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Conigliaro R, Pigò F, Gottin M, Grande G, Russo S, Cocca S, Marocchi M, Lupo M, Marsico M, Sculli S, Bertani H. Safety of endoscopist-directed nurse-administered sedation in an Italian referral hospital: An audit of 2 years and 19,407 procedures. Dig Liver Dis 2025; 57:630-635. [PMID: 39462711 DOI: 10.1016/j.dld.2024.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Revised: 07/23/2024] [Accepted: 10/03/2024] [Indexed: 10/29/2024]
Abstract
BACKGROUND AND STUDY AIMS Balanced propofol sedation (BPS) administered by adequately trained non-anaesthesiologist personnel has gained popularity in GI endoscopy because of its shorter procedure and recovery time, high patient satisfaction, and low rate of adverse events (AEs), despite being considered controversial. We report data from an audit of endoscopist-directed (ED) nurse-administered sedation in an Italian referral hospital. PATIENTS AND METHODS Consecutive endoscopic procedures performed between 2020 and 2022 were considered. Under the guidance of the endoscopist, the nurse administered midazolam/fentanyl, followed by a progressive top-up dosage of a 10-20 mg bolus of propofol to achieve moderate to deep sedation. The endoscopists and nurses were all certified in our hospital with a continuous and scheduled training from 2006. RESULTS During the study period, a total of 19,407 examinations (7,803 EGDS, 10,439 colonoscopies, 77 PEG, 697 EUS, and 365 ERCP) and 14,415 patients were included. Of these, 29.4 % of patients were classified as ASA I, 66.5 % as ASA II, and 5.1 % as ASA III. Hypotension was recorded in 1,293 (6 %) examinations and bradycardia in 176 (0.9 %) patients. Eleven patients (0.06 %) had minor respiratory adverse events. Two patients (0.01 %) had major AEs requiring orotracheal intubation. CONCLUSIONS ED-BPS is safe in low-risk patients. Major AEs occurred in 0.01 % of procedures.
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Affiliation(s)
- R Conigliaro
- Gastroenterology and Digestive Endoscopy Unit, Azienda Ospedaliero Universitaria Modena, Modena, Italy
| | - F Pigò
- Gastroenterology and Digestive Endoscopy Unit, Azienda Ospedaliero Universitaria Modena, Modena, Italy.
| | - M Gottin
- Gastroenterology Unit Ospedale San Bassiano, Bassano del Grappa, Italy
| | - G Grande
- Gastroenterology and Digestive Endoscopy Unit, Azienda Ospedaliero Universitaria Modena, Modena, Italy
| | - S Russo
- Gastroenterology and Digestive Endoscopy Unit, Azienda Ospedaliero Universitaria Modena, Modena, Italy
| | - S Cocca
- Gastroenterology and Digestive Endoscopy Unit, Azienda Ospedaliero Universitaria Modena, Modena, Italy
| | - M Marocchi
- Gastroenterology and Digestive Endoscopy Unit, Azienda Ospedaliero Universitaria Modena, Modena, Italy
| | - M Lupo
- Gastroenterology and Digestive Endoscopy Unit, Azienda Ospedaliero Universitaria Modena, Modena, Italy
| | - M Marsico
- Gastroenterology and Digestive Endoscopy Unit, Azienda Ospedaliero Universitaria Modena, Modena, Italy
| | - S Sculli
- Anaesthesiology Department, Azienda Ospedaliero Universitaria Modena, Modena, Italy
| | - H Bertani
- Gastroenterology and Digestive Endoscopy Unit, Azienda Ospedaliero Universitaria Modena, Modena, Italy
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Manno M, Bonura GF, Soriani P, Pileggi R, Aragona G, Cennamo V, Colecchia A, Conigliaro R, DI Marco M, Fabbri C, Fuccio L, LA Fortezza RF, Merighi A, Mussetto A, Nervi G, Orsi P, Sassatelli R, Zagari RM, Biancheri P. Anesthesiologist-directed care for elective gastrointestinal endoscopy: results of an Italian multicentric prospective observational study. Minerva Gastroenterol (Torino) 2024; 70:405-412. [PMID: 38842039 DOI: 10.23736/s2724-5985.24.03656-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
BACKGROUND Sedation, ranging from minimal, moderate and deep sedation to general anesthesia, improves patient comfort and procedure quality in gastrointestinal endoscopy (GIE). There are currently no comprehensive recommendations on sedation practice in diagnostic and therapeutic GIE. We aimed to investigate real-life sedation practice in elective GIE. METHODS We performed a multicentric observational study across 14 Endoscopy Units in Italy. We recorded consecutive data on all diagnostic procedures performed with Anesthesiologist-directed care (ADC) and all therapeutic procedures performed with ADC or non-Anesthesiologist sedation (NAS) over a three-month period. RESULTS Dedicated ADC is available five days/week in 28.6% (4/14), four days/week in 21.5% (3/14), three days/week in 35.7% (5/14), two days/week in 7.1% (1/14) and one day/week in 7.1% (1/14) of participating Centers. ADC use for elective diagnostic GIE varied from 15.4% to 75.1% of the total number of procedures performed with ADC among different Centers. ADC use for elective therapeutic GIE varied from 10.8% to 98.9% of the total number of elective therapeutic procedures performed among different Centers. CONCLUSIONS Our study highlights the lack of standardization and consequent great variability in sedation practice for elective GIE, with ADC being potentially overused for diagnostic procedures and underused for complex therapeutic procedures. A collaborative effort involving Endoscopists, Anesthesiologist and Institutions is needed to optimize sedation practice in GIE.
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Affiliation(s)
- Mauro Manno
- Gastroenterology and Digestive Endoscopy Unit, Azienda USL di Modena, Carpi, Modena, Italy -
| | - Giuliano F Bonura
- Gastroenterology and Digestive Endoscopy Unit, Azienda USL di Modena, Carpi, Modena, Italy
| | - Paola Soriani
- Gastroenterology and Digestive Endoscopy Unit, Azienda USL di Modena, Carpi, Modena, Italy
| | - Roberta Pileggi
- Gastroenterology and Digestive Endoscopy Unit, Azienda USL di Modena, Carpi, Modena, Italy
| | - Giovanni Aragona
- Gastroenterology and Hepatology Unit, Civil Hospital, Azienda USL di Piacenza, Piacenza, Italy
| | | | | | - Rita Conigliaro
- Gastroenterology and Digestive Endoscopy Unit, A.O.U. di Modena, Modena, Italy
| | - Marco DI Marco
- Gastroenterology and Digestive Endoscopy Unit, Azienda USL della Romagna, Rimini, Italy
| | - Carlo Fabbri
- Gastroenterology and Digestive Endoscopy Unit, Morgagni-Pierantoni Hospital, Forlì, Italy
| | - Lorenzo Fuccio
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Rosa F LA Fortezza
- Gastrointestinal Unit, Department of Internal Medicine, Hospital of Imola, University of Bologna, Imola, Bologna, Italy
| | - Alberto Merighi
- Gastroenterology and Digestive Endoscopy Unit, A.O.U. di Ferrara, Ferrara, Italy
| | | | - Giorgio Nervi
- Gastroenterology Unit, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Paolo Orsi
- Gastroenterology Unit, Azienda USL di Parma, Parma, Italy
| | - Romano Sassatelli
- Gastroenterology and Digestive Endoscopy Unit, Arcispedale Santa Maria Nuova, Reggio Emilia, Italy
| | - Rocco M Zagari
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
- Esophagus and Stomach Organic Diseases Unit, IRCCS A.O.U. di Bologna, Bologna, Italy
| | - Paolo Biancheri
- Gastroenterology and Digestive Endoscopy Unit, Azienda USL di Modena, Carpi, Modena, Italy
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Sneyd JR. Why sedative hypnotics often fail in development. Curr Opin Anaesthesiol 2024; 37:391-397. [PMID: 38841982 DOI: 10.1097/aco.0000000000001381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
PURPOSE OF REVIEW Drug development to support anaesthesia and sedation has been slow with few candidates emerging from preclinical discovery and limited innovation beyond attempted reformulation of existing compounds. RECENT FINDINGS The market is well supported by low-cost generic products and development compounds have not been shown to improve patient outcomes or possess other distinctive characteristics to justify the cost of development. SUMMARY To make progress in a large-volume, low margin and highly competitive environment requires meaningful advances in relevant basic science. Opportunities exist, but probably require bolder initiatives than further attempts at reformulation or fiddling with the structure of propofol. Extending development ambitions to include nonanaesthesiologist providers challenges professional boundaries but may facilitate cost-effective changes in patterns of care.
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Affiliation(s)
- J Robert Sneyd
- Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth, Plymouth, UK
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Wiemer SJ, Mediratta JK, Triana RR, Card J, Rallis D, Rieck KL, Holmes E, Krishnan DG. What Is the Incidence of Anesthesia-Related Adverse Events in Oral and Maxillofacial Surgery Offices? A Review of 61,237 Sedation Cases From a Large Private Practice Consortium. J Oral Maxillofac Surg 2024; 82:895-901. [PMID: 38750658 DOI: 10.1016/j.joms.2024.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 04/16/2024] [Accepted: 04/17/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND The safety of the anesthesia team model performed in oral and maxillofacial surgery (OMS) offices has been criticized by professional and mainstream media. PURPOSE This study aims to assess the incidence of adverse anesthetic events (AEs) associated with the OMS anesthesia team model and identify risk factors associated with AEs. STUDY DESIGN, SETTING, SAMPLE This was a retrospective cohort study utilizing a patient database from Paradigm Oral Health, Lincoln, Nebraska, a managed service organization (MSO). Subjects included were 14 and older, undergoing open-airway intravenous anesthesia for ambulatory OMS procedures using the OMS anesthesia team model at multiple private practices in the MSO network between June 30, 2010, and September 30, 2022. Exclusion criteria included patients younger than 14 or patients with incomplete medical records. PREDICTOR VARIABLE Primary predictor variables were age, sex, American Society of Anesthesiologists physical status classification system (ASA) score, type of surgical procedure performed, and the types of medications administered during sedation. MAIN OUTCOME VARIABLE(S) The presence of an AE. The definition of an AE was modeled on the World Society of Intravenous Anesthesia definition. All AEs were identified through surrogate markers, which were identified through chart review. One example of an AE is ventricular fibrillation, which necessitates the application of medications; here the medication is the surrogate marker. COVARIATES None. ANALYSES The data were analyzed using t-tests and χ2 tests. P values ≤ .05 were considered statistically significant. RESULTS Included in the study were 61,237 sedation cases (53.87% female and 46.13% male), for 56,076 unique patients ranging from 14 to 98 years of age (mean 33.26 ± 18.35). An AE incidence of 3 per 100,000 per year (25 total events) was observed. Neither age, sex, ASA score, nor type of surgical procedure exhibited statistically significant associations with AEs. A statistically significant association was found between AEs and fentanyl (P = .0008). CONCLUSION AND RELEVANCE This investigation shows a smaller incidence of AEs than previous studies of the OMS anesthesia team model.
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Affiliation(s)
- Steven J Wiemer
- Oral and Maxillofacial Surgeon, Nebraska Oral & Facial Surgery, Lincoln and Columbus, NE; Oral and Maxillofacial Surgeon, Paradigm Oral Health, Lincoln, NE
| | - Jai Kumar Mediratta
- Resident, Mayo Clinic College of Medicine and Science, Division of Oral & Maxillofacial Surgery, Department of Surgery, Rochester, MN
| | - Reese R Triana
- MBA Student, Boston University, Questrom School of Business, Boston, MA
| | - James Card
- Vice President of Business Intelligence, Paradigm Oral Health, Lincoln, NE
| | - David Rallis
- Oral and Maxillofacial Surgeon, Nebraska Oral & Facial Surgery, Lincoln and Columbus, NE; Oral and Maxillofacial Surgeon, Paradigm Oral Health, Lincoln, NE
| | - Kevin L Rieck
- Oral and Maxillofacial Surgeon, Nebraska Oral & Facial Surgery, Lincoln and Columbus, NE; Oral and Maxillofacial Surgeon, Paradigm Oral Health, Lincoln, NE
| | - Eric Holmes
- Clinical Research Coordinator, Division of Oral and Maxillofacial Surgery, Department of Surgery, University of Cincinnati, Cincinnati, OH
| | - Deepak G Krishnan
- Professor of Surgery, Section Chief, Division of Oral and Maxillofacial Surgery, Department of Surgery, University of Cincinnati, Cincinnati, OH.
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Wang Z, Ma J, Liu X, Gao J. Development and validation of a predictive model for PACU hypotension in elderly patients undergoing sedated gastrointestinal endoscopy. Aging Clin Exp Res 2024; 36:149. [PMID: 39023685 PMCID: PMC11258065 DOI: 10.1007/s40520-024-02807-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 07/05/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND Hypotension, characterized by abnormally low blood pressure, is a frequently observed adverse event in sedated gastrointestinal endoscopy procedures. Although the examination time is typically short, hypotension during and after gastroscopy procedures is frequently overlooked or remains undetected. This study aimed to construct a risk nomogram for post-anesthesia care unit (PACU) hypotension in elderly patients undergoing sedated gastrointestinal endoscopy. METHODS This study involved 2919 elderly patients who underwent sedated gastrointestinal endoscopy. A preoperative questionnaire was used to collect data on patient characteristics; intraoperative medication use and adverse events were also recorded. The primary objective of the study was to evaluate the risk of PACU hypotension in these patients. To achieve this, the least absolute shrinkage and selection operator (LASSO) regression analysis method was used to optimize variable selection, involving cyclic coordinate descent with tenfold cross-validation. Subsequently, multivariable logistic regression analysis was applied to build a predictive model using the selected predictors from the LASSO regression. A nomogram was visually developed based on these variables. To validate the model, a calibration plot, receiver operating characteristic (ROC) curve, and decision curve analysis (DCA) were used. Additionally, external validation was conducted to further assess the model's performance. RESULTS The LASSO regression analysis identified predictors associated with an increased risk of adverse events during surgery: age, duration of preoperative water abstinence, intraoperative mean arterial pressure (MAP) <65 mmHg, decreased systolic blood pressure (SBP), and use of norepinephrine (NE). The constructed model based on these predictors demonstrated moderate predictive ability, with an area under the ROC curve of 0.710 in the training set and 0.778 in the validation set. The DCA indicated that the nomogram had clinical applicability when the risk threshold ranged between 20 and 82%, which was subsequently confirmed in the external validation with a range of 18-92%. CONCLUSION Incorporating factors such as age, duration of preoperative water abstinence, intraoperative MAP <65 mmHg, decreased SBP, and use of NE in the risk nomogram increased its usefulness for predicting PACU hypotension risk in elderly patient undergoing sedated gastrointestinal endoscopy.
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Affiliation(s)
- Zi Wang
- Department of Anesthesiology, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Jiangsu, Yangzhou, 225001, China
- Yangzhou University, Jiangsu, Yangzhou, 225001, China
| | - Juan Ma
- Department of Anesthesiology, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Jiangsu, Yangzhou, 225001, China
- Yangzhou University, Jiangsu, Yangzhou, 225001, China
| | - Xin Liu
- Department of Anesthesiology, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Jiangsu, Yangzhou, 225001, China
| | - Ju Gao
- Department of Anesthesiology, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Jiangsu, Yangzhou, 225001, China.
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Meeusen V, Barach P, van Zundert A. Designing safe procedural sedation: adopting a resilient culture. HANDBOOK OF PERIOPERATIVE AND PROCEDURAL PATIENT SAFETY 2024:115-163. [DOI: 10.1016/b978-0-323-66179-9.00012-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
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Xie P, Wu Z, Zha B, Xu L, Shen S, Zhuang H, Wei H. Risk factors for pharyngalgia and xerostomia undergoing supraglottic jet oxygenation and ventilation in gastrointestinal endoscopy: a retrospective study. Sci Rep 2023; 13:21949. [PMID: 38081892 PMCID: PMC10713572 DOI: 10.1038/s41598-023-49473-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 12/08/2023] [Indexed: 12/18/2023] Open
Abstract
Supraglottic jet oxygenation/ventilation (SJOV) can reduce hypoxemia in sedated endoscopy but may increase minor side effects like pharyngalgia and xerostomia. This study aimed to identify risk factors for pharyngalgia/xerostomia with SJOV during gastrointestinal endoscopy. From January 1 to December 31, 2021, 5313 patients with propofol sedation and SJOV underwent gastrointestinal endoscopy or removal of gastrointestinal polyps was analyzed retrospectively. Data included patient characteristics, operation details, postoperative adverse events, and potential risk factors for postoperative adverse events. Parameters considered as potential risk factors were identified based on study results published previously and based on the researcher's idea and clinical experience. The patient factors and the incidence of pharyngalgia/xerostomia at 30 min post-procedure were assessed. Descriptive statistics were calculated using SPSS software. Evaluation potential risk factors using univariate and multivariate logistic regression. Pharyngalgia/xerostomia occurred in 18.7% of patients at 30 min after procedure. A multivariable analysis showed that procedure time and pharyngalgia/xerostomia within 2 weeks were independent risk factors. Procedure time had the strongest association with postoperative pharyngalgia/xerostomia (OR, 8.09 [95% CI, 4.197-6.312]). No factors were significantly associated with hypoxemia risk (1.7% incidence). There were no barotrauma or other serious morbidity or mortality. Procedure duration and recent pharyngalgia/xerostomia increased risk of pharyngalgia/xerostomia with SJOV during endoscopy. Limiting SJOV duration may reduce side effects in susceptible patients. No predictors of hypoxemia were identified.
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Affiliation(s)
- Ping Xie
- Department of Anesthesiology, 910th Hospital of PLA, Quanzhou, 362000, China
| | - Zhiyun Wu
- Department of Anesthesiology, 910th Hospital of PLA, Quanzhou, 362000, China
| | - Benjun Zha
- Department of Anesthesiology, 910th Hospital of PLA, Quanzhou, 362000, China.
| | - Li Xu
- Department of Anesthesiology, 910th Hospital of PLA, Quanzhou, 362000, China
| | - Shanyi Shen
- Department of Anesthesiology, 910th Hospital of PLA, Quanzhou, 362000, China
| | - Haibin Zhuang
- Department of Anesthesiology, 910th Hospital of PLA, Quanzhou, 362000, China
| | - Huafeng Wei
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
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Behrens A, Ell C. Safety of endoscopist-guided sedation in a low-risk collective. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:1593-1602. [PMID: 36630976 DOI: 10.1055/a-1957-7788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Worldwide, gastrointestinal endoscopies are predominantly performed under sedation. National and international guidelines and recommendations contain very different specifications for the use of sedation in gastrointestinal endoscopy. These differences come from specific requirements for staffing during endoscopy. AIM The aim of the study is to evaluate whether endoscopist-guided sedation without additional sedation assistance is not inferior to endoscopist-guided sedation with additional sedation assistance with respect to the rate of sedation-associated complications in a defined low-risk population (low-risk procedure and low-risk patient). METHODS Prospective, multicenter, randomized study. RESULTS 27 German study centers participated in the study. A total of 30 569 endoscopies were recorded during the study period from 1.8.2015 to 10.3.2020. The final data analysis included 28 673 examinations (64.1 % esophagosgastroduodenoscopies and 35.9 % colonoscopies). In 307 (1.1 %) examinations, 322 sedation-associated complications occurred. Of these, 321 (1.1 %) were minor complications and one (0.003 %) was a major complication. There was no statistically significant difference in the frequency of sedation-associated complications between endoscopist-guided sedation with versus without additional sedation assistance. Within the legal framework, a "shadow" sedation assistant was present in the study group without sedation assistance. This assistant intervened because of sedation-associated complications in 101 (0.7 %) of the endoscopies. CONCLUSION The study documents the safety of propofol-based endoscopist-guided sedation in a low-risk population. In 98.9 % of all endoscopies, no sedation-associated complication occurred or it was so minimal that no intervention (e. g., increase of oxygen supply) was necessary. The study cannot answer to what extent a serious complication was avoided by the active intervention of the "shadow" sedation assistance in the group without sedation assistance.The study proves in a randomized, prospective design that sedation in low-risk endoscopy (low-risk patient, low-risk procedure) can be performed as endoscopist-guided sedation without additional sedation assistance, without demonstrably accepting a reduction in safety.
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Affiliation(s)
- Angelika Behrens
- Klinik für Innere Medizin mit den Schwerpunkten Gastroenterologie und Pneumologie, Evangelische Elisabeth Klinik Krankenhausbetriebs gGmbH, Berlin, Germany
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A comparative study on the efficacy and safety of propofol combined with different doses of alfentanil in gastroscopy: a randomized controlled trial. J Anesth 2022; 37:201-209. [PMID: 36482231 DOI: 10.1007/s00540-022-03145-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 11/22/2022] [Indexed: 12/13/2022]
Abstract
PURPOSE Propofol can be used alone or in combination with opioids during gastroscopy. This study aimed to assess the efficacy and safety of intravenous propofol and different doses of alfentanil in patients undergoing gastroscopy. METHODS A total of 300 patients undergoing sedative gastroscopy were randomly divided into four groups, and 0.9% saline (group A), 2 μg/kg alfentanil (group B), 3 μg/kg alfentanil (group C) or 4 μg/kg alfentanil (group D) were injected intravenously 1 min before the intravenous injection of 1.5 mg/kg propofol. If body movement and coughing occurred during the procedure, 0.5 mg/kg propofol would be administered intravenously. The primary outcome (awakening time) and secondary outcomes were recorded and analyzed, including hemodynamic changes, the incidences of body movement, coughing, hypoxemia, hypotension, hypertension, bradycardia, tachycardia, nausea and vomiting, drowsiness and dizziness. RESULTS Patients in group C (7.0 [5.0 to 8.0] min) and group D (6.0 [5.0 to 7.0] min) woke up significantly earlier than those in group A (8.0 [6.0 to 10.0] min) (P < 0.001). Patients in group A experienced more body movement (P = 0.001) and coughing (P < 0.001) than the other groups. With the increasing dose of alfentanil, the morbidity of hypotension and bradycardia increased significantly (P = 0.001), while the incidence of dizziness decreased significantly (P = 0.037). The incidences of hypoxemia, tachycardia, drowsiness, nausea and vomiting were similar among the four groups (P > 0.05). CONCLUSIONS Intravenous 1.5 mg/kg propofol combined with 3 μg/kg alfentanil is more suitable for patients undergoing gastroscopy, and the dose of alfentanil can be reduced according to the patient's actual physical condition.
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Park SY, Lee JK, Park CH, Kim BW, Lee CK, Park HJ, Jang BI, Kim DU, Park JM, Lee JM, Cho YS, Chon HK, Seo SY, Paik WH, the Committees of Quality Management and Conscious Sedation of Korean Society of Gastrointestinal Endoscopy (KSGE). Endoscopist-Driven Sedation Practices in South Korea: Re-evaluation Considering the Nationwide Survey in 2019. Gut Liver 2022; 16:899-906. [PMID: 35912649 PMCID: PMC9668492 DOI: 10.5009/gnl210466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 01/17/2022] [Accepted: 02/10/2022] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND/AIMS This study aimed to determine changes in endoscopist-driven sedation practices 5 years after the first nationwide survey in 2014 by the Korean Society of Gastrointestinal Endoscopy (KSGE). METHODS A 59-item survey covering current practices was electronically mailed to all members of the KSGE in 2019. RESULTS In total, 955 (12.8%) out of 7,486 questionnaires were returned. A total of 738 (77.7%) out of 955 respondents attended dedicated sedation education programs. The American Society of Anesthesiologists class was recorded by 464 (51.2%) out of 907 respondents. The recording rate was higher in respondents who completed sedation education (p=0.014) and worked in general or tertiary hospitals (p<0.001). Compared to that reported in the previous survey, the reported use of propofol was higher in 2019. The respondents had higher satisfaction scores for propofol-based sedation compared with midazolam monotherapy (p<0.001). The rates of oxygen supplementation (p<0.001) and oxygen saturation level monitoring (p<0.001) during sedative endoscopy were higher in 2019 than in the previous survey. A total of 876 (98.4%) out of 890 respondents reported a separate recovery bay, and 615 (70.5%) out of 872 respondents reported that personnel were assigned solely to the recovery bay. CONCLUSIONS Endoscopist-driven sedation and monitoring practices in 2019 were significantly different than those in 2014. The respondents favored propofol-based sedation and utilized oxygen supplementation and monitoring of O2 saturation more frequently in 2019 than in 2014.
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Affiliation(s)
- Seon-Young Park
- Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Jun Kyu Lee
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Chang-Hwan Park
- Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Byung-Wook Kim
- Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
| | - Chang Kyun Lee
- Department of Internal Medicine, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Hong Jun Park
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Byung Ik Jang
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Dong Uk Kim
- Department of Internal Medicine, Biomedical Research Institute, Pusan National University School of Medicine, Pusan, Korea
| | - Jin Myung Park
- Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Jae Min Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Young Sin Cho
- Division of Gastroenterology, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Hyung Ku Chon
- Institute of Wonkwang Medical Science, Wonkwang University Hospital, Wonkwang University College of Medicine, Iksan, Korea
| | - Seung Young Seo
- Department of Internal Medicine, Jeonbuk National University Hospital, Jeonbuk National University Medical School, Jeonju, Korea
| | - Woo Hyun Paik
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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Sui Y, Chen X, Ma T, Lu J, Xiao T, Wang Z, Wen Q, Wang G, Jia H, Cao F, Wu X, Zhang Y, Hao J, Wang N. Comparison of three sedation models for same-day painless bidirectional endoscopy: A multicenter randomized controlled trial. J Gastroenterol Hepatol 2022; 37:1603-1609. [PMID: 35618650 PMCID: PMC9543240 DOI: 10.1111/jgh.15901] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 05/12/2022] [Accepted: 05/24/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM We investigated the most beneficial propofol sedation model for same-day painless bidirectional endoscopy (BDE). METHODS Asymptomatic participants scheduled for same-day painless BDE examination from October 2020 to September 2021 were randomized to three groups: sedated esophagogastroduodenoscopy followed by unsedated colonoscopy (Group A); sedated esophagogastroduodenoscopy followed by sedated colonoscopy (Group B); and sedated esophagogastroduodenoscopy followed by sedated insertion colonoscopy (Group C). Patient discomfort, colonoscopy performance, doses of propofol, cardiovascular stress, anesthesia resuscitation, and sedation-related adverse events were evaluated. RESULTS A total of 3200 participants were analyzed. Baseline demographics, patient discomfort, cecal intubation rate, adenoma detection rate and sedation-related adverse events were similar in the three groups. Propofol dose was the lowest in Group A (137.65 ± 36.865 mg) compared with Group B (177.71 ± 40.112 mg, P < 0.05) and Group C (161.63 ± 31.789 mg, P < 0.05). Decline in vital signs was most obvious in Group B during the procedure (P < 0.05). Recovery time was the shortest in Group A (5.01 ± 1.404 min) compared with Group B (9.51 ± 2.870 min, P < 0.05) and Group C (5.83 ± 2.594 min, P < 0.05); discharge time was the shortest in Group A (3.53 ± 1.685 min) compared with Group B (11.29 ± 5.172 min, P < 0.05) and Group C (6.47 ± 2.338 min, P < 0.05). Adenomas per positive patient of Group A (2.29 ± 1.055) and Group C (2.28 ± 0.931) were more than that in Group B (2.11 ± 0.946, P < 0.05). CONCLUSIONS Sedated esophagogastroduodenoscopy followed by unsedated colonoscopy is the superior model for same-day painless BDE with the benefits of satisfactory patient comfort, reduced sedation dose, less cardiovascular stress, faster recovery, shorter discharge time and high colonoscopy quality.
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Affiliation(s)
- Yue Sui
- Shanxi Medical UniversityTaiyuanChina
| | - Xing Chen
- Shanxi Medical UniversityTaiyuanChina,The First Hospital of Shanxi Medical UniversityTaiyuanChina
| | - Ting Ma
- Shanxi Medical UniversityTaiyuanChina
| | - Junhui Lu
- Shanxi Medical UniversityTaiyuanChina
| | - Tao Xiao
- Shanxi Cancer HospitalTaiyuanChina
| | | | - Qing Wen
- The Second People's Hospital of DatongDatongChina
| | | | - Hui Jia
- Erdos Kangning Physical Examination CenterErdosChina
| | - Fengzhen Cao
- Erdos Kangning Physical Examination CenterErdosChina
| | - Xiaopeng Wu
- Lvliang Traditional Chinese Medicine HospitalLvliangChina
| | - Yiping Zhang
- Datong Shoujia Digestive Disease HospitalDatongChina
| | - Junlian Hao
- Xiaoyi Traditional Chinese Medicine HospitalXiaoyiChina
| | - Naping Wang
- The First Hospital of Shanxi Medical UniversityYunchengChina
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Fatima H, Imperiale T. Safety Profile of Endoscopist-directed Balanced Propofol Sedation for Procedural Sedation: An Experience at a Hospital-based Endoscopy Unit. J Clin Gastroenterol 2022; 56:e209-e215. [PMID: 34739402 DOI: 10.1097/mcg.0000000000001630] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 09/27/2021] [Indexed: 12/10/2022]
Abstract
BACKGROUND Nurse-administered propofol sedation was restricted to anesthesiologists in 2009, a practice that has contributed to spiraling health care costs in the United States. AIM The aim of this study was to evaluate the safety of endoscopist-directed balanced propofol sedation (EDBPS). MATERIALS AND METHODS We identified patients undergoing endoscopy with EDBPS from January 1, 2017, to June 20, 2017, and abstracted their medical records. Adverse events (AEs) included: hypoxia (oxygen saturation < 90%); hypotension [(a) systolic blood pressure < 90 mm Hg, (b) systolic blood pressure decline of >50 mm Hg, (c) decline in mean arterial pressure of >30%]; bradycardia (heart rate of < 40 beats/min). Logistic regression identified factors independently associated with AEs. RESULTS A total of 1897 patients received EDBPS during the study period [mean age: 55 y (SD=11.4 y); 56.4% women]. Patients received median doses of 50 µg fentanyl, 2 mg of midazolam, and a mean propofol dose of 160±99 mg. There were no major complications (upper 95% confidence interval, 0.19%). Overall, 334 patients (17.6%) experienced a clinically insignificant AE: 65 (3.4%) experienced transient hypoxia, 277 patients (14.6%) experienced hypotension, 2 had transient bradycardia. In bivariate analysis, older age was associated with risk for hypotension, propofol dose was associated with transient hypoxemia, and procedure duration was associated with both hypotension and transient hypoxia. In multivariate analysis, only procedure length was associated with AEs (odds ratio scale 10; odds ratio=1.07; 95% confidence interval, 1.05-1.09, P<0.001). CONCLUSIONS EDBPS is safe for endoscopic sedation. Given the higher cost of anesthesia-administered propofol, endoscopists should reinstate EDBPS by revising institutional sedation policies.
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Affiliation(s)
- Hala Fatima
- Division of Gastroenterology/Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN
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Medina-Prado L, Martínez J, Bozhychko M, Mangas-Sanjuan C, Compañy Català L, Ruiz Gómez F, Aparicio Tormo JR, Casellas Valde JA. Safety of endoscopist-administered deep sedation with propofol in patients ASA III. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2021; 114:468-473. [PMID: 34894711 DOI: 10.17235/reed.2021.8289/2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Deep sedation controlled by the endoscopist is safe in patients with low anesthetic risk (ASA I-II). However, scarce evidence is available in patients with intermediate risk (ASA III). OBJETIVE To evaluate the safety of deep sedation with propofol controlled by the usual endoscopy staff (endoscopist, nurse, assistant) in outpatients classified as ASA III and the risk factors for the occurrence of complications during deep sedation in these patients. DESIGN This observational and single-centre cross-sectional study includes consecutive patients undergoing non-complex procedures in which deep sedation is administered by the endoscopy staff. Patients were divided into group I (ASA=III) and group II (ASA<III). RESULTS A total of 562 patients were included, 80 (14.2%) group I. Complications related to deep sedation were more frequent in group I (23.8% vs 14.5%; p=0.036), mainly mild desaturations (13.8% vs 7.5%; p=0.058). Emergency intervention or exitus were not registered. The adjusted analysis identified age as the one independent baseline risk factor for developing global adverse events. CONCLUSION ASA III patients developed more sedation-related complications that ASA I-II patients. However these complications were mild and do not prevent to correctly perform the procedure.
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Affiliation(s)
- Lucía Medina-Prado
- Endoscopia Digestiva, Hospital General Universitario de Alicante , España
| | - Juan Martínez
- Endoscopia Digestiva, Hospital General Universitario de Alicante , España
| | - Maryana Bozhychko
- Endoscopia Digestiva, Hospital General Universitario de Alicante , España
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Sneyd JR. What we do, what we call ourselves, and how we spell it. Br J Anaesth 2021; 127:505-508. [PMID: 34548151 DOI: 10.1016/j.bja.2021.04.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 04/26/2021] [Accepted: 04/26/2021] [Indexed: 11/16/2022] Open
Affiliation(s)
- J Robert Sneyd
- Faculty of Medicine and Dentistry, University of Plymouth, Plymouth, UK.
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15
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Current status of perioperative hypnotics, role of benzodiazepines, and the case for remimazolam: a narrative review. Br J Anaesth 2021; 127:41-55. [PMID: 33965206 DOI: 10.1016/j.bja.2021.03.028] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 02/22/2021] [Accepted: 03/10/2021] [Indexed: 12/19/2022] Open
Abstract
Anaesthesiologists and non-anaesthesiologist sedationists have a limited set of available i.v. hypnotics, further reduced by the withdrawal of thiopental in the USA and its near disappearance in Europe. Meanwhile, demand for sedation increases and new clinical groups are using what traditionally are anaesthesiologists' drugs. Improved understanding of the determinants of perioperative morbidity and mortality has spotlighted hypotension as a potent cause of patient harm, and practice must be adjusted to respect this. High-dose propofol sedation may be harmful, and a critical reappraisal of drug choices and doses is needed. The development of remimazolam, initially for procedural sedation, allows reconsideration of benzodiazepines as the hypnotic component of a general anaesthetic even if their characterisation as i.v. anaesthetics is questionable. Early data suggest that a combination of remimazolam and remifentanil can induce and maintain anaesthesia. Further work is needed to define use cases for this technique and to determine the impact on patient outcomes.
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Lin OS, La Selva D, Kozarek RA, Weigel W, Beecher R, Gluck M, Chiorean M, Boden E, Venu N, Krishnamoorthi R, Larsen M, Ross A. Nurse-Administered Propofol Continuous Infusion Sedation: A New Paradigm for Gastrointestinal Procedural Sedation. Am J Gastroenterol 2021; 116:710-716. [PMID: 33982940 DOI: 10.14309/ajg.0000000000000969] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 08/21/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Nurse-Administered Propofol Continuous Infusion Sedation (NAPCIS) is a new nonanesthesia propofol delivery method for gastrointestinal endoscopy. NAPCIS is adopted from the computer-assisted propofol sedation (CAPS) protocol. We evaluated the effectiveness, efficiency, and safety of NAPCIS in low-risk subjects. METHODS Between December 2016 and July 2017, patients who underwent esophagogastroduodenoscopy or colonoscopy with NAPCIS at our center were compared against 2 historical control groups of similar patients who had undergone procedures with CAPS or midazolam and fentanyl (MF) sedation. RESULTS The mean age of the NAPCIS cohort (N = 3,331) was 55.2 years (45.8% male) for 945 esophagogastroduodenoscopies and 57.8 years (48.7% male) for 2,386 colonoscopies. The procedural success rates with NAPCIS were high (99.1%-99.2%) and similar to those seen in 3,603 CAPS (98.8%-99.0%) and 3,809 MF (99.0%-99.3%) controls. NAPCIS recovery times were shorter than both CAPS and MF (24.8 vs 31.7 and 52.4 minutes, respectively; P < 0.001). On arrival at the recovery unit, 86.6% of NAPCIS subjects were recorded as "Awake" compared with 82.8% of CAPS and 40.8% of MF controls (P < 0.001). Validated clinician and patient satisfaction scores were generally higher for NAPCIS compared with CAPS and MF subjects. For NAPCIS, there were only 4 cases of oxygen desaturation requiring transient mask ventilation and no serious sedation-related complications. These low complication rates were similar to those seen with CAPS (8 cases of mask ventilation) and MF (3 cases). DISCUSSION NAPCIS seems to be a safe, effective, and efficient means of providing moderate sedation for upper endoscopy and colonoscopy in low-risk patients.
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Affiliation(s)
- Otto S Lin
- 1Digestive Disease Institute, Virginia Mason Medical Center, Seattle; 2Department of Anesthesia, Virginia Mason Medical Center, Seattle
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Tonner PH. [The Guideline "Sedation for Gastrointestinal Endoscopy"]. Anasthesiol Intensivmed Notfallmed Schmerzther 2021; 56:201-209. [PMID: 33725740 DOI: 10.1055/a-1017-9138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The guideline "Sedation for gastrointestinal endoscopy" (AWMF-register-no. 021/014) was published initially in 2008. Because of new and developing evidence, the guideline was updated in 2015. The aim of the guideline is to define the necessary structural, equipment and personnel requirements that contribute to minimizing the risk of sedation for endoscopy. In view of the high and increasing significance of gastrointestinal endoscopy, the guideline will remain highly relevant in the future. Essential aspects are the selection of sedatives/hypnotics, structural requirements, personnel requirements with regard to number, availability and training, management of complications and quality assurance. In this article, the development and evaluation of the evidence and its influence on the practical implementation, in particular for anaesthesia, are highlighted.
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Zhou S, Zhu Z, Dai W, Qi S, Tian W, Zhang Y, Zhang X, Huang L, Tian J, Yu W, Su D. National survey on sedation for gastrointestinal endoscopy in 2758 Chinese hospitals. Br J Anaesth 2021; 127:56-64. [PMID: 33685636 DOI: 10.1016/j.bja.2021.01.028] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 01/20/2021] [Accepted: 01/25/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Although sedation during gastrointestinal endoscopy is widely used in China, the characteristics of sedation use, including regional distribution, personnel composition, equipment used, and drug selection, remain unclear. The present study aimed to provide insights into the current practice and regional distribution of sedation for gastrointestinal endoscopy in China. METHODS A questionnaire consisting of 19 items was distributed to directors of anaesthesiology departments and anaesthesiologists in charge of endoscopic sedation units in mainland China through WeChat. RESULTS The results from 2758 participating hospitals (36.7% of the total) showed that 9 808 182 gastroscopies (69.3%) and 4 353 950 colonoscopies (30.7%), with a gastroscopy-to-colonoscopy ratio of 2.3, were conducted from January to December 2016. Sedation was used with 4 696 648 gastroscopies (47.9%) and 2 148 316 colonoscopies (49.3%), for a ratio of 2.2. The most commonly used sedative was propofol (61.0% for gastroscopies and 60.4% for colonoscopies). Haemoglobin oxygen saturation (SpO2) was monitored in most patients (96.1%). Supplemental oxygen was routinely administered, but the availability of other equipment was variable (anaesthesia machine in 64.9%, physiological monitor in 84.4%, suction device in 72.3%, airway equipment in 75.5%, defibrillator in 32.7%, emergency kit in 57.0%, and difficult airway kit in 20.8% of centres responding). CONCLUSIONS The sedation rate for gastrointestinal endoscopy is much lower in China than in the USA and in Europe. The most commonly used combination of sedatives was propofol plus an opioid (either fentanyl or sufentanil). Emergency support devices, such as difficult airway devices and defibrillators, were not usually available.
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Affiliation(s)
- Shujing Zhou
- Department of Anaesthesiology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ziyu Zhu
- Department of Anaesthesiology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Wanbing Dai
- Department of Anaesthesiology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Siyi Qi
- Department of Anaesthesiology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Weitian Tian
- Department of Anaesthesiology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yizhe Zhang
- Department of Anaesthesiology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xiao Zhang
- Department of Anaesthesiology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Lili Huang
- Department of Anaesthesiology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jie Tian
- Department of Anaesthesiology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Weifeng Yu
- Department of Anaesthesiology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.
| | - Diansan Su
- Department of Anaesthesiology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.
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Gururatsakul M, Lee R, Ponnuswamy SK, Gilhotra R, McGowan C, Whittaker D, Ombiga J, Boyd P. Prospective audit of the safety of endoscopist-directed nurse-administered propofol sedation in an Australian referral hospital. J Gastroenterol Hepatol 2021; 36:490-497. [PMID: 33448489 DOI: 10.1111/jgh.15204] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/29/2020] [Accepted: 07/21/2020] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Endoscopist directed nurse administered propofol sedation (EDNAPS) is widely considered to be safe and efficient, but there are limited data from the Australian health-care setting, and Australian sedation guidelines do not support the practice. Thus, we report data from a prospective audit of EDNAPS over a 6.5-year period in an Australian referral hospital. METHODS Consecutive endoscopic procedures performed between January 2013 and June 2019. Sedation protocol was an initial dose of midazolam 1-3 mg intravenously (i.v.) and propofol 10-50 mg i.v.. Further aliquots of propofol 10-30 mg i.v. were given as required. ProvationMD® endoscopic reporting system was used to prospectively record patient demographics, medication and dose, American Society of Anesthesiologist's (ASA) class, and sedation-related complications. RESULTS During the 78-month period, 28 051 eligible procedures were performed; 3093 procedures performed with anesthetic support or without EDNAPS were excluded. In total, 24 958 procedures with EDNAPS were analyzed including 7563 gastroscopies, 12 941 colonoscopies, 2932 gastroscopy and colonoscopy, 1440 flexible sigmoidoscopies, and 82 combined gastroscopy and flexible sigmoidoscopy. Of these, 9539 were ASA 1 (38.2%), 13 680 were ASA 2 (54.8%), 1733 were ASA 3 (6.9%), and 4 were ASA 4 (0.02%). Sedation-related complications occurred in 66 patients (0.26%), predominantly transient hypoxic episodes. No patient required intubation for an airway emergency, and there was no sedation-related mortality. Sedation-related complications increased with ASA class and were significantly more common with gastroscopy. CONCLUSIONS Endoscopist directed nurse administered propofol sedation is a safe way of performing endoscopic sedation in low-risk patients in the hospital setting.
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Affiliation(s)
- Montri Gururatsakul
- Department of Gastroenterology and Hepatology, Cairns Hospital, Cairns, Queensland, Australia
| | - Richard Lee
- Department of Gastroenterology and Hepatology, Cairns Hospital, Cairns, Queensland, Australia
| | | | - Rajit Gilhotra
- Department of Gastroenterology and Hepatology, Cairns Hospital, Cairns, Queensland, Australia
| | - Cathal McGowan
- Department of Gastroenterology and Hepatology, Cairns Hospital, Cairns, Queensland, Australia
| | - Debra Whittaker
- Department of Gastroenterology and Hepatology, Cairns Hospital, Cairns, Queensland, Australia
| | - John Ombiga
- Department of Gastroenterology and Hepatology, Cairns Hospital, Cairns, Queensland, Australia
| | - Peter Boyd
- Department of Gastroenterology and Hepatology, Cairns Hospital, Cairns, Queensland, Australia
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20
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Schoonjans C, Tate DJ. Endoscopist-administered propofol sedation during colonoscopy: Time to take over the syringe? Gastrointest Endosc 2021; 93:209-211. [PMID: 33353617 DOI: 10.1016/j.gie.2020.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 07/07/2020] [Indexed: 02/08/2023]
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Wiemer SJ, Nathan JM, Heggestad BT, Fillmore WJ, Viozzi CF, Van Ess JM, Arce K, Ettinger KS. Safety of Outpatient Procedural Sedation Administered by Oral and Maxillofacial Surgeons: The Mayo Clinic Experience in 17,634 Sedations (2004 to 2019). J Oral Maxillofac Surg 2020; 79:990-999. [PMID: 33382992 DOI: 10.1016/j.joms.2020.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 12/01/2020] [Accepted: 12/01/2020] [Indexed: 01/13/2023]
Abstract
PURPOSE The safety of the team anesthesia model routinely used by the specialty of oral and maxillofacial surgery has recently been called into question. The purpose of this article is to measure the frequency of adverse anesthetic events related to ambulatory surgical procedures performed under intravenous (IV) sedation by the Division of Oral and Maxillofacial Surgery at the Mayo Clinic during a 15-year period using the team anesthesia model. MATERIALS AND METHODS A retrospective cohort study was designed, and a sample of subjects identified undergoing IV sedation at Mayo Clinic from 2004 to 2019. The primary outcome variable of interest was the presence of anesthetic-related adverse events (AEs) consistent with the World Society of Intravenous Anesthesia International Sedation Task Force's intervention-based definitions of adverse anesthetic events. Additional covariates included patient age, gender, American Society of Anesthesiologists (ASA) score, type of surgical procedure performed, and the type/dosage of medications administered periprocedurally. Univariate logistic regression analysis was used to assess for associations between AEs and covariates. RESULTS The study identified 17,634 sedations administered to 16,609 unique subjects. In 17,634 sedations, 16 (0.1%) AEs and no subject deaths (0%) were identified. There were no statistically significant associations between AEs and age (hazard ratio [HR], 0.4; 95% confidence interval [95% CI], 0.2 to 1.3; P = .13); gender (HR, 0.9; 95% CI, 0.3 to 2.5; P = .87); ASA 2 classification (HR, 1.6; 95% CI, 0.6 to 4.5; P = .33); ASA 3 classification (HR, 1.3; 95% CI, 0.1 to 22.0; P = .86), or types of IV sedation medications administered during the procedure: fentanyl (HR, 0.4; 95% CI, 0.02 to 6.3; P = .5); midazolam (HR, 1.0; 95% CI, 0.2 to 4.3; P = .98); propofol (HR, 1.0; 95% CI, 0.3 to 3.5; P = .99); or ketamine (HR, 1.0; 95% CI, 0.1 to 7.3; P = .97). CONCLUSIONS The frequency of AEs (0.1%) and 0% mortality rate reported in this study demonstrate that the anesthesia team model used by oral and maxillofacial surgeons compares favorably to standardized intervention-based adverse anesthetic event outcomes reported by other nonanesthesiology specialties routinely performing outpatient procedural sedation.
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Affiliation(s)
- Steven J Wiemer
- Chief Resident, Division of Oral and Maxillofacial Surgery, Department of Surgery, Mayo Clinic and Mayo College of Medicine, Rochester, MN
| | - John M Nathan
- Senior Resident, Division of Oral and Maxillofacial Surgery, Department of Surgery, Mayo Clinic and Mayo College of Medicine, Rochester, MN
| | - Benjamin T Heggestad
- Chief Resident, Division of Oral and Maxillofacial Surgery, Department of Surgery, Mayo Clinic and Mayo College of Medicine, Rochester, MN
| | - W Jonathan Fillmore
- Assistant Professor of Surgery, Division of Oral and Maxillofacial Surgery, Department of Surgery, Mayo Clinic and Mayo College of Medicine, Rochester, MN
| | - Christopher F Viozzi
- Assistant Professor of Surgery, Division of Oral and Maxillofacial Surgery, Department of Surgery, Mayo Clinic and Mayo College of Medicine, Rochester, MN
| | - James M Van Ess
- Assistant Professor of Surgery, Division of Oral and Maxillofacial Surgery, Department of Surgery, Mayo Clinic and Mayo College of Medicine, Rochester, MN
| | - Kevin Arce
- Assistant Professor of Surgery and Division Chair, Section of Head & Neck Oncologic and Reconstructive Surgery, Division of Oral and Maxillofacial Surgery, Department of Surgery, Mayo Clinic and Mayo College of Medicine, Rochester, MN
| | - Kyle S Ettinger
- Assistant Professor of Surgery, Section of Head & Neck Oncologic and Reconstructive Surgery, Division of Oral and Maxillofacial Surgery, Department of Surgery, Mayo Clinic and Mayo College of Medicine, Rochester, MN.
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Jiménez Sánchez J, Serrano Díaz L, Gallego Pérez B, Marín Bernabé CM, García Belmonte D, Gómez Lozano M, Gajownik Ú, Martínez Crespo JJ. Percutaneous hepatic biopsy under propofol sedation. A safe and effective procedure. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2020; 112:903-908. [PMID: 33118358 DOI: 10.17235/reed.2020.6942/2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION the percutaneous hepatic biopsy is a necessary procedure for the diagnosis of liver diseases which can cause complications and psychological discomfort for the patient. AIMS to determine the safety profile of propofol in percutaneous hepatic biopsy, the complications of the technique per se and patients satisfaction once completed. METHODS a retrospective observational study was performed via the acquisition of data of tolerance and perceived quality by the patients using a transversal survey. RESULTS ninety-seven patients were included with an average propofol dose of 170.46 mg. Of the complications resulting from the sedation, there were six slight desaturations (6.2 %) resolved with a forehead maneuver (50 %) or cessation of the propofol infusion pump (50 %) and eleven hypotension episodes (11.3 %) resolved without intervention (82.82 %) or with fluid replacement (18.18 %). Of the complications resulting from the technique, there were three cases of early-onset pain (3.1 %) and one delayed (1.03 %); all were resolved with 1 g of intravenous paracetamol. All patients were discharged with oral tolerance and without the need for analgesia 24 hours after the procedure. General satisfaction, as well as psychological discomfort, were evaluated as "very good/excellent" in 100 % of the patients. DISCUSSION propofol demonstrated a favorable safety profile in hepatic biopsy, aiding in the ultimate success of the procedure and tolerance for the patient. We propose the expansion of the use of sedation with propofol to this procedure.
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Affiliation(s)
| | | | | | | | | | | | - Úrszula Gajownik
- Aparato Digestivo , Hospital Clínico Universitario Virgen de la Arrixaca, España
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High Incidence of Burst Suppression during Propofol Sedation for Outpatient Colonoscopy: Lessons Learned from Neuromonitoring. Anesthesiol Res Pract 2020; 2020:7246570. [PMID: 32636880 PMCID: PMC7321500 DOI: 10.1155/2020/7246570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 05/07/2020] [Accepted: 05/16/2020] [Indexed: 12/15/2022] Open
Abstract
Background Although anesthesia providers may plan for moderate sedation, the depth of sedation is rarely quantified. Using processed electroencephalography (EEG) to assess the depth of sedation, this study investigates the incidence of general anesthesia with variable burst suppression in patients receiving propofol for outpatient colonoscopy. The lessons learned from neuromonitoring can then be used to guide institutional best sedation practice. Methods This was a prospective observational study of 119 outpatients undergoing colonoscopy at Thomas Jefferson University Hospital (TJUH). Propofol was administered by CRNAs under anesthesiologists' supervision. The Patient State Index (PSi™) generated by the Masimo SedLine® Brain Root Function monitor (Masimo Corp., Irvine, CA) was used to assess the depth of sedation. PSi data correlating to general anesthesia with variable burst suppression were confirmed by neuroelectrophysiologists' interpretation of unprocessed EEG. Results PSi values of <50 consistent with general anesthesia were attained in 118/119 (99.1%) patients. Of these patients, 33 (27.7%) attained PSi values <25 consistent with variable burst suppression. The 118 patients that reached PSi <50 spent a significantly greater percentage (53.1% vs. 42%) of their case at PSi levels <50 compared to PSi levels >50 (p=0.001). Mean total propofol dose was significantly correlated to patient PSi during periods of PSi <25 (R=0.406, p=0.021). Conclusion Although providers planned for moderate to deep sedation, processed EEG showed patients were under general anesthesia, often with burst suppression. Anesthesiologists and endoscopists may utilize processed EEG to recognize their institutional practice patterns of procedural sedation with propofol and improve upon it.
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Protopapas AA, Stournaras E, Neokosmidis G, Stogiannou D, Filippidis A, Protopapas AN. Endoscopic sedation practices of Greek gastroenterologists: a nationwide survey. Ann Gastroenterol 2020; 33:366-373. [PMID: 32624656 PMCID: PMC7315718 DOI: 10.20524/aog.2020.0494] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 04/21/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Sedation in gastrointestinal endoscopy is rapidly evolving worldwide. However, this has led to significant disagreements, especially regarding the use of propofol by non-anesthesiologists. The aim of this study was to document the practices of Greek gastroenterologists regarding sedation and compare them to previous surveys. METHODS The study was conducted in 2 periods, December 2015 and June 2018. In each period, the same online questionnaire regarding endoscopic sedation practices was sent to all registered Greek gastroenterologists (509 and 547 gastroenterologists, respectively). RESULTS The response rates were 38.3% and 47.1%, respectively. In each period, 25.1% and 16.7% of physicians did not use sedation. Most gastroenterologists (approx. 70% in both instances) answered that they "almost never" collaborate with an anesthesiologist during endoscopy. Midazolam was by far the most popular sedation agent, used by almost 90% of physicians in both periods. Propofol was used by 30.8% and 27% of physicians, respectively. Physicians using propofol were significantly more satisfied with the sedation than other physicians, while propofol was the agent selected by most physicians if they were to undergo endoscopy themselves. Most physicians cited medicolegal reasons and inadequate training as chief reasons for not using propofol. CONCLUSIONS Sedation use is widespread among Greek gastroenterologists. Although midazolam is the most commonly used agent, propofol is preferred (theoretically) by most physicians and achieves the best satisfaction. The introduction of a strict training curriculum for endoscopic sedation can effectively eliminate the barriers preventing gastroenterologists from administering propofol, while at the same time ensuring optimal patient safety during endoscopy.
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Affiliation(s)
- Adonis A. Protopapas
- First Propaedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece (Adonis A. Protopapas, Evangelos Stournaras, Georgios Neokosmidis, Dimitrios Stogiannou, Athanasios Filippidis, Andreas N. Protopapas)
| | - Evangelos Stournaras
- First Propaedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece (Adonis A. Protopapas, Evangelos Stournaras, Georgios Neokosmidis, Dimitrios Stogiannou, Athanasios Filippidis, Andreas N. Protopapas)
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom (Evangelos Stournaras)
| | - Georgios Neokosmidis
- First Propaedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece (Adonis A. Protopapas, Evangelos Stournaras, Georgios Neokosmidis, Dimitrios Stogiannou, Athanasios Filippidis, Andreas N. Protopapas)
| | - Dimitrios Stogiannou
- First Propaedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece (Adonis A. Protopapas, Evangelos Stournaras, Georgios Neokosmidis, Dimitrios Stogiannou, Athanasios Filippidis, Andreas N. Protopapas)
| | - Athanasios Filippidis
- First Propaedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece (Adonis A. Protopapas, Evangelos Stournaras, Georgios Neokosmidis, Dimitrios Stogiannou, Athanasios Filippidis, Andreas N. Protopapas)
| | - Andreas N. Protopapas
- First Propaedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece (Adonis A. Protopapas, Evangelos Stournaras, Georgios Neokosmidis, Dimitrios Stogiannou, Athanasios Filippidis, Andreas N. Protopapas)
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Review on colorectal endoscopic submucosal dissection focusing on the technical aspect. Surg Endosc 2020; 34:3766-3787. [PMID: 32342217 DOI: 10.1007/s00464-020-07599-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 04/23/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) enables removal of broad-based colorectal polyps or lateral spreading tumors with a higher rate of en bloc resection and a lower risk of local recurrence. However, it is technically demanding. Over the past 20 years, various equipment and innovative techniques have been developed to reduce the difficulty of ESD. The information in the literature is scattered. Our aim is to provide a comprehensive review on the setup and technical aspects of colorectal ESD. METHODS We searched the PubMed database and systemically reviewed all original and review articles related to colorectal ESD. Further manual search according to reference lists of identified articles were done. The selected articles were categorized and reviewed. Original figures were created to help readers understand some of the ESD techniques. RESULTS A total of 216 articles were identified, in which 25 of them were review articles and 191 of them were original articles. They were categorized and reviewed. An in-depth appraisal of the setting, equipment, and technical aspects of colorectal ESD was performed. CONCLUSIONS Although ESD is a technically demanding procedure that requires expert endoscopic skills, it can be mastered. With good peri-procedural preparation, sufficient knowledge of the equipment, and thorough understanding of the useful endoscopic tricks and maneuvers, colorectal ESD can be performed smoothly and safely.
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Yang C, Feng Y, Wang S, Han M, Wang S, Kang F, Huang X, Li J. Effect of sex differences in remifentanil requirements for inhibiting the response to a CO 2 pneumoperitoneum during propofol anesthesia: an up-and-down sequential allocation trial. BMC Anesthesiol 2020; 20:35. [PMID: 32013877 PMCID: PMC6998344 DOI: 10.1186/s12871-020-0951-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 01/23/2020] [Indexed: 11/10/2022] Open
Abstract
Background A CO2 pneumoperitoneum during a laparoscopic procedure causes violent hemodynamic changes. However, the remifentanil required to inhibit the cardiovascular response to a CO2 pneumoperitoneum combined with propofol remains unknown. Moreover, the sex of the patient may influence the response to opioids, which can affect this requirement. The main objective of this study was to compare the required median effective concentration (EC50) of remifentanil for inhibiting the cardiovascular response to a CO2 pneumoperitoneum between female and male patients during propofol anesthesia. Methods The current study is an up-and-down sequential allocation trial. Forty-six patients with American Society of Anesthesiologists physical status I or II, a body mass index 18 to 30 kg/m2, aged 20 to 60 years, and scheduled for laparoscopic surgery were enrolled. Induction of anesthesia was performed by target-controlled infusion. The effective effect-site concentration (Ce) of propofol was 4 μg/ml. The Ce of remifentanil was initially 4 ng/ml and then adjusted to a predetermined level after I-gel laryngeal mask airway insertion. The Ce of remifentanil for each patient was determined by the response of the previous patient using the modified Dixon “up-and-down” method. The first patient received remifentanil at 5.0 ng/ml Ce, and the step size between patients was 0.5 ng/ml. Results Patients characteristics including age, body mass index, American Society of Anesthesiologists physical status, type of surgery and surgery duration, were comparable between male and female patients. The EC50 of remifentanil required to inhibit the response to a CO2 pneumoperitoneum based on the Dixon “up-and-down” method in women (4.17 ± 0.38 ng/ml) was significantly lower than that in men (5.00 ± 0.52 ng/ml) during propofol anesthesia (P = 0.01). Conclusions The EC50 of remifentanil required to inhibit the response to a CO2 pneumoperitoneum was lower in women than in men during propofol anesthesia. Trial registration The study was registered at http://www.chictr.org.cn (ChiCTR-IOR-17011906, 8th, July, 2017).
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Affiliation(s)
- Chengwei Yang
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230036, China
| | - Yuanyuan Feng
- Department of Hematology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230031, China
| | - Sheng Wang
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230036, China
| | - Mingming Han
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230036, China
| | - Song Wang
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230036, China
| | - Fang Kang
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230036, China
| | - Xiang Huang
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230036, China
| | - Juan Li
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230036, China.
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Yoldas H, Yildiz I, Karagoz I, Sit M, Ogun MN, Demirhan A, Bilgi M. Effects of Bispectral Index-controlled Use of Magnesium on Propofol Consumption and Sedation Level in Patients Undergoing Colonoscopy. Medeni Med J 2019; 34:380-386. [PMID: 32821465 PMCID: PMC7433725 DOI: 10.5222/mmj.2019.99705] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 11/10/2019] [Indexed: 12/16/2022] Open
Abstract
Objective The aim of this study is to investigate the effects of bispectral index-controlled use of magnesium on propofol consumption, periprocedural hemodynamic response and patient comfort. Material A total of 60 patients were enrolled in the study. In Group 1 (magnesium), a single dose 50 mg/kg magnesium sulfate diluted with 100 mL 0.9% NaCl was administered 10 minutes before the beginning of the procedure. Initially bolus dose of 0.5 mg/kg propofol was applied. The maintenance dose of propofol was 60 mcg/kg/min. During the procedure, the propofol infusion was increased by titration until the bispectral index (BIS) value of 70 was achieved. In Group 2 (saline), 100 ml 0.9% NaCl was administered 10 minutes before the beginning of the procedure. The bolus and maintenance doses of propofol, and target BIS values were the same as those in Group 1. Results When BIS values were compared between the groups, the initial BIS values in the magnesium group (Group 1) were significantly higher than those of the saline group (Group 2) (p<0.05). The time to reach BIS 70 was significantly shorter in the magnesium group (p<0.05). Propofol consumption was greater in Group 2 than in Group 1 (p<0.05). The time to reach BIS 70 was significantly shorter in Group 1 (p<0.05). No significant difference was found between the groups in terms of patient- and endoscopist-satisfaction (p<0.05). Conclusion The use of magnesium in addition to propofol may be an efficient and reliable option to reduce the drug consumption during colonoscopic interventions.
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Affiliation(s)
- Hamit Yoldas
- Bolu Abant Izzet Baysal University Faculty of Medicine, Department of Anesthesiology and Reanimation, Bolu, Turkey
| | - Isa Yildiz
- Bolu Abant Izzet Baysal University Faculty of Medicine, Department of Anesthesiology and Reanimation, Bolu, Turkey
| | - Ibrahim Karagoz
- Bolu Abant Izzet Baysal University Faculty of Medicine, Department of Anesthesiology and Reanimation, Bolu, Turkey
| | - Mustafa Sit
- Bolu Abant Izzet Baysal University Faculty of Medicine, Department of General Surgery, Bolu, Turkey
| | - Muhammed Nur Ogun
- Bolu Abant Izzet Baysal University Faculty of Medicine, Department of Neurology, Bolu, Turkey
| | - Abdullah Demirhan
- Bolu Abant Izzet Baysal University Faculty of Medicine, Department of Anesthesiology and Reanimation, Bolu, Turkey
| | - Murat Bilgi
- Bolu Abant Izzet Baysal University Faculty of Medicine, Department of Anesthesiology and Reanimation, Bolu, Turkey
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Lin OS, La Selva D, Kozarek RA, Tombs D, Weigel W, Beecher R, Koch J, McCormick S, Chiorean M, Drennan F, Gluck M, Venu N, Larsen M, Ross A. Computer-Assisted Propofol Sedation for Esophagogastroduodenoscopy Is Effective, Efficient, and Safe. Dig Dis Sci 2019; 64:3549-3556. [PMID: 31165379 DOI: 10.1007/s10620-019-05685-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Accepted: 05/25/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIMS Computer-assisted propofol sedation (CAPS) allows non-anesthesiologists to administer propofol for gastrointestinal procedures in relatively healthy patients. As the first US medical center to adopt CAPS technology for routine clinical use, we report our 1-year experience with CAPS for esophagogastroduodenoscopy (EGD). METHODS Between September 2014 and August 2015, 926 outpatients underwent elective EGDs with CAPS at our center. All EGDs were performed by 1 of 17 gastroenterologists certified in the use of CAPS. Procedural success rates, procedure times, and recovery times were compared against corresponding historical controls done with midazolam and fentanyl sedation from September 2013 to August 2014. Adverse events in CAPS patients were recorded. RESULTS The mean age of the CAPS cohort was 56.7 years (45% male); 16.2% of the EGDs were for variceal screening or Barrett's surveillance and 83.8% for symptoms. The procedural success rates were similar to that of historical controls (99.0% vs. 99.3%; p = 0.532); procedure times were also similar (6.6 vs. 7.4 min; p = 0.280), but recovery time was markedly shorter (31.7 vs. 52.4 min; p < 0.001). There were 11 (1.2%) cases of mild transient oxygen desaturation (< 90%), 15 (1.6%) cases of marked agitation due to undersedation, and 1 case of asymptomatic hypotension. In addition, there were six (0.6%) patients with more pronounced desaturation episodes that required brief (< 1 min) mask ventilation. There were no other serious adverse events. CONCLUSIONS CAPS appears to be a safe, effective, and efficient means of providing sedation for EGD in healthy patients. Recovery times were much shorter than historical controls.
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Affiliation(s)
- Otto S Lin
- Digestive Disease Institute, Virginia Mason Medical Center, 1100 Ninth Avenue, Seattle, WA, 98101, USA.
| | - Danielle La Selva
- Digestive Disease Institute, Virginia Mason Medical Center, 1100 Ninth Avenue, Seattle, WA, 98101, USA
| | - Richard A Kozarek
- Digestive Disease Institute, Virginia Mason Medical Center, 1100 Ninth Avenue, Seattle, WA, 98101, USA
| | - Deborah Tombs
- Digestive Disease Institute, Virginia Mason Medical Center, 1100 Ninth Avenue, Seattle, WA, 98101, USA
| | - Wade Weigel
- Department of Anesthesia, Virginia Mason Medical Center, Seattle, USA
| | - Ryan Beecher
- Department of Anesthesia, Virginia Mason Medical Center, Seattle, USA
| | - Johannes Koch
- Digestive Disease Institute, Virginia Mason Medical Center, 1100 Ninth Avenue, Seattle, WA, 98101, USA
| | - Susan McCormick
- Digestive Disease Institute, Virginia Mason Medical Center, 1100 Ninth Avenue, Seattle, WA, 98101, USA
| | - Michael Chiorean
- Digestive Disease Institute, Virginia Mason Medical Center, 1100 Ninth Avenue, Seattle, WA, 98101, USA
| | - Fred Drennan
- Digestive Disease Institute, Virginia Mason Medical Center, 1100 Ninth Avenue, Seattle, WA, 98101, USA
| | - Michael Gluck
- Digestive Disease Institute, Virginia Mason Medical Center, 1100 Ninth Avenue, Seattle, WA, 98101, USA
| | - Nanda Venu
- Digestive Disease Institute, Virginia Mason Medical Center, 1100 Ninth Avenue, Seattle, WA, 98101, USA
| | - Michael Larsen
- Digestive Disease Institute, Virginia Mason Medical Center, 1100 Ninth Avenue, Seattle, WA, 98101, USA
| | - Andrew Ross
- Digestive Disease Institute, Virginia Mason Medical Center, 1100 Ninth Avenue, Seattle, WA, 98101, USA
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Julián Gómez L, Fuentes Coronel A, López Ramos C, Ochoa Sangrador C, Fradejas Salazar P, Martín Garrido E, Conde Gacho P, Bailador Andrés C, García-Alvarado M, Rascarachi G, Castillo Trujillo R, Rodríguez Gómez SJ. A clinical trial comparing propofol versus propofol plus midazolam in diagnostic endoscopy of patients with a low anesthetic risk. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2019; 110:691-698. [PMID: 30318893 DOI: 10.17235/reed.2018.5289/2017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND OBJECTIVES propofol and midazolam are two of the most commonly used sedatives in upper gastrointestinal endoscopy (UGE). The objective of this study was to evaluate these two sedation regimens administered to patients who underwent an UGE with regard to security, efficiency, quality of exploration and patient response. PATIENTS AND METHODS a prospective, randomized and double-blind study was performed which included 83 patients between 18 and 80 years of age of a low anesthetic risk (ASA - American Society of Anesthesiologists- I-II) who underwent a diagnostic UGE. Patients were randomized to receive sedation with either placebo plus propofol (group A) or midazolam plus propofol (group B). RESULTS in group A, 42 patients received a placebo bolus (saline solution) and on average up to 115 mg of propofol in boluses of 20 mg. In group B, 41 patients received 3 mg of midazolam and an average of up to 83 mg of propofol in boluses of 20 mg. There were no significant differences in the adverse effects observed in either group and all adverse events were treated conservatively. The patients in group B (midazolam plus propofol) entered the desired sedated state more quickly with no variation in the overall time of the exploration. The quality of the endoscopic evaluation was similar in both groups and the patients were equally satisfied regardless of the sedatives they received. CONCLUSIONS the use of midazolam plus propofol as a sedative does not affect the overall exploration time, a lower dose of propofol can be used and it is as safe as administering propofol as a monotherapy while providing the same level of both exploration quality and patient approval.
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Lapidus A, Gralnek IM, Suissa A, Yassin K, Khamaysi I. Safety and efficacy of endoscopist-directed balanced propofol sedation during endoscopic retrograde cholangiopancreatography. Ann Gastroenterol 2019; 32:303-311. [PMID: 31040629 PMCID: PMC6479659 DOI: 10.20524/aog.2019.0360] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Accepted: 01/17/2019] [Indexed: 12/17/2022] Open
Abstract
Background Endoscopist-directed balanced propofol sedation (BPS) appears to be safe and effective for routine endoscopy. However, there are limited data on its use in endoscopic retrograde cholangiopancreatography (ERCP). We evaluated the safety and efficacy of endoscopist-directed BPS for ERCP, and compared patient outcomes with anesthesiologist-administered moderate sedation. Methods This was a retrospective cohort study, using prospectively collected endoscopy data from a tertiary care medical center where endoscopist-directed BPS during ERCP is routine practice. Adverse outcomes included need for bag-mask ventilation or intubation, aborted ERCP due to sedation, hospital admission post-ERCP (outpatients)/change in the level of care (inpatients), and death within 24 h. Results A total of 501 patients underwent ERCP with the use of endoscopist-directed BPS: Cohort 1 - 380 (76%) inpatients, mean age 64.1, 46% male, 24% American Society of Anesthesiologists physical status (ASA) score I, 65% ASA II, 11% ASA III. Concurrently, 24 patients received anesthesiologist-administered moderate sedation: Cohort 2 - 19 (79%) inpatients, mean age 65.0, 67% male, 12% ASA I, 25% ASA II, 38% ASA III, 25% ASA IV. In Cohort 1, none of the adverse outcomes were observed. Propofol dose was inversely correlated with age (r=-0.42, P<0.001), ASA score (r=-0.19, P<0.001), and Mallampati score (r=-0.24, P<0.001). One patient in Cohort 2 who received anesthesiologist-administered BPS required bag-mask ventilation and the ERCP was prematurely aborted because of the sedation. There were no deaths from any cause within 24 h of ERCP. Conclusion Endoscopist-directed BPS appears safe, efficacious, and feasible for ASA I-III patients undergoing inpatient or ambulatory ERCP.
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Affiliation(s)
- Alon Lapidus
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa (Alon Lapidus, Ian M. Gralnek, Iyad Khamaysi), Israel
| | - Ian M Gralnek
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa (Alon Lapidus, Ian M. Gralnek, Iyad Khamaysi), Israel.,Ellen and Pinchas Mamber Institute of Gastroenterology, Hepatology, and Nutrition, Emek Medical Center, Afula (Ian M. Gralnek), Israel
| | - Alain Suissa
- Department of Gastroenterology, Rambam Health Care Campus, Haifa (Alain Suissa, Kamel Yassin, Iyad Khamaysi), Israel
| | - Kamel Yassin
- Department of Gastroenterology, Rambam Health Care Campus, Haifa (Alain Suissa, Kamel Yassin, Iyad Khamaysi), Israel
| | - Iyad Khamaysi
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa (Alon Lapidus, Ian M. Gralnek, Iyad Khamaysi), Israel.,Department of Gastroenterology, Rambam Health Care Campus, Haifa (Alain Suissa, Kamel Yassin, Iyad Khamaysi), Israel
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Sato M, Horiuchi A, Tamaki M, Ichise Y, Kajiyama M, Yamamoto Y, Tanaka N. Safety and Effectiveness of Nurse-Administered Propofol Sedation in Outpatients Undergoing Gastrointestinal Endoscopy. Clin Gastroenterol Hepatol 2019; 17:1098-1104.e1. [PMID: 29933097 DOI: 10.1016/j.cgh.2018.06.025] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 06/02/2018] [Accepted: 06/15/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Esophagogastroduodenoscopy (EGD) and colonoscopy are common outpatient gastrointestinal endoscopic procedures that frequently use sedation. We aimed to identify a protocol that combines safety with cost effectiveness. METHODS We collected data from consecutive outpatients (age, 20-98 y) who underwent diagnostic EGD (n = 117,661) or colonoscopy (n = 32,550) with propofol sedation from January 2006 through December 2016. Propofol was administered by a nurse via bolus injection using an age-adjusted standard protocol, up to a total of 200 mg. The primary outcome measure was occurrence of adverse events within 24 hours. Secondary outcome measures included rates of procedure success, respiratory depression, and other procedure-related adverse events. RESULTS The median dose of propofol administered for EGD was 77 mg (range, 20-160 mg) and for colonoscopy was 99 mg (range, 40-200 mg). Among patients undergoing EGD, those younger than 41 years required 1.5-fold more propofol than patients 61-80 years old. The only adverse event was the transient need for supplemental oxygen supply, required by 1950 patients (1.3%): 1689 undergoing EGD (1.4%) and 261 undergoing colonoscopy (0.8%). Patients were discharged after 60 minutes and at least 66,250 patients (44%) drove themselves from the hospital. None experienced a traffic accident within 24 hours after receiving propofol sedation. CONCLUSIONS Nurse-administered propofol monosedation using an age-adjusted standard protocol up to a maximal of 200 mg is safe and practical for outpatient gastrointestinal endoscopy.
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Affiliation(s)
- Masamichi Sato
- Digestive Disease Center, Showa Inan General Hospital, Komagane, Japan; Department of Pediatrics, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Akira Horiuchi
- Digestive Disease Center, Showa Inan General Hospital, Komagane, Japan.
| | - Michio Tamaki
- Digestive Disease Center, Showa Inan General Hospital, Komagane, Japan
| | - Yasuyuki Ichise
- Digestive Disease Center, Showa Inan General Hospital, Komagane, Japan
| | - Masashi Kajiyama
- Digestive Disease Center, Showa Inan General Hospital, Komagane, Japan
| | - Yuta Yamamoto
- Digestive Disease Center, Showa Inan General Hospital, Komagane, Japan
| | - Naoki Tanaka
- Digestive Disease Center, Showa Inan General Hospital, Komagane, Japan
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Feng LL, Ding WX, Sun YY, Zhang YY, Yuan NP, Zhang LJ, Han WJ, Xi HJ. Risk factors for hypoxemia during routine anesthesia for gastrointestinal endoscopy. Shijie Huaren Xiaohua Zazhi 2019; 27:427-434. [DOI: 10.11569/wcjd.v27.i7.427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Gastrointestinal endoscopy under anesthesia has been carried out as a routine procedure in China. Hypoxemia is still an adverse event with a high incidence in routine anesthesia for gastrointestinal endoscopy, but the incidence of hypoxemia varies greatly across countries (< 1% to 85%), and there is a lack of relevant high-quality reports in China. Propofol, as a sedative for anesthetic gastroscopy in outpatients, has been recognized for its safety and effectiveness and is recommended by the expert consensus on Sedation/Anesthesia for Digestive Endoscopic Diagnosis and Treatment in China (2014). However, there are still some debate over its safety in foreign countries. In this study, we used propofol as a sedative for gastroscopy in outpatients to observe its effect on the incidence of hypoxemia.
AIM To observe and analyze the incidence of and risk factors for hypoxemia in anesthesia for gastrointestinal endoscopy.
METHODS A total of 580 outpatients who were sedated with propofol from September 1, 2018 to November 30, 2018 in Digestive Endoscopy Center of Shanghai Changhai Hospital were included in the study. These patients were divided into either a hypoxemia (n = 110) group or a non-hypoxemia group (n = 470). The basic information, anesthesia procedure, and endoscopic operation related information of the two groups were recorded.
RESULTS The information of patients in the two groups was compared and analyzed. It was found that there were significantly differences between the two groups in snoring history, biopsy, age, body mass index, abdominal circumference, endoscopic operation time, propofol dosage, ASA classification, and endoscopic physician classification (P < 0.05). Multivariate Logistic regression analysis showed that age (>5 years, OR = 8.955, 95 %CI: 2.070-38.746) and propofol dosage (>197 mg, OR = 2.360, 95 %CI: 1.320-4.219) were independent risk factors for hypoxemia.
CONCLUSION Intervention is needed for elderly patients (especially patients over 75 years old) and patients requiring large amounts of propofol (especially > 197 mg) to prevent the occurrence of hypoxemia.
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Affiliation(s)
- Li-Li Feng
- Department of Anesthesiology, Changhai Hospital, Shanghai 200433, China
| | - Wen-Xia Ding
- Digestive Endoscopy Center, Changhai Hospital, Shanghai 200433, China
| | - Yuan-Yuan Sun
- Department of Anesthesiology, Changhai Hospital, Shanghai 200433, China
| | - Ying-Ying Zhang
- Department of Anesthesiology, Changhai Hospital, Shanghai 200433, China
| | - Ning-Ping Yuan
- Department of Anesthesiology, Changhai Hospital, Shanghai 200433, China
| | - Li-Jun Zhang
- Department of Anesthesiology, Changhai Hospital, Shanghai 200433, China
| | - Wen-Jun Han
- Department of Anesthesiology, Changhai Hospital, Shanghai 200433, China
| | - Hui-Jun Xi
- Digestive Endoscopy Center, Changhai Hospital, Shanghai 200433, China
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Patel J, Fang J, Taylor LJ, Adler DG, Gawron AJ. Safety and efficacy of non-anesthesiologist administration of propofol sedation during esophagogastroduodenoscopy in the intensive care unit. Endosc Int Open 2019; 7:E625-E629. [PMID: 30993168 PMCID: PMC6461546 DOI: 10.1055/a-0829-6284] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 11/15/2018] [Indexed: 12/17/2022] Open
Abstract
Background and study aims Propofol sedation is an increasingly popular method of sedation for gastrointestinal endoscopic procedures. The safety and efficacy of the non-anesthesiologist administration of propofol (NAAP) sedation has been demonstrated in the ambulatory setting. However, NAAP sedation in intensive care unit (ICU) patients has not been reported. The purpose of this study is to determine safety and efficacy of NAAP sedation in an ICU population. Methods We retrospectively reviewed esophagogastroduodenoscopies (EGD) performed with NAAP sedation in our intensive care units from June 2014 to September 2016. All EGDs were performed for evaluation of gastrointestinal bleeding. The primary end point of this study was to analyze the incidence of sedation-related adverse events (AEs). The secondary end points included successful completion of procedure and any endoscopic interventions performed. Results Two of 161 procedures (1.2 %) had sedation-related AEs requiring procedure termination. One hundred forty-six of 161 procedures (90.7 %) were successfully completed. Incomplete procedures were due to excess heme, retained food or obstructive lesions (13/161, 8.1 %). Endoscopic intervention was performed successfully in 17/24 cases (70.8 %) that had endoscopically treated lesions identified. One hundred six of 161 patients (66 %) were American Society of Anesthesiologists (ASA) classification III or IV. Conclusion Our retrospective analysis demonstrated that EGDs can be successfully completed in ICU patients using NAAP sedation. When procedures cannot be completed, it is rarely due to sedation-related AEs. NAAP sedation further allows adequate examination and successful treatment of high-risk lesions. NAAP sedation appears safe and effective for endoscopic procedures in the ICU setting.
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Affiliation(s)
- Janaki Patel
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - John Fang
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - Linda J. Taylor
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - Douglas G. Adler
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - Andrew J. Gawron
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, United States,Corresponding author Andrew J. Gawron 30 N 1900 E, SOM 4R118Salt Lake City, UT 84132+1-801-581-7476
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Behrens A, Kreuzmayr A, Manner H, Koop H, Lorenz A, Schaefer C, Plauth M, Jetschmann JU, von Tirpitz C, Ewald M, Sackmann M, Renner W, Krüger M, Schwab D, Hoffmann W, Engelke O, Pech O, Kullmann F, Pampuch S, Lenfers B, Weickert U, Schilling D, Boehm S, Beckebaum S, Cicinnati V, Erckenbrecht JF, Dumoulin FL, Benz C, Rabenstein T, Haltern G, Balsliemke M, de Mas C, Kleber G, Pehl C, Vogt C, Kiesslich R, Fischbach W, Koop I, Kuehne J, Breidert M, Sass NL, May A, Friedrich C, Veitt R, Porschen R, Ellrichmann M, Arlt A, Schmitt W, Dollhopf M, Schmidbaur W, Dignass A, Schmitz V, Labenz J, Kaiser G, Krannich A, Barteska N, Ell C. Acute sedation-associated complications in GI endoscopy (ProSed 2 Study): results from the prospective multicentre electronic registry of sedation-associated complications. Gut 2019; 68:445-452. [PMID: 29298872 DOI: 10.1136/gutjnl-2015-311037] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Revised: 11/22/2017] [Accepted: 11/28/2017] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Sedation has been established for GI endoscopic procedures in most countries, but it is also associated with an added risk of complications. Reported complication rates are variable due to different study methodologies and often limited sample size. DESIGNS Acute sedation-associated complications were prospectively recorded in an electronic endoscopy documentation in 39 study centres between December 2011 and August 2014 (median inclusion period 24 months). The sedation regimen was decided by each study centre. RESULTS A total of 368 206 endoscopies was recorded; 11% without sedation. Propofol was the dominant drug used (62% only, 22.5% in combination with midazolam). Of the sedated patients, 38 (0.01%) suffered a major complication, and overall mortality was 0.005% (n=15); minor complications occurred in 0.3%. Multivariate analysis showed the following independent risk factors for all complications: American Society of Anesthesiologists class >2 (OR 2.29) and type and duration of endoscopy. Of the sedation regimens, propofol monosedation had the lowest rate (OR 0.75) compared with midazolam (reference) and combinations (OR 1.0-1.5). Compared with primary care hospitals, tertiary referral centres had higher complication rates (OR 1.61). Notably, compared with sedation by a two-person endoscopy team (endoscopist/assistant; 53.5% of all procedures), adding another person for sedation (nurse, physician) was associated with higher complication rates (ORs 1.40-4.46), probably due to higher complexity of procedures not evident in the multivariate analysis. CONCLUSIONS This large multicentre registry study confirmed that severe acute sedation-related complications are rare during GI endoscopy with a very low mortality. The data are useful for planning risk factor-adapted sedation management to further prevent sedation-associated complications in selected patients. TRIAL REGISTRATION NUMBER DRKS00007768; Pre-results.
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Affiliation(s)
- Angelika Behrens
- Department of Internal Medicine and Gastroenterology, Evangelische Elisabeth Klinik, Teaching Hospital, Charité University Medicine, Berlin, Germany
| | - Anton Kreuzmayr
- Klinik für Innere Medizin und Gastroenterologie, Klinikum Traunstein, Essen, Germany
| | - Hendrik Manner
- Klinik für Innere Medizin und Gastroenterologie, Dr. Horst-Schmidt-Kliniken, Wiesbaden, Germany
| | - Herbert Koop
- Klinik für Allgemeine Innere Medizin und Gastroenterologie, Helios Klinikum Berlin-Buch, Berlin, Germany
| | - Albrecht Lorenz
- Klinik für Allgemeine Innere Medizin und Gastroenterologie, Helios Klinikum Berlin-Buch, Berlin, Germany
| | - Claus Schaefer
- Medizinische Klinik II, Klinikum Neumarkt, Neumarkt, Germany
| | - Mathais Plauth
- Klinik für Innere Medizin, Gastroenterologie, Klinikum Dessau, Dessau, Germany
| | - Jens-Uwe Jetschmann
- Klinik für Innere Medizin, Gastroenterologie, Klinikum Dessau, Dessau, Germany
| | | | - Marcus Ewald
- Medizinische Klinik - Schwerpunkt Gastroenterologie, Onkologie, Klinikum Kulmbach, Kulmbach, Germany
| | | | - Wanja Renner
- Medizinische Klinik II, Klinikum Bamberg, Bamberg, Germany
| | - Martin Krüger
- Klinik für Innere Medizin und Gastroenterologie, Ev. Krankehaus Bielefeld, Bielefeld, Germany
| | - Dieter Schwab
- Medizinische Klinik II, Krankenhaus Martha-Maria Nürnberg, Nuremberg, Germany
| | | | - Olaf Engelke
- Medizinische Klinik II, St. Anna Hospital, Herne, Germany
| | - Oliver Pech
- Klinik für Innere Medizin und interventionelle Gastroenterologie, Krankenhaus Barmherzige Brüder, Regensburg, Germany
| | | | - Sonja Pampuch
- Medizinische Klinik I, Klinikum Weiden, Weiden, Germany
| | - Berthold Lenfers
- Klinik für Gastroeterologie, St. Marien Hospital Klinikum Lünen, Luenen, Germany
| | - Uwe Weickert
- Medizinische Klinik II, SLK Kliniken Heilbronn, Heilbronn, Germany
| | - Dieter Schilling
- Medizinische Klinik II, Diakonissenkrankenhaus Mannheim, Mannheim, Germany
| | - Stephan Boehm
- Medizinische Klinik für Innere Medizin, Gastroenterologie und Hepatologie, Katholische Kliniken Ruhrhalbinsel, Essen, Germany
| | - Susanne Beckebaum
- Medizinische Klinik für Innere Medizin, Gastroenterologie und Hepatologie, Katholische Kliniken Ruhrhalbinsel, Essen, Germany
| | - Vito Cicinnati
- Medizinische Klinik für Innere Medizin, Gastroenterologie und Hepatologie, Katholische Kliniken Ruhrhalbinsel, Essen, Germany
| | - Joachim F Erckenbrecht
- Klinik für Innere Medizin mit Gastroenterologie und Onkologie, Florence-Nightingale-Krankenhaus, Düsseldorf, Germany
| | - Franz Ludwig Dumoulin
- Allgemeine Innere Medizin, Gastroenterologie und Diabetologie, Gemeinschaftskrankenhaus Bonn, Bonn, Germany
| | - Claus Benz
- Innere Medizin, Evangelisches Krankenhaus Köln-Weyertal, Cologne, Germany
| | - Thomas Rabenstein
- Klinik für Innere Medizin, Diakonissen-Stiftungs-Krankenhaus Speyer, Speyer, Germany
| | - Georg Haltern
- Gastroenterologie, Kreiskrankenhaus Dormagen, Dormagen, Germany
| | | | - Christian de Mas
- Klinik für Innere Medizin - Gastroenterologie, Marienhaus St.Elisabeth Neuwied, Neuwied, Germany
| | | | - Christian Pehl
- Innere Medizin, Krankenhaus Vilsbiburg, Vilsbiburg, Germany
| | - Christoph Vogt
- Innere Medizin, St. Josef Krankenhaus Moers, Moers, Germany
| | - Ralf Kiesslich
- Innere Medizin, St. Marienkrankenhaus, Frankfurt, Germany
| | | | - Irmtraut Koop
- Allgemeine Innere Medizin und Gastroenterologie, Ev. Amalie Sieveking-Krankenhaus, Hamburg, Germany
| | - Jens Kuehne
- Klinik für Innere Medizin, Pius-Hospital, Oldenburg, Germany
| | - Matthias Breidert
- Gastroenterologie und Infektiologie, Klinik Koesching, Koesching, Germany
| | | | - Andrea May
- Medizinische Klinik II, Sana Klinikum Offenbach, Offenbach, Germany
| | | | - Ronni Veitt
- Klinik für Innere Medizin I - Gastroenterologie, internistische Onkologie, Elisabeth Klinikum Schmalkalden, Schmalkalden, Germany
| | - Rainer Porschen
- Klinik für Innere Medizin, Klinikum Bremen-Ost, Bremen, Germany
| | - Mark Ellrichmann
- Klinik für Innere Medizin 1, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Alexander Arlt
- Klinik für Innere Medizin 1, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Wolfgang Schmitt
- Klinik für Gastroenterologie und Hepatologie, Klinikum Neuperlach, Munich, Germany
| | - Markus Dollhopf
- Klinik für Gastroenterologie und Hepatologie, Klinikum Neuperlach, Munich, Germany
| | - Werner Schmidbaur
- Klinik für Gastroenterologie und Hepatologie, Stiftungsklinik Weissenhorn, Weissenhorn, Germany
| | - Axel Dignass
- Medizinische Klinik I, Agaplesion Markus Krankenhaus, Frankfurt, Germany
| | - Volker Schmitz
- Innere Medizin, Krankenhaus St. Marienwörth, Bad Kreuznach, Germany
| | - J Labenz
- Innere Medizin, Ev.-Jung-Stilling-KKH, Siegen, Germany
| | - Gernot Kaiser
- FB Wirtschafts- und Sozialwissenschaften, Hochschule Nordhausen, Nordhausen, Germany
| | - Alexander Krannich
- Koordinierungszentrum Klinische Studien, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Nico Barteska
- Klinik für Gastroenterologie, Vivantes Klinikum im Friedrichshain, Teaching hospital, Charité University Medicine, Berlin, Germany
| | - Christian Ell
- Medizinische Klinik II, Sana Klinikum Offenbach, Offenbach, Germany
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Kayaaltı S, Kayaaltı Ö. Safety of applying midazolam-ketamine-propofol sedation combination under the supervision of endoscopy nurse with patient-controlled analgesia pump in colonoscopy. World J Clin Cases 2018; 6:1146-1154. [PMID: 30613673 PMCID: PMC6306640 DOI: 10.12998/wjcc.v6.i16.1146] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 11/09/2018] [Accepted: 11/23/2018] [Indexed: 02/05/2023] Open
Abstract
AIM To compare the results of midazolam-ketamine-propofol sedation performed by an endoscopy nurse and anaesthetist during colonoscopy in terms of patient satisfaction and safety. METHODS American Statistical Association (ASA) I-II 60 patients who underwent colonoscopy under sedation were randomly divided into two groups: sedation under the supervision of an anaesthetist (SSA) and sedation under the supervision of an endoscopy nurse (SSEN). Both groups were initially administered 1 mg midazolam, 50 mg ketamine and 30-50 mg propofol. Continuation of sedation was performed by the anaesthetist in the SSA group and the nurse with a patient-controlled analgesia (PCA) pump in the SSEN group. The total propofol consumption, procedure duration, recovery times, pain using the visual analogue scale (VAS) and satisfaction score of the patients, and side effects were recorded. In addition, the patients were asked whether they remembered the procedure and whether they would prefer the same method in the case of re-endoscopy. RESULTS Total propofol consumption in the SSEN group was significantly higher (P < 0.05) than that in the SSA group. When the groups were compared in terms of VAS score, recovery time, patient satisfaction, recall of the procedure, re-preference for the same method in case of re-endoscopy, and side effects, there were no significant differences (P > 0.05) between the two groups. No long-term required intervention side effects were observed in either group. CONCLUSION Colonoscopy sedation in ASA I-II patients can be safely performed by an endoscopy nurse using PCA pump with the incidence of side effects and patient satisfaction levels similar to sedation under anaesthetist supervision.
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Affiliation(s)
- Selda Kayaaltı
- Division of Anaesthesiology and Reanimation, Develi Public Hospital, Develi, Kayseri 38400, Turkey
| | - Ömer Kayaaltı
- Computer Technology, Kayseri University, Develi Huseyin Sahin Vocational College, Develi, Kayseri 38400, Turkey
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Qin Y, Li LZ, Zhang XQ, Wei Y, Wang YL, Wei HF, Wang XR, Yu WF, Su DS. Supraglottic jet oxygenation and ventilation enhances oxygenation during upper gastrointestinal endoscopy in patients sedated with propofol: a randomized multicentre clinical trial. Br J Anaesth 2018; 119:158-166. [PMID: 28974061 DOI: 10.1093/bja/aex091] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2017] [Indexed: 12/14/2022] Open
Abstract
Background Hypoventilation is the main reason for hypoxia during upper gastrointestinal endoscopy procedures with sedation. The key to preventing hypoxia is to maintain normal ventilation during the procedure. We introduced supraglottic jet oxygenation and ventilation (SJOV) through a new Wei nasal jet tube (WNJ) to reduce the incidence of hypoxia in patients sedated with propofol during upper gastrointestinal endoscopy procedures. Methods In a multicentre, prospective randomized single-blinded study, 1781 outpatients undergoing routine upper gastrointestinal endoscopy who were sedated with propofol by an anaesthetist were randomized into the following three groups: the supplementary oxygen via nasal cannula group [nasal cannula oxygen: O 2 (2 litres min -1 ) was administered via a nasal cannula]; the supplementary oxygen via WNJ group [WNJ oxygen: O 2 (2 litres min -1 ) was administered through a WNJ]; and the SJOV via WNJ group (WNJ SJOV: SJOV was administered via WNJ) at three centres from March 2015 to July 2016. The primary outcome of interest was the incidence of hypoxia (peripheral oxygen saturation of 75-89%). Other adverse events were also recorded. Results Supraglottic jet oxygenation and ventilation decreased the incidence of hypoxia from 9 to 3% ( P <0.0001). No severe hypoxia occurred in the WNJ SJOV group, one instance occurred in the WNJ oxygen group, and two instances were observed in the nasal cannula oxygen supply control group. Supraglottic jet oxygenation and ventilation-related minor adverse events increased significantly within 1 min after the procedure but decreased 30 min later. Conclusions The use of SJOV during upper gastrointestinal endoscopy for patients who are sedated with propofol reduces the incidence of hypoxia, with minor and tolerable adverse events. Supraglottic jet oxygenation and ventilation has a favourable risk-to-benefit ratio and may improve patient safety. Clinical trial registration NCT02436018.
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Affiliation(s)
- Y Qin
- Department of Anaesthesiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200127, China
| | - L Z Li
- Department of Anaesthesiology, Pudong New Area People's Hospital, Shanghai 201200, China
| | - X Q Zhang
- Department of Anaesthesiology, Shanghai Tongji Hospital, Shanghai 200065, China
| | - Y Wei
- Department of Anaesthesiology, Pudong New Area People's Hospital, Shanghai 201200, China
| | - Y L Wang
- Department of Anaesthesiology, Shanghai Tongji Hospital, Shanghai 200065, China
| | - H F Wei
- Department of Anaesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - X R Wang
- Department of Anaesthesiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200127, China
| | - W F Yu
- Department of Anaesthesiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200127, China
| | - D S Su
- Department of Anaesthesiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200127, China
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Urahama R, Uesato M, Aikawa M, Yamaguchi Y, Hayano K, Matsumura T, Arai M, Kunii R, Isono S, Matsubara H. Polysomnographic assessment of respiratory disturbance during deep propofol sedation for endoscopic submucosal dissection of gastric tumors. World J Gastrointest Endosc 2018; 10:340-347. [PMID: 30487944 PMCID: PMC6247095 DOI: 10.4253/wjge.v10.i11.340] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 08/21/2018] [Accepted: 10/08/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate that polysomnographic monitoring can accurately evaluate respiratory disturbance incidence during sedation for gastrointestinal endoscopy compare to pulse oximetry alone. METHODS This prospective observational study included 10 elderly patients with early gastric cancer undergoing endoscopic submucosal dissection (ESD) under propofol sedation. Apart from routine cardiorespiratory monitoring, polysomnography measurements were acquired. The primary hypothesis was tested by comparing the apnea hypopnea index (AHI), defined as the number of apnea and hypopnea instances per hour during sedation, with and without hypoxemia; hypoxemia was defined as the reduction in oxygen saturation by ≥ 3% from baseline. RESULTS Polysomnography (PSG) detected 207 respiratory disturbances in the 10 patients. PSG yielded a significantly greater AHI (10.44 ± 5.68/h) compared with pulse oximetry (1.54 ± 1.81/h, P < 0.001), thus supporting our hypothesis. Obstructive AHI (9.26 ± 5.44/h) was significantly greater than central AHI (1.19 ± 0.90/h, P < 0.001). Compared with pulse oximetry, PSG detected the 25 instances of respiratory disturbances with hypoxemia 107.4 s earlier on average. CONCLUSION Compared with pulse oximetry, PSG can better detect respiratory irregularities and thus provide superior AHI values, leading to avoidance of fatal respiratory complications during ESD under propofol-induced sedation.
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Affiliation(s)
- Ryuma Urahama
- Department of Frontier Surgery, Chiba University Graduate School of Medicine, Chiba 260-8670, Japan
| | - Masaya Uesato
- Department of Frontier Surgery, Chiba University Graduate School of Medicine, Chiba 260-8670, Japan
| | - Mizuho Aikawa
- Department of Frontier Surgery, Chiba University Graduate School of Medicine, Chiba 260-8670, Japan
| | - Yukiko Yamaguchi
- Department of Frontier Surgery, Chiba University Graduate School of Medicine, Chiba 260-8670, Japan
| | - Koichi Hayano
- Department of Frontier Surgery, Chiba University Graduate School of Medicine, Chiba 260-8670, Japan
| | - Tomoaki Matsumura
- Department of Gastroenterology, Chiba University Graduate School of Medicine, Chiba 260-8670, Japan
| | - Makoto Arai
- Department of Medical Oncology, Chiba University Graduate School of Medicine, Chiba 260-8670, Japan
| | - Reiko Kunii
- Staff of Clinical Laboratory, Chiba University Hospital, Chiba 260-8677, Japan
| | - Shiroh Isono
- Department of Anesthesiology, Chiba University Graduate School of Medicine, Chiba 260-8670, Japan
| | - Hisahiro Matsubara
- Department of Frontier Surgery, Chiba University Graduate School of Medicine, Chiba 260-8670, Japan
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Leslie K, Allen ML, Hessian EC, Peyton PJ, Kasza J, Courtney A, Dhar PA, Briedis J, Lee S, Beeton AR, Sayakkarage D, Palanivel S, Taylor JK, Haughton AJ, O'Kane CX. Safety of sedation for gastrointestinal endoscopy in a group of university-affiliated hospitals: a prospective cohort study. Br J Anaesth 2018; 118:90-99. [PMID: 28039246 DOI: 10.1093/bja/aew393] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2016] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Service models for gastrointestinal endoscopy sedation must be safe, as endoscopy is the most common procedure performed under sedation in many countries. The aim of this prospective cohort study was to determine the patient risk profile, and incidence of and risk factors for significant unplanned events, in adult patients presenting for gastrointestinal endoscopy in a group of university-affiliated hospitals where most sedation is managed by anaesthetists. METHODS Patients aged ≥18 yr presenting for elective and emergency gastrointestinal endoscopy under anaesthetist-managed sedation at nine hospitals affiliated with the University of Melbourne, Australia, were included. Outcomes included significant airway obstruction, hypoxia, hypotension and bradycardia; unplanned tracheal intubation; abandoned procedure; advanced life support; prolonged post-procedure stay; unplanned over-night admission and 30-day mortality. RESULTS 2,132 patients were included. Fifty percent of patients were aged >60 yr, 50% had a BMI >27 kg m -2, 42% were ASA physical status III-V and 17% were emergency patients. The incidence of significant unplanned events was 23.0% (including significant hypotension 11.8%). Significant unplanned intraoperative events were associated with increasing age, BMI <18.5 kg m -2, ASA physical status III-V, colonoscopy and planned tracheal intubation. Thirty-day mortality was 1.2% (0.2% in electives and 6.0% in emergencies) and was associated with ASA physical status IV-V and emergency status. CONCLUSIONS Patients presenting for gastrointestinal endoscopy at a group of public university-affiliated hospitals where most sedation is managed by anaesthetists, had a high risk profile and a substantial incidence of significant unplanned intraoperative events and 30-day mortality.
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Affiliation(s)
- K Leslie
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Australia .,Anaesthesia, Perioperative and Pain Medicine Unit, University of Melbourne, Melbourne, Australia.,Department of Pharmacology and Therapeutics, University of Melbourne, Melbourne, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - M L Allen
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Australia.,Anaesthesia, Perioperative and Pain Medicine Unit, University of Melbourne, Melbourne, Australia.,Department of Cancer Anaesthesia, Pain and Perioperative Medicine, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - E C Hessian
- Anaesthesia, Perioperative and Pain Medicine Unit, University of Melbourne, Melbourne, Australia.,Department of Anaesthesia and Pain Medicine, Western Hospital, Melbourne, Australia
| | - P J Peyton
- Department of Anaesthesia, Austin Hospital, Melbourne, Australia.,Department of Surgery, University of Melbourne, Melbourne, Australia
| | - J Kasza
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - A Courtney
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Australia
| | - P A Dhar
- Department of Cancer Anaesthesia, Pain and Perioperative Medicine, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - J Briedis
- Department of Anaesthesia and Perioperative Medicine, Northern Hospital, Melbourne, Australia
| | - S Lee
- Department of Anaesthesia and Perioperative Medicine, Northern Hospital, Melbourne, Australia
| | - A R Beeton
- Department of Anaesthesia, Goulburn Valley Base Hospital, Shepparton, Australia
| | - D Sayakkarage
- Department of Anaesthesia, Goulburn Valley Base Hospital, Shepparton, Australia
| | - S Palanivel
- Department of Anaesthesia, Ballarat Base Hospital, Ballarat, Australia
| | - J K Taylor
- Department of Anaesthesia, St Vincent's Hospital, Melbourne, Australia
| | - A J Haughton
- Department of Anaesthesia, Wangaratta Base Hospital, Wangaratta, Australia
| | - C X O'Kane
- Department of Anaesthesia, Wangaratta Base Hospital, Wangaratta, Australia
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Smith I, Durkin D, Lau KW, Hebbar S. Establishing an anaesthetist-delivered propofol sedation service for advanced endoscopic procedures: implementing the RCA/BSG guidelines. Frontline Gastroenterol 2018; 9:185-191. [PMID: 30046422 PMCID: PMC6056079 DOI: 10.1136/flgastro-2017-100839] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 09/26/2017] [Accepted: 10/18/2017] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Following recommendations from the Royal College of Anaesthetists and the British Society of Gastroenterology, we report our results of propofol sedation for complex endoscopic procedures delivered by a single consultant anaesthetist over a 5-year period. METHODS A weekly session was provided in the endoscopy department for procedures that were complex or could previously not be completed successfully. Deep sedation was provided by intermittent propofol bolus doses, supplemented with fentanyl where necessary, titrated to clinical effect. Patients were usually in semiprone or lateral positions and spontaneously breathed air supplemented with nasal oxygen. Service evaluation included patient recall, endoscopist satisfaction with conditions, procedural success and airway-related adverse outcomes. RESULTS We completed 1000 procedures, 42.5% of which were endoscopic retrograde cholangiopancreatography, with the remainder comprising a diverse range of endoscopic procedures of 3-156 min duration. Procedural conditions were excellent in 79% of cases, 261 procedures were completed which had been previously abandoned, 246 patients (24.6%) had a better experience than previously and none recalled any part of their procedure. Three patients required transient bag and mask ventilation, and nasal airways were used in 12 patients, but none required tracheal intubation or vasopressor support. CONCLUSIONS These guidelines facilitated a propofol sedation service with considerable benefits for patients and endoscopists. Provision of deep propofol sedation by an anaesthetist, in patients with an unsecured airway, appears practical, effective and efficient. Small adjustments to the airway were fairly common, but the incidence of adverse events and requirement for airway instrumentation was low.
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Affiliation(s)
- Ian Smith
- Directorate of Anaesthesia, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, Staffordshire, UK
| | - Damien Durkin
- Surgery, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, Staffordshire, UK
| | - Kaw Wai Lau
- Gastroenterology, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, Staffordshire, UK
| | - Srisha Hebbar
- Gastroenterology, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, Staffordshire, UK
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Abstract
PURPOSE OF REVIEW To assess the trends in nonoperating room anesthesia (NORA) for gastrointestinal endoscopy over the past few years, and to describe alternative methods of delivering propofol sedation in selected low-risk patients. RECENT FINDINGS The use of NORA for routine gastrointestinal endoscopic procedures has been rising steadily over the past decade in the United States, considerably increasing healthcare costs. Because of this, there have been attempts to develop nonanesthesiologist-administered propofol sedation methods in low-risk patients. There is controversy as to whether properly trained nonanesthesia personnel can use propofol safely via the modalities of nurse-administered propofol sedation, computer-assisted propofol sedation or nurse-administered continuous propofol sedation SUMMARY: The deployment of nonanesthesia-administered propofol sedation for low-risk procedures allows for optimal allocation of scarce anesthesia resources, which can be more appropriately used for more complex cases. This can address some of the current shortages in anesthesia provider supply, and can potentially reduce overall healthcare costs without sacrificing sedation quality. We also address the realm of anesthesia provider care for advanced endoscopic procedures including setup for administration of anesthesia, decision-making regarding placement of an endotracheal tube, and the potential need to move a challenging case to the operating room.
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Marín-Gabriel JC, Martínez-Montiel P. Safety of propofol sedation directed by endoscopists: how long should we continue to generate evidence? REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2018; 110:260. [PMID: 29578349 DOI: 10.17235/reed.2018.5531/2018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The administration of propofol by endoscopists is a source of permanent friction with the Societies of Anesthesiology, which is based more on a clear conflict of economic interest on the part of the anesthesiologists than supported by scientific evidence. Maestro Antolín et al. (1) presented a series of more than 33,000 sedations performed with propofol by endoscopists, observing a frequency of cardiorespiratory adverse events of 0.13%. Rather than confrontation between different specialties, where the corporatism of the Anesthesiology Societies and their interest in monopolizing the use of a safe drug such as propofol prevails with no scientific support, anesthesiologists, endoscopists and nurses should instead work together for the benefit of our patients.
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Sneyd J, O'Sullivan E. Modified supraglottic airway for gastroscopy: an advance in patient safety? Br J Anaesth 2018; 120:209-211. [DOI: 10.1016/j.bja.2017.10.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 10/08/2017] [Accepted: 10/19/2017] [Indexed: 01/27/2023] Open
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Early DS, Lightdale JR, Vargo JJ, Acosta RD, Chandrasekhara V, Chathadi KV, Evans JA, Fisher DA, Fonkalsrud L, Hwang JH, Khashab MA, Muthusamy VR, Pasha SF, Saltzman JR, Shergill AK, Cash BD, DeWitt JM. Guidelines for sedation and anesthesia in GI endoscopy. Gastrointest Endosc 2018; 87:327-337. [PMID: 29306520 DOI: 10.1016/j.gie.2017.07.018] [Citation(s) in RCA: 350] [Impact Index Per Article: 50.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 07/13/2017] [Indexed: 02/08/2023]
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Conigliaro R, Fanti L, Manno M, Brosolo P. Italian Society of Digestive Endoscopy (SIED) position paper on the non-anaesthesiologist administration of propofol for gastrointestinal endoscopy. Dig Liver Dis 2017; 49:1185-1190. [PMID: 28951114 DOI: 10.1016/j.dld.2017.08.038] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Revised: 07/30/2017] [Accepted: 08/24/2017] [Indexed: 12/11/2022]
Abstract
Propofol sedation by non-anesthesiologists in GI endoscopy, despite generally considered a safe procedure, is still a matter of debate. Benefits of propofol sedation include rapid onset of action, greater patient comfort and fast recovery with prompt discharge from the endoscopy unit. The use of propofol for sedation in GI endoscopy, preceded by dedicated training courses, has been approved by several anaesthesiologist and gastroenterologist societies but an Italian position paper taking into account the Italian law is lacking. In the present document, the Italian Society of Digestive Endoscopy (SIED) Sedation Group, on behalf of the SIED, presents a series of updated position statements concerning propofol sedation in GI endoscopy. The paper summarizes the advantages of propofol, how it should be administered and how patients should be monitored. Moreover, details concerning proper training of non-anaesthesiologist personnel involved in its use are provided. Protocols concerning propofol use s must be shared with the hospital's anaesthesiology staff and approved by the hospital's Executive Director.
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Affiliation(s)
- Rita Conigliaro
- Gastroenterology and Digestive Endoscopy Unit, Ospedale S. Agostino-Estense Hospital/Hospital-University Institution, Modena, Italy.
| | - Lorella Fanti
- Division of Gastroenterology and Gastrointestinal Endoscopy, Vita-Salute San Raffaele, University-Scientific Institute San Raffaele, Milan, Italy
| | - Mauro Manno
- Digestive Endoscopy Unit, Ospedale di Carpi, Ramazzini Hospital, Carpi, Modena, Italy
| | - Piero Brosolo
- Gastroenterology Unit, Ospedale S. Maria degli Angeli Hospital, Pordenone, Italy
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Lin OS. Sedation for routine gastrointestinal endoscopic procedures: a review on efficacy, safety, efficiency, cost and satisfaction. Intest Res 2017; 15:456-466. [PMID: 29142513 PMCID: PMC5683976 DOI: 10.5217/ir.2017.15.4.456] [Citation(s) in RCA: 87] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 08/03/2017] [Accepted: 08/03/2017] [Indexed: 02/07/2023] Open
Abstract
Most gastrointestinal endoscopic procedures are now performed with sedation. Moderate sedation using benzodiazepines and opioids continue to be widely used, but propofol sedation is becoming more popular because its unique pharmacokinetic properties make endoscopy almost painless, with a very predictable and rapid recovery process. There is controversy as to whether propofol should be administered only by anesthesia professionals (monitored anesthesia care) or whether properly trained non-anesthesia personnel can use propofol safely via the modalities of nurse-administered propofol sedation, computer-assisted propofol sedation or nurse-administered continuous propofol sedation. The deployment of non-anesthesia administered propofol sedation for low-risk procedures allows for optimal allocation of scarce anesthesia resources, which can be more appropriately used for more complex cases. This can address some of the current shortages in anesthesia provider supply, and can potentially reduce overall health care costs without sacrificing sedation quality. This review will discuss efficacy, safety, efficiency, cost and satisfaction issues with various modes of sedation for non-advanced, non-emergent endoscopic procedures, mainly esophagogastroduodenoscopy and colonoscopy.
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Affiliation(s)
- Otto S Lin
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
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Lin OS, Kozarek RA, Tombs D, La Selva D, Weigel W, Beecher R, Jensen A, Gluck M, Ross A. The First US Clinical Experience With Computer-Assisted Propofol Sedation: A Retrospective Observational Comparative Study on Efficacy, Safety, Efficiency, and Endoscopist and Patient Satisfaction. Anesth Analg 2017; 125:804-811. [PMID: 28319511 DOI: 10.1213/ane.0000000000001898] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Computer-assisted propofol sedation (CAPS) is now approved for moderate sedation of American Society of Anesthesiologists (ASA) class I and II patients undergoing routine endoscopy. As the first US medical center to adopt CAPS for routine clinical use, we compared patient and endoscopist satisfaction with CAPS versus midazolam and fentanyl (MF) sedation. METHODS Patients who underwent elective outpatient upper endoscopy and colonoscopy with CAPS were compared with concurrent patients sedated with MF. The primary end points were patient satisfaction (measured by the validated Patient Sedation Satisfaction Index [PSSI]), and endoscopist satisfaction (Clinician Sedation Satisfaction Index [CSSI]). Secondary end points included procedural success rates, polyp detection rates, adverse events, and procedure/recovery times. Multivariable regression was used for comparative analysis. RESULTS CAPS was utilized to sedate 244 patients, of whom 55 underwent upper endoscopy, 173 colonoscopy, and 16 double procedures. During the same period, 75 upper endoscopies, 223 colonoscopies, and 30 doubles were performed with MF on similar patients. For upper endoscopy, the procedural success rate was 98.2% for CAPS versus 98.7% for MF (P = .96), whereas for colonoscopy, the success rate was 98.9% vs 98.8% (P = .59). Colonoscopic polyp detection rate was 54.5% for CAPS and 59.3% for MF (P = .67). Procedure times were similar between CAPS and MF. For CAPS, the mean recovery time was 26.4 vs 39.1 minutes for MF (P < .001). One CAPS patient required mask ventilation, 4 experienced asymptomatic hypotension or desaturation, and 5 experienced marked agitation resulting from undersedation. For MF, 5 patients had hypotension or desaturation, and 8 experienced undersedation. For colonoscopy, the CAPS group had higher PSSI scores for sedation adequacy, the recovery process and global satisfaction, and higher CSSI scores for ease of sedation administration, the recovery process and global satisfaction. For upper endoscopy and doubles, the CAPS CSSI score was higher for the recovery process only. All P values were adjusted for confounding by using regression analysis. CONCLUSIONS In low-risk patients, CAPS appears to be effective and efficient. CAPS is associated with higher satisfaction than MF for colonoscopies and, to a lesser extent, upper endoscopies.
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Affiliation(s)
- Otto S Lin
- From the *Digestive Disease Institute and †Department of Anesthesia, Virginia Mason Medical Center, Seattle, Washington
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Editorial: Endoscopic Sedation: Who, Which, When? Am J Gastroenterol 2017; 112:303-305. [PMID: 28154379 DOI: 10.1038/ajg.2016.557] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 11/04/2016] [Indexed: 12/11/2022]
Abstract
The costs of medical care are rising and media has focused attention on the costs of colonoscopy as a potential cause. A major component of procedural costs is the sedation, which is a combination of the drugs used and who administers them. An analysis of advanced endoscopic procedures revealed that the rate of sedation failure was significantly lower among patients administered sedation by anesthesia compared with patients who received moderate sedation administered by endoscopy staff. The authors argue that all endoscopic retrograde cholangiopancreatography (ERCP) should be performed with anesthesia-administered sedation. Balancing this argument, another paper reported a significant increase in the proportion of endoscopic procedures performed with anesthesia assistance with the majority being performed in low-risk patients. Propofol and who administers the drug will be a key issue in managing health-care costs.
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