BY RENE MIGUEL GONZALEZ, MD, ANESTHESIOLOGIST, STAFFORD TOWNSHIP, NJ
Anesthesiology patient safety literature(1,2) clearly indicates that the majority of medical malpractice lawsuits arising from GI endoscopies are a result of respiratory complications, specifically hypoxia (inadequate, dangerously low blood oxygen levels). Hypoxia during endoscopy can result in prolongations, delays and cancellations of procedures, and even worse, in cardiac arrest, brain damage and death.
The greatest technical challenges to providing adequate oxygenation during upper endoscopies results from the fact that we have been unable to use our best method of supplemental oxygen delivery, the traditional oxygen facemask, for the simple reason that the plastic dome of the facemask prevents insertion of the endoscope into the patient’s mouth. As a result, for decades, we have had to settle for our least effective method of oxygen delivery, namely nasal oxygen cannula, for upper endoscopies.
While nasal cannula provide an “open face” to allow oral insertion of the endoscope, the room air, which is entrained via the mouth with every breath, dilutes and severely limits the oxygen actually delivered to the lungs to a maximum of 35-40 percent, as opposed to the 85-100 percent oxygen concentrations that can be delivered by oxygen facemasks.
In recent years, however, there has been a major positive development in this area: oxygen facemasks designed for upper endoscopies and approved by the FDA, such as the Procedural Oxygen Mask, or POM from POM Medical, Simi Valley, California. The POM endoscopy oxygen mask resembles a traditional oxygen mask, except it has a self-sealing endoscopy port that allows insertion of the endoscope, while simultaneously providing much superior (2-3 times greater) oxygen delivery than nasal cannula.
In 2019, as part of an endoscopy patient safety initiative, our anesthesia department came across these new POM endoscopy oxygen masks, and incorporated them into our very busy endoscopy practice. The POM masks are inexpensive, easy to use, FDA approved and have greatly improved our ability to deliver adequate oxygenation during upper endoscopies.
Staff Safety/Infection Control
At the beginning of the COVID-19 pandemic, we also noticed another very important side-benefit of the POM oxygen mask. Upper endoscopy frequently precipitates coughing in the procedure room, which often continues into the recovery area. For decades, we have become so accustomed to patients coughing in the direction of our faces and equipment that we have come to accept and almost ignore this. When it became clear at the start of the pandemic that the SARS-CoV-2 virus was transmitted primarily via respiratory aerosolization (coughing, gagging), it became evident that the POM mask provided a mechanical barrier to coughing that could limit aerosolized respiratory pathogen load, and thus reduce risk to staff and other patients. Thus we leave the POM mask on our patients into the recovery room until they have stopped coughing and are ready for discharge. Our endoscopy room and recovery room nursing staff are very appreciative to no longer have patients coughing directly into their faces and ambient work environments.
This new paradigm shift to a superior oxygen delivery system for upper endoscopies represents a significant opportunity for improvement in patient and staff safety and infection control, as well as a reduction in liability potential in the GI endoscopy suite.
It is likely that endoscopy oxygen masks will become—in fact, may already have become— the medicolegal standard of care over nasal cannula, as it would be hard to justify why a readily available, superior oxygen delivery device was not used should a serious hypoxic event occur.
Administration, risk management, and organizational patient safety officers at all healthcare facilities providing upper endoscopy services should be aware of this new paradigm in oxygen delivery for upper endoscopy, and should discuss this important patient safety and risk management issue with the nursing and anesthesiology leadership and other stakeholders in their GI endoscopy suite.
1. Walls JD et al. Safety in Non-Operating Room Anesthesia (NORA). Anesthesia Patient Safety Foundation Newsletter. June 2019; 3-4,21.
2. Chang B et al. Interventional Procedures Outside of the Operating Room: Results from the National Anesthesia Clinical Outcomes Registry. Journal of Patient Safety 2018;14: 9-16