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Kim A, Kim H, Kim ER, Kim JE, Hong SN, Chang DK, Kim YH. Risk factors and management of iatrogenic colorectal perforation in diagnostic colonoscopy: a single-center cohort study. Scand J Gastroenterol 2024; 59:749-754. [PMID: 38380637 DOI: 10.1080/00365521.2024.2316766] [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: 10/16/2023] [Accepted: 02/05/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND AND AIMS Diagnostic colonoscopy plays a central role in colorectal cancer screening programs. We analyzed the risk factors for perforation during diagnostic colonoscopy and discussed the treatment outcomes. METHODS We performed a retrospective analysis of risk factors and treatment outcomes of perforation during 74,426 diagnostic colonoscopies between 2013 and 2018 in a tertiary hospital. RESULTS A total of 19 perforations were identified after 74,426 diagnostic colonoscopies or sigmoidoscopies, resulting in a standardized incidence rate of 0.025% or 2.5 per 10,000 colonoscopies. The majority (15 out of 19, 79%) were found at the sigmoid colon and recto-sigmoid junction. Perforation occurred mostly in less than 1000 cases of colonoscopy (16 out of 19, 84%). In particular, the incidence of perforation was higher in more than 200 cases undergoing slightly advanced colonoscopy rather than beginners who had just learned colonoscopy. Old age (≥ 70 years), inpatient setting, low body mass index (BMI), and sedation status were significantly associated with increased risk of perforation. Nine (47%) of the patients underwent operative treatment and ten (53%) were managed non-operatively. Patients who underwent surgery were often diagnosed with delayed or concomitant abdominal pain. Perforations of rectum tended to be successfully treated with endoscopic clipping. CONCLUSIONS Additional precautions are required to prevent perforation in elderly patients, hospital settings, low BMI, sedated patients, or by a doctor with slight familiarity with endoscopies (but still insufficient experience). Endoscopic treatment should be actively considered if diagnosis is prompt, abdominal pain absent, and especially the rectal perforation is present.
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Affiliation(s)
- Aryoung Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Heejung Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Eun Ran Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ji Eun Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sung Noh Hong
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dong Kyung Chang
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Young-Ho Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Minciullo A, Filomeno L. Nurse-Administered Propofol Sedation Training Curricula and Propofol Administration in Digestive Endoscopy Procedures: A Scoping Review of the Literature. Gastroenterol Nurs 2024; 47:33-40. [PMID: 37937982 DOI: 10.1097/sga.0000000000000780] [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] [Received: 10/19/2022] [Accepted: 07/21/2023] [Indexed: 11/09/2023] Open
Abstract
Although efficacy and safety of nonanesthesiologist administration of propofol and nurse-administered propofol sedation practices have been amply demonstrated in patients at low American Society of Anesthesiologists physical status risk, they are still severely limited. To date, it is quite difficult to find a protocol or a shared training program. The aim of the study was to verify requirements, types of training, and operating methods described in the literature for the administration of propofol by a nurse. A scoping review of the literature was conducted in accordance with the PRISMA-ScR guidelines and in line with Arksey and O'Malley's framework, within four main databases of biomedical interest: MEDLINE, CINAHL, Scopus, and Web of Science. We selected studies published during the last 20 years, including only nurses not trained in anesthesia. Seventeen articles were eligible. Despite the differences between the training and administration methods, efficacy and safety of deep sedation managed by trained nurses were comparable, just like when sedation was administered by certified registered nurse anesthetists. Training programs have been investigated in detail by only a small number of studies, although its efficacy and safety have been widely demonstrated. It is important, then, to collect evidence that allows developing of unified international guidelines for training methods to offer safe and cost-effective quality sedation.
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Affiliation(s)
- Andrea Minciullo
- Andrea Minciullo, MSN, RN, is Head Nurse, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
- Lucia Filomeno, MSN, RN, is Research Fellow, Sapienza University of Rome, Rome, Italy
| | - Lucia Filomeno
- Andrea Minciullo, MSN, RN, is Head Nurse, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
- Lucia Filomeno, MSN, RN, is Research Fellow, Sapienza University of Rome, Rome, Italy
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Wehrmann T, Riphaus A, Eckardt AJ, Klare P, Kopp I, von Delius S, Rosien U, Tonner PH. Updated S3 Guideline "Sedation for Gastrointestinal Endoscopy" of the German Society of Gastroenterology, Digestive and Metabolic Diseases (DGVS) - June 2023 - AWMF-Register-No. 021/014. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:e654-e705. [PMID: 37813354 DOI: 10.1055/a-2165-6388] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Affiliation(s)
- Till Wehrmann
- Clinic for Gastroenterology, DKD Helios Clinic Wiesbaden, Wiesbaden, Germany
| | - Andrea Riphaus
- Internal Medicine, St. Elisabethen Hospital Frankfurt Artemed SE, Frankfurt, Germany
| | - Alexander J Eckardt
- Clinic for Gastroenterology, DKD Helios Clinic Wiesbaden, Wiesbaden, Germany
| | - Peter Klare
- Department Internal Medicine - Gastroenterology, Diabetology, and Hematology/Oncology, Hospital Agatharied, Hausham, Germany
| | - Ina Kopp
- Association of the Scientific Medical Societies in Germany e.V. (AWMF), Berlin, Germany
| | - Stefan von Delius
- Medical Clinic II - Internal Medicine - Gastroenterology, Hepatology, Endocrinology, Hematology, and Oncology, RoMed Clinic Rosenheim, Rosenheim, Germany
| | - Ulrich Rosien
- Medical Clinic, Israelite Hospital, Hamburg, Germany
| | - Peter H Tonner
- Anesthesia and Intensive Care, Clinic Leer, Leer, Germany
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Wehrmann T, Riphaus A, Eckardt AJ, Klare P, Kopp I, von Delius S, Rosien U, Tonner PH. Aktualisierte S3-Leitlinie „Sedierung in der gastrointestinalen Endoskopie“ der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS). ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:1246-1301. [PMID: 37678315 DOI: 10.1055/a-2124-5333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Affiliation(s)
- Till Wehrmann
- Klinik für Gastroenterologie, DKD Helios Klinik Wiesbaden, Wiesbaden, Deutschland
| | - Andrea Riphaus
- Innere Medizin, St. Elisabethen Krankenhaus Frankfurt Artemed SE, Frankfurt, Deutschland
| | - Alexander J Eckardt
- Klinik für Gastroenterologie, DKD Helios Klinik Wiesbaden, Wiesbaden, Deutschland
| | - Peter Klare
- Abteilung Innere Medizin - Gastroenterologie, Diabetologie und Hämato-/Onkologie, Krankenhaus Agatharied, Hausham, Deutschland
| | - Ina Kopp
- Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V. (AWMF), Berlin, Deutschland
| | - Stefan von Delius
- Medizinische Klinik II - Innere Medizin - Gastroenterologie, Hepatologie, Endokrinologie, Hämatologie und Onkologie, RoMed Klinikum Rosenheim, Rosenheim, Deutschland
| | - Ulrich Rosien
- Medizinische Klinik, Israelitisches Krankenhaus, Hamburg, Deutschland
| | - Peter H Tonner
- Anästhesie- und Intensivmedizin, Klinikum Leer, Leer, Deutschland
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Qin Y, Chen S, Zhang Y, Liu W, Lin Y, Chi X, Chen X, Yu Z, Su D. A Bibliometric Analysis of Endoscopic Sedation Research: 2001-2020. Front Med (Lausanne) 2022; 8:775495. [PMID: 35047526 PMCID: PMC8761812 DOI: 10.3389/fmed.2021.775495] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 12/06/2021] [Indexed: 12/28/2022] Open
Abstract
Background and Aims: To evaluate endoscopic sedation research and predict research hot spots both quantitatively and qualitatively using bibliometric analysis. Methods: We extracted relevant publications from the Web of Science Core Collection (WoSCC) on 13 December 2020. We examined the retrieved data by bibliometric analysis (e.g., co-cited and cluster analysis, keyword co-occurrence) using the software CiteSpace and VOSviewer and the website of bibliometrics, the Online Analysis Platform of Literature Metrology (http://bibliometric.com/), to analyse and predict the trends and hot spots in this field. Main Results: We identified 2,879 articles and reviews on endoscopic sedation published between 2001 and 2020. Although the overall trend is increasing, with slight fluctuation in some years, there were significant increases in 2007 and 2012. In respect of the contributions on endoscopic sedation research, the United States (US) had the greatest number of publications, and it was followed by Japan and China. In addition, collaboration network analysis revealed that the most frequent collaboration was between the US and China. Six of the top ten most prolific research institutions were located in the US. The most publications on endoscopic sedation research in the past two decades were found primarily in journals on gastroenterology and hepatology. Keyword co-occurrence and co-citation cluster analysis revealed the most popular terms relating to endoscopic sedation in the manner of cluster labels; these included patient anxiety, tolerance, ketamine, propofol, hypoxia, nursing shortage, endoscopic ultrasonography, colorectal cancer, carbon dioxide insufflation, and water exchange (WE). Keyword burst detection suggested that propofol sedation, adverse event, adenoma detection rate (ADR), hypoxemia, and obesity were newly-emergent research hot spots. Conclusions: Our findings showed that hypoxia, adverse event, and ADR, along with conscious sedation and propofol sedation, have been foci of endoscopic sedation research over the past 20 years. The research focus has shifted from sedative drugs to sedative complications and endoscopy quality control, which means that there will be higher requirements and standards for sedative quality and endoscopy quality in the future.
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Affiliation(s)
- Yi Qin
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Sifan Chen
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuanyuan Zhang
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wanfeng Liu
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuxuan Lin
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaoying Chi
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xuemei Chen
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhangjie Yu
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Diansan Su
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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McKenzie P, Fang J, Davis J, Qiu Y, Zhang Y, Adler DG, Gawron AJ. Safety of endoscopist-directed nurse-administered balanced propofol sedation in patients with severe systemic disease (ASA class III). Gastrointest Endosc 2021; 94:124-130. [PMID: 33309879 DOI: 10.1016/j.gie.2020.11.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 11/28/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS The safety of endoscopist-directed nurse-administered propofol sedation (EDNAPS) has been demonstrated in low-risk patients (American Society of Anesthesiologists [ASA] class I and II). There are limited data regarding the safety of EDNAPS for endoscopic procedures in ASA class III patients. The purpose of this study was to determine the safety of EDNAPS for routine outpatient endoscopy in this population. METHODS We retrospectively reviewed all outpatient EGDs and colonoscopies performed with EDNAPS at the University of Utah from January 2015 to November 2018. Exclusion criteria were inpatient procedures, combined procedures, ASA IV or higher, use of continuous or bilevel positive airway pressure at the start of the procedure, or procedures performed by a nongastroenterologist. Major adverse events were defined as intubation or death. Minor adverse events were defined as hypoxia, hypotension, bradycardia, or need for airway interventions. Patients were stratified by procedure type and ASA I/II status and were compared with patients with ASA III status and matched according to age, gender, and the involvement of a fellow in a 3 to 1 fashion. RESULTS The final sample size was 18,910 colonoscopy procedures (17,205 patients) and 9178 EGD procedures (6827 patients). In both colonoscopy and EGD procedures, there were no major adverse events such as intubation, need for resuscitation, or death. The rates of any airway intervention, jaw thrust, oral nasal airway, or use of positive pressure ventilation were low in both procedure types and not different between ASA I/II and ASA III patients. CONCLUSION EDNAPS is safe in both ASA I/II and ASA class III patients undergoing routine outpatient endoscopy.
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Affiliation(s)
| | - John Fang
- University of Utah, Salt Lake City, Utah, USA
| | | | - Yuqing Qiu
- University of Utah, Salt Lake City, Utah, USA
| | - Yue Zhang
- University of Utah, Salt Lake City, Utah, USA
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7
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Green SM, Roback MG, Krauss BS, Miner JR, Schneider S, Kivela PD, Nelson LS, Chumpitazi CE, Fisher JD, Gesek D, Jackson B, Kamat P, Kowalenko T, Lewis B, Papo M, Phillips D, Ruff S, Runde D, Tobin T, Vafaie N, Vargo J, Walser E, Yealy DM, O'Connor RE. Unscheduled Procedural Sedation: A Multidisciplinary Consensus Practice Guideline. Ann Emerg Med 2020; 73:e51-e65. [PMID: 31029297 DOI: 10.1016/j.annemergmed.2019.02.022] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Indexed: 11/15/2022]
Abstract
The American College of Emergency Physicians (ACEP) organized a multidisciplinary effort to create a clinical practice guideline specific to unscheduled, time-sensitive procedural sedation, which differs in important ways from scheduled, elective procedural sedation. The purpose of this guideline is to serve as a resource for practitioners who perform unscheduled procedural sedation regardless of location or patient age. This document outlines the underlying background and rationale, and issues relating to staffing, practice, and quality improvement.
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8
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Green SM, Leroy PL, Roback MG, Irwin MG, Andolfatto G, Babl FE, Barbi E, Costa LR, Absalom A, Carlson DW, Krauss BS, Roelofse J, Yuen VM, Alcaino E, Costa PS, Mason KP. An international multidisciplinary consensus statement on fasting before procedural sedation in adults and children. Anaesthesia 2019; 75:374-385. [PMID: 31792941 PMCID: PMC7064977 DOI: 10.1111/anae.14892] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2019] [Indexed: 01/29/2023]
Abstract
The multidisciplinary International Committee for the Advancement of Procedural Sedation presents the first fasting and aspiration prevention recommendations specific to procedural sedation, based on an extensive review of the literature. These were developed using Delphi methodology and assessment of the robustness of the available evidence. The literature evidence is clear that fasting, as currently practiced, often substantially exceeds recommended time thresholds and has known adverse consequences, for example, irritability, dehydration and hypoglycaemia. Fasting does not guarantee an empty stomach, and there is no observed association between aspiration and compliance with common fasting guidelines. The probability of clinically important aspiration during procedural sedation is negligible. In the post-1984 literature there are no published reports of aspiration-associated mortality in children, no reports of death in healthy adults (ASA physical status 1 or 2) and just nine reported deaths in adults of ASA physical status 3 or above. Current concerns about aspiration are out of proportion to the actual risk. Given the lower observed frequency of aspiration and mortality than during general anaesthesia, and the theoretical basis for assuming a lesser risk, fasting strategies in procedural sedation can reasonably be less restrictive. We present a consensus-derived algorithm in which each patient is first risk-stratified during their pre-sedation assessment, using evidence-based factors relating to patient characteristics, comorbidities, the nature of the procedure and the nature of the anticipated sedation technique. Graded fasting precautions for liquids and solids are then recommended for elective procedures based upon this categorisation of negligible, mild or moderate aspiration risk. This consensus statement can serve as a resource to practitioners and policymakers who perform and oversee procedural sedation in patients of all ages, worldwide.
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Affiliation(s)
- S M Green
- Department of Emergency Medicine, Loma Linda University, Loma Linda, CA, USA
| | - P L Leroy
- Department of Pediatrics, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - M G Roback
- University of Colorado School of Medicine, Aurora, CO, USA
| | - M G Irwin
- Department of Anaesthesiology, University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - G Andolfatto
- University of British, Columbia Department of Emergency Medicine, Lions Gate Hospital, North Vancouver, BC, Canada
| | - F E Babl
- Department of Emergency Medicine, Royal Children's Hospital, Parkville, Vic., Australia
| | - E Barbi
- Department of Pediatrics, Institute for Maternal and Child Health-IRCCS 'Burlo Garofolo', Trieste, Italy
| | - L R Costa
- Department of Pediatric Dentistry, Federal University of Goias, Goiania-Goias, Brazil
| | - A Absalom
- Department of Anaesthesia, University of Groningen, University Medical Center Groningen, the Netherlands
| | - D W Carlson
- Department of Pediatrics, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - B S Krauss
- Department of Pediatrics, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | - J Roelofse
- Departments of Anaesthesia, University of the Western Cape, Stellenbosch University, Tygerberg, Republic of South Africa
| | - V M Yuen
- Department of Anaesthesiology, Hong Kong Children's Hospital and Queen Mary Hospital, University of Hong Kong, Hong Kong
| | - E Alcaino
- Department of Paediatric Dentistry, University of Sydney, Westmead Centre for Oral Health, Sydney, NSW, Australia
| | - P S Costa
- Department of Pediatrics, Federal University of Goias, Goiania-Goias, Brazil
| | - K P Mason
- Department of Anesthesia, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
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Bodnar J. The Use of Propofol for Continuous Deep Sedation at the End of Life: A Definitive Guide. J Pain Palliat Care Pharmacother 2019; 33:63-81. [DOI: 10.1080/15360288.2019.1667941] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- John Bodnar
- John Bodnar, Penn Hospice at Chester County, West Chester, Pennsylvania, USA
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10
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The rise, fall, and future direction of computer-assisted personalized sedation. Curr Opin Anaesthesiol 2019; 32:480-487. [DOI: 10.1097/aco.0000000000000761] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Bode K, Whittaker P, Lucas J, Müssigbrodt A, Hindricks G, Richter S, Doering M. Deep sedation for transvenous lead extraction: a large single-centre experience. Europace 2019; 21:1246-1253. [DOI: 10.1093/europace/euz131] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 04/11/2019] [Indexed: 11/12/2022] Open
Abstract
Abstract
Aims
Transvenous lead extraction for cardiac implantable electronic devices (CIED) is of growing importance. Nevertheless, the optimal anaesthetic approach, general anaesthesia vs. deep sedation (DS), remains unresolved. We describe our tertiary centre experience of the feasibility and safety of DS.
Methods and results
Extraction procedures were performed in the electrophysiology (EP) laboratory by two experienced electrophysiologists. We used intravenous Fentanyl, Midazolam, and Propofol for DS. A stepwise approach with locking stylets, dilator sheaths, and mechanical sheaths via subclavian, femoral, or internal jugular venous access was utilized. Patient characteristics and procedural data were collected. Logistic regression models were used to identify parameters associated with sedation-related complications. Extraction of 476 leads (dwelling time/patient 88 ± 49 months, 30% ICD leads) was performed in 220 patients (64 ± 17 years, 80% male). Deep sedation was initiated with bolus administration of Fentanyl, Midazolam, and Propofol; mean doses 0.34 ± 0.12 μg/kg, 24.3 ± 6.8 μg/kg, and 0.26 ± 0.13 mg/kg, respectively. Deep sedation was maintained with continuous Propofol infusion (initial dose 3.7 ± 1.1 mg/kg/h; subsequently increased to 4.7 ± 1.2 mg/kg/h with 3.9 ± 2.6 adjustments) and boluses of Midazolam and Fentanyl as indicated. Sedation-related episodes of hypotension, requiring vasopressors, and hypoxia, requiring additional airway management, occurred in 25 (11.4%) and 5 (2.3%) patients, respectively. These were managed without adverse consequences. Five patients (2.3%) experienced major intraprocedural complications; there were no procedure-related deaths. All of our logistic regression models indicated intraprocedural support was associated with administration higher Fentanyl doses.
Conclusion
Transvenous lead extraction under DS in the EP laboratory is a safe procedure with high success rates when performed by experienced staff.
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Affiliation(s)
- Kerstin Bode
- Department of Electrophysiology, Heart Center Leipzig, University of Leipzig, Struempellstrasse 39, Leipzig, Germany
| | - Peter Whittaker
- Department of Emergency Medicine, Cardiovascular Research Institute, Wayne State University, Detroit, MI, USA
| | - Johannes Lucas
- Department of Electrophysiology, Heart Center Leipzig, University of Leipzig, Struempellstrasse 39, Leipzig, Germany
| | - Andreas Müssigbrodt
- Department of Electrophysiology, Heart Center Leipzig, University of Leipzig, Struempellstrasse 39, Leipzig, Germany
| | - Gerhard Hindricks
- Department of Electrophysiology, Heart Center Leipzig, University of Leipzig, Struempellstrasse 39, Leipzig, Germany
| | - Sergio Richter
- Department of Electrophysiology, Heart Center Leipzig, University of Leipzig, Struempellstrasse 39, Leipzig, Germany
| | - Michael Doering
- Department of Electrophysiology, Heart Center Leipzig, University of Leipzig, Struempellstrasse 39, Leipzig, Germany
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12
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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: 1.0] [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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13
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Green SM, Mason KP, Krauss BS. Pulmonary aspiration during procedural sedation: a comprehensive systematic review. Br J Anaesth 2018; 118:344-354. [PMID: 28186265 DOI: 10.1093/bja/aex004] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background Although pulmonary aspiration complicating operative general anaesthesia has been extensively studied, little is known regarding aspiration during procedural sedation. Methods We performed a comprehensive, systematic review to identify and catalogue published instances of aspiration involving procedural sedation in patients of all ages. We sought to report descriptively the circumstances, nature, and outcomes of these events. Results Of 1249 records identified by our search, we found 35 articles describing one or more occurrences of pulmonary aspiration during procedural sedation. Of the 292 occurrences during gastrointestinal endoscopy, there were eight deaths. Of the 34 unique occurrences for procedures other than endoscopy, there was a single death in a moribund patient, full recovery in 31, and unknown recovery status in two. We found no occurrences of aspiration in non-fasted patients receiving procedures other than endoscopy. Conclusions This first systematic review of pulmonary aspiration during procedural sedation identified few occurrences outside of gastrointestinal endoscopy, with full recovery typical. Although diligent caution remains warranted, our data indicate that aspiration during procedural sedation appears rare, idiosyncratic, and typically benign.
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Affiliation(s)
- S M Green
- Department of Emergency Medicine, Loma Linda University Medical Center and Children's Hospital, Loma Linda, CA, USA
| | - K P Mason
- Department of Anesthesia, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | - B S Krauss
- Division of Emergency Medicine, Boston Children's Hospital and the Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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14
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Josephy CP, Vinson DR. Feasibility of single- vs two-physician procedural sedation in a small community emergency department. Am J Emerg Med 2018; 36:977-982. [DOI: 10.1016/j.ajem.2017.11.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 11/02/2017] [Indexed: 11/25/2022] Open
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15
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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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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: 69] [Impact Index Per Article: 9.9] [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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17
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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: 1.0] [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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Gouda B, Gouda G, Borle A, Singh A, Sinha A, Singh PM. Safety of non-anesthesia provider administered propofol sedation in non-advanced gastrointestinal endoscopic procedures: A meta-analysis. Saudi J Gastroenterol 2017; 23:133-143. [PMID: 28611336 PMCID: PMC5470372 DOI: 10.4103/sjg.sjg_501_16] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND/AIMS The aim of the study was to evaluate the safety of non-anesthesia provider (NAPP) administered propofol sedation in patients undergoing non-advanced gastrointestinal (GI) endoscopic procedures. MATERIALS AND METHODS Pubmed, Embase, Cochrane central register of controlled trials, Scopus, and Web of Science databases were searched for prospective observational trials involving non-advanced endoscopic procedures. From a total of 608 publications, 25 [colonoscopy (9), upper GI endoscopy (5), and combined procedures (11)] were identified to meet inclusion criteria and were analyzed. Data was analyzed for hypoxia rates, airway intervention rates, and airway complication rates. RESULTS A total of 137,087 patients were involved. A total of 2931 hypoxia episodes (defined as an oxygen saturation below 90%) were reported with a pooled hypoxia rate of 0.014 (95% CI being 0.008-0.023). Similarly, pooled airway intervention rates and pooled airway complication rates were 0.002 (95% CI being 0.006-0.001) and 0.001 (95% CI being 0.000-0.001), respectively. CONCLUSIONS The rates of adverse events in patients undergoing non-advanced GI endoscopic procedures with NAPP sedation are extremely small. Similar data for anesthesia providers is not available. It is prudent for anesthesia providers to demonstrate their superiority in prospective randomized controlled trials, if they like to retain exclusive ownership over propofol sedation in patients undergoing GI endoscopy.
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Affiliation(s)
- Basavana Gouda
- Department of Anesthesia, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA,Address for correspondence: Dr. Basavana Gouda, Department of Anesthesia, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA. E-mail:
| | - Gowri Gouda
- Department of Anesthesia, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anuradha Borle
- Department of Anesthesia, All India Institute of Medical Sciences, New Delhi, India
| | - Akash Singh
- Department of Anesthesia, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ashish Sinha
- Department of Anesthesiology and Critical Care Medicine, Lewis Katz School of Medicine, Medicine Education and Research, Philadelphia, PA 19140, USA
| | - Preet M. Singh
- Department of Anesthesia, All India Institute of Medical Sciences, New Delhi, India
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Abstract
Endoscopist-directed propofol (EDP) refers to delivery of propofol for endoscopic sedation under the direction of an endoscopist without any involvement of an anesthesia specialist (anesthesiologist or nurse anesthetist). EDP has been proven to be safe and is also cost-effective compared with the anesthetist delivered sedation for endoscopy. EDP has been endorsed by US gastroenterology societies as an appropriate paradigm for clinical practice. EDP has proliferated in Switzerland and Germany, but its expansion in the United States has been limited by financial disincentives, concerns about medical-legal risk for endoscopists, and regulatory obstacles.
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Affiliation(s)
- Douglas K Rex
- Indiana University Hospital, Room 4100, 550 North University Boulevard, Indianapolis, IN 46202, USA.
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20
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Chung HK, Lightdale JR. Sedation and Monitoring in the Pediatric Patient during Gastrointestinal Endoscopy. Gastrointest Endosc Clin N Am 2016; 26:507-25. [PMID: 27372774 DOI: 10.1016/j.giec.2016.02.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Sedation is a fundamental component of pediatric gastrointestinal procedures. The 2 main types of sedation for pediatric endoscopy remain general anesthesia and procedural sedation. Although anesthesiologist-administered sedation protocols are more common, there is no ideal regimen for endoscopy in children. This article discusses specific levels of sedation for endoscopy as well as various regimens that can be used to achieve each. Risks and considerations that may be specific to performing gastrointestinal procedures in children are reviewed. Finally, potential future directions for sedation and monitoring that may change the practice of pediatric gastroenterology and ultimately patient outcomes are examined.
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Affiliation(s)
- Hyun Kee Chung
- Pediatric Anesthesia, Department of Anesthesia, UMass Memorial Medical Center, 55 Lake Street North, Worcester, MA 01655, USA
| | - Jenifer R Lightdale
- Pediatric Gastroenterology and Nutrition, UMass Memorial Children's Medical Center, University Campus, 55 Lake Street North, Worcester, MA 01655, USA.
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Outcomes of Propofol Sedation During Emergency Endoscopy Performed for Upper Gastrointestinal Bleeding. Dig Dis Sci 2016; 61:825-34. [PMID: 26541992 DOI: 10.1007/s10620-015-3942-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 10/22/2015] [Indexed: 01/10/2023]
Abstract
BACKGROUND Although propofol-based sedation can be used during emergency endoscopy for upper gastrointestinal bleeding (UGIB), there is a potential risk of sedation-related adverse events, especially in patients with variceal bleeding. AIM We compared adverse events related to propofol-based sedation during emergency endoscopy between patients with non-variceal and variceal bleeding. METHODS Clinical records of patients who underwent emergency endoscopy for UGIB under sedation were reviewed. Adverse events, including shock, hypoxia, and paradoxical reaction, were compared between the non-variceal and variceal bleeding groups. RESULTS Of 703 endoscopies, 539 and 164 were performed for non-variceal and variceal bleeding, respectively. Shock was more common in patients with variceal bleeding compared to those with non-variceal bleeding (12.2 vs. 3.5%, P < 0.001). All patients except one recovered from shock after normal saline hydration, and emergency endoscopy could be finished without interruption in most cases. The incidence of hypoxia and paradoxical reaction did not differ based on the source of bleeding (non-variceal bleeding vs. variceal bleeding: hypoxia, 3.5 vs. 1.8%, P = 0.275; paradoxical reaction interfering with the procedure, 4.1 vs. 5.5%, P = 0.442). CONCLUSIONS Although shock was more common in patients with variceal bleeding compared to those with non-variceal bleeding, most cases could be controlled without procedure interruption. Paradoxical reaction, rather than shock or hypoxia, was the most common cause of procedure interruption in patients with variceal bleeding, but the rate did not differ between patients with non-variceal and variceal bleeding.
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Asserhøj LL, Mosbech H, Krøigaard M, Garvey LH. No evidence for contraindications to the use of propofol in adults allergic to egg, soy or peanut†. Br J Anaesth 2016; 116:77-82. [PMID: 26675952 DOI: 10.1093/bja/aev360] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Propofol is thought to be a potential cause of allergic reactions in patients allergic to egg, soy or peanut, since current formulations contain an emulsion that includes egg lecithin and soybean oil. However, other than six case reports lacking in confirmatory evidence of an allergic reaction, there is no evidence linking the two types of allergies. The aim of this study was to examine the frequency of propofol allergy and to investigate if patients with specific immunoglobulin E (IgE) to egg, soy or peanut tolerated propofol. METHODS Study A examined the frequency of propofol allergy in 273 patients systematically investigated for suspected perioperative allergic reactions. Of these, 153 had been exposed to propofol and underwent skin tests and intravenous provocation. Study B retrospectively investigated propofol exposure and tolerance in 520 adult patients with a positive specific IgE to egg, soy or peanut. RESULTS Four of the 153 propofol-exposed patients (2.6%) investigated in study A were diagnosed with propofol allergy. Of these, three tested positive only on intravenous provocation. None of the four had allergic symptoms when eating egg, soy or peanut and none had detectable levels of specific IgE to egg or soy in their serum. In study B we found no signs of allergic reactions towards propofol in 171 retrieved anaesthetic charts from 99 patients with specific IgE to egg, soy or peanut. CONCLUSION No connection between allergy to propofol and allergy to egg, soy or peanut was found. The present practice of choosing alternatives to propofol in patients with this kind of food allergy is not evidence based and should be reconsidered.
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Affiliation(s)
- L L Asserhøj
- Danish Anaesthesia Allergy Centre (DAAC), Allergy Clinic UA-816, Copenhagen University Hospital, Gentofte, Kildegårdsvej 28, 2900 Hellerup, Denmark
| | - H Mosbech
- Danish Anaesthesia Allergy Centre (DAAC), Allergy Clinic UA-816, Copenhagen University Hospital, Gentofte, Kildegårdsvej 28, 2900 Hellerup, Denmark
| | - M Krøigaard
- Danish Anaesthesia Allergy Centre (DAAC), Allergy Clinic UA-816, Copenhagen University Hospital, Gentofte, Kildegårdsvej 28, 2900 Hellerup, Denmark
| | - L H Garvey
- Danish Anaesthesia Allergy Centre (DAAC), Allergy Clinic UA-816, Copenhagen University Hospital, Gentofte, Kildegårdsvej 28, 2900 Hellerup, Denmark
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Finkelmeier F, Tal A, Ajouaou M, Filmann N, Zeuzem S, Waidmann O, Albert J. ERCP in elderly patients: increased risk of sedation adverse events but low frequency of post-ERCP pancreatitis. Gastrointest Endosc 2015; 82:1051-9. [PMID: 26089104 DOI: 10.1016/j.gie.2015.04.032] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 04/26/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS The continually increasing life expectancy in man comes along with an increasing number of endoscopic interventions performed in patients with advanced or even very advanced age. Data on the feasibility and safety of ERCP in elderly patients are relatively scarce. METHODS By a systematic query of the University Hospital Frankfurt clinical database, patients undergoing their first ERCP procedure at our center were retrospectively identified. Patients were grouped according to age at the day of the intervention (>80 years, 61-80 years, 40-60 years, and <40 years). Demographic data, indication, outcome, and risk factors were compared among the indicated groups. RESULTS A total of 758 patients who underwent ERCP procedures at our center were identified and included in the study. Main indications for ERCP were intraductal gallstones in 345 patients (45%) and tumor obstruction of the bile ducts (distal common bile duct: n = 126 [16.5%], hilar cholangiocarcinoma: n = 89 [11.7%], tumor of papilla of Vater: n = 16 [2.1%]). Gallstones were the most common cause for ERCP in patients aged >80 years (53.8%), and normal findings indicating exclusion of relevant disease were more frequent in patients <80 years (13.4%) compared with older patients (4.3%) (P < .01). Sedation adverse events were significantly more common in individuals aged >80 years compared with younger patients (3.4% vs 0.5%; P < .01). However, post-ERCP pancreatitis was significantly less frequent in the older patients (>80 years) (0.9% vs 5.3%; P < .05). Other adverse events were equally distributed in all age groups. The ERCP success rate (>80%) was not different among age groups. CONCLUSIONS ERCP is safe and efficient in patients aged 80 years or older. However, conscious sedation must be carefully monitored in older patients because risk of sedation adverse events is increased. The incidence of post-ERCP pancreatitis is lower in older patients compared with younger ones.
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Affiliation(s)
- Fabian Finkelmeier
- Department of Medicine 1, J.W. Goethe University Hospital, Frankfurt, Germany
| | - Andrea Tal
- Department of Medicine 1, J.W. Goethe University Hospital, Frankfurt, Germany
| | - Mariam Ajouaou
- Department of Medicine 1, J.W. Goethe University Hospital, Frankfurt, Germany
| | - Natalie Filmann
- Institute of Biostatistics and Math Modeling, Faculty of Medicine, J.W. Goethe University, Frankfurt, Germany
| | - Stefan Zeuzem
- Department of Medicine 1, J.W. Goethe University Hospital, Frankfurt, Germany
| | - Oliver Waidmann
- Department of Medicine 1, J.W. Goethe University Hospital, Frankfurt, Germany
| | - Jörg Albert
- Department of Medicine 1, J.W. Goethe University Hospital, Frankfurt, Germany
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Chan MTV, Wu WKK, Tang RSY. Optimizing depth of sedation for colonoscopy. Can J Anaesth 2015; 62:1143-8. [PMID: 26307188 DOI: 10.1007/s12630-015-0462-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 08/13/2015] [Indexed: 12/22/2022] Open
Affiliation(s)
- Matthew T V Chan
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China.
| | - William K K Wu
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
- State Key Laboratory of Digestive Disease, Department of Medicine & Therapeutics and LKS Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Raymond S Y Tang
- State Key Laboratory of Digestive Disease, Department of Medicine & Therapeutics and LKS Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
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25
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Amornyotin S. Registered nurse-administered sedation for gastrointestinal endoscopic procedure. World J Gastrointest Endosc 2015; 7:769-76. [PMID: 26191341 PMCID: PMC4501967 DOI: 10.4253/wjge.v7.i8.769] [Citation(s) in RCA: 4] [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: 11/04/2014] [Revised: 12/24/2014] [Accepted: 05/05/2015] [Indexed: 02/05/2023] Open
Abstract
The rising use of nonanesthesiologist-administered sedation for gastrointestinal endoscopy has clinical significances. Most endoscopic patients require some forms of sedation and/or anesthesia. The goals of this sedation are to guard the patient's safety, minimize physical discomfort, to control behavior and to diminish psychological responses. Generally, moderate sedation for these procedures has been offered by the non-anesthesiologist by using benzodiazepines and/or opioids. Anesthesiologists and non-anesthesiologist personnel will need to work together for these challenges and for safety of the patients. The sedation training courses including clinical skills and knowledge are necessary for the registered nurses to facilitate the patient safety and the successful procedure. However, appropriate patient selection and preparation, adequate monitoring and regular training will ensure that the use of nurse-administered sedation is a feasible and safe technique for gastrointestinal endoscopic procedures.
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26
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Fanti L, Gemma M, Agostoni M, Rossi G, Ruggeri L, Azzolini ML, Dabizzi E, Beretta L, Testoni PA. Target Controlled Infusion for non-anaesthesiologist propofol sedation during gastrointestinal endoscopy: The first double blind randomized controlled trial. Dig Liver Dis 2015; 47:566-71. [PMID: 25840875 DOI: 10.1016/j.dld.2015.03.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 03/02/2015] [Accepted: 03/06/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Target Controlled Infusion is a sophisticated tool for providing optimal sedation regimen avoiding under or oversedation in gastrointestinal endoscopy. AIMS To compare standard moderate sedation vs. non-anaesthesiologist-administered propofol sedation during gastrointestinal endoscopy. METHODS Randomized controlled trial of 70 consecutive colonoscopies and 70 consecutive esophagogastroduodenoscopies (EGD). Standard group (n=70), received fentanyl (1 μg/kg)+midazolam (0.03-0.04 mg/kg) or midazolam only; propofol group (n=70), received fentanyl (1 μg/kg)+propofol Target Controlled Infusion (1.2-1.6 μg/ml) or propofol Target Controlled Infusion only. Discharge time, endoscopist satisfaction and patient satisfaction were recorded in all endoscopies. RESULTS Colonoscopy: discharge time was significantly shorter in the propofol than the standard group (1.1 ± 0.3 vs. 5 ± 10.2 min, respectively; P=0.03). Endoscopist satisfaction was significantly higher (98.3 ± 11.4/100 vs. 87.2±12/100; P=0.001); patient satisfaction was significantly higher (95 ± 9.3/100 vs. 85.5 ± 14.4/100; P=0.002) in the propofol compared to the standard group. EGD: discharge time was not significantly different in the propofol and standard groups (1.1 ± 0.7 vs. 3.9 ± 9.2 min, respectively; P=0.146). Endoscopist satisfaction was significantly higher (92.7 ± 14.3/100 vs. 82.8 ± 21.2/100; P=0.03); patient satisfaction was significantly higher (93.8 ± 18.2/100 vs. 76.5 ± 25.2/100; P=0.003). In the propofol group 94.3% of patients vs. 71.4% of patients in standard group asked to receive the same sedation in the future (P=0.021). CONCLUSION Target Controlled Infusion is a promising method for non-anaesthesiologist-administered propofol sedation.
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Affiliation(s)
- Lorella Fanti
- Division of Gastroenterology and Gastrointestinal Endoscopy, Vita-Salute San Raffaele University - Scientific Institute San Raffaele, Milan, Italy.
| | - Marco Gemma
- Department of Anesthesiology, Vita-Salute San Raffaele University - Scientific Institute San Raffaele, Milan, Italy
| | - Massimo Agostoni
- Department of Anesthesiology, Vita-Salute San Raffaele University - Scientific Institute San Raffaele, Milan, Italy
| | - Gemma Rossi
- Division of Gastroenterology and Gastrointestinal Endoscopy, Vita-Salute San Raffaele University - Scientific Institute San Raffaele, Milan, Italy
| | - Laura Ruggeri
- Department of Anesthesiology, Vita-Salute San Raffaele University - Scientific Institute San Raffaele, Milan, Italy
| | - Maria Luisa Azzolini
- Department of Anesthesiology, Vita-Salute San Raffaele University - Scientific Institute San Raffaele, Milan, Italy
| | - Emanuele Dabizzi
- Division of Gastroenterology and Gastrointestinal Endoscopy, Vita-Salute San Raffaele University - Scientific Institute San Raffaele, Milan, Italy
| | - Luigi Beretta
- Department of Anesthesiology, Vita-Salute San Raffaele University - Scientific Institute San Raffaele, Milan, Italy
| | - Pier Alberto Testoni
- Division of Gastroenterology and Gastrointestinal Endoscopy, Vita-Salute San Raffaele University - Scientific Institute San Raffaele, Milan, Italy
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Studying and Incorporating Efficiency into Gastrointestinal Endoscopy Centers. Gastroenterol Res Pract 2015; 2015:764153. [PMID: 26101525 PMCID: PMC4458534 DOI: 10.1155/2015/764153] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2015] [Accepted: 04/26/2015] [Indexed: 02/07/2023] Open
Abstract
Efficiency is defined as the use of resources in such a way as to maximize the production of goods and services. Improving efficiency has been the focus of management in many industries; however, it has not been until recently that incorporating efficiency models into healthcare has occurred. In particular, the study and development of improvement projects aimed at enhancing efficiency in GI have been growing rapidly in recent years. This focus on improving efficiency in GI has been spurred by the dramatic rise in the demand for endoscopic procedures as well as the rising number of insured patients requiring GI care coupled at the same time with limited resources in terms of staffing and space in endoscopy centers. This paper will critically review the history of efficiency in endoscopy centers, first by looking at other healthcare industries that have extensively studied and improved efficiency in their fields, examine a number of proposed efficiency metrics and benchmarks in endoscopy centers, and finally discuss opportunities where endoscopy centers could improve their efficiency.
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28
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Yamamoto H, Gotoda T, Nakamura T, Yamamoto T, Kikuchi H, Kitamura M, Itoi T, Moriyasu F. Clinical impact of gastroenterologist-administered propofol during esophagogastroduodenoscopy: a randomized comparison at a single medical clinic. Gastric Cancer 2015; 18:326-31. [PMID: 24695971 DOI: 10.1007/s10120-014-0371-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Accepted: 03/09/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although midazolam is widely used during endoscopic procedures by endoscopists, propofol has been recently favored for its rapid action and metabolism. The aim of this study is to compare the clinical advantages between propofol and midazolam use during screening esophagogastroduodenoscopy (EGD) for gastric cancer and post-procedure management at a medical clinic. METHODS One hundred six healthy patients aged 20-69 years requesting sedation for screening EGD from October 2012 to May 2013 at a single clinic in Japan were randomly assigned to propofol (n = 54) or midazolam (n = 52). Medications were given by bolus injection, and the dose was adjusted by body weight. Sedation level and tolerability during EGD and recovery time were assessed. Sedation level and tolerability were evaluated by American Society of Anesthesiologists responsiveness levels and four levels of the gag reflex, respectively. For safety purposes, endoscopists and nurses were trained in administering propofol and an anesthesiologist was on call at all times. RESULTS No statistically significant differences were found between the two groups in sedation level and patient tolerability. Full recovery time in the propofol group (4.7 min) was significantly shorter than that in the midazolam group (24 min, P < 0.01). CONCLUSIONS Regarding post-procedure management of patients in a medical clinic, propofol use might not necessitate a recovery room and excessive assessment tasks because of rapid recovery time without any prolonged reaction, which causes patient compliance. ( CLINICAL TRIAL REGISTRATION NUMBER UMIN000009142.).
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Affiliation(s)
- Hisae Yamamoto
- Department of Gastroenterology, Tokyo East Hospital, Tokyo, Japan
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Jensen JT, Konge L, Møller A, Hornslet P, Vilmann P. Endoscopy nurse-administered propofol sedation performance. Development of an assessment tool and a reliability testing model. Scand J Gastroenterol 2014; 49:1014-9. [PMID: 24989064 DOI: 10.3109/00365521.2014.896411] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE A gold standard of skills required for nurse-administered propofol sedation (NAPS) for gastroenterological endoscopic procedures has been proposed but not established. Due to the potentially hazardous nature of NAPS, an assessment tool is needed to objectively judge the adequacy of training and for future certification. The aim of this study was to develop an assessment tool for measuring competency in propofol sedation and to explore the reliability and validity of the tool. MATERIAL AND METHODS The nurse-administered propofol assessment tool (NAPSAT) was developed in a Delphi-like fashion. Consensus was achieved on 17 items. Validity evidence was gathered in a case-control study in a full-scale simulation setting. Six experienced nurses and six novice nurses were filmed in two scenarios for assessment according to the assessment tool by three content expert raters. RESULTS A total of 72 NAPSAT assessment forms were analyzed. Inter-rater reliability, Cronbach's α = 0.54 and generalizability coefficient = 0.68. The experienced nurses scored higher than the novices, 52.8 versus 62.7, p = 0.009. The provided pass/borderline/fail assessment showed significant difference, p = < 0.001, Cronbach's α = 0.80, with the novices being more likely to fail and the experienced more likely to pass. CONCLUSION Assessing sedation skills in a simulator is possible. Video assessment requires expert knowledge of the procedure and the rating matrix. Overall, NAPSAT showed fair inter-rater reliability and good construct validity. This makes NAPSAT fit for formative assessment and proficiency feedback; however, high stakes and summative assessment cannot be advised.
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Affiliation(s)
- Jeppe Thue Jensen
- Endoscopy Unit, University Hospital Herlev, Department of Surgery , Herlev , Denmark
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Risk factors for early colonoscopic perforation include non-gastroenterologist endoscopists: a multivariable analysis. Clin Gastroenterol Hepatol 2014; 12:85-92. [PMID: 23891916 PMCID: PMC4050305 DOI: 10.1016/j.cgh.2013.06.030] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Revised: 06/03/2013] [Accepted: 06/17/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Bowel perforation is a rare but serious complication of colonoscopy. Its prevalence is increasing with the rapidly growing volume of procedures performed. Although colonoscopies have been performed for decades, the risk factors for perforation are not completely understood. We investigated risk factors for perforation during colonoscopy by assessing variables that included sedation type and endoscopist specialty and level of training. METHODS We performed a retrospective multivariate analysis of risk factors for early perforation (occurring at any point during the colonoscopy but recognized during or immediately after the procedure) in adult patients by using the Clinical Outcomes Research Initiative National Endoscopic Database. Risk factors were determined from published articles. Additional variables assessed included endoscopist specialty and years of experience, trainee involvement, and sedation with propofol. RESULTS We identified 192 perforation events during 1,144,900 colonoscopies from 85 centers entered into the database from January 2000-March 2011. On multivariate analysis, increasing age, American Society of Anesthesia class, female sex, hospital setting, any therapy, and polyps >10 mm were significantly associated with increased risk of early perforation. Colonoscopies performed by surgeons and endoscopists of unknown specialty had higher rates of perforation than those performed by gastroenterologists (odds ratio, 2.00; 95% confidence interval, 1.30-3.08). Propofol sedation did not significantly affect risk for perforation. CONCLUSIONS In addition to previously established risk factors, non-gastroenterologist specialty was found to affect risk for perforations detected during or immediately after colonoscopy. This finding could result from differences in volume and style of endoscopy training. Further investigation into these observed associations is warranted.
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Okholm C, Hadikhadem T, Andersen LT, Donatsky AM, Vilmann P, Achiam MP. No increased risk of perforation during colonoscopy in patients undergoing Nurse Administered Propofol Sedation. Scand J Gastroenterol 2013; 48:1333-8. [PMID: 24063514 DOI: 10.3109/00365521.2013.837951] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Nurse Administered Propofol Sedation (NAPS) contributes to a deeper sedation of the patients, making them unable to respond to pain and an increased incidence of perforations has been speculated. The objective of this study was to evaluate the risk of perforations during colonoscopies performed with either NAPS or conventional sedation regimes. MATERIAL AND METHODS Data were retrospectively retracted from medical journals from 1 January 2007 to 31 December 2011. All journals were examined and cross-referenced to reveal any perforations. We analyzed all colonoscopies in regard to nature of the procedure (diagnostic vs therapeutic), experience of the endoscopist and ASA-classification of the patients. RESULTS A total of 6371 colonoscopies were performed, of which 3155 were performed under propofol sedation. There were 16 perforations (0.25%); 10 of these performed during NAPS and 6 during conventional colonoscopy (p = 0.454, OR: 1.7 (95% CI: 0.6-5.7)). There were 4874 diagnostic and 1497 therapeutic colonoscopies, with a majority of the perforations (94%) occurring during a diagnostic procedure (p = 0.389). No statistically difference was found in the incidence of perforations caused by an experienced or less experienced endoscopist (p = 0.589). CONCLUSION The risk of colonic perforations during colonoscopy was not found to be significantly higher in patients undergoing NAPS compared to patients undergoing conventional sedation, although a tendency may exist. Furthermore, we found no correlation to neither experience of the endoscopist, nature of the procedure nor sex of the patients. Larger and prospective studies are needed to further evaluate on this subject.
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Affiliation(s)
- Cecilie Okholm
- Department of Surgery, Herlev Hospital, University of Copenhagen , Herlev , Denmark
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Slagelse C, Vilmann P, Hornslet P, Jørgensen HL, Horsted TI. The role of capnography in endoscopy patients undergoing nurse-administered propofol sedation: a randomized study. Scand J Gastroenterol 2013; 48:1222-30. [PMID: 23992025 DOI: 10.3109/00365521.2013.830327] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE. Standard benzodiazepine/opioid cocktail has proven inferior to propofol sedation during complicated endoscopic procedures and in low-tolerance patients. Propofol is a short-acting hypnotic with a potential risk of respiratory depression at levels of moderate to deep sedation. The existing literature on capnography for endoscopy patients sedated with nurse-administered propofol sedation (NAPS) is limited. Can the addition of capnography to standard monitoring during endoscopy with NAPS reduce the number, duration, and level of hypoxia. MATERIALS AND METHODS. This study was a randomized controlled trial with an intervention group (capnography) and a control group (without capnography). Eligible subjects were consecutive patients for endoscopy at Gentofte Hospital compliant with the criteria of NAPS. RESULTS. Five hundred and forty patients, 263 with capnography and 277 without capnography, were included in the analysis. The number and total duration of hypoxia was reduced by 39.3% and 21.1% in the intervention group compared to the control group (p > 0.05). No differences in actions taken against insufficient respiration were found. Changes in end-tidal carbon dioxide (R = 0.177, p-value < 0.001) and respiratory rate (R = 0.092, p-value < 0.001) were correlated to oxygen saturation (SpO2) up to 36 s prior to changes in SpO2. CONCLUSIONS. Capnography seems to reduce the number and duration of hypoxia in NAPS patients (p > 0.05). Capnography is able to detect insufficient respiration that may lead to hypoxia prior to changes in pulse oximetry. However, due to a limited clinical benefit and additional costs associated with capnography, we do not find capnography necessary during the use of NAPS.
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Affiliation(s)
- Charlotte Slagelse
- Department of Endoscopy, Copenhagen University Hospital Gentofte , Hellerup , Denmark
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Chung HJ, Bang BW, Kim HG, Kwon KS, Shin YW, Jeong S, Lee DH, Park SG. Delayed flumazenil injection after endoscopic sedation increases patient satisfaction compared with immediate flumazenil injection. Gut Liver 2013; 8:7-12. [PMID: 24516695 PMCID: PMC3916690 DOI: 10.5009/gnl.2014.8.1.7] [Citation(s) in RCA: 3] [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: 01/26/2013] [Revised: 03/10/2013] [Accepted: 03/13/2013] [Indexed: 12/20/2022] Open
Abstract
Background/Aims Flumazenil was administered after the completion of endoscopy under sedation to reduce recovery time and increase patient safety. We evaluated patient satisfaction after endoscopy under sedation according to the timing of a postprocedural flumazenil injection. Methods In total, 200 subjects undergoing concurrent colonoscopy and upper endoscopy while sedated with midazolam and meperidine were enrolled in our investigation. We randomly administered 0.3 mg of flumazenil either immediately or 15 minutes after the endoscopic procedure. A postprocedural questionnaire and next day telephone interview were conducted to assess patient satisfaction. Results Flumazenil injection timing did not affect the time spent in the recovery room when comparing the two groups of patients. However, the subjects in the 15 minutes injection group were more satisfied with undergoing endoscopy under sedation than the patients in the immediate injection group according to the postprocedural survey (p=0.019). However, no difference in overall satisfaction, memory, or willingness to undergo a future endoscopy was observed between the two groups when the telephone survey was conducted on the following day. Conclusions This study demonstrated that a delayed flumazenil injection after endoscopic sedation increased patient satisfaction without prolonging recovery time, even though the benefit of the delayed flumazenil injection did not persist into the following day.
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Affiliation(s)
- Hyun Jung Chung
- Division of Gastroenterology, Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | - Byoung Wook Bang
- Division of Gastroenterology, Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | - Hyung Gil Kim
- Division of Gastroenterology, Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | - Kye Sook Kwon
- Division of Gastroenterology, Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | - Yong Woon Shin
- Division of Gastroenterology, Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | - Seok Jeong
- Division of Gastroenterology, Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | - Don Haeng Lee
- Division of Gastroenterology, Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | - Shin Goo Park
- Department of Occupational and Environmental Medicine, Inha University School of Medicine, Incheon, Korea
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Vinson DR, Hoehn CL. Sedation-assisted Orthopedic Reduction in Emergency Medicine: The Safety and Success of a One Physician/One Nurse Model. West J Emerg Med 2013; 14:47-54. [PMID: 23447756 PMCID: PMC3582522 DOI: 10.5811/westjem.2012.4.12455] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Revised: 04/09/2012] [Accepted: 04/30/2012] [Indexed: 02/01/2023] Open
Abstract
Introduction Much of the emergency medical research on sedation-assisted orthopedic reductions has been undertaken with two physicians––one dedicated to the sedation and one to the procedure. Clinical practice in community emergency departments (EDs), however, often involves only one physician, who both performs the procedure and simultaneously oversees the crendentialed registered nurse who administers the sedation medication and monitors the patient. Although the dual-physician model is advocated by some, evidence in support of its superiority is lacking. Methods: In this electronic health records review we describe sedation-assisted closed reductions of major joints and forearm fractures in three suburban community EDs. The type of procedure and sedation medication, need for specialty assistance, success rates, and intervention-requiring adverse events are reported. Results: During the 18-month study period, procedural sedation was performed 457 times on 442 patients undergoing closed reduction for shoulder dislocations (n = 111), elbow dislocations (n = 29), hip dislocations (n = 101), and forearm fractures (n = 201). In the vast majority of this cohort (98.4% [435/442]), a single emergency physician simultaneously managed both the procedural sedation and the initial orthopedic reduction without the assistance of a second physician. The reduction was successful or satisfactory in 96.6% (425/435; 95% confidence interval [CI], 95.8–98.8%) of these cases, with a low incidence of intervention-requiring adverse events (2.8% [12/435]; 95% CI, 1.5–4.8%). Conclusion: Sedation-assisted closed reduction of major joint dislocations and forearm fractures can be performed effectively and safely in the ED using a one physician/one nurse model. A policy that requires a separate physician (or nurse anesthetist) to administer medications for all sedation-assisted ED procedures appears unwarranted. Further research is needed to determine which specific clinical scenarios might benefit from a dual-physician approach.
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Affiliation(s)
- David R Vinson
- Kaiser Permanente Roseville Medical Center, Department of Emergency Medicine, Roseville, California ; The Permanente Medical Group, Oakland, California
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Park CH, Min JH, Yoo YC, Kim H, Joh DH, Jo JH, Shin S, Lee H, Park JC, Shin SK, Lee YC, Lee SK. Sedation methods can determine performance of endoscopic submucosal dissection in patients with gastric neoplasia. Surg Endosc 2013; 27:2760-7. [PMID: 23389074 DOI: 10.1007/s00464-013-2804-z] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Accepted: 12/26/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND Although proper sedation is mandatory for endoscopic procedures such as endoscopic submucosal dissection (ESD), there is no research investigating the effects of sedation on ESD performance and complications. We aimed to evaluate the relationship among sedation methods, clinical outcomes, and complications after ESD for gastric neoplasia. METHODS We retrospectively reviewed clinical data of 1,367 patients with 1,485 lesions who had undergone ESD for gastric adenoma or early gastric cancer at our tertiary teaching hospital in Seoul, Korea, between January 2008 and May 2011. Of these, 1,035 lesions in 958 patients were included in the intermittent midazolam/propofol injection by endoscopists (IMIE) group, and 450 lesions in 409 patients were included in the continuous propofol infusion with opioid administration by anesthesiologists (CPIA) group. RESULTS En bloc resection and complete resection rates were higher in the CPIA group than in the IMIE group (CPIA vs. IMIE; en bloc resection, 99.8 and 95.0 %, P < 0.001; complete resection, 94.2 and 88.3 %, P < 0.001). Duration of procedure was shorter in the CPIA group than in the IMIE group (CPIA vs. IMIE; 48.2 ± 32.5 and 57.6 ± 41.3 min, P < 0.001). In multivariate analysis, sedation method was an independent factor associated with en bloc resection and complete resection. Additionally, sedation with CPIA was not a risk factor for bleeding (P = 0.403) or perforation (P = 0.474); however, aspiration pneumonia developed more frequently in patients sedated with CPIA (CPIA vs. IMIE, 4.4 and 1.5 %, P = 0.002). CONCLUSIONS Sedation with CPIA can improve ESD performance.
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Affiliation(s)
- Chan Hyuk Park
- Division of Gastroenterology, Department of Internal Medicine, Yonsei Institute of Gastroenterology, Yonsei University College of Medicine, 250 Seongsanno, Seodaemun-gu, Seoul, Republic of Korea
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Horiuchi A, Nakayama Y, Kajiyama M, Kato N, Kamijima T, Ichise Y, Tanaka N. Safety and effectiveness of propofol sedation during and after outpatient colonoscopy. World J Gastroenterol 2012; 18:3420-5. [PMID: 22807612 PMCID: PMC3396195 DOI: 10.3748/wjg.v18.i26.3420] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2011] [Revised: 04/05/2012] [Accepted: 04/22/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To study the safety and effectiveness of propofol sedation for outpatient colonoscopy.
METHODS: Propofol was given by bolus injection with an age-adjusted standard protocol consisting of 60 mg for patients < 70 years old, 40 mg for patients age 70-89 years, and 20 mg for those ≥ 90 years, and additional injections of 20 mg propofol were given up to a maximum of 200 mg. The principal parameters were the occurrence of adverse events within 24 h after colonoscopy and overall satisfaction for this procedure. Secondary parameters included successful procedure, respiratory depression, and other complications.
RESULTS: Consecutive patients were entered prospectively and all 2101 entered successfully completed outpatient colonoscopy. The mean dose of propofol used was 96.4 mg (range 40-200 mg). Younger patients required higher doses of propofol than older patients (20-40 years vs≥ 61 years: 115.3 ± 32 mg vs 89.7 ± 21 mg, P < 0.001). Transient supplemental oxygen supply was needed by five patients (0.2%); no other complications occurred. The questionnaires were completed by 1820 (87%) of 2101 patients and most rated their overall satisfaction as excellent (80%) or good (17%). The majority (65%) of patients drove home or to their office after their colonoscopy. Most (99%) were willing to repeat the same procedure. No incidents occurred within 24 h after colonoscopy.
CONCLUSION: Propofol sedation using a dose < 200 mg proved both safe and practical for outpatient colonoscopy.
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Norton C. The future of gastroenterology nursing. Frontline Gastroenterol 2012; 3:i6-i8. [PMID: 28839684 PMCID: PMC5551953 DOI: 10.1136/flgastro-2012-100195] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Accepted: 04/11/2012] [Indexed: 02/04/2023] Open
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Vargo JJ, DeLegge MH, Feld AD, Gerstenberger PD, Kwo PY, Lightdale JR, Nuccio S, Rex DK, Schiller LR. Multisociety Sedation Curriculum for Gastrointestinal Endoscopy. Am J Gastroenterol 2012:ajg2012112. [PMID: 22613907 DOI: 10.1038/ajg.2012.112] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- John J Vargo
- Department of Gastroenterology and Hepatology, Cleveland Clinic Lerner College of Medicine, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mark H DeLegge
- Digestive Disease Center, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Andrew D Feld
- Group Health Cooperative, Division of Gastroenterology, University of Washington, Seattle, Washington, USA
| | | | - Paul Y Kwo
- Liver Transplantation, Gastroenterology/Hepatology Division, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jenifer R Lightdale
- Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts, USA
| | - Susan Nuccio
- Aurora St Luke's Medical Center, Milwaukee, Wisconsin, USA
| | - Douglas K Rex
- Indiana School of Medicine, Indiana University Hospital, Indianapolis, Indiana, USA
| | - Lawrence R Schiller
- Digestive Health Associates of Texas, Baylor University Medical Center, Dallas, Texas, USA
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Bisanzo M, Nichols K, Hammerstedt H, Dreifuss B, Nelson SW, Chamberlain S, Kyomugisha F, Noble A, Arthur A, Thomas S. Nurse-Administered Ketamine Sedation in an Emergency Department in Rural Uganda. Ann Emerg Med 2012; 59:268-75. [DOI: 10.1016/j.annemergmed.2011.11.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Revised: 10/18/2011] [Accepted: 11/02/2011] [Indexed: 11/29/2022]
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Horiuchi A, Nakayama Y, Kajiyama M, Tanaka N. Effectiveness of outpatient percutaneous endoscopic gastrostomy replacement using esophagogastroduodenoscopy and propofol sedation. World J Gastrointest Endosc 2012; 4:45-9. [PMID: 22347532 PMCID: PMC3280355 DOI: 10.4253/wjge.v4.i2.45] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2011] [Revised: 11/23/2011] [Accepted: 02/06/2012] [Indexed: 02/05/2023] Open
Abstract
AIM: To evaluate the effectiveness of outpatient percutaneous endoscopic gastrostomy (PEG) replacement using esophagogastroduodenoscopy (EGD) and propofol sedation.
METHODS: We retrospectively assessed the outcome and complications of consecutive patients referred for PEG replacement which was performed using EGD under propofol sedation in the outpatient setting. The success rate, the mean dose of propofol, procedure time, EGD findings, discharge time from endoscopy unit, respiratory depression, and complications within 72 h of the procedure were evaluated. In a subset of these patients, the blood concentrations of propofol were measured.
RESULTS: All 221 patients underwent successful PEG replacement. The mean dose of propofol was 34 mg (range, 20-60 mg) with a mean procedure time of 5.9 min (range, 3-8 min). Reflux esophagitis (12 patients), gastric ulcer (5), gastric neoplasm (2), and duodenal ulcer (1) were newly diagnosed at replacement. Discharge from endoscopy unit was possible in 100% of patients 45 min after the procedure. Only 3.6% (8) required transient supplemental oxygen. No complications occurred within 72 h of the procedure. During EGD the level of sedation and propofol blood concentrations after administration of propofol (30 mg) in these PEG patients corresponded to those of propofol (60 mg) in middle aged subjects (control).
CONCLUSION: PEG replacement using EGD and propofol sedationin the outpatient setting was safe and practical.
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Affiliation(s)
- Akira Horiuchi
- Akira Horiuchi, Yoshiko Nakayama, Masashi Kajiyama, Naoki Tanaka, Digestive Disease Center, Showa Inan General Hospital, Komagane, 399-4117 Matsumoto, Japan
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Slagelse C, Vilmann P, Hornslet P, Hammering A, Mantoni T. Nurse-administered propofol sedation for gastrointestinal endoscopic procedures: first Nordic results from implementation of a structured training program. Scand J Gastroenterol 2011; 46:1503-9. [PMID: 22050137 DOI: 10.3109/00365521.2011.619274] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Proper training to improve safety of NAPS (nurse-administered propofol sedation) is essential. OBJECTIVE To communicate our experience with a training program of NAPS. MATERIALS AND METHODS In 2007, a training program was introduced for endoscopists and endoscopy nurses in collaboration with the Department of Anaesthesiology. During a 2.5-year period, eight nurses were trained. Propofol was given as monotherapy. The training program for nurses consisted of a 6-week course including theoretical and practical training whereas the training program for endoscopists consisted of 2.5 h of theory. Patients were selected based on strict criteria including patients in ASA (American Society of Anesthesiologists) group I-III. RESULTS 2527 patients undergoing 2.656 gastrointestinal endoscopic procedures were included. The patients were ASA group I, II and III in 34.7%, 56% and 9,3%, respectively. Median dose of propofol was 300 mg. No mortality was noted. 119 of 2527 patients developed short lasting hypoxia (4.7%); 61 (2.4%) needed suction; 22 (0.9%) required bag-mask ventilation and 8 (0.3%) procedures had to be discontinued. In 11 patients (0.4%), anesthetic assistance was called due to short lasting desaturation. 34 patients (1.3%) experienced a change in blood pressure greater than 30%. CONCLUSION NAPS provided by properly trained nurses according to the present protocol is safe and only associated with a minor risk (short lasting hypoxia 4.7%). National or international structured training programs are at present few or non-existing. The present training program has documented its value and is suggested as the basis for the current development of guidelines.
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Affiliation(s)
- Charlotte Slagelse
- Department of Endoscopy, Copenhagen University Hospital Gentofte, Hellerup, Denmark
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Fanti L, Agostoni M, Gemma M, Radaelli F, Conigliaro R, Beretta L, Rossi G, Guslandi M, Testoni PA. Sedation and monitoring for gastrointestinal endoscopy: A nationwide web survey in Italy. Dig Liver Dis 2011; 43:726-30. [PMID: 21640673 DOI: 10.1016/j.dld.2011.04.012] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2011] [Revised: 04/08/2011] [Accepted: 04/15/2011] [Indexed: 12/11/2022]
Abstract
BACKGROUND Best strategy of sedation/analgesia in gastrointestinal (GI) endoscopy is still debated. AIMS OF THE STUDY To evaluate sedation and monitoring practice among Italian gastroenterologists and to assess their opinion about non-anaesthesiologist propofol administration. METHODS A 19-item survey was mailed to all 1192 members of the Italian Society of Digestive Endoscopy (SIED). For each respondent were recorded demographic data, medical specialty, years of practise and practise setting. RESULTS A total of 494 SIED members returned questionnaires, representing a response rate of 41.4%. The most employed sedation pattern was benzodiazepines for oesophagogastroduodenoscopies (EGDS) in 50.8% of procedures, benzodiazepines plus opioids for colonoscopy and enteroscopy in 39.5% and 35.3% of procedures, respectively, propofol for endoscopic retrograde colangiopancreatography (ERCP) and endoscopic ultrasound (EUS) in 42.3% and 35.6% of procedures, respectively. With regard to propofol use, 66% respondents stated that propofol was exclusively administered by anaesthesiologists. However, 76.9% respondents would consider non-anaesthesiologist propofol administration after appropriate training. Pulse oximetry is the most employed system for procedural monitoring. Supplemental O(2) is routinely administered by 39.3% respondents. CONCLUSIONS Use of sedation has become a standard practise during GI endoscopy in Italy. Pattern varies for each type of procedure. Pulse oximetry is the most employed system of monitoring. Administration of propofol is still directed by anaesthesiologists.
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Affiliation(s)
- Lorella Fanti
- Division of Gastroenterology and Gastrointestinal Endoscopy, Vita-Salute San Raffaele University-Scientific Institute San Raffaele, Milan, Italy.
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Gaitan BD, Trentman TL, Fassett SL, Mueller JT, Altemose GT. Sedation and Analgesia in the Cardiac Electrophysiology Laboratory: A National Survey of Electrophysiologists Investigating the Who, How, and Why? J Cardiothorac Vasc Anesth 2011; 25:647-59. [DOI: 10.1053/j.jvca.2010.11.006] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2010] [Indexed: 12/27/2022]
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Martínez Palli G, Ubré M, Rivas E, Blasi A, Borrat X, Pujol R, Taurà RP, Balust J. [An established anesthesia team-care model: over 12000 cases in a digestive endoscopy unit]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2011; 58:406-411. [PMID: 22046861 DOI: 10.1016/s0034-9356(11)70103-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
BACKGROUND AND OBJECTIVE The growing demand for digestive and other endoscopic procedures outside the operating room, both in terms of type of endoscopy and number of patients, requires reorganization of the anesthesiology department's workload. We describe 2 years of our hospital digestive endoscopy unit's experience with a now well-established care model involving both anesthesiologists and nurse anesthetists. MATERIAL AND METHODS After previously reviewing the medical records of outpatients and conducting a telephone interview about state of health, nurse anesthetists administered a combination of propofol and remifentanil through a target-controlled infusion system under an anesthesiologist's direct supervision. RESULTS The ratio of anesthesiologists to nurses ranged from 1:2 to 1:3 according to the complexity of the examination procedure. Over 12000 endoscopies (simple to advanced) in a total of 11853 patients were performed under anesthesia during the study period. Airway management maneuvers were required by 4.9% of the patients; 0.18% required bag ventilation for respiratory depression, and 0.084% required bolus doses of a vasopressor to treat hypotension or atropine to treat bradycardia. The procedure had to be halted early in 9 patients (0.07%). No patient required orotracheal intubation and none died. Nor were any complications related to sedation recorded. CONCLUSION The results suggest that this care model can safely accommodate a large caseload in anesthesia at an optimum level of quality.
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Affiliation(s)
- G Martínez Palli
- Servicio de Anestesiología y Reanimación, Sección del Instituto de Enfermedades Digestivas, Hospital Clinic de Barcelona.
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Poincloux L, Laquière A, Bazin JE, Monzy F, Artigues F, Bonny C, Abergel A, Dapoigny M, Bommelaer G. A randomized controlled trial of endoscopist vs. anaesthetist-administered sedation for colonoscopy. Dig Liver Dis 2011; 43:553-8. [PMID: 21450542 DOI: 10.1016/j.dld.2011.02.007] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2010] [Revised: 01/25/2011] [Accepted: 02/04/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND Endoscopist-administered propofol sedation for colonoscopy has not been compared to anaesthetist-administered deep sedation in clinical trials. Our aim was to compare patients' satisfaction and safety during these two sedation modalities. METHODS 90 adult patients undergoing colonoscopy were randomized into Group A, Endoscopist-administered propofol sedation and Group B, anaesthetist-administered deep sedation. Group A patients received an initial dose of 30-50 mg of intravenous propofol; additional doses were injected by the endoscopist using a pre-programmed pump. Global satisfaction was measured on a 0-100 mm visual analogue scale. RESULTS The average satisfaction scores after examination completion amongst group were not statistically different (90.8 mm for Group A vs. 89 mm for Group B). Group A patients expressed more frequently a good level of satisfaction (95% vs. 75%; p=0.03) and willingness to undergo further colonoscopies under the same conditions (95% vs. 79%; p=0.02). Total duration time and procedural difficulty did not differ between the groups. Group A received a lower total propofol dose than Group B (94 mg vs. 260 mg) and experienced fewer side-effects (16 vs. 3, respectively; p < 0.008). CONCLUSION Endoscopist-administered propofol sedation for colonoscopy offered a better level of satisfaction and fewer side-effects than anaesthetist-administered deep sedation.
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KOTTKAMP HANS, HINDRICKS GERHARD, EITEL CHARLOTTE, MÜLLER KRISTIN, SIEDZIAKO ANGELA, KOCH JULIA, ANASTASIOU-NANA MARIA, VAROUNIS CHRISTOS, ARYA ARASH, SOMMER PHILIPP, GASPAR THOMAS, PIORKOWSKI CHRISTOPHER, DAGRES NIKOLAOS. Deep Sedation for Catheter Ablation of Atrial Fibrillation: A Prospective Study in 650 Consecutive Patients. J Cardiovasc Electrophysiol 2011; 22:1339-43. [DOI: 10.1111/j.1540-8167.2011.02120.x] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Banerjee S, Desilets D, Diehl DL, Farraye FA, Kaul V, Kethu SR, Kwon RS, Mamula P, Pedrosa MC, Rodriguez SA, Song LMWK, Tierney WM. Computer-assisted personalized sedation. Gastrointest Endosc 2011; 73:423-7. [PMID: 21237458 DOI: 10.1016/j.gie.2010.10.035] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2010] [Accepted: 10/20/2010] [Indexed: 02/08/2023]
Abstract
The American Society for Gastrointestinal Endoscopy (ASGE) Technology Committee provides reviews of new or emerging endoscopic technologies that have the potential to have an impact on the practice of GI endoscopy. Evidence-based methodology is used, with a MEDLINE literature search to identify pertinent preclinical and clinical studies on the topic, and a MAUDE (Manufacturer and User Facility Device Experience; U.S. Food and Drug Administration Center for Devices and Radiological Health) database search to identify the reported complications of a given technology. Both are supplemented by accessing the "related articles" feature of PubMed and by scrutinizing pertinent references cited by the identified studies. Controlled clinical trials are emphasized but, in many cases, data from randomized, controlled trials are lacking. In such cases, large case series, preliminary clinical studies, and expert opinions are used. Technical data are gathered from traditional and Web-based publications, proprietary publications, and informal communications with pertinent vendors. For this review, the MEDLINE database was searched through January 2010 using the keywords "computer," "computerized," "computer-assisted," "sedation," "propofol." Reports on Emerging Technology are drafted by 1 or 2 members of the ASGE Technology Committee, reviewed and edited by the committee as a whole, and approved by the Governing Board of the ASGE. These reports are scientific reviews provided solely for educational and informational purposes. Reports on Emerging Technology are not rules and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment or payment for such treatment.
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Kauling ALC, Locks GDF, Brunharo GM, da Cunha VJL, de Almeida MCS. Conscious sedation for upper digestive endoscopy performed by endoscopists. Rev Bras Anestesiol 2010; 60:577-83, 320-3. [PMID: 21146053 DOI: 10.1016/s0034-7094(10)70072-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2010] [Accepted: 06/06/2010] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Conscious sedation in the ambulatory setting albeit common is not risk-free. The present study aimed at evaluating the blood pressure, heart rate and peripheral oxygen saturation in patients submitted to conscious sedation for upper digestive endoscopy performed by endoscopists. METHODS A total of 105 patients of both sexes were selected, aged 18 and older, physical status ASA I to III, submitted to upper digestive endoscopy under conscious sedation. The patients were monitored through noninvasive blood pressure measurements, pulse oximetry and heart rate recorded before, during and after the examination. The sedation was carried out with midazolam or meperidine. RESULTS The variations in oxygen saturation, blood pressure and heart rate throughout time were not statistically significant. However, an incidence of hypoxia of 41.9% was observed; 53.3% of the cases presented arterial hypotension and 25.6% presented tachycardia. Obese patients were more prone to hypoxia and hypotension than those non obese. CONCLUSIONS The occurrence of hypoxia and arterial hypotension is common in upper digestive endoscopic examinations under conscious sedation when midazolam and meperidine are associated. Obese patients demonstrated to be more susceptible to hypoxemia and arterial hypotension.
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Pediatric sedation: a global challenge. Int J Pediatr 2010; 2010:701257. [PMID: 20981309 PMCID: PMC2958496 DOI: 10.1155/2010/701257] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2010] [Revised: 08/06/2010] [Accepted: 08/16/2010] [Indexed: 11/17/2022] Open
Abstract
Pediatric sedation is a challenge which spans all continents and has grown to encompass specialties outside of anesthesia, radiology and emergency medicine. All sedatives are not universally available and local and national regulations often limit the sedation practice to specific agents and those with specific credentials. Some specialties have established certification and credentials for sedation delivery whereas most have not. Some of the relevant sedation guidelines and recommendations of specialty organizations worldwide will be explored. The challenge facing sedation care providers moving forward in the 21st century will be to determine how to apply the local, regional and national guidelines to the individual sedation practices. A greater challenge, perhaps impossible, will be to determine whether the sedation community can come together worldwide to develop standards, guidelines and recommendations for safe sedation practice.
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