Prospective audit of upper gastrointestinal endoscopy in two regions of England: safety, staffing, and sedation methods.

TLDR

A prospective audit of 14,149 gastroscopies performed in 36 hospitals across two regions recorded 1,113 therapeutic and 13,036 diagnostic procedures. Most patients received intravenous sedation, with midazolam preferred in the North West and diazepam in East Anglia; mean doses were 5.7 mg and 13.8 mg, yet only half had IV access and few received supplemental oxygen, leading to a diagnostic mortality rate of 1 in 2,000, morbidity of 1 in 200, and a strong link between high‑dose benzodiazepines, lack of monitoring, and adverse cardiorespiratory events, while local anaesthetic sprays were associated with pneumonia (p < 0.001), and 20 perforations occurred during 774 dilatations with eight deaths (1 in 100), compounded by staffing shortages, inadequate facilities, and unsupervised junior endoscopists.

Abstract

A prospective audit of upper gastrointestinal endoscopy in 36 hospitals across two regions provided data from 14,149 gastroscopies of which 1113 procedures were therapeutic and 13,036 were diagnostic. Most patients received gastroscopy under intravenous sedation; midazolam was the preferred agent in the North West and diazepam was preferred in East Anglia. Mean doses of each agent used were 5.7 mg and 13.8 mg respectively, although there was a wide distribution of doses reported. Only half of the patients endoscoped had some form of intravenous access in situ and few were supplied with supplementary oxygen. The death rate from this study for diagnostic endoscopy was 1 in 2000 and the morbidity rate was 1 in 200; cardiorespiratory complications were the most prominent in this group and there was a strong relation between the lack of monitoring and use of high dose benzodiazepines and the occurrence of adverse outcomes. In particular there was a link between the use of local anaesthetic sprays and the development of pneumonia after gastroscopy (p < 0.001). Twenty perforations occurred out of a total of 774 dilatations of which eight patients died (death rate 1 in 100). A number of units were found to have staffing problems, to be lacking in basic facilities, and to have poor or virtually non-existent recovery areas. In addition, a number of junior endoscopists were performing endoscopy unsupervised and with minimal training.