title: A novel index of hypoxemia for assessment of risk during procedural sedation.
abstract: BACKGROUND
  Procedural sedation is essential for many procedures. Sedation has an excellent safety profile; however, it is not without risks. Assessment of risk using clinical outcomes in clinical studies is difficult due to their rare occurrence. Therefore, surrogate end points are frequently used in a clinical study in lieu of clinical outcomes. As a clinician integrates multiple aspects of a physiological variable to determine potential risk, a surrogate end point should consider a similar approach. In this study, we identified and tested the appropriateness of a new surrogate end point that may be used in clinical studies, area under the curve of oxygen desaturation (AUCDesat). A review of patient sedation records by anesthesiologists was conducted to assess its relationship to the anesthesia professional perception of risk.
  
  
  METHODS
  This study was a post hoc analysis and assessment of perceived risk by anesthesiologists. It consisted of 13 U.S.-trained board-certified anesthesiologists ranking physiological variables as indicators of risk and then reviewing 204 records from 3 completed sedation studies involving the SEDASYS System. After review, each anesthesiologist assigned a Likert score based on his or her perception of risk for oversedation-related sequelae in each record. These scores were analyzed to determine their relationship to desaturation presence/absence, duration, depth, number of events, and AUCDesat that incorporates each component.
  
  
  RESULTS
  Anesthesiologists ranked arterial oxygenation to be the most important factor in assessing risk post hoc (mean rank of 4.69 of 5, P = 0.0007 compared with next highest ranked factor-respiratory rate, N = 13). AUCDesat was better correlated to the Likert scores (rs = 0.85) when compared with the individual elements of AUCDesat, binary assessment of desaturation (rs = 0.73), desaturation depth (rs = -0.70), desaturation duration (rs = 0.70), and incidence of desaturations (rs = 0.55) (all 4 comparisons versus rs = 0.85, P < 0.0001).
  
  
  CONCLUSIONS
  Anesthesiologists determined arterial oxygenation to be the most important physiological variable in assessing sedation risk and the potential for adverse clinical outcomes. AUCDesat, a composite index that incorporates duration, incidence, and depth of oxygen desaturation, was better correlated to the Likert scores. AUCDesat, given that it is a single numerical variable, is an ideal end point for assessment of risk of adverse clinical outcomes in clinical sedation studies. Future studies using AUCDesat and actual physiological outcomes may be useful in further defining this end point.
authors.affiliation: From Ethicon Endo-Surgery, Inc., Cincinnati, Ohio; Department of Neuroscience, University of Cincinnati, Cincinnati, Ohio; Department of Anesthesiology, University of Cincinnati Medical Center, Cincinnati, Ohio.
authors.forename: Paul J
authors.initials: PJ
authors.lastname: Niklewski
authors.forename: James C
authors.initials: JC
authors.lastname: Phero
authors.forename: James F
authors.initials: JF
authors.lastname: Martin
authors.forename: Steven J
authors.initials: SJ
authors.lastname: Lisco
mesh_terms: D015415:Biomarkers / Q000378:metabolism; D054810:Deep Sedation / Q000009:adverse effects* / Q000379:methods; D006801:Humans; D000860:Hypoxia / Q000139:chemically induced* / Q000175:diagnosis / Q000378:metabolism*; D010101:Oxygen Consumption / Q000187:drug effects / Q000502:physiology*; D010820:Physicians; D011446:Prospective Studies; D011897:Random Allocation; D018570:Risk Assessment; D012307:Risk Factors
chemical_list: D015415:Biomarkers