Factors Predicting High Doses of Sedation and Incomplete Colonoscopy among Patients with Inflammatory Bowel Diseases: 2011

Purpose: Current clinical practices necessitate routine colonoscopies for patients with inflammatory bowel diseases (IBD). Many practitioners offer IBD patients monitored anesthesia care (MAC) with propofol to provide a deeper level of sedation, but these services are not readily available in all medical facilities and augment medical costs. The aim of this study was to identify predictive factors resulting in the administration of high doses of moderate sedation (HDS) so that practitioners could better identify patients who might benefit the most from MAC. Methods: We performed a cross-sectional study including consecutive patients with Crohn's disease (CD) or ulcerative colitis (UC) who underwent a first colonoscopy at Jackson Memorial Hospital (Miami, FL) between January of 2001 and January of 2013. In the medical facility, all colonoscopies are scheduled with moderate sedation (midazolam and meperidine); MAC is only utilized when previous endoscopic procedures have been unsuccessful with moderate sedation where the desired level of sedation has not been achieved or if the patient has significant co-morbidities warranting the additional monitoring by anesthesia staff. Variables considered were demographics, IBD phenotype, IBD medications, use of antidepressants and benzodiazepines, laboratory values and surgical history. The primary outcome was the administration of HDS defined as ≥8 mg of midazolam and/or ≥150 mg of meperidine. The secondary outcome was premature cessation of the procedure due to inability to achieve adequate sedation. Results: The baseline characteristics of the 171 patients included are shown in Table 1. The mean time of procedure was 34 minutes (SD:14). 22 (12.8%) of patients required HDS; the colonoscopy was terminated prematurely in 2 cases (1.1%). The mean doses of midazolam and meperidine used were 4.5 (SD: 1.7) and 60 (SD:21) mg respectively. There was a significant and proportional association between younger age and HDS (ROC: 0.7, p=0.01). No association between body mass (ROC: 0.6, p=0.2) or duration of IBD (ROC: 0.5, p=0.9) was observed. Categorical variables significantly associated with HDS included male gender, age <40 years and the prescription of biologic medications for IBD (Table 2). Trends toward HDS were observed for patients with colonic CD.Table 1: Baseline characteristics of the study populationTable 2: Association between the HDS and study variablesConclusion: While moderate sedation for colonoscopy is a viable option for most patients with IBD, young males may benefit from MAC, avoiding potential complications. Patients receiving biologic agents were also identified as a sub-group which required higher sedation, likely representing patients with more aggressive disease. Further research into patient preference and the associated costs with competing methods of anesthesia are warranted.