A comparison of sedation protocols for gastric endoscopic submucosal dissection: Moderate sedation with analgesic supplementation vs analgesia targeted light sedation

Background Moderate to deep sedation has been recommended during endoscopic submucosal dissection (ESD). However, it is often accompanied by adverse events such as respiratory depression or aspiration pneumonia. This study investigated the respiratory complications and ESD outcomes of two sedation protocols: moderate sedation with analgesic supplementation (MSAS) and analgesia targeted light sedation (ATLS). Methods The clinical data of 293 patients who underwent ESD between May and December 2012 were reviewed. During the first 4 months, 155 patients were managed by moderate sedation [Modified Observer Assessment of Alertness/Sedation (MOAA/S) at 2-3] with the MSAS protocol. During the latter period, 138 patients were managed using the ATLS protocol (MOAA/S at 4-5). For both protocols, propofol and remifentanil were infused for sedation and pain control, respectively. Results The ATLS protocol required less propofol [22.9 (sd 17.3) vs 88.1 (44.0) μg kg^-1 min^-1, P<0.001] and more remifentanil [6.8 (sd 3.1) vs 4.9 (3.0) μg kg^-1 hr^-1, P<0.001] than the MSAS protocol. The desaturation events during the procedure occurred significantly less often (2.2 vs 12.9%, P=0.001) and recovery was significantly faster [19.7 (sd 4.8) vs 27.9 (16.0) min, P<0.001] with the ATLS protocol than with the MSAS protocol. The incidence of aspiration pneumonia with the ATLS protocol was 1.4% compared with 5.2% with the MSAS protocol (P=0.109). There were no differences in outcomes and complications of ESD. Conclusion The ATLS protocol reduced the incidence of desaturation events without affecting ESD performance compared with the MSAS protocol. There was also a trend towards a low incidence of aspiration pneumonia with the ATLS protocol.