Impact of variations in endoscopy local anaesthesia and sedation practice among providers on aspiration pneumonia risk following percutaneous endoscopic gastrostomy

Objective To examine the association between local anaesthetic throat spray and sedation practice and aspiration pneumonia following percutaneous endoscopic gastrostomy (PEG) insertion. Methods A retrospective cohort study of adults undergoing PEG, identified from Hospital Episode Statistics between January 2016 and December 2021, and their 7-day post-PEG aspiration pneumonia rate at provider level. The National Endoscopy Database provided contemporaneous throat spray and sedation data during PEG at provider level. Logistic regression analysis examined associations with post-PEG aspiration pneumonia. Results 33 357 patients were analysed (59.8% male; age median 67 (IQR 56–77) years). 47% of providers predominantly used Midazolam and opioid, 19% Midazolam only, and 23% local anaesthetic throat spray with or without other sedation. Stroke was the main PEG indication (33%). Compared with stroke, all other indications were inversely associated with aspiration pneumonia. The strongest association with aspiration pneumonia was in providers predominantly using general anaesthetic/propofol (OR 4.83, 95% CI 2.66 to 8.79, p<0.001) and Midazolam and local anaesthetic throat spray (OR 4.52 (2.71–7.53), p<0.001). The association was much weaker with providers predominantly using Midazolam only (1.61 (1.02–2.56), p=0.042) or Midazolam with opioid (1.82 (1.20–2.75), p=0.004). Other associated factors included: fewer PEGs per provider ≤23 per annum (1.19 (1.05–1.36), p=0.009), emergency admission 15% vs 3% (4.29 (3.81–4.83), p<0.001) and increasing age >79 years (1.86 (1.61–2.15), p<0.001). Conclusions The strongest association with aspiration pneumonia was in providers who predominantly used propofol/general anaesthesia and midazolam with local anaesthetic throat spray for PEG insertion.