The HHS Report On Joan River’s Death Following Her Procedural Sedation

This post would have been more relevant two years ago, but I was only able to find the HHS report just recently.

Here is a link to the Health and Human Services report on Joan River’s death from her procedural sedation.

Joan Rivers died in the ICU as a result of cardiac arrest that occurred during her procedural sedation for an upper GI endoscopy. She also underwent nasopharyngoscopy for unclear reasons. And there were deficiencies in her care. And there were some conflicts in the medical record as to what happened.

Her procedural sedation was monitored and directed by an anesthesiologist and Ms. Rivers was monitored with cardio-respiratory monitor, oximeter, capnography, and automated blood pressure cuff monitoring.

In reviewing the HHS report, it appears that there were of instances where the record appeared incomplete or contradictory.

The resources below are all relevant to an understanding her tragic outcome.

The resources below are also relevant to the prevention of cardiac arrest in endoscopy sedation.

Resource (1) is an analysis of cardiac arrest in patients undergoing GI endoscopy. Here are some excerpts:

From a total of 73,029 GI (36,092 males and 36,937 females) endoscopic procedures performed, 20 cardiac arrests were reported [Table 1]. These were the patients who sustained cardiac arrest (irrespective of the outcome) during or after the procedure, irrespective of the length after the procedure. About 28,008 (14,083 males and 13,925 females) procedures received propofol-based sedation, whereas 45,021 (22,009 males and 23,012 females) procedures received non–propofol-based sedation (typically with midazolam, fentanyl, and rarely diphenhydramine). Propofol-based sedation was administered by either a nurse anesthetist or a resident (physician training in anesthesia) under the supervision of an experienced anesthesiologist, whereas non–propofol-based sedation was administered by a registered nurse under the guidance of the endoscopist performing the procedure. Irrespective of the cause of cardiac arrest and death (sedation related, procedure complication related, or unrelated to either of these), patients who received propofol-based sedation had a higher risk of cardiac arrest and death. As displayed in Table 1, the overall incidence of cardiac arrest in patients undergoing GI procedures with PS (6.069 per 10000) was 9.11 times greater when compared with those undergoing GI procedures with NPBS (0.666 per 10000, Chi-square test 12.46, P < 0.001). The odds ratio of patient developing cardiac arrest in PS group was 9.109 (95% CI, 2.67–31.079). The incidence of death was even higher, at 11.25 times greater in PS (4.28 per 10000) compared with that of NPBS (0.444 per 10000) with a P < 0.001 using Chi-square test.

The above is not what I expected and the authors consider various explanations in their article.

Resource (2) comes to the following conclusion [but both articles are using the same data set]:

Background/Aims: The landscape of sedation for gastrointestinal (GI) endoscopic procedures and the nature of the procedures themselves have changed over the last decade. In this study, an attempt is made to analyze the frequency and etiology of all major adverse events associated with GI endoscopy.

Methods: All adverse events extracted from the electronic database and local registry were analyzed. Although the data analysis was retrospective, the adverse events themselves were documented prospectively. These events were evaluated after subdivision into propofol-based anesthesia and intravenous conscious sedation groups.

Results: Cardiorespiratory events, including cardiac arrest, were the most common adverse events during esophagogastroduodenoscopy, while bleeding was more frequent in patients undergoing colonoscopy. Pancreatitis was the most frequent adverse event in patients undergoing endoscopic retrograde cholangiopancreatography. The frequencies of most adverse events were significantly higher in patients anesthetized with propofol. Automatic regression modeling showed that the type of sedation, the American Society of Anesthesiologists physical status classification, and the procedure type were some of the predictors of immediate life-threatening complications.

Conclusions: Clearly, our regression modeling suggests a strong association between the type of sedation as well as various patient factors and the frequency of adverse events. The possible reasons for our results are the changing demographics, the worsening comorbidities of the patient population, and the increasing technical complexity of these procedures. Although extensive use of propofol has increased patient satisfaction and procedure acceptability, its use is also associated with more frequent adverse events.

And the final way to prevent cardiac arrest during endoscopy is to ask “Does This patient Need An Upper GI Endoscopy?”

Joan Rivers had the upper GI endoscopy


(1) Cardiac Arrests in Patients Undergoing Gastrointestinal Endoscopy: A Retrospective Analysis of 73,029 Procedure [PubMed Abstract] [Full Text HTML] [Download Full Text PDF]. Saudi J Gastroenterol. 2015 Nov-Dec;21(6):400-11. doi: 10.4103/1319-3767.164202.

(2) Association between Type of Sedation and the Adverse Events Associated with Gastrointestinal Endoscopy: An Analysis of 5 Years’ Data from a Tertiary Center in the USA [PubMed Abstract] [Full Text HTML] [Full Text PDF]. Clin Endosc. 2016 Apr 29. doi: 10.5946/ce.2016.019. [Epub ahead of print].

(3) Adverse events of upper GI endoscopy [PubMed Citation] [Full Text PDF]. Gastrointest Endosc. 2012 Oct;76(4):707-18. doi: 10.1016/j.gie.2012.03.252.

(4) Sedation and anesthesia in GI endoscopy [PubMed Citation] [Full Text PDF]. . Gastrointest Endosc 2008;68:815-26.

(5) Propofol for adult procedural sedation in a UK emergency department: safety profile in 1008 cases. [PubMed Abstract] [Full Text HTML]. Br J Anaesth. 2013 Oct;111(4):651-5. doi: 10.1093/bja/aet168. Epub 2013 May 9.

(6) Adverse event reporting tool to standardize the reporting and tracking of adverse events during procedural sedation: a consensus document from the World SIVA International Sedation Task Force. [PubMed Abstract] [Full Text HTML]. Br J Anaesth. 2012 Jan;108(1):13-20. doi: 10.1093/bja/aer407.

(7) Diagnostic value of symptoms of oesophagogastric cancers in primary care: a systematic review and meta-analysis [PubMed Abstract] [Full Text HTML] [Full Text PDF]. Br J Gen Pract. 2015 Oct;65(639):e677-91. doi: 10.3399/bjgp15X686941.

(8) Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management Clinical guideline [CG184] Published date: September 2014 Last updated: November 2014

(9) Suspected cancer: recognition and referral NICE guideline [NG12] Published date: June 2015


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