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Hong SJ. Concerns about non-anesthesiologists administration of intravenous anesthetics. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2013. [DOI: 10.5124/jkma.2013.56.8.642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Sung Jin Hong
- Department of Anesthesia and Pain Medicine, Yeouido St. Mary's Hospital, Catholic University of Korea College of Medicine, Seoul, Korea
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Murugesan SV, Davies MW, Nicholson J, Hughes M, Haslam N, Smart HL, Sarkar S. Evaluation of a new anaesthetist-led propofol sedation service for endoscopy within a UK day-case setting. Frontline Gastroenterol 2013; 4:73-81. [PMID: 28839703 PMCID: PMC5369790 DOI: 10.1136/flgastro-2012-100255] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2012] [Revised: 10/01/2012] [Accepted: 10/02/2012] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION The use of propofol in endoscopy is becoming more prevalent both in Europe and North America. Potential advantages over conscious sedation include controlled deep sedation for therapeutic endoscopy and improved patient satisfaction. A new anaesthetist-led propofol-based day-case sedation service was introduced within the endoscopy unit at the Royal Liverpool University Hospital in April 2011. AIMS To evaluate this new service of anaesthetist-led propofol-based sedation for safety, compliance with current guidelines and satisfaction (patient, anaesthetist and endoscopist). DESIGN A prospective, service evaluation audit of a new, weekly, anaesthetist-led propofol-based sedation service. Administrative records, anaesthetic notes and satisfaction scores (1=very dissatisfied; 5=very satisfied; patients, anaesthetists, endoscopists) and the 'patient journey' were evaluated for 40 consecutive patients treated over 18 weeks. Outcomes were measured against current British Society of Gastroenterology/Royal College of Anaesthetists guidelines. RESULTS All procedures were completed (100% intention-to-treat rate), all patients were discharged on the day of the procedure and none were readmitted within 7 days. Adverse events were minor (10%) and there were no deaths within 30 days. The median satisfaction score was 5 for patients, anaesthetists and endoscopists. The additional cost for provision of such a service included the services of the anaesthetist (one programmed activity) and operating department personnel and for drugs (propofol). The demand for the service rapidly increased. CONCLUSIONS Anaesthetist-led propofol-assisted endoscopy is safe in a day-case endoscopy unit and is associated with high satisfaction scores for patients, anaesthetists and endoscopists. There is a high demand for this service in this UK endoscopy day-case unit.
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Affiliation(s)
- Senthil V Murugesan
- Department of Gastroenterology & Hepatology, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Mark W Davies
- Department of Anaesthetics, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Jill Nicholson
- Department of Anaesthetics, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Mark Hughes
- Department of Radiology, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Neil Haslam
- Department of Gastroenterology & Hepatology, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Howard L Smart
- Department of Gastroenterology & Hepatology, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Sanchoy Sarkar
- Department of Gastroenterology & Hepatology, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK,University of Liverpool, Liverpool, UK
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Park CS. The current state of sedation outside the operating room. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2013. [DOI: 10.5124/jkma.2013.56.4.264] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Chul Soo Park
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Seoul, Korea
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Angsuwatcharakon P, Rerknimitr R, Ridtitid W, Kongkam P, Poonyathawon S, Ponauthai Y, Sumdin S, Kullavanijaya P. Cocktail sedation containing propofol versus conventional sedation for ERCP: a prospective, randomized controlled study. BMC Anesthesiol 2012; 12:20. [PMID: 22873637 PMCID: PMC3434082 DOI: 10.1186/1471-2253-12-20] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2011] [Accepted: 08/03/2012] [Indexed: 03/03/2023] Open
Abstract
Background ERCP practically requires moderate to deep sedation controlled by a combination of benzodiazepine and opiod. Propofol as a sole agent may cause oversedation. A combination (cocktail) of infused propofol, meperidine, and midazolam can reduce the dosage of propofol and we hypothesized that it might decrease the risk of oversedation. We prospectively compare the efficacy, recovery time, patient satisfactory, and side effects between cocktail and conventional sedations in patients undergoing ERCP. Methods ERCP patients were randomized into 2 groups; the cocktail group (n = 103) and the controls (n = 102). For induction, a combination of 25 mg of meperidine and 2.5 mg of midazolam were administered in both groups. In the cocktail group, a bolus dose of propofol 1 mg/kg was administered and continuously infused. In the controls, 25 mg of meperidine or 2.5 mg/kg of midazolam were titrated to maintain the level of sedation. Results In the cocktail group, the average administration rate of propofol was 6.2 mg/kg/hr. In the control group; average weight base dosage of meperidine and midazolam were 1.03 mg/kg and 0.12 mg/kg, respectively. Recovery times and patients’ satisfaction scores in the cocktail and control groups were 9.67 minutes and 12.89 minutes (P = 0.045), 93.1and 87.6 (P <0.001), respectively. Desaturation rates in the cocktail and conventional groups were 58.3% and 31.4% (P <0.001), respectively. All desaturations were corrected with temporary oxygen supplementation without the need for scope removal. Conclusions Cocktail sedation containing propofol provides faster recovery time and better patients’ satisfaction for patients undergoing ERCP. However, mild degree of desaturation may still develop. Trial registration ClinicalTrials.gov, NCT01540084
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Affiliation(s)
- Phonthep Angsuwatcharakon
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, 10310, Thailand.
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Balanced propofol sedation versus propofol monosedation in therapeutic pancreaticobiliary endoscopic procedures. Dig Dis Sci 2012; 57:2113-21. [PMID: 22615018 DOI: 10.1007/s10620-012-2234-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2012] [Accepted: 05/02/2012] [Indexed: 12/18/2022]
Abstract
BACKGROUND Prolonged or complex endoscopic procedures are frequently performed under deep sedation. However, no studies of therapeutic ERCP have yet compared the use of balanced propofol sedation (BPS) to propofol alone, titrated to moderate levels of sedation. AIM This prospective, randomized, double-blind study was planned to compare the sedation efficacy and safety of BPS (propofol in combination with midazolam and fentanyl) and propofol monosedation in therapeutic ERCP and EUS. METHODS BPS, or propofol monosedation titrated to a moderate level of sedation, was performed by trained registered nurses under endoscopist supervision. The main outcome measurements included sedation efficacy focusing on recovery time, sedation safety, endoscopic procedure outcomes, and complications. RESULTS There were no significant differences in sedation efficacy, safety, procedure outcomes, and complications, with the exception of recovery time. Mean recovery time (standard deviation) was 18.37 (7.86) min in BPS and 13.4 (6.24) min in propofol monosedation (P < 0.001). In a safety analysis, cardiopulmonary complication rates related to BPS and propofol monosedation were 7.8 % (8/102) and 9.6 % (10/104), respectively (P = 0.652). No patient required assisted ventilation or permanent termination of a procedure in either group. Technical success of the endoscopic procedures was 96.3 and 97.2 %, respectively (P = 0.701). Endoscopic procedure-related complications and outcomes did not differ depending on sedation procedure. CONCLUSIONS Propofol monosedation by trained, registered sedation nurses under supervision resulted in a more rapid recovery time than BPS. There were no differences in the sedation safety, endoscopic procedure outcomes, and complications between BPS and propofol monosedation.
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Garewal D, Powell S, Milan SJ, Nordmeyer J, Waikar P. Sedative techniques for endoscopic retrograde cholangiopancreatography. Cochrane Database Syst Rev 2012:CD007274. [PMID: 22696368 DOI: 10.1002/14651858.cd007274.pub2] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is an uncomfortable therapeutic procedure that cannot be performed without adequate sedation or general anaesthesia. A considerable number of ERCPs are performed annually in the UK (at least 48,000) and many more worldwide. OBJECTIVES The primary objective of our review was to evaluate and compare the efficacy and safety of sedative or anaesthetic techniques used to facilitate the procedure of ERCP in adult (age > 18 years) patients. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 8); MEDLINE (1950 to September 2011); EMBASE (1950 to September 2011); CINAHL, Web of Science and LILACS (all to September 2011). We searched for additional studies drawn from reference lists of retrieved trial materials and review articles and conference proceedings. SELECTION CRITERIA We considered all randomized or quasi-randomized controlled studies where the main procedures performed were ERCPs. The three interventions we searched for were (1) conscious sedation (using midazolam plus opioid) versus deep sedation (using propofol); (2) conscious sedation versus general anaesthesia; and (3) deep sedation versus general anaesthesia. We considered all studies regardless of which healthcare professional administered the sedation. DATA COLLECTION AND ANALYSIS We reviewed 124 papers and identified four randomized trials (with a total of 510 participants) that compared the use of conscious sedation using midazolam and meperidine with deep sedation using propofol in patients undergoing ERCP procedures. All sedation was administered by non-anaesthetic personnel. Due to the clinical heterogeneity of the studies we decided to review the papers from a narrative perspective as opposed to a full meta-analysis. Our primary outcome measures included mortality, major complications and inability to complete the procedure due to sedation-related problems. Secondary outcomes encompassed sedation efficacy and recovery. MAIN RESULTS No immediate mortality was reported. There was no significant difference in serious cardio-respiratory complications suffered by patients in either sedation group. Failure to complete the procedure due to sedation-related problems was reported in one study. Three studies found faster and better recovery in patients receiving propofol for their ERCP procedures. Study protocols regarding use of supplemental oxygen, intravenous fluid administration and capnography monitoring varied considerably. The studies showed either moderate or high risk of bias. AUTHORS' CONCLUSIONS Results from individual studies suggested that patients have a better recovery profile after propofol sedation for ERCP procedures than after midazolam and meperidine sedation. As there was no difference between the two sedation techniques as regards safety, propofol sedation is probably preferred for patients undergoing ERCP procedures. However, in all of the studies that were identified only non-anaesthesia personnel were involved in administering the sedation. It would be helpful if further research was conducted where anaesthesia personnel were involved in the administration of sedation for ERCP procedures. This would clarify the extent to which anaesthesia personnel should be involved in the administration of propofol sedation.
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Affiliation(s)
- Davinder Garewal
- AnaestheticDepartment, StGeorge’sHealthcareNHS Trust, London, UK.
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Kawa C, Stewart J, Hilden K, Adler DG, Tietze C, Bromberg MB, Fang JC. A Retrospective Study of Nurse-Assisted Propofol Sedation in Patients With Amyotrophic Lateral Sclerosis Undergoing Percutaneous Endoscopic Gastrostomy. Nutr Clin Pract 2012; 27:540-4. [PMID: 22645103 DOI: 10.1177/0884533612443712] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Chad Kawa
- University Hospitals Case Medical Center, Cleveland, Ohio
| | - James Stewart
- Carl T. Hayden Veterans Affairs Medical Center, Phoenix, Arizona
| | - Kristen Hilden
- University of Utah, Division of Gastroenterology, Salt Lake City, Utah
| | - Douglas G. Adler
- University of Utah, Division of Gastroenterology, Salt Lake City, Utah
| | | | | | - John C. Fang
- University of Utah, Division of Gastroenterology, Salt Lake City, Utah
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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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Al-Haddad M, McKenna D, Ko J, Sherman S, Selzer DJ, Mattar SG, Imperiale TF, Rex DK, Nakeeb A, Jeong SM, Johnson CS, Freeman LJ. Deep sedation in natural orifice transluminal endoscopic surgery (NOTES): a comparative study with dogs. Surg Endosc 2012; 26:3163-73. [PMID: 22580877 DOI: 10.1007/s00464-012-2309-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Accepted: 04/02/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND Natural orifice transluminal endoscopic surgery (NOTES) has been mostly performed with the animal under general and inhalational anesthesia (IA-NOTES). To date, NOTES using propofol sedation (PS-NOTES) has not been investigated. This study aimed to assess the feasibility and safety of PS-NOTES for transgastric oophorectomy with carbon dioxide insufflation and to compare its success rates with those of conventional IA-NOTES. METHODS In this prospective randomized study, NOTES oophorectomy was performed for 19 female dogs randomized to two conditions: PS (study group) and IA (control group). Sedation success rates (ability to visualize and resect ovaries without converting to IA), operative success rates (ability to resect and retrieve both ovaries in full using only NOTES), and vital parameters including hemodynamic and respiratory changes were documented. RESULTS In the PS-NOTES group (n = 9), the sedation success rate was 100 %. The operative success rate was 67 % (6 of 9 animals) compared with 80 % (8 of 10 animals) in the IA-NOTES group. No purposeful movement occurred during surgical manipulation and no respiratory or cardiovascular complications in occurred the PS group. Heart rate (HR) and end-tidal carbon dioxide (ETCO(2)) were significantly higher in the PS group than in the IA group. Blood pressure (BP) was significantly higher in the PS group only during the middle part of the procedure. Only mild respiratory depression was noted in the PS group, as indicated by elevated but acceptable ETCO(2). Elevations in BP and HR are thought to be related to elevated CO(2) but did not appear to have an adverse impact on the course of the procedure. Recovery was uneventful for all the animals. CONCLUSION The use of PS-NOTES appears to be feasible, resulting in outcomes comparable with those for IA in dogs. Further studies are needed to determine the applicability of this concept in human NOTES.
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Affiliation(s)
- Mohammad Al-Haddad
- Department of Medicine, Division of Gastroenterology, Indiana University School of Medicine, 550 N University Boulevard, UH 4100, Indianapolis, IN 46202, USA.
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Kwon JS, Kim ES, Cho KB, Park KS, Park WY, Lee JE, Kim TY, Jang BK, Chung WJ, Hwang JS. Incidence of propofol injection pain and effect of lidocaine pretreatment during upper gastrointestinal endoscopy. Dig Dis Sci 2012; 57:1291-7. [PMID: 22160549 DOI: 10.1007/s10620-011-1992-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2011] [Accepted: 11/15/2011] [Indexed: 12/28/2022]
Abstract
BACKGROUND/AIMS Propofol has been used in the past for sedation in upper gastrointestinal (GI) endoscopic procedures. This study aimed to measure the incidence of propofol injection pain and evaluate the effect of lidocaine on pain caused during sedative upper GI endoscopic examinations. METHODS Subjects scheduled to undergo sedative diagnostic upper GI endoscopy were randomly assigned to lidocaine and placebo groups. Pretreatment with a bolus of 1% lidocaine 2 ml or normal saline 2 ml into the largest dorsal vein of the non-dominant hand was followed by propofol administration. Pain intensity was estimated by an examiner blinded to the group assignment using a four-point verbal rating scale. A score of 1-3 was regarded as pain. RESULTS A total of 121 patients (males, 69; age, 58.6 ± 12.1 years) completed the study; 61 and 60 subjects were randomly assigned to the lidocaine and placebo groups, respectively. The incidence of pain during upper GI endoscopy was 60%. The lidocaine group showed a lower incidence of pain than the placebo group (37.7% vs. 60.0%, P = 0.018). The lidocaine group perceived significantly less pain than the placebo group (median pain score, 0 vs. 1, P = 0.008). Only lidocaine pretreatment was an independently associated factor against pain perception (OR, 0.380; 95% CI, 0.177-0.815; P = 0.013). CONCLUSIONS Pretreatment using lidocaine was found to be effective in reducing propofol injection-induced pain. However, its usefulness for GI endoscopic procedures in daily clinical practice needs further evaluation because of the low intensity of pain.
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Affiliation(s)
- Ji Suk Kwon
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Keimyung University School of Medicine, 194 Dong San-dong, Jung-gu, Daegu 700-712, South Korea
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Horiuchi A, Nakayama Y, Fujii H, Katsuyama Y, Ohmori S, Tanaka N. Psychomotor recovery and blood propofol level in colonoscopy when using propofol sedation. Gastrointest Endosc 2012; 75:506-12. [PMID: 22115604 DOI: 10.1016/j.gie.2011.08.020] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2011] [Accepted: 08/11/2011] [Indexed: 12/18/2022]
Abstract
BACKGROUND It is commonly recommended that patients refrain from driving for 24 hours after endoscopy for which sedation is given. OBJECTIVE The aim of this study was to evaluate psychomotor recovery and blood propofol concentrations after colonoscopy with propofol sedation to determine whether driving might be safe. DESIGN A prospective, consecutive study. SETTING Municipal hospital outpatients. PATIENTS This study involved 48 consecutive patients scheduled for colonoscopy with propofol sedation. INTERVENTION Patient clinical features, psychomotor recovery, and blood concentrations of propofol were assessed. Psychomotor recovery was assessed before colonoscopy and 1 and 2 hours after colonoscopy by using the number connection test and a driving simulator test. MAIN OUTCOME MEASUREMENTS Clinical features, psychomotor recovery, and blood concentration of propofol. RESULTS All patients successfully completed the post-sedation assessments. Although there was a significant difference in results of the number connection test between before colonoscopy and 1 hour after colonoscopy, all number connection test results were within normal limits (<40 seconds). Scores were as follows: mean time (standard deviation) before colonoscopy, 32.2 (2.0) seconds (range 29-36 seconds) versus after colonoscopy, 32.7 (2.0) seconds (range 27-38 seconds); P = .0019. Driving skills had recovered to the baseline levels 1 hour after colonoscopy. Scores were as follows: tracking error (%) before colonoscopy, 45.0 (5.6) versus after colonoscopy, 46.0 (5.5); P = .61; accelerating reaction time in seconds before colonoscopy, 0.65 (0.15) versus after colonoscopy, 0.62 (0.14); P = .40; braking reaction time in seconds before colonoscopy, 0.58 (0.13) versus after colonoscopy, 0.61 (0.13); P = .50. LIMITATIONS Small sample size, single-center study. CONCLUSION Although consistent findings on the number connection test and driving simulation (psychomotor recovery) test are present as early as 1 hour after propofol sedation, a study of additional numbers of patients as well as different patient populations are needed before these results can be universally recommended.
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Affiliation(s)
- Akira Horiuchi
- Digestive Disease Center, Showa Inan General Hospital, Komagane, Japan
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Ibarra P, Galindo M, Molano A, Niño C, Rubiano A, Echeverry P, Rincón J, Hani A, Gil F, Sabbagh L, Donado J, Artunduaga I, Carbonell R, Vieira F, Gaidos C, María Orozco A, Trigos J, Ruiz C, Barona R, Sarmiento R, Juan Polanía MFY. Recomendaciones para la sedación y la analgesia por médicos no anestesiólogos y odontólogos de pacientes mayores de 12 años. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2012. [DOI: 10.1016/s0120-3347(12)70012-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Sedation and analgesia recommendations for non-anesthesiologist physicians and dentists in patients over 12 years old. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2012. [DOI: 10.1016/s2256-2087(12)40012-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Ibarra P. Analysis of a poor outcome during deep sedation: potential impact of the 2011 SCARE recommendations for sedation by non-anesthesiologists. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2012. [DOI: 10.1016/s2256-2087(12)40007-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Ibarra P. Análisis de un desenlace trágico con sedación profunda: potencial impacto de las recomendaciones SCARE 2011 de sedación por no anestesiólogos. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2012. [DOI: 10.1016/s0120-3347(12)70007-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Propofol sedation for ERCP procedures: a dilemna? Observations from an anesthesia perspective. DIAGNOSTIC AND THERAPEUTIC ENDOSCOPY 2012; 2012:639190. [PMID: 22272061 PMCID: PMC3261459 DOI: 10.1155/2012/639190] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/08/2011] [Accepted: 11/16/2011] [Indexed: 12/28/2022]
Abstract
Propofol sedation for endoscopic retrograde cholangiopancreatography (ERCP) procedures is a popular current technique that has generated controversy in the medical field. Worldwide, both anesthetic and nonanesthetic personnel administer this form of sedation. Although the American and Canadian societies of gastroenterologists have endorsed the administration of propofol by nonanesthesia personnel, the US Food and Drug Administration (FDA) has not licensed its use in this manner. There is some evidence for the safe use of propofol by nonanesthetic personnel in patients undergoing endoscopy procedures, but there are few randomized trials addressing the safety and efficacy of propofol in patients undergoing ERCP procedures. A serious possible consequence of propofol sedation in patients is that it may result in rapid and unpredictable progression from deep sedation to general anesthesia, and skilled airway support may be required as a rescue measure. Potential complications following deep propofol sedation include hypoxemia and hypotension. Propofol sedation for ERCP procedures is an area of clinical practice where discussion and mutual cooperation between anesthesia and nonanesthesia personnel may enhance patient safety.
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Analysis of a poor outcome during deep sedation: potential impact of the 2011 SCARE recommendations for sedation by non-anesthesiologists. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2012. [DOI: 10.1097/01819236-201240010-00008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Safety of propofol in cirrhotic patients undergoing colonoscopy and endoscopic retrograde cholangiography: results of a prospective controlled study. Eur J Gastroenterol Hepatol 2012; 24:70-6. [PMID: 21941187 DOI: 10.1097/meg.0b013e32834c16ab] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Safety of propofol sedation in patients with liver cirrhosis undergoing colonoscopy or endoscopic retrograde cholangiopancreatography (ERCP) remains to be studied. The aim of this study was to investigate whether the use of propofol is safe for endoscopic procedures more complex than gastroscopy in patients with liver cirrhosis in a prospective controlled study. METHODS Two hundred and fourteen consecutive patients, with or without cirrhosis, who underwent colonoscopy or ERCP with propofol sedation were recruited between January and June 2009. Administration of sedation was performed by anesthesiologists and outcome measures were recorded. Main outcomes were complication rates and recovery times. RESULTS Sixty-one (28.5%) cirrhotic patients and 153 (71.5%) noncirrhotic patients were included. The incidence of sedation-related complications did not significantly differ between the two populations (11.5 vs. 17.0%, respectively, P=0.31). The mean (±SD) dose of propofol administered (213±86 vs. 239±100 mg, P=0.07), the mean time to achieve adequate sedation (3.3±1.1 vs. 3.0±1.2 min, P=0.21), the mean total duration of the endoscopic procedure (24.5±10.6 vs. 27.4±11.8 min, P=0.08), the mean time to reach Observer's Assessment of Alertness and Sedation Scale 5 (17.2±4.4 vs. 18.4±5.6 min, P=0.15), the mean time from completion of the procedure to release (9.0±2.5 vs. 9.1±3.2 min, P=0.86), and the mean time to full recovery (42.2±7.3 vs. 42.3±7.8 min, P=0.88) were very similar between the two groups. The limitation of this study was lack of randomization, and a control group of cirrhotic patients using standard sedation with benzodiazepines and opioids. CONCLUSION Propofol deep sedation administered by an anesthesiologist with appropriate monitorings seems to be a safe procedure during colonoscopy or ERCP in cirrhotic patients.
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Khiani VS, Soulos P, Gancayco J, Gross CP. Anesthesiologist involvement in screening colonoscopy: temporal trends and cost implications in the medicare population. Clin Gastroenterol Hepatol 2012; 10:58-64.e1. [PMID: 21782768 PMCID: PMC3214600 DOI: 10.1016/j.cgh.2011.07.005] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2011] [Revised: 07/01/2011] [Accepted: 07/13/2011] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Colonoscopy is a recommended component of screening for colorectal cancer. We conducted a retrospective study of Medicare data to determine the frequency of anesthesiologist involvement and to identify patient and provider characteristics and cost implications associated with anesthesiologist involvement. METHODS We used the linked Surveillance, Epidemiology, and End Results Medicare dataset to identify patients without cancer who received a screening colonoscopy examination from July 2001 through 2006 (n = 16,268). The outcome variable was anesthesiologist involvement, which was identified by searching Medicare claims. Logistic regression was used to explore the association between patient and provider characteristics and anesthesiologist involvement. Costs associated with the use of an anesthesiologist were derived based on a cost assessment by the Agency for Healthcare Research and Quality. RESULTS Of the screening colonoscopies assessed, 17.2% involved an anesthesiologist. The screening colonoscopy rate more than doubled during the study period. The frequency of anesthesiologist involvement increased from 11.0% of screening colonoscopies in 2001 to 23.4% in 2006. Surgeons involved an anesthesiologist in 24.2% of colonoscopies, compared with 18.0% of gastroenterologists and 11.3% of primary care providers. The percentage of colonoscopies that involved an anesthesiologist varied among regions, ranging from 1.6% in San Francisco to 57.8% in New Jersey. Anesthesiologist involvement increased the cost by approximately 20% per screening colonoscopy. CONCLUSIONS An increase in the involvement of anesthesiologists has significantly increased the cost of screening colonoscopies. Studies are needed to assess the effects of anesthesiologists on risks and benefits of colonoscopy, to determine the most safe and cost-effective approaches.
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Affiliation(s)
- Vijay S. Khiani
- Digestive Diseases, Yale School of Medicine, New Haven, CT,Yale Cancer Outcomes, Policy, and Effectiveness Research Center (COPPER)
| | - Pamela Soulos
- General Internal Medicine, Yale School of Medicine, New Haven, CT,Yale Cancer Outcomes, Policy, and Effectiveness Research Center (COPPER)
| | - John Gancayco
- Digestive Diseases, Yale School of Medicine, New Haven, CT,Yale Cancer Outcomes, Policy, and Effectiveness Research Center (COPPER)
| | - Cary P. Gross
- General Internal Medicine, Yale School of Medicine, New Haven, CT,Yale Cancer Outcomes, Policy, and Effectiveness Research Center (COPPER)
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Sedation and analgesia recommendations for non-anesthesiologist physicians and dentists in patients over 12 years old. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2012. [DOI: 10.1097/01819236-201240010-00013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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71
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Abstract
Sedation is the drug-induced reduction of a patient's consciousness. The aim of sedation in endoscopic procedures is to increase the patient's comfort and to improve endoscopic performance, especially in therapeutic procedures. The most commonly used sedation regimen for conscious sedation in gastrointestinal endoscopy is still the combination of benzodiazepines with opioids. However, the use of propofol has increased enormously in the past decade and several studies show advantages of propofol over the traditional regimes in terms of faster recovery time. It is important to be aware that the complication rate of endoscopies increases when sedation is used; therefore, a thorough risk evaluation before the procedure and monitoring during the procedure must be performed. In addition, properly trained staff and emergency equipment should be available. The best approach to sedation in endoscopy is to choose a sedation regimen for the individual patient, tailored according to the clinical risk assessment and the anxiety level of the patient, as well as to the type of planned endoscopic procedure.
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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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73
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Lightdale JR, Weinstock P. Simulation and training of procedural sedation. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2011. [DOI: 10.1016/j.tgie.2011.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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74
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Beilenhoff U, Neumann CS. Quality assurance in endoscopy nursing. Best Pract Res Clin Gastroenterol 2011; 25:371-85. [PMID: 21764005 DOI: 10.1016/j.bpg.2011.05.005] [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: 04/26/2011] [Accepted: 05/16/2011] [Indexed: 01/31/2023]
Abstract
Since the 1960s quality assurance has become an integral part of medicine and nursing. The aims of quality assurance cover patient and staff safety and satisfaction, economical factors and the implementation of health care policy. Endoscopy units can be established in hospitals, primary care or ambulatory endoscopy centres. The quality of endoscopy facilities should be the same irrespective where endoscopy is carried out. Endoscopy staff is responsible for individualised, comprehensive patient care, technical assistance including reprocessing, documentation and management of endoscopy units. Quality criteria for endoscopy nursing cover pre, intra and post procedure care. However, a complete separation between clinical medical and nursing outcome criteria is often difficult in Endoscopy, as the clinical interventions are a combination of both medical and nursing actions. It is the combined effort of all staff with the support from the health care provider that leads to a high quality of patient care in Endoscopy.
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75
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Affiliation(s)
- David C Klonoff
- Mills-Peninsula Health Services, San Mateo, California, USA.
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Coté GA. The debate for nonanesthesiologist-administered propofol sedation in endoscopy rages on: who will be the "King of Prop?". Gastrointest Endosc 2011; 73:773-6. [PMID: 21457817 DOI: 10.1016/j.gie.2010.11.041] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2010] [Accepted: 11/26/2010] [Indexed: 12/28/2022]
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Patient-controlled sedation with propofol and remifentanil for ERCP: a randomized, controlled study. Gastrointest Endosc 2011; 73:260-6. [PMID: 21295639 DOI: 10.1016/j.gie.2010.10.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2010] [Accepted: 10/05/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND Deep sedation with propofol and an opioid is commonly used for ERCP but is associated with increased risk and may require the presence of an anesthesiologist. Delivery of propofol and a short-acting, potent opioid analgesic remifentanil by patients to themselves (patient-controlled sedation, PCS) could be another option. Comparative studies with propofol PCS for ERCP are lacking. OBJECTIVE To compare PCS with propofol/remifentanil to anesthesiologist-managed propofol sedation. DESIGN Prospective, randomized, controlled human trial. SETTING University hospital. PATIENTS This study involved 80 patients presenting for elective ERCP. INTERVENTION Patients were randomized to PCS with propofol/remifentanil (PCS group) or anesthesiologist-managed propofol sedation (propofol infusion group). Sedation level was estimated every 5 minutes throughout the procedure by using Ramsay and Gillham sedation scores. The total amount of propofol was calculated at the end of the procedure. Endoscopist and patient satisfaction with the procedures was evaluated with a structured questionnaire. MAIN OUTCOME MEASUREMENTS Patient vital signs, amount of consumed propofol, sedation levels, and degree of endoscopist and patient satisfaction. RESULTS PCS was successful with 38 of 40 (95%) ERCP patients. In the PCS group, the mean (±standard deviation) level of sedation was markedly lighter and propofol consumption significantly smaller (175±98 mg) than in the propofol infusion group (249±138 mg) (P<.01). Degrees of patient and endoscopist satisfaction were equally high in both groups. All of the patients preferred the same sedation method should a repeat ERCP be required. LIMITATIONS Single-center study. CONCLUSION PCS with propofol/remifentanil is a suitable and well-accepted sedation method for ERCP. Anesthesiologist-managed propofol sedation with constant propofol infusion is associated with unnecessary deep sedation without any impact on the degree of patient or endoscopist satisfaction. Further larger-scale studies are needed to assess the safety of PCS in ERCP patients. ( CLINICAL TRIAL REGISTRATION NUMBER NCT01079312.).
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Lee CK, Lee SH, Chung IK, Lee TH, Park SH, Kim EO, Lee SH, Kim HS, Kim SJ. Balanced propofol sedation for therapeutic GI endoscopic procedures: a prospective, randomized study. Gastrointest Endosc 2011; 73:206-14. [PMID: 21168838 DOI: 10.1016/j.gie.2010.09.035] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2010] [Accepted: 09/22/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND There are few controlled studies on balanced propofol sedation (BPS) for therapeutic endoscopy. OBJECTIVE To compare the safety and efficacy of BPS (propofol in combination with midazolam and meperidine) with conventional sedation (midazolam and meperidine) in patients undergoing therapeutic endoscopic procedures. DESIGN Prospective, randomized, single-blinded study. SETTING Tertiary-care referral center. PATIENTS This study involved 222 consecutive patients undergoing therapeutic EGD or ERCP from July 2009 to March 2010. INTERVENTION Conventional sedation or BPS by trained registered nurses under endoscopist supervision. MAIN OUTCOME MEASUREMENTS Rates of sedation-related cardiopulmonary complications and interruption of the procedures, procedure-related times, and assessments of health care providers (endoscopists and sedation nurses) and patients. RESULTS There were no significant differences between the BPS and conventional groups in the rates of cardiopulmonary complications (8.8% [9/102] vs 5.8% [6/104], respectively) and transient interruption of procedures (2.9% [3/102] vs 0% [0/104], respectively). No patient required assisted ventilation or premature termination of a procedure. BPS provided significantly higher health care provider satisfaction (mean±SD 10-cm visual analog scale [VAS] score) compared with conventional sedation (endoscopists: 7.57±2.61 vs 6.55±2.99, respectively; P=.011; sedation nurses: 7.86±2.31 vs 6.67±2.90, respectively; P=.001). Patient cooperation was significantly better in the BPS group (VAS; endoscopists: 7.24±2.97 vs 6.27±3.09, P=.024; sedation nurses: 7.75±2.30 vs 6.54±2.99, P=.001). LIMITATIONS Single-center and single-blinded study. CONCLUSION Compared with conventional sedation, BPS provides higher health care provider satisfaction, better patient cooperation, and similar adverse event profiles in patients undergoing therapeutic endoscopic procedures.
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Affiliation(s)
- Chang Kyun Lee
- Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, Korea
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Correia LM, Bonilha DQ, Gomes GF, Brito JR, Nakao FS, Lenz L, Rohr MRS, Ferrari AP, Libera ED. Sedation during upper GI endoscopy in cirrhotic outpatients: a randomized, controlled trial comparing propofol and fentanyl with midazolam and fentanyl. Gastrointest Endosc 2011; 73:45-51, 51.e1. [PMID: 21184869 DOI: 10.1016/j.gie.2010.09.025] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2010] [Accepted: 09/14/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND Patients with liver cirrhosis frequently undergo diagnostic or therapeutic upper GI endoscopy (UGIE), and the liver disease might impair the metabolism of drugs usually administered for sedation. OBJECTIVE AND SETTING To compare sedation with a combination of propofol plus fentanyl and midazolam plus fentanyl in cirrhotic outpatients undergoing UGIE. DESIGN A prospective, randomized, controlled trial was conducted between February 2008 and February 2009. MAIN OUTCOMES MEASUREMENTS Efficacy (proportion of complete procedures using the initial proposed sedation scheme), safety (occurrence of sedation-related complications), and recovery time were measured. RESULTS Two hundred ten cirrhotic patients referred for UGIE were randomized to 2 groups: midazolam group (0.05 mg/kg plus fentanyl 50 μg intravenously) or propofol group (0.25 mg/kg plus fentanyl 50 μg intravenously). There were no differences between groups regarding age, sex, weight, etiology of cirrhosis, and Child-Pugh or American Society of Anesthesiologists classification. Sedation with propofol was more efficacious (100% vs 88.2%; P < .001) and had a shorter recovery time than sedation with midazolam (16.23 ± 6.84 minutes and 27.40 ± 17.19 minutes, respectively; P < .001). Complication rates were similar in both groups (14% vs 7.3%; P = .172). LIMITATIONS Single-blind study; sample size. CONCLUSION Both sedation schemes were safe in this setting. Sedation with propofol plus fentanyl was more efficacious with a shorter recovery time compared with midazolam plus fentanyl. Therefore, the former scheme is an alternative when sedating cirrhotic patients undergoing UGIE.
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Affiliation(s)
- Lucianna Motta Correia
- Disciplina de Gastroenterologia Clínica, Universidade Federal de São Paulo, São Paulo, Brasil
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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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81
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Inadomi JM, Gunnarsson CL, Rizzo JA, Fang H. Projected increased growth rate of anesthesia professional-delivered sedation for colonoscopy and EGD in the United States: 2009 to 2015. Gastrointest Endosc 2010; 72:580-6. [PMID: 20630511 DOI: 10.1016/j.gie.2010.04.040] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2010] [Accepted: 04/23/2010] [Indexed: 12/14/2022]
Abstract
BACKGROUND Anesthesia professional-delivered sedation has become increasingly common when performing colonoscopy and EGD. OBJECTIVE To provide an estimate of anesthesia professional-participation rates in colonoscopy and EGD procedures and to examine rate changes over time and geographic variations for both procedures. DESIGN Retrospective sample design. SETTING National survey data from i3 Innovus for the period 2003 to 2007 on the use rate of anesthesia professionals in both procedures. PATIENTS A sample of 3688 observations included 3-digit zip code-level information on anesthesia professional use rates. INTERVENTIONS Data were linked to the Bureau of Health Professions' Area Resource File to control for sociodemographic factors and provider supply characteristics for anesthesia professional use rates. MAIN OUTCOME MEASUREMENTS Multivariable regression analyses were performed to identify factors predicting the use rate of anesthesia professionals in these procedures and to forecast use rates for the years 2009 to 2015. RESULTS For colonoscopy and EGD, anesthesia professional participation is projected to grow from 23.9% and 24.4% in 2007 to 53.4% and 52.9% by 2015, respectively. Average growth rates were highest in the northeast for colonoscopy (145.8%) and EGD (146.6%). Anesthesia professional use rates were significantly greater in areas having a higher percentage of older subjects (45 years and older), higher per capita income and lower unemployment rates, and higher per capita inpatient admissions and were significantly lower in areas having more per capita outpatient visits for both procedures. LIMITATIONS Nonexperimental retrospective sample study design. Database sample may not be nationally representative. Market area characteristics were used to control for socioeconomic and demographic factors. However, there may remain some important market factors that we were unable to control. CONCLUSIONS Anesthesia professional-delivered sedation is projected to grow substantially for both procedures.
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Affiliation(s)
- John M Inadomi
- University of California, San Francisco, California, USA
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82
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Berzin TM. Endoscopic sedation training in gastroenterology fellowship. Gastrointest Endosc 2010; 71:597-9. [PMID: 20189520 DOI: 10.1016/j.gie.2010.01.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2010] [Accepted: 01/13/2010] [Indexed: 02/08/2023]
Affiliation(s)
- Tyler M Berzin
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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