What factors determine patient tolerance of gastroscopy using conscious sedation? AG Fraser 1, GD Gamble 1, T Rose 2 and the endoscopists of MercyAscot Hospital 2, Department of Medicine 1, University of Auckland, New Zealand.  Logistic regression of the nurses rating of procedure  endoscopist was most significant factor (p<0.0001)  Procedures were rated as poorly tolerated by nurses if  lower midazolam dose 0.84 (0.71;1.00)p = 0.05  procedure time > 7 mins 0.81(0.57,1.10) p = 0.02  Logistic regression of patients rating of procedure  endoscopist was the most significant factor p =  Procedures were poorly tolerated if there was  “lighter” level of consciousness (1 or 2 vs. 3 or 4) 0.56 (0.32, 0.97) p = 0.04  longer procedure time 1.05 (1.02, 1.08) p =  younger age 0.98 (0.97, 0.99) p =0.001  lower midazolam dose 0.64 (0.55, 0.73) p =  Logistic regression for factors predictive of loss of memory for procedure  endoscopist p =  deeper LOC 1.97 (1.56, 3.34)p =  higher midazolam dose0.65 (0.50, 0.75)p =  longer procedure time 1.06 (1.02; 1.09) p =  increasing age 0.98 (0.97, 0.99)p =  female gender 0.66 (0.53, 0.83)p =  All consecutive gastroscopies were audited for a private endoscopy clinic over 2 years.  Conscious sedation was performed with midazolam and fentanyl; procedures with no sedation were included; procedures with propofol were excluded. All patients had xylocaine throat spray.  Data was collected on duration of procedure (mins), midazolam and fentanyl dose (mgs) and time from giving midazolam and fentanyl to start of procedure (mins).  Level of consciousness was graded from 1 – 5 1 = awake; 2 = rouses to voice; 3 = rouses to touch; 4 = rouses to pain; 5 = unrousable.  The nurses rating of procedure was graded from 1 – 4 1 = well tolerated; 2 = mild, brief gagging; 3 = gagged and coughed throughout; 4 = distressed throughout  The patient rating of procedure was graded 1 – 41 = comfortable; 2 = mildly uncomfortable; 3 = moderately uncomfortable; 4 = very uncomfortable.  Patient recollection of the procedure was graded 1 – 3 1 = remembered all; 2 = vague recollection; 3 = no memory.  Logistic regression was performed for patients having conscious sedation only (no sedation excluded)  Gastroscopy has received less attention in the audit process than colonoscopy but can be a poorly tolerated procedure.  This audit was conducted to assess how well gastroscopy was tolerated using conscious sedation and to determine the predictors of poor tolerance.  The time to peak effect for midazolam and fentanyl is 3- 5 mins. It was predicted that a delay between administration of these drugs and time of intubation would increase patient tolerance of the procedure.  Conscious sedation is effective for improving patient tolerance - using no sedation leads to a high proportion with bad experiences (24% of patients report moderate to severe discomfort).  The study confirms the predictable effect of higher doses of midazolam (not fentanyl) and deeper levels of consciousness on better tolerance and higher levels of amnesia.  The effect of midazolam on patient tolerance may be limited in duration.  Young males have poor tolerance to gastroscopy (and less amnesia).  Data was collected on 2735 procedures by 16 endoscopists  128 procedures had no sedation  The nurses rating of procedure  The patients rating of procedure  Patient recollection was good for 23%, vague for 20% and no memory for 56%  Level of consciousness  Midazolam dose (mgs)  Fentanyl dose (μgs)  There was no association between timing of midazolam and fentanyl dosing and patient tolerance  Mean midazolam dose ranged from 2.1mg to 3.7mg for each endoscopist  Nurses rating of tolerance of procedure at 1 or 2 ranged from 89% to 98% for each endoscopist  Patient rating of procedure at 1 or 2 ranged from 85% to 98% METHODS RESULTS CONCLUSION 1234 Sedation80.1%16.0%2.9%0.9% No sedation51.6%22.7%23.4%2.3% 1234 Sedation84.8.%12.7%1.8%0.7% No sedation35.7%40.5%19.8%4.0% 1234/5 31%63%3.4%0.7% < >5 0.5%9%23%38%20.5%8.5%0.5% %35.9%59.8%0.4%0.5%  Tolerance (whether self reported or reported by the nurse) is closely related to specific endoscopist factors, presumably related to technique (possibly related to ease of intubation).  Improving the patient experience involves good safe practice with conscious sedation but some teaching from endoscopists that can achieve high levels of tolerance may also be helpful.  Patient recollection of the procedure is related to midazolam dose and duration of procedure, as would be predicted, but surprisingly is also closely related to the individual endoscopist.