prior to the procedure, demographic data such as age, sex, notes of the disease for which they were referred for the procedure, such as abdominal pain, nausea, vomiting, dyspepsia, hematemesis, or melena, gastroesophageal reflux, and hematological report such as hemoglobin, were collected. The exclusion criteria of the study were hemoglobin less than 10gm%, baseline oxygen saturation of less than 90%, chronic renal disease, and acute cardiorespiratory disorders. Patients were instructed to have an empty stomach for at least 8h. After explaining the total procedure to the patients, 10% xylocaine was sprayed in the mouth of the patients and asked them to swallow it. After waiting for at least 2min, the patients were directed to lie down in the left lateral position, and at the same time, the Nellcor N-180 the pulse oximeter was fixed with the index finger to measure oxygen, pulse, and automated blood pressure monitors to measure blood pressure prior to the procedure and these measurements were taken as baseline. Total 1814 patients were included in this study, below 50 years were 1137 (females = 494 and males = 643) and above 50 years were 677 (females = 307 and males = 370). Olympus gastroscope was introduced into the mouth of the patients very carefully so that the posterior wall of the pharynx should not be touched as it will initiate GAG reflex and thus produce bradycardia. Prior to (baseline) and during insertion of the scope, while viewing the interior of the stomach, after extubation of the scope and 10min after the total procedure all four readings were taken (pulse, oxygen saturation, and blood pressure) data were measured. Here, tachycardia can be defined as a pulse of more than 100/per minutes or an increase of more than 20 beats per minute from the baseline, similarly bradycardia as less than 60 beats per minute. Similarly, systolic hypertension can be defined as more than 160mm Hg and hypotension as less than 90mm Hg. In the case of oxygen desaturation, mild, moderate, and severe desaturations can be defined as 94%–90%, 89%–85%, and less than 85%, respectively. In this study, patients with chronic obstructive airway disease, severe ischemic heart disease, and hemoglobin of less than 10 gm% were excluded.
All the data were tabulated and analyzed in Statistical Package for the Social Sciences (SPSS) version 20.0 to get the mean and standard deviation. A value of P < 0.05 was then used to achieve statistical significance.
| Results|| |
Among 1814 patients below 50 years were 1137 (females = 494 and males = 643) and above 50 years were 677 (females = 307 and males = 370). Their average hemoglobin level was 11.9 gm%. The baseline value of oxygen saturation, pulse, and systolic blood pressure was within normal limits. During the insertion of the endoscope, there was a sudden dip of oxygen saturation in both the age groups which was highly significant in the case of more than 50 years of age group (P < 0.05) as compared to less than 50 years of age. Systolic blood pressure also increased significantly during insertion (P > 0.05) in both the age groups as compared to baseline. But the pulse rate did not significantly increase as compared to the baseline rate prior to insertion in both groups. But with the progress of endoscopy procedure oxygen saturation as well as blood pressure came to normal but pulse rate increased as compared to baseline [Table 1] [Figure 1][Figure 2][Figure 3].
|Table 1: Comparison of mean oxygen saturation, pulse, and blood pressure in two age groups during various stage of endoscopy procedure|
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|Figure 1: Line diagram showing comparison between two age groups with respect to oxygen desaturation in different phases of endoscopy|
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|Figure 2: Line diagram showing comparison between two age groups with respect to oxygen desaturation in different phases of endoscopy|
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| Discussion|| |
Diagnostic UGIE previously was done with intravenous sedation, mainly in the United States and the United Kingdom, which carried incidences of large numbers of arterial desaturation induced cardiovascular incidence due to respiratory depression, aspiration of gastric contents leading to arterial desaturation, but in other developed countries such as Spain, France, Germany, and also other under-developed countries this procedure was carried out in nonsedative patients., Though studies of O2 saturation during UGIE in nonsedated patients are very few, the results regarding the incident of oxygen desaturation in these studies widely varied.,,, This may be due to different factors such as age of the patient, stages of endoscopy, duration of endoscopy, the skill of the endoscopist, therapeutic endoscopy and the level of oral anesthesia, different methodologies, and different definitions of hypoxemia.,,,, In some of these studies, it was shown that there was a higher incidence of arterial oxygen desaturation in patients of more than 50 years old compared to patients of less than 50 years old. This study showed that there was a dipping of arterial oxygen saturation during insertion of the endoscope in both the age groups with high (P < 0.05) statistical difference in the extent of dipping (98.05 ± 2.214 to 93.99 ± 1.756 vs. 97.465 ± 1.903 to 92.447 ± 2.003) which was contrary to the study done by Aal-Haim et al., but arterial oxygen saturation rose to normal value after completion of the procedure in this study which was contradictory the study of Aal-Haim et al., it may be due to the following factors, like, a large number of people included in this study (1814 vs. 68 patients), duration of endoscopy (5.12 ± 8.65min vs. 14.71 ± 4.81min). In this study during insertion, mild (<94%–90%) moderate (85%–89%) severe (<85%) oxygen saturation were found in 21, 3, and 2 patients of less than 50 years of age (total = 26) and 23, 4, and 2 patients of more than 50 years of age (total = 29), the cumulating number being 55 of 1814 patients (3.03% total, mild 2.59%, moderate 0.38%, and severe 0.22%) which was very less as compared to the study done by Aal-Haim et al. (mild hypoxemia in 19.12% and severe hypoxemia in 1.47%) and also other studies.,,, The arterial oxygen saturation returned to normal after completion of the procedure, but during the procedure only two patients of more than 50 years of age suffered from moderate hypoxemia during the procedure. No patient in this study required oxygen supplementation, whereas two patients in the study by Aal-Haim et al. required oxygen supplementation and one patient required termination of the procedure. In some studies, there was evidence of apnea or disorders of respiration followed by arterial desaturation in nonsedated patients, but according to the author of those studies pulse oximetry was not mandatory in all diagnostic UGIE cases., On the contrary, many other studies have indicated the urgency of use of pulse oximeter during the UGIE as there is the possibility of undetected hypoxemia during insertion and throughout the procedure.,, Though this study showed mild-to-severe hypoxemia in 55 patients, these patients may be undetected if no pulse oximeter was used during this procedure and severe cardiovascular compromise can be prevented by oxygen supplementation; hence, pulse oximeter should be indicated in all cases who will undergo this procedure?
Contrary to this study, there was no dipping in arterial oxygen desaturationin the study done by Osinaike et al. (94.53% ± 3.39% vs. 93.99% ± 1.756% and <50 years of age and 92.447% ± 2.003% in >50 years of age), but incidence of tachycardia was absent in this study. In this study, 47.5% and 12.5% of patients suffered from mild to moderate and severe hypertension, respectively, which was significantly high as compared to this study (3.03%), this is due to the administration of intravenous diazepam.
| Conclusion|| |
Peripheral arterial desaturation is a common occurrence during insertion of an upper gastrointestinal endoscope which can be detected only by the use of a pulse oximeter probe in the finger during the procedure, this will prevent the consequence of arterial desaturation, like cardiopulmonary complications especially in the elderly. Sedation should not be given and it is not required nowadays because of the small diameter of endoscope, the excellent skill of the endoscopist, small duration of the procedure, and the proper process of insertion. Only oral anesthesia with xylocaine is sufficient for the procedure.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]