Subscribe to RSS
![](/products/assets/desktop/img/oa-logo.png)
DOI: 10.1055/s-0042-100719
Modeling the costs and benefits of capnography monitoring during procedural sedation for gastrointestinal endoscopy
Publication History
submitted 30 September 2015
accepted after revision 04 January 2016
Publication Date:
18 March 2016 (online)
![](https://www.thieme-connect.de/media/10.1055-s-00025476/201603/lookinside/thumbnails/406_10-1055-s-0042-100719-1.jpg)
Background and study aims: The addition of capnography to procedural sedation/analgesia (PSA) guidelines has been controversial due to limited evidence of clinical utility in moderate PSA and cost concerns.
Patients and methods: A comprehensive model of PSA during gastrointestinal endoscopy was developed to capture adverse events (AEs), guideline interventions, outcomes, and costs. Randomized, controlled trials and large-scale studies were used to inform the model. The model compared outcomes using pulse oximetry alone with pulse oximetry plus capnography. Pulse oximetry was assumed at no cost, whereas capnography cost USD 4,000 per monitor. AE costs were obtained from literature review and Premier database analysis. The model population (n = 8,000) had mean characteristics of age 55.5 years, body mass index 26.2 kg/m2, and 45.3 % male.
Results: The addition of capnography resulted in a 27.2 % and 18.0 % reduction in the proportion of patients experiencing an AE during deep and moderate PSA, respectively. Sensitivity analyses demonstrated significant reductions in apnea and desaturation with capnography. The median (95 % credible interval) number needed to treat to avoid any adverse event was 8 (2; 72) for deep and 6 (−59; 92) for moderate. Reduced AEs resulted in cost savings that accounted for the additional upfront purchase cost. Capnography was estimated to reduce the cost per procedure by USD 85 (deep) or USD 35 (moderate).
Conclusions: Capnography is estimated to be cost-effective if not cost saving during PSA for gastrointestinal endoscopy. Savings were driven by improved patient safety, suggesting that capnography may have an important role in the safe provision of PSA.
-
References
- 1 Atkinson P, French J, Nice CA. Procedural sedation and analgesia for adults in the emergency department. BMJ 2014; 348: g2965
- 2 Brown SC, Hart G, Chastain DP et al. Reducing distress for children during invasive procedures: randomized clinical trial of effectiveness of the PediSedate. Paediatr Anaesth 2009; 19: 725-731
- 3 Abraham NS, Fallone CA, Mayrand S et al. Sedation versus no sedation in the performance of diagnostic upper gastrointestinal endoscopy: a Canadian randomized controlled cost-outcome study. Am J Gastroenterol 2004; 99: 1692-1699
- 4 Meredith JR, O'Keefe KP, Galwankar S. Pediatric procedural sedation and analgesia. J Emerg Trauma Shock 2008; 1: 88-96
- 5 Porostocky P, Chiba N, Colacino P et al. A survey of sedation practices for colonoscopy in Canada. Can J Gastroenterol 2011; 25: 255-260
- 6 Liu H, Waxman DA, Main R et al. Utilization of anesthesia services during outpatient endoscopies and colonoscopies and associated spending in 2003-2009. JAMA 2012; 307: 1178-1184
- 7 Aisenberg J, Cohen LB. Sedation in endoscopic practice. Gastrointest. Endosc. Clin. N. Am 2006; 16: 695-708
- 8 Godwin SA, Burton JH, Gerardo CJ et al. Clinical policy: procedural sedation and analgesia in the emergency department. Ann Emerg Med 2014; 63: 247-258 e218
- 9 Srinivasan M, Turmelle M, DePalma LM et al. Procedural Sedation for Diagnostic Imaging in Children by Pediatric Hospitalists using Propofol: Analysis of the Nature, Frequency, and Predictors of Adverse Events and Interventions. J. Pediatr 2012; 160: 801-806.e801
- 10 Cravero JP, Beach ML, Blike GT et al. The incidence and nature of adverse events during pediatric sedation/anesthesia with propofol for procedures outside the operating room: a report from the Pediatric Sedation Research Consortium. Anesth Analg 2009; 108: 795-804
- 11 Lucendo AJ, Olveira A, Friginal-Ruiz AB et al. Nonanesthesiologist-administered propofol sedation for colonoscopy is safe and effective: a prospective Spanish study over 1000 consecutive exams. Eur J Gastroenterol Hepatol 2012; 24: 787-792
- 12 Beitz A, Riphaus A, Meining A et al. Capnographic monitoring reduces the incidence of arterial oxygen desaturation and hypoxemia during propofol sedation for colonoscopy: a randomized, controlled study (ColoCap Study). Am J Gastroenterol 2012; 107: 1205-1212
- 13 Deitch K, Miner J, Chudnofsky CR et al. Does end tidal CO2 monitoring during emergency department procedural sedation and analgesia with propofol decrease the incidence of hypoxic events? A randomized, controlled trial. Ann Emerg Med 2010; 55: 258-264
- 14 Qadeer MA, Vargo JJ, Dumot JA et al. Capnographic monitoring of respiratory activity improves safety of sedation for endoscopic cholangiopancreatography and ultrasonography. Gastroenterology 2009; 136: 1568-1576 ; quiz 1819-1520
- 15 Metzner J, Posner KL, Domino KB. The risk and safety of anesthesia at remote locations: the US closed claims analysis. Curr Opin Anaesthesiol 2009; 22: 502-508
- 16 Robbertze R, Posner KL, Domino KB. Closed claims review of anesthesia for procedures outside the operating room. Curr Opin Anaesthesiol 2006; 19: 436-442
- 17 Bhananker SM, Posner KL, Cheney FW et al. Injury and liability associated with monitored anesthesia care: a closed claims analysis. Anesthesiology 2006; 104: 228-234
- 18 Lightdale JR, Goldmann DA, Feldman HA et al. Microstream capnography improves patient monitoring during moderate sedation: a randomized, controlled trial. Pediatrics 2006; 117: e1170-e1178
- 19 Adams L, Butas S, Spurlock Jr D. Capnography (ETCO2), respiratory depression, and nursing interventions in moderately sedated adults undergoing transesophageal echocardiography (TEE). J Perianesth Nurs 2015; 30: 14-22
- 20 Langhan ML, Shabanova V, Li FY et al. A randomized controlled trial of capnography during sedation in a pediatric emergency setting. Am J Emerg Med 2015; 33: 25-30
- 21 American Society for Gastrointestinal Endoscopy, American College of Gastroenterology, Association TAG. Universal adoption of capnography for moderate sedation in adults undergoing upper endoscopy and colonoscopy has not been shown to improve patient safety or clinical outcomes and significantly increases costs for moderate sedation. 2012
- 22 Weaver J. The latest ASA mandate: CO(2) monitoring for moderate and deep sedation. Anesth Prog 2011; 58: 111-112
- 23 Friedrich-Rust M, Welte M, Welte C et al. Capnographic monitoring of propofol-based sedation during colonoscopy. Endoscopy 2014; 46: 236-244
- 24 Walsh BK, Crotwell DN, Restrepo RD. Capnography/Capnometry during mechanical ventilation: 2011. Respir Care 2011; 56: 503-509
- 25 Caro JJ, Briggs AH, Siebert U et al. Modeling good research practices--overview: a report of the ISPOR-SMDM Modeling Good Research Practices Task Force--1. Value Health 2012; 15: 796-803
- 26 Scheuermeyer FX, Andolfatto G, Qian H et al. Does the sedation regimen affect adverse events during procedural sedation and analgesia in injection drug users?. CJEM 2013; 15: 279-288
- 27 Mehta PP, Kochhar G, Kalra S et al. Can a validated sleep apnea scoring system predict cardiopulmonary events using propofol sedation for routine EGD or colonoscopy? A prospective cohort study. Gastrointest Endosc 2014; 79: 436-444
- 28 Wani S, Azar R, Hovis CE et al. Obesity as a risk factor for sedation-related complications during propofol-mediated sedation for advanced endoscopic procedures. Gastrointest Endosc 2011; 74: 1238-1247
- 29 Enestvedt BK, Eisen GM, Holub J et al. Is the American Society of Anesthesiologists classification useful in risk stratification for endoscopic procedures?. Gastrointest Endosc 2013; 77: 464-471
- 30 Waugh JB, Epps CA, Khodneva YA. Capnography enhances surveillance of respiratory events during procedural sedation: a meta-analysis. J Clin Anesth 2011; 23: 189-196
- 31 Statistics USBoL. Consumer price index – all urban consumers. In. series ID: CUUR0000SA0 ed. Postal Square Building, 2 Massachusetts Avenue, NE Washington, DC 20212-0001. . U.S. Bureau of Labor Statistics; 2015
- 32 Couloures KG, Beach M, Cravero JP et al. Impact of provider specialty on pediatric procedural sedation complication rates. Pediatrics 2011; 127: e1154-e1160
- 33 Ferguson K, Young J, Panagopoulos P et al. Anesthesia Related Closed Claims and Litigations at the Detroit Medical Center: Analysis, Lessons Learned, and Conclusions. Open J Anesthesiol 2014; 4: 88-98
- 34 Maglinte DD, Applegate KE, Rajesh A et al. Conscious sedation for patients undergoing enteroclysis: comparing the safety and patient-reported effectiveness of two protocols. Eur J Radiol 2009; 70: 512-516
- 35 Mehta P, Kochhar G, Albeldawi M et al. Capnographic Monitoring Does Not Improve Detection of Hypoxemia in Colonoscopy With Moderate Sedation: A Randomized, Controlled Trial. Am J Gastroenterol 2014; 109: S588
- 36 Sharma VK, Nguyen CC, Crowell MD et al. A national study of cardiopulmonary unplanned events after GI endoscopy. Gastrointest Endosc 2007; 66: 27-34
- 37 Finn JP. Sedation in MR Imaging: What Price Safety?. Radiology 2000; 216: 633-634
- 38 Garcia RT, Cello JP, Nguyen MH et al. Unsedated ultrathin EGD is well accepted when compared with conventional sedated EGD: a multicenter randomized trial. Gastroenterology 2003; 125: 1606-1612
- 39 Dunham CM, Hileman BM, Hutchinson AE et al. Perioperative hypoxemia is common with horizontal positioning during general anesthesia and is associated with major adverse outcomes: a retrospective study of consecutive patients. BMC Anesthesiol 2014; 14: 43
- 40 Green SM, Krauss B. Pulmonary aspiration risk during emergency department procedural sedation--an examination of the role of fasting and sedation depth. Acad Emerg Med 2002; 9: 35-42
- 41 Wehrmann T, Riphaus A. Sedation with propofol for interventional endoscopic procedures: a risk factor analysis. Scand. J. Gastroenterol 2008; 43: 368-374
- 42 Rex DK, Heuss LT, Walker JA et al. Trained registered nurses/endoscopy teams can administer propofol safely for endoscopy. Gastroenterology 2005; 129: 1384-1391
- 43 Jensen JT, Vilmann P, Horsted T et al. Nurse-administered propofol sedation for endoscopy: a risk analysis during an implementation phase. Endoscopy 2011; 43: 716-722
- 44 Vargo JJ. Procedural sedation. Curr Opin Gastroenterol 2010; 26: 421-424
- 45 Bhatt M, Kennedy RM, Osmond MH et al. Consensus-based recommendations for standardizing terminology and reporting adverse events for emergency department procedural sedation and analgesia in children. Ann Emerg Med 2009; 53: 426-435 e424
- 46 Melendez E, Bachur R. Serious adverse events during procedural sedation with ketamine. Pediatr Emerg Care 2009; 25: 325-328
-
Supplementary References
- 47 Ferguson K, Young J, Panagopoulos P et al. Anesthesia Related Closed Claims and Litigations at the Detroit Medical Center: Analysis, Lessons Learned, and Conclusions. Open J Anesthesiol 2014; 4: 88-98
- 48 Beitz A, Riphaus A, Meining A et al. Capnographic monitoring reduces the incidence of arterial oxygen desaturation and hypoxemia during propofol sedation for colonoscopy: a randomized, controlled study (ColoCap Study). Am J Gastroenterol 2012; 107: 1205-1212
- 49 Mehta PP, Kochhar G, Kalra S et al. Can a validated sleep apnea scoring system predict cardiopulmonary events using propofol sedation for routine EGD or colonoscopy? A prospective cohort study. Gastrointest Endosc 2014; 79: 436-444
- 50 Vargo JJ. Procedural sedation. Curr Opin Gastroenterol 2010; 26: 421-424
- 51 Wehrmann T, Riphaus A. Sedation with propofol for interventional endoscopic procedures: a risk factor analysis. Scand. J. Gastroenterol 2008; 43: 368-374
- 52 Qadeer MA, Vargo JJ, Dumot JA et al. Capnographic monitoring of respiratory activity improves safety of sedation for endoscopic cholangiopancreatography and ultrasonography. Gastroenterology 2009; 136: 1568-1576 ; quiz 1819-1520
- 53 Rex DK, Heuss LT, Walker JA et al. Trained registered nurses/endoscopy teams can administer propofol safely for endoscopy. Gastroenterology 2005; 129: 1384-1391
- 54 Jensen JT, Vilmann P, Horsted T et al. Nurse-administered propofol sedation for endoscopy: a risk analysis during an implementation phase. Endoscopy 2011; 43: 716-722
- 55 Green SM, Krauss B. Pulmonary aspiration risk during emergency department procedural sedation--an examination of the role of fasting and sedation depth. Acad Emerg Med 2002; 9: 35-42
- 56 Srinivasan M, Turmelle M, DePalma LM et al. Procedural Sedation for Diagnostic Imaging in Children by Pediatric Hospitalists using Propofol: Analysis of the Nature, Frequency, and Predictors of Adverse Events and Interventions. J Pediatr 2012; 160: 801-806.e801
- 57 Couloures KG, Beach M, Cravero JP et al. Impact of provider specialty on pediatric procedural sedation complication rates. Pediatrics 2011; 127: e1154-e1160
- 58 Waugh JB, Epps CA, Khodneva YA. Capnography enhances surveillance of respiratory events during procedural sedation: a meta-analysis. J Clin Anesth 2011; 23: 189-196
- 59 Wani S, Azar R, Hovis CE et al. Obesity as a risk factor for sedation-related complications during propofol-mediated sedation for advanced endoscopic procedures. Gastrointest Endosc 2011; 74: 1238-1247
- 60 Enestvedt BK, Eisen GM, Holub J et al. Is the American Society of Anesthesiologists classification useful in risk stratification for endoscopic procedures?. Gastrointest Endosc 2013; 77: 464-471
- 61 Maglinte DD, Applegate KE, Rajesh A et al. Conscious sedation for patients undergoing enteroclysis: comparing the safety and patient-reported effectiveness of two protocols. Eur J Radiol 2009; 70: 512-516
- 62 Mehta P, Kochhar G, Albeldawi M et al. Capnographic Monitoring Does Not Improve Detection Of Hypoxemia In Colonoscopy With Moderate Sedation. A Randomized, Controlled Trial. American College of Gastroenterology 2014 Annual Scientific Meeting Philadelphia, PA, USA: 2014
- 63 Sharma VK, Nguyen CC, Crowell MD et al. A national study of cardiopulmonary unplanned events after GI endoscopy. Gastrointest Endosc 2007; 66: 27-34