Sedation-related complications in gastrointestinal endoscopy

Development of a deep learning-based software for calculating cleansing score in small bowel capsule endoscopy

A standardized small bowel (SB) cleansing scale is currently not available. The aim of this study was to develop an automated calculation software for SB cleansing score using deep learning. Consecutively performed capsule endoscopy cases were enrolled from three hospitals. A 5-step scoring system based on mucosal visibility was trained for deep learning in the training set. Performance of the trained software was evaluated in the validation set. Average cleansing score (1.0 to 5.0) by deep learning was compared to clinical grading (A to C) reviewed by clinicians. Cleansing scores decreased as clinical grading worsened (scores of 4.1, 3.5, and 2.9 for grades A, B, and C, respectively, P < 0.001). Adequate preparation was achieved for 91.7% of validation cases. The average cleansing score was significantly different between adequate and inadequate group (4.0 vs. 2.9, P < 0.001). ROC curve analysis revealed that a cut-off value of cleansing score at 3.25 had an AUC of 0.977. Diagnostic yields for small, hard-to-find lesions were associated with high cleansing scores (4.3 vs. 3.8, P < 0.001). We developed a novel scoring software which calculates objective, automated cleansing scores for SB preparation. The cut-off value we suggested provides a standard criterion for adequate bowel preparation as a quality indicator.

Complication rates in emergent endoscopy for foreign bodies under different sedation modalities: A large single-center retrospective review

BACKGROUND

Foreign object ingestion (FOI) and food bolus impaction (FBI) are common causes of emergent endoscopic intervention. The choice of sedation used is often dictated by physician experience. Many endoscopists frequently prefer to use monitored anesthesia care (MAC) and general anesthesia (GA) as opposed to conscious sedation (CS) due to the concern for inadequate airway protection. However, there is insufficient data examining the safety of different sedation modalities in emergent endoscopic management of FOI and FBI.

AIM

To investigate the complication rates of emergent endoscopic extraction performed under different sedation modalities.

METHODS

We conducted a retrospective chart review of patients presenting with acute FBI and FOI between 2010 and 2018 in two hospitals. A standardized questionnaire was utilized to collect data on demographics, endoscopic details, sedation practices, hospital stay and adverse events. Complications recognized during and within 24 h of the procedure were considered early, whereas patients presenting with a procedure-related adverse event within two weeks of the index event were considered delayed complications. Complication rates of patients who underwent emergent endoscopic retrieval were compared based on sedation types, namely CS, MAC and GA. Chi-square analysis and multiple logistic regression were used to compare complication rate based on sedation type.

RESULTS

Among the 929 procedures analyzed, 353 procedures (38.0%) were performed under CS, 278 procedures (29.9%) under MAC and the rest (32.1%) under GA. The median age of the subjects was 52 years old, with 57.4% being male. The majority of the procedures (64.3%) were FBI with the rest being FOI (35.7%). A total of 132 subjects (14.2%) had chronic comorbidities while 29.0% had psychiatric disorders. The most commonly observed early complications were mucosal laceration (3.8%) and bleeding (2.6%). The most common delayed complication was aspiration pneumonia (1.8%). A total of 20 patients (5.6%) could not adequately be sedated with CS and had to be converted to MAC or GA. Patient sedated with MAC and GA were more likely to require hospitalization, P < 0.0001. Analysis revealed no statistically significant difference in the complication rate between patients sedated under CS (14.7%), MAC (14.7%) and GA (19.5%), P = 0.19.

CONCLUSION

For patients who present with FOI or FBI and undergo emergent endoscopic treatment, there is no significant difference in adverse event rates between CS, MAC and GA.

Remimazolam tosilate in upper gastrointestinal endoscopy: A multicenter, randomized, non-inferiority, phase III trial

BACKGROUND AND AIM

Remimazolam tosilate (RT) is a new short-acting GABA(A) receptor agonist, having potential to be an effective option for procedural sedation. Here, we aimed to compare the efficacy and safety of RT with propofol in patients undergoing upper gastrointestinal endoscopy.

METHODS

This positive-controlled, non-inferiority, phase III trial recruited patients at 17 centers, between September 2017 and November 2017. A total of 384 patients scheduled to undergo upper gastrointestinal endoscopy were randomly assigned to receive RT or propofol. Primary endpoint was the success rate of sedation. Adverse events (AEs) were recorded to evaluate safety.

RESULTS

The success rate of sedation in the RT group was non-inferior to that in the propofol group (97.34% vs 100.00%; difference in rate -2.66%, 95% CI -4.96 to -0.36, meeting criteria for non-inferiority). Patients in the RT group had longer time to adequate sedation (P < 0.0001) but shorter time to fully alert (P < 0.0001) than that in the propofol group. The incidences of hypotension (13.04% vs 42.86%, P < 0.0001), treatment-related hypotension (0.54% vs 5.82%, P < 0.0001), and respiratory depression (1.09% vs 6.88%, P = 0.0064) were significantly lower in the RT group. AEs were reported in 74 (39.15%) patients in the RT group and 114 (60.32%) patients in the propofol group, with significant difference (P < 0.0001).

CONCLUSION

This trial established non-inferior sedation success rate of RT compared with propofol. RT allows faster recovery from sedation compared with propofol. The safety profile is favorable and appears to be superior to propofol, indicating that it was feasible and well tolerated for patients.

Clinical efficacy of high-flow nasal oxygen in patients undergoing ERCP under sedation

Hypoxemia can occur during endoscopic retrograde cholangiography (ERCP) and it is difficult to achieve adequate ventilation with the prone position. High-flow nasal oxygen (HFNO) has been recommended to be more effectively help ventilation than conventional low flow oxygen. The aim of this study was to evaluate the effect of HFNO during sedated ERCP and to identify predictors of desaturation during ERCP. The investigated variables were age, gender, American Society of Anesthesiologists classes (ASA), duration of exam, and sedative used for midazolam or/and propofol of 262 patients with sedated ERCP. The differences between categorical and continuous variables were analyzed using the Student's t test and the chi-square test. Desaturation (SpO2 ≤ 90%) occurred in 9(3.4%) patients among 262 patients during sedated ERCP. The variables found to predict desaturation were older age (p < 0.01), higher sedation dose for midazolam or propofol (p < 0.01), and use of midazolam (p < 0.01). Desaturation rate was lower during sedated ERCP with HFNO compared to the preliminary study with conventional low flow nasal oxygen. Patients with older age, higher sedation dose, or the use of midazolam might require close monitoring for desaturation and hypoventilation by nursing staff. The study shows the use of high-flow nasal oxygen reduces the incidence of desaturation during ERCP.

Airway Management for Initial PEG Insertion in the Pediatric Endoscopy Unit: A Retrospective Evaluation of 168 Patients

PURPOSE

Percutaneous endoscopic gastrostomy (PEG) tube placements are commonly performed pediatric endoscopic procedures. Because of underlying disease, these patients are at increased risk for airway-related complications. This study compares patient characteristics and complications following initial PEG insertion with general endotracheal anesthesia (GETA) vs. anesthesia-directed deep sedation with a natural airway (ADDS).

METHODS

All patients 6 months to 18 years undergoing initial PEG insertion within the endoscopy suite were considered for inclusion in this retrospective cohort study. Selection of GETA vs. ADDS was made by the anesthesia attending after discussion with the gastroenterologist.

RESULTS

This study included 168 patients (GETA n=38, ADDS n=130). Cohorts had similar characteristics with respect to sex, race, and weight. Compared to ADDS, GETA patients were younger (1.5 years vs. 2.9 years, p=0.04), had higher rates of severe American Society of Anesthesiologists (ASA) disease severity scores (ASA 4-5) (21% vs. 3%, p<0.001), and higher rates of cardiac comorbidities (39.5% vs. 18.5%, p=0.02). Significant associations were not observed between GETA/ADDS status and airway support, 30-day readmission, fever, or pain medication in unadjusted or adjusted models. GETA patients had significantly increased length of stay (e^β=1.55, 95% confidence interval [CI]=1.11-2.18) after adjusting for ASA class, room time, anesthesia time, fever, and cardiac diagnosis. GETA patients also had increased room time (e^β=1.20, 95% CI=1.08-1.33) and anesthesia time (e^β=1.50, 95% CI=1.30-1.74) in adjusted models.

CONCLUSION

Study results indicate that younger and higher risk patients are more likely to undergo GETA. Children selected for GETA experienced longer room times, anesthesia times, and hospital length of stay.

Predictor of respiratory disturbances during gastric endoscopic submucosal dissection under deep sedation

BACKGROUND

Sedation is commonly performed for the endoscopic submucosal dissection (ESD) of early gastric cancer. Severe hypoxemia occasionally occurs due to the respiratory depression during sedation.

AIM

To establish predictive models for respiratory depression during sedation for ESD.

METHODS

Thirty-five adult patients undergoing sedation using propofol and pentazocine for gastric ESDs participated in this prospective observational study. Preoperatively, a portable sleep monitor and STOP questionnaires, which are the established screening tools for sleep apnea syndrome, were utilized. Respiration during sedation was assessed by a standard polysomnography technique including the pulse oximeter, nasal pressure sensor, nasal thermistor sensor, and chest and abdominal respiratory motion sensors. The apnea-hypopnea index (AHI) was obtained using a preoperative portable sleep monitor and polysomnography during ESD. A predictive model for the AHI during sedation was developed using either the preoperative AHI or STOP questionnaire score.

RESULTS

All ESDs were completed successfully and without complications. Seventeen patients (49%) had a preoperative AHI greater than 5/h. The intraoperative AHI was significantly greater than the preoperative AHI (12.8 ± 7.6 events/h vs 9.35 ± 11.0 events/h, P = 0.049). Among the potential predictive variables, age, body mass index, STOP questionnaire score, and preoperative AHI were significantly correlated with AHI during sedation. Multiple linear regression analysis determined either STOP questionnaire score or preoperative AHI as independent predictors for intraoperative AHI ≥ 30/h (area under the curve [AUC]: 0.707 and 0.833, respectively) and AHI between 15 and 30/h (AUC: 0.761 and 0.778, respectively).

CONCLUSION

The cost-effective STOP questionnaire shows performance for predicting abnormal breathing during sedation for ESD that was equivalent to that of preoperative portable sleep monitoring.

Noninvasive continuous monitoring versus intermittent oscillometric measurements for the detection of hypotension during digestive endoscopy

BACKGROUND

Hemodynamic monitoring during digestive endoscopy is usually minimal and involves intermittent brachial pressure measurements. New continuous noninvasive devices to acquire instantaneous arterial blood pressure may be more sensitive to detect procedural hypotension.

PURPOSE

To compare the ability of noninvasive continuous monitoring with that of intermittent oscillometric measurements to detect hypotension during digestive endoscopy.

METHODS

In this observational prospective study, patients scheduled for gastrointestinal endoscopy and colonoscopy under sedation were monitored using intermittent pressure measurements and a noninvasive continuous technique (ClearSight™, Edwards). Stroke volume was estimated from the arterial pressure waveform. Mean arterial pressure and stroke volume values were recorded at T1 (prior to anesthetic induction), T2 (after anesthetic induction), T3 (gastric insufflation), T4 (end of gastroscopy), T5 (colonic insufflation). Hypotension was defined as mean arterial pressure < 65 mmHg.

RESULTS

Twenty patients (53±17 years) were included. Six patients (30%) had a hypotension detected using intermittent pressure measurements versus twelve patients (60%) using noninvasive continuous monitoring (p = 0.06). Mean arterial pressure decreased during the procedure with respect to T1 (p < 0.05), but the continuous method provided an earlier warning than the intermittent method (T3 vs T4). Nine patients (45%) had at least a 25% reduction in stroke volume, with respect to baseline.

CONCLUSION

Noninvasive continuous monitoring was more sensitive than intermittent measurements to detect hypotension. Estimation of stroke volume revealed profound reductions in systemic flow. Noninvasive continuous monitoring in high-risk patients undergoing digestive endoscopy under sedation could help in detecting hypoperfusion earlier than the usual intermittent blood pressure measurements.

Patient participation in gastrointestinal endoscopy - From patients' perspectives

Background

Patient participation is associated with satisfaction and improved health‐related outcomes. In gastrointestinal endoscopy, patient participation is an underexplored area.

Objective

To gain understanding on patients' experiences, attitudes and preferences concerning patient participation in the endoscopy pathway.

Methods

Semi‐structured interviews with endoscopy patients (n = 17, female n = 8, male n = 9, ages 19‐80 years) were performed. Interview transcripts were analysed using qualitative content analysis. Participants were recruited by purposive sampling from an endoscopy unit in a Swedish university hospital. Inclusion:≥ 18 years, fluency in Swedish and recent experience of endoscopy at the unit.

Results

Five generic categories emerged, two within the area of the patient's role, which was described as active or passive/included or excluded. Another three generic categories related to factors, critical to active participation, including organizational aspects, impressions of staff and individual circumstances were identified. In this context, patient participation described in the interviews was on a low to basic level, although sometimes reaching a higher level when staff ‘invited’ patients in decision making.

Discussion

This study contributes to the understanding of patient participation in endoscopy. Patients are in an inferior position and need support from the staff for an active role in their care. Although there were variations on the perceived importance of different factors, a heavy responsibility lies on the endoscopy staff to acknowledge the patients' individual needs and to facilitate patient participation.

Conclusions

Endoscopy staff has a key role in supporting patient participation. In endoscopy settings, patient participation is vulnerable to multiple factors.

Esophageal Function Tests are Not Associated with Barium Swallow Findings in Advanced Lung Disease

Gastroesophageal reflux disease and esophageal dysmotility are common in patients with advanced lung disease (ALD) and are associated with worse outcomes. Assessing esophageal function in these patients is relevant for determining pulmonary transplant eligibility and prognosticating post-transplant outcomes. Barium Swallow (BaS) is a non-invasive testing modality often performed as a complement to formal esophageal function tests (EFTs), but its role and clinical utility in this context is unknown. Therefore, we aimed to determine the relationship between BaS and EFTs with high-resolution manometry (HRM) and 24-h ambulatory pH-metry in patients with ALD. We performed a retrospective study of 226 consecutive patients undergoing evaluation for lung transplantation at a single center. All patients underwent EFTs and BaS independent of clinical history or symptoms per institutional protocol. Appropriate statistical tests were performed to evaluate the relationship between EFTs and BaS. Mucosal, reflux and motility findings were categorized. Abnormal motility was reported in 133 (59%) patients by BaS and 99 (44%) by HRM, with a significant difference in the proportions of patients with abnormal studies (p < 0.01). There were 7 (26%) patients with abnormal barium tablet passage who had normal HRM. The sensitivity (35%) and specificity (77%) for detecting pathologic reflux with BaS was poor. Inducibility of reflux and barium column height were not associated with pH-metry results. No clinically significant luminal irregularities were identified. In conclusion, while BaS can non-invasively assess esophageal mucosa, its findings are not associated with EFTs in patients with ALD.

New oropharyngeal double lumen cannula for sedation for transesophageal echocardiography: case series

Introduction

Method

Results

Conclusions

Creation of a score to predict risk of high conscious sedation requirements in patients undergoing endoscopy

BACKGROUND AND AIMS

The administration of intravenous conscious sedation to patients undergoing GI endoscopy carries a risk of cardiopulmonary adverse events. Our study aim was to create a score that stratifies the risk of occurrence of either high-dose conscious sedation requirements or a failed procedure.

METHODS

Patients receiving endoscopy via endoscopist-directed conscious sedation were included. The primary outcome was occurrence of sedation failure, which was defined as one of the following: (1) high-dose sedation, (2) the need for benzodiazepine/narcotic reversal agents, (3) nurse-documented poor patient tolerance to the procedure, or (4) aborted procedure. High-dose sedation was defined as >10 mg of midazolam and/or >200 μg of fentanyl or the meperidine equivalent. Patients with sedation failure (n = 488) were matched to controls (n = 976) without a sedation failure by endoscopist and endoscopy date.

RESULTS

Significant associations with sedation failure were identified for age, sex, nonclonazepam benzodiazepine use, opioid use, and procedure type (EGD, colonoscopy, or both). Based on these 5 variables, we created the high conscious sedation requirements (HCSR) score, which predicted the risk of sedation failure with an area under the curve of 0.70. Compared with the patients with a risk score of 0, risk of a sedation failure was highest for patients with a score ≥3.5 (odds ratio, 17.31; P = 2 × 10^-14). Estimated area under the curve of the HCSR score was 0.68 (95% confidence interval, 0.63-0.72) in a validation series of 250 cases and 250 controls.

CONCLUSIONS

The HCSR risk score, based on 5 key patient and procedure characteristics, can function as a useful tool for physicians when discussing sedation options with patients before endoscopy.

[New oropharyngeal double lumen cannula for sedation for transesophageal echocardiography: case series]

INTRODUCTION

Currently, transesophageal echodopplercardiography (TEE) is frequently performed under sedation on an outpatient basis. Sedation is related with increase in incidents on airways. Bearing in mind this scenario, we developed a new double lumen oropharyngeal cannula aimed at keeping airway patency, in addition to reducing risks to patients during endoscopy procedures performed under sedation. The main objective of our study was to assess the incidence of oxygen desaturation in a series of cases of adult patients submitted to outpatient TEE exam, under sedation and using the oropharyngeal cannula.

METHOD

Thirty patients under sedation with intravenous midazolam and propofol were assessed. After loss of consciousness, the cannula was placed and patients were maintained on spontaneous breathing. Oxygen saturation, capnometry, heart rate and non-invasive arterial blood pressure, in addition to subjective data: airway patency, handling of cannula insertion, and comfort of examiner were analyzed.

RESULTS

The incidence of mild desaturation was 23.3%, and there was no severe desaturation in any of the cases. The insertion of the oropharyngeal cannula was considered easy for 29 patients (96.6%), and TEE probe handling was appropriate in 93.33% of exams performed.

CONCLUSIONS

TEE exams under sedation aided by the double-lumen oropharyngeal cannula presented a low incidence of desaturation in patients assessed, and allowed analysis of expired CO₂ during the exams.

[Medical Dispute Related to Gastrointestinal Endoscopy Complications: Prevention and Management]

Because gastrointestinal (GI) endoscopy examinations are being performed increasingly frequently, the rate of detection of cancer and of precancerous lesions has increased. Moreover, development of more advanced endoscopic technologies has expanded the indications for, and thus frequency of, therapeutic endoscopic procedures. However, the incidence of complications associated with diagnostic or therapeutic GI endoscopy has also increased. The complications associated with GI endoscopy can be ameliorated by endoscopic or conservative treatment, but caution is needed as some of the more serious complications, such as perforation, can lead to death. In this chapter, we review the possible complications of GI endoscopy and discuss methods for their prevention and treatment.

The Effect of Transversus Abdominis Plane Block for Analgesia in Patients Undergoing Liver Transplantation: A Systematic Review and Meta-Analysis

Objective

Ultrasound-guided regional anaesthesia using transversus abdominis plane (TAP) block is a newer and safer method that can be used in patients undergoing liver transplant surgeries. This systematic review and meta-analysis was done to quantify the analgesic potential and opioid-sparing capability of TAP block in these patients.

Methods

The studies comparing TAP-block to conventional analgesic regimens for liver transplant were searched. The studies evaluating the comparative 24-h morphine consumption during postoperative period in patients undergoing liver transplant surgeries were searched and included as the primary outcome in the analysis.

Results

We found two randomised controlled trials and two retrospective studies that on meta-analysis showed that TAP block group had significantly lower requirement of morphine (WMD=27.59 mg; 95% CI: 33.47-21.70) at 24 h for pain mitigation. Also, postoperative nausea and vomiting was lower (RR=0.76; 95% CI: 0.47-1.22) but not statistically significant.

Conclusion

Ultrasound-guided TAP block provides postoperative analgesic efficacy in patients undergoing liver transplant surgeries. This study was registered in International prospective register of systematic reviews [PROSPERO: CRD42018094595].

High-flow nasal cannula oxygen therapy and hypoxia during gastroscopy with propofol sedation: a randomized multicenter clinical trial

BACKGROUND AND AIMS

Hypoxia is one of the most frequent adverse events with sedated GI endoscopy and can lead to serious consequences. No modalities have been found previously to prevent hypoxia. High-flow nasal cannula (HFNC) supportive oxygen therapy provides heated and humidified oxygen up to 60 L/minute. Because of its ability to improve respiratory function and good tolerance, we aimed to evaluate the validity and safety of HFNC supportive oxygen therapy in preventing the incidence of hypoxia in patients undergoing gastroscopy with propofol sedation.

METHODS

In a multicenter, prospective randomized single-blinded study, 1994 outpatients undergoing routine gastroscopy with propofol sedation provided by an anesthesiologist were randomized into 2 groups: the nasal cannula group (O₂ [2 L/minute] was supplied via an HFNC) and the HFNC group (O₂ [30-60 L/minute] was supplied via an HFNC) at 3 centers from November 2017 to February 2018. The primary outcome was the incidence of hypoxia. Other adverse events were also recorded.

RESULTS

HFNC supportive oxygen therapy decreased the incidence of hypoxia (75% ≤ Spo₂ < 90% for <60 seconds) and severe hypoxia (Spo₂ < 75% for any duration or 75% ≤ Spo₂ < 90% for ≥60 seconds) from 8.4% to 0% (P < .001) and from 0.6% to 0% (P = .03), respectively. The only HFNC-related adverse event was xeromycteria/rhinalgia (1.7%), which was observed 1 minute after the procedure and disappeared after 30 minutes.

CONCLUSIONS

HFNC supportive oxygen therapy can prevent the incidence of hypoxia and severe hypoxia in patients in America Society of Anesthesiologists class I-II undergoing elective gastroscopy under propofol sedation, with minimal related adverse events and good tolerance. (Clinical trial registration number: NCT03332433.).

Dexamethasone Reduces Postoperative Nausea in Pediatric Upper Endoscopy With Deep Sedation: A Randomized Controlled Trial

OBJECTIVES

We aimed to evaluate the effect of a single dose of preoperative dexamethasone on postoperative nausea and vomiting (PONV), a frequent complication and a major cause of delayed recovery in pediatric upper gastrointestinal endoscopy (UGIE) under sedation.

METHODS

In this double-blind randomized controlled study, 98 children aged 2 to 14, with American Society of Anesthesiologists status I to II, and undergoing elective UGIE with deep sedation were included and randomly assigned to 2 groups. Preoperatively, after anesthesia induction with sodium thiopental and maintenance with sevoflurane, patients in the intervention (n = 49) and control (n = 49) groups, respectively received 0.1 mg/kg i.v. dexamethasone and 2 cm i.v. 0.9% saline. Postoperatively, PONV incidence was measured as the primary outcome.

RESULTS

PONV incidence was significantly less in dexamethasone group (8.2%) compared to the control group (26.5%) (difference = 18.3%, 95% confidence interval: 3.4%-33%, P = 0.016). For secondary outcomes, between-group differences were not statistically significant: incidence of bronchospasm or laryngospasm (both 4.1%, P = 1); emergence delirium assessed with Pediatric Anesthesia Emergence Delirium scale (5.9 ± 3.4 vs 5.7 ± 3.2, P = 0.751); Modified Aldrete score at 0 minutes (9.4 ± 0.8 vs 9.3 ± 0.9, P = 0.909) and at 5 minutes (9.5 ± 0.7 vs 9.4 ± 0.9, P = 0.527); and recovery time (21.1 ± 6.6 vs 23.4 ± 8.6 minutes, P = 0.130).

CONCLUSIONS

A single preoperative dose of i.v. dexamethasone reduces PONV in children undergoing elective UGIE with deep sedation, but has no significant effect on the patient recovery time or the incidence of postoperative bronchospasm or laryngospasm and emergence delirium.

Explosive Vomiting Associated with Proximal Colonic Distention during a Difficult Propofol-Assisted Colonoscopy

We present a case of explosive vomiting associated with the extensive manipulation of the proximal colon during a difficult colonoscopy procedure. The cause of vomiting in this case may have been multifactorial; however, proximal colonic distention was the most likely factor because the onset of vomiting coincided with proximal colonic manipulation and happened without any prodromal signs, coughing, and airway obstruction. Propofol, the sedative most commonly administered to the patient during colonoscopy, allows for a deep state of sedation, and consequently extensive colonic distention and scope manipulation. Colonic distention may lead to a higher risk of vomiting. We reviewed the neurocircuitry associated with vomiting and discussed why proximal colonic distention may increase the risk of vomiting. We emphasize vigilance during the manipulation of the proximal colon because vomiting increases the potential for aspiration pneumonitis and pneumonia in patients under deep propofol sedation with attenuated airway responses.

Unilateral Rhinorrhea and Sneezing After Upper Gastrointestinal Endoscopy Under Intravenous Propofol Sedation With Supplemental Oxygen Administered via a Nasal Cannula: A Case Report

We present a rarely described complication of unilateral rhinorrhea and sneezing in a patient who received intravenous sedation with propofol and supplemental oxygen via a nasal cannula during upper gastrointestinal endoscopy. The literature is reviewed and a mechanism is proposed. Mechanical irritation of the nasal mucosa is felt to be the trigger. Suggestions to avoid and to treat are offered.

Moderate versus deep sedation in adults undergoing colonoscopy: systematic review and meta-analysis

OBJECTIVE

To perform a systematic review and meta-analysis comparing effectiveness and safety of moderate and deep sedation during colonoscopy.

RESEARCH DESIGN AND METHODS

We searched Medline, Embase, Central and Google scholar in May 2017 and updated in March 2018 to identify all randomized controlled trials that compared the effectiveness and safety of moderate and deep sedation during colonoscopy. The quality of studies was assessed using the "Risk of bias" tool. The primary endpoints were defined as patient satisfaction, physician satisfaction, incidence of recall and incidence of desaturation. Recovery time was also evaluated. Review Manager and Comprehensive Meta-Analysis software were used for statistical analysis.

RESULTS

A total of 919 patients from three studies were included in the final analysis. The combined analysis did not reveal any differences in patient satisfaction between moderate and deep sedation (RR = 0.94; 95% CI: 0.86 to 1.04; P_chi² = 0.06; I² = 65%; number needed to treat to harm [NNTH] = 15.6; 95% CI: NNTH 7.8 to ∞ to number needed to treat to benefit [NNTB] = 3078.0), physician satisfaction (RR = 0.35; 95% CI: 0.02 to 6.95; P_chi² < 0.001; I² = 100%; NNTB = 1.6; 95% CI: 1.5 to 1.8), incidence of recall (RR = 5.82; 95% CI: 0.51 to 66.48; P_chi² = 0.11; I² = 60%; NNTH = 11.0; 95% CI: 7.5 to 20.5) or recovery time (mean difference = -6.77; 95% CI: -16.21 to 2.67; P_chi² < 0.001; I² = 99%). However, incidence of desaturation was higher in the deep group than in the moderate group (RR = 0.18; 95% CI: 0.01 to 0.99; P_chi² = 0.48; I² = 0%; NNTB = 56.7; 95% CI: 31.6 to 273.1).

CONCLUSIONS

Moderate sedation showed comparable safety and effectiveness to deep sedation with respect to patient satisfaction, physician satisfaction, incidence of recall and recovery time.

Propofol Sedation by Pediatric Gastroenterologists for Endoscopic Procedures: A Retrospective Analysis

Background: There is a substantial literature on the favorable outcome of propofol administration by non-anesthesiologists for endoscopy in adults; however, very few data are currently available on propofol sedation by pediatric gastroenterologists. Aims: to evaluate the safety of propofol sedation by pediatric gastroenterologists. Methods: A retrospective chart review of all children who were sedated by pediatric gastroenterologists in three Northern Israeli hospitals over a 4 years period Demographic and medical characteristics and any data regarding the procedure were extracted from patient's records. The main outcome measurements were procedure completion and reported adverse events. Results: Overall, 1,214 endoscopic procedures for were performed during this period. Complete data was available for 1,190 procedures. All children sedated by pediatric gastroenterologists were classified as ASA I or II. Propofol dosage (in mg/kg) inversely correlated with patient age. The younger the child the higher the dose needed to reach a satisfactory level of sedation (r = -0.397, p < 0.001). The addition of fentanyl significantly decreased propofol dosage needed to provide optimal sedation, p < 0.001. Nine (0.7%) reversible adverse events were reported. All the procedures were successfully completed and all patients were discharged home. Conclusions: We conclude that our approach is safe in children as it is in adults and can be implemented for children with ASA I, II.

Video capsule endoscopy as a tool for evaluation of obscure overt gastrointestinal bleeding in the intensive care unit

BACKGROUND AND STUDY AIMS

 Video capsule endoscopy (VCE) is a minimally invasive tool that helps visualize the gastrointestinal tract from the esophagus to the right colon without the need for sedation or preparation. VCE is safe with very few contraindications. However, its role and safety profile in the intensive care unit (ICU) population have not been reported. The aim of this study is to evaluate the safety, efficacy, and feasibility of VCE use in ICU patients.

PATIENTS AND METHODS

 We conducted a single-center retrospective observational study of patients who underwent VCE for evaluation of obscure overt gastrointestinal bleeding in the ICU between 2008 and 2016.

RESULTS

 This study included 48 patients who were admitted to the UMass Memorial Medical Center ICUs for gastrointestinal bleeding. VCE was successfully completed in 43/48 (90 %) patients. The entire length of small bowel could be evaluated in 75 % and the source of bleeding was identified in 44 % of the patients. The most commonly identified source of bleeding included small bowel angioectasias, duodenal erosions/ulcers, and small bowel polyps. No major complications could be attributed to the VCE. Only 1 capsule was retained after 2 wk; however, there was no incidence of bowel obstruction, perforation, or capsule aspiration.

CONCLUSIONS

 This observational retrospective study demonstrates that VCE may be a safe, feasible, and effective diagnostic tool in evaluation of gastrointestinal bleeding in the ICU population with few complications. VCE may be a safe diagnostic prelude and be a guide to the correct therapeutic procedure if needed, in the context of patients who are seriously ill.

Procedural sedation by advanced care paramedics for emergency gastrointestinal endoscopy

OBJECTIVES

At the QEII Health Sciences Centre Emergency Department (ED) in Halifax, Nova Scotia, advanced care paramedics (ACPs) perform procedural sedation and analgesia (PSA) for many indications, including orthopedic procedures. We have begun using ACPs as sedationists for emergent upper gastrointestinal (UGI) endoscopy. This study compares ACP-performed ED PSA for UGI endoscopy and orthopedic procedures in terms of adverse events, airway intervention, vasopressor requirement, and PSA medication use.

METHODS

A data set was built from an ED PSA quality control database matching 61 UGI endoscopy PSAs to 183 orthopedic PSAs by propensity scores calculated using age, gender, and the American Society of Anesthesiologists (ASA) classification. Outcomes assessed were hypotension (systolic BP30 sec), vomiting, arrhythmias, death, airway intervention, vasopressor requirement, and PSA medication use.

RESULTS

UGI endoscopy patients experienced hypotension more frequently than orthopedic patients (OR=4.11, CI: 2.05-8.22) and required airway repositioning less often (OR=0.24, CI: 0.10-0.59). They received ketamine more frequently (OR=15.7, CI: 4.75-67.7) and fentanyl less often (OR=0.30, CI: 0.15-0.63) than orthopedic patients. Four endoscopy patients received phenylephrine, and one required intubation. No patient died in either group.

CONCLUSIONS

In ACP-led sedation for UGI endoscopy and orthopedic procedures, adverse events were rare with the notable exception of hypotension, which was more frequent in the endoscopy group. Only endoscopy patients required vasopressor treatment and intubation. We provide preliminary evidence that ACPs can manage ED PSA for emergent UGI endoscopy, although priorities must shift from pain control to hemodynamic optimization.

Topical pharyngeal anesthesia provides no additional benefit to propofol sedation for esophagogastroduodenoscopy: a randomized controlled double-blinded clinical trial

Propofol sedation has been applied during esophagogastroduodenoscopy procedures, but whether topical pharyngeal anesthesia should be administered at the same time has rarely been reported. Our study examined the role of topical pharyngeal anesthesia in sedated endoscopies in a randomized controlled double-blinded clinical trial. A total of 626 patients who underwent sedated esophagogastroduodenoscopy were randomized into the experimental group (n = 313) or the control group (n = 313). The discomfort score, immediately and one day after the procedure, was not statistically significant [7.2 (5-9) vs. 7.5 (6-9), P = 0.210; 2.3 (0-3) vs. 2.6 (0-4), P = 0.095, respectively]. Two patients in the experimental group and three patients in the control group needed oral medication for pharyngeal discomfort (P = 0.354). The satisfaction score was 9.2 (8-10) in the experimental group and 8.9 (7-10) in the control group (P = 0.778). Lidocaine topical pharyngeal anesthesia in propofol-sedated esophagogastroduodenoscopy did not further reduce the pharyngeal discomfort or improve the satisfaction. This clinical trial was registered at ClinicalTrials.gov (ClinicalTrials.gov ID: NCT03070379).

Person-centered endoscopy safety checklist: Development, implementation, and evaluation

AIM

To describe the development and implementation of a person-centered endoscopy safety checklist and to evaluate the effects of a “checklist intervention”.

METHODS

The checklist, based on previously published safety checklists, was developed and locally adapted, taking patient safety aspects into consideration and using a person-centered approach. This novel checklist was introduced to the staff of an endoscopy unit at a Stockholm University Hospital during half-day seminars and team training sessions. Structured observations of the endoscopy team’s performance were conducted before and after the introduction of the checklist. In addition, questionnaires focusing on patient participation, collaboration climate, and patient safety issues were collected from patients and staff.

RESULTS

A person-centered safety checklist was developed and introduced by a multi-professional group in the endoscopy unit. A statistically significant increase in accurate patient identity verification by the physicians was noted (from 0% at baseline to 87% after 10 mo, P < 0.001), and remained high among nurses (93% at baseline vs 96% after 10 mo, P = nonsignificant). Observations indicated that the professional staff made frequent attempts to use the checklist, but compliance was suboptimal: All items in the observed nurse-led “summaries” were included in 56% of these interactions, and physicians participated by directly facing the patient in 50% of the interactions. On the questionnaires administered to the staff, items regarding collaboration and the importance of patient participation were rated more highly after the introduction of the checklist, but this did not result in statistical significance (P = 0.07/P = 0.08). The patients rated almost all items as very high both before and after the introduction of the checklist; hence, no statistical difference was noted.

CONCLUSION

The intervention led to increased patient identity verification by physicians - a patient safety improvement. Clear evidence of enhanced person-centeredness or team work was not found.

Is whole-colon investigation by colonoscopy, computerised tomography colonography or barium enema necessary for all patients with colorectal cancer symptoms, and for which patients would flexible sigmoidoscopy suffice? A retrospective cohort study

BACKGROUND

For patients referred to hospital with suspected colorectal cancer (CRC), it is current standard clinical practice to conduct an examination of the whole colon and rectum. However, studies have shown that an examination of the distal colorectum using flexible sigmoidoscopy (FS) can be a safe and clinically effective investigation for some patients. These findings require validation in a multicentre study.

OBJECTIVES

To investigate the links between patient symptoms at presentation and CRC risk by subsite, and to provide evidence of whether or not FS is an effective alternative to whole-colon investigation (WCI) in patients whose symptoms do not suggest proximal or obstructive disease.

DESIGN

A multicentre retrospective study using data collected prospectively from two randomised controlled trials. Additional data were collected from trial diagnostic procedure reports and hospital records. CRC diagnoses within 3 years of referral were sourced from hospital records and national cancer registries via the Health and Social Care Information Centre.

SETTING

Participants were recruited to the two randomised controlled trials from 21 NHS hospitals in England between 2004 and 2007.

PARTICIPANTS

Men and women aged ≥ 55 years referred to secondary care for the investigation of symptoms suggestive of CRC.

MAIN OUTCOME MEASURE

Diagnostic yield of CRC at distal (to the splenic flexure) and proximal subsites by symptoms/clinical signs at presentation.

RESULTS

The data set for analysis comprised 7380 patients, of whom 59% were women (median age 69 years, interquartile range 62-76 years). Change in bowel habit (CIBH) was the most frequently presenting symptom (73%), followed by rectal bleeding (38%) and abdominal pain (29%); 26% of patients had anaemia. CRC was diagnosed in 551 patients (7.5%): 424 (77%) patients with distal CRC, 122 (22%) patients with cancer proximal to the descending colon and five patients with both proximal and distal CRC. Proximal cancer was diagnosed in 96 out of 2021 (4.8%) patients with anaemia and/or an abdominal mass. The yield of proximal cancer in patients without anaemia or an abdominal mass who presented with rectal bleeding with or without a CIBH or with a CIBH to looser and/or more frequent stools as a single symptom was low (0.5%). These low-risk groups for proximal cancer accounted for 41% (3032/7380) of the cohort; only three proximal cancers were diagnosed in 814 low-risk patients examined by FS (diagnostic yield 0.4%).

LIMITATIONS

A limitation to this study is that changes to practice since the trial ended, such as new referral guidelines and improvements in endoscopy quality, potentially weaken the generalisability of our findings.

CONCLUSIONS

Symptom profiles can be used to determine whether or not WCI is necessary. Most proximal cancers were diagnosed in patients who presented with anaemia and/or an abdominal mass. In patients without anaemia or an abdominal mass, proximal cancer diagnoses were rare in those with rectal bleeding with or without a CIBH or with a CIBH to looser and/or more frequent stools as a single symptom. FS alone should be a safe and clinically effective investigation in these patients. A cost-effectiveness analysis of symptom-based tailoring of diagnostic investigations for CRC is recommended.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN95152621.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 66. See the NIHR Journals Library website for further project information.

The Comparison of Etomidate and Propofol Anesthesia in Patients Undergoing Gastrointestinal Endoscopy: A Systematic Review and Meta-Analysis

INTRODUCTION

Etomidate and propofol played an important role in the sedation of patients undergoing gastrointestinal endoscopy. We conducted a systematic review and meta-analysis to compare their efficacy and safety.

MATERIALS AND METHODS

PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases were systematically searched. Randomized controlled trials assessing the effect of etomidate versus propofol for the anesthesia of patients undergoing gastrointestinal endoscopy were included. Two investigators independently searched articles, extracted data, and assessed the quality of included studies. The primary outcomes were anesthesia duration and recovery time. Meta-analysis was performed using random-effect model.

RESULTS

Six randomized controlled trials involving 1115 patients were included in the meta-analysis. Overall, compared with propofol, etomidate resulted in comparable anesthesia duration [standard mean difference (Std. MD)=-0.03; 95% confidence interval (CI), -0.16 to 0.10; P=0.66], recovery time (Std. MD=0.25; 95% CI, -0.42 to 0.92; P=0.47), mean arterial pressure at intubation (Std. MD=0.44; 95% CI, -0.26 to 1.15; P=0.21), heart pulse at intubation (Std. MD=0.93; 95% CI, -0.69 to 2.55; P=0.26), SPO2 at intubation (Std. MD=-0.52; 95% CI, -1.04 to 0.01; P=0.05), patient satisfaction [odds risk (OR)=0.42; 95% CI, 0.11-1.66; P=0.22], hypotension (OR=0.14; 95% CI, 0.02-1.22; P=0.07), changes of heart rate (OR=0.97; 95% CI, 0.61-1.53; P=0.88), nausea-vomiting (OR=2.02; 95% CI, 0.73-5.57; P=0.17), and the reduction in apnea or hyoxemia (OR=0.39; 95% CI, 0.24-0.64; P=0.0002), and injection pain (OR=0.03; 95% CI, 0.01-0.08; P<0.00001), but the increase in myoclonus (OR=8.54; 95% CI, 3.14-23.20; P<0.0001).

CONCLUSIONS

Between etomidate and propofol, no significant difference was revealed regarding anesthesia duration, recovery time, mean arterial pressure at intubation, heart pulse at intubation, SPO2 at intubation, patient satisfaction, hypotension, changes of heart rate and nausea-vomiting. Compared with propofol, etomidate showed reduced apnea or hyoxemia, and injection pain, but with an increased myoclonus.

Combination of Five Body Positions Can Effectively Improve the Rate of Gastric Mucosa's Complete Visualization by Applying Magnetic-Guided Capsule Endoscopy

Objectives. Achieving a comprehensive view of gastric mucosa has been a challenge for magnetic-guided capsule endoscopy (MGCE) for years. This study works on optimizing the performance of MGCE by changing the conventional positions to the five body positions. Methods. Sixty patients were enrolled in the study and underwent MGCE. All patients were asked to adopt five body positions (left lateral, supine, right lateral, knee-chest, and sitting). In each position, the ability to visualize the six gastric landmarks (cardia, fundus, body, angulus, antrum, and pylorus) was assessed. Rates of complete visualization were calculated for different position combinations. Results. Supine position was the best for cardia and body visualization (91.7% and 86.7%, resp., p < 0.001). Left lateral position was the best for fundus visualization (91.7%, p < 0.001). Knee-chest position was the best for angulus observation (80.0%, p < 0.001). Right lateral and sitting positions were the best for antrum observation (88.3% and 90.0%, resp., p < 0.001). Right lateral position was the best for pylorus observation (81.7%, p < 0.001). The supine + right lateral + knee-chest combination achieved better angulus visualization than conventional 3-position combination (93.3% versus 63.3%, p < 0.001). Five-position combination significantly improved the comprehensive gastric landmark visualization (93.3%, p < 0.001). Conclusion. Compared with 3-position combination, 5-position combination should be adopted for gastric mucosal visualization by MGCE.

Advanced Monitoring Is Associated with Fewer Alarm Events During Planned Moderate Procedure-Related Sedation: A 2-Part Pilot Trial

Supplemental Digital Content is available in the text.

Published ahead of print February 1, 2016

Diagnostic and interventional procedures are often facilitated by moderate procedure-related sedation. Many studies support the overall safety of this sedation; however, adverse cardiovascular and respiratory events are reported in up to 70% of these procedures, more frequently in very young, very old, or sicker patients. Monitoring with pulse oximetry may underreport hypoventilation during sedation, particularly if supplemental oxygen is provided. Capnometry may result in false alarms during sedation when patients mouth breathe or displace sampling devices. Advanced monitor use during sedation may allow event detection before complications develop. This 2-part pilot study used advanced monitors during planned moderate sedation to (1) determine incidences of desaturation, low respiratory rate, and deeper than intended sedation alarm events; and (2) determine whether advanced monitor use is associated with fewer alarm events.

Risk Factors and Outcomes of Reversal Agent Use in Moderate Sedation During Endoscopy and Colonoscopy

BACKGROUND

Moderate sedation has been standard for noninvasive gastrointestinal procedures for decades yet there are limited data on reversal agent use and outcomes associated with need for reversal of sedation.

AIM

To determine prevalence and clinical significance of reversal agent use during endoscopies and colonoscopies.

METHODS

Individuals with adverse events requiring naloxone and/or flumazenil during endoscopy or colonoscopy from 2008 to 2013 were identified. A control group was obtained by random selection of patients matched by procedure type and date. Prevalence of reversal agent use and statistical comparison of patient demographics and risk factors against controls were determined.

RESULTS

Prevalence of reversal agent use was 0.03% [95% confidence interval (CI), 0.02-0.04]. Events triggering reversal use were oxygen desaturation (64.4%), respiration changes (24.4%), hypotension (8.9%), and bradycardia (6.7%). Two patients required escalation of care and the majority of patients were stabilized and discharged home. Compared with the control group, the reversal group was older (61±1.8 vs. 55±1.6, P=0.01), mostly female (82% vs. 50%, P<0.01), and had lower body mass index (24±0.8 vs. 27±0.7, P=0.03) but received similar dosages of sedation. When adjusted for age, race, sex, and body mass index, the odds of reversal agent patients having a higher ASA score than controls was 4.7 (95% CI, 1.7-13.1), and the odds of having a higher Mallampati score than controls was 5.0 (95% CI, 2.1-11.7) with P<0.01.

CONCLUSIONS

Prevalence of reversal agent use during moderate sedation is low and outcomes are generally good. Several clinically relevant risk factors for reversal agent use were found suggesting that certain groups may benefit from closer monitoring.

Registered nurse-administered sedation for gastrointestinal endoscopic procedure

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.

Gastrointestinal Endoscopy Is Safe in Patients Before and After Lung or Heart Transplantation

BACKGROUND

Gastrointestinal complications are common in patients after lung and heart transplantation. Endoscopy is a standard method for the assessment of gastrointestinal morbidities. The aim of this study was to analyze the number and type of complications during endoscopic procedures in patients before and after lung or heart transplantation.

METHODS

A retrospective single centre analysis of endoscopic procedures in patients before and after lung and heart transplantation from May 1999 to September 2012 was performed compared to a control group.

RESULTS

Four hundred fifty-nine endoscopic procedures were performed in 175 patients after transplantation (84 lung and 91 heart) and 213 procedures in 160 transplant candidates on the waiting list for lung (n = 126) or heart (n = 34) transplantation. In 26% (n = 56/214) of the endoscopic examinations, an intervention was necessary in the lung transplant group compared to 32% (n = 79/245) in the heart transplant group and 27% (n = 43/160) and 21% (n = 11/53) in the lung and heart transplant candidates, respectively. In the control group, endoscopic interventions were performed in 24% (n = 195/805) of the examinations. Overall, 14 (1%) complications resulted from 1,477 endoscopic examinations. Only four (0.9%) of 459 endoscopic examinations were followed by complications in the transplant recipients, whereas in the control group, 10 complications (1.2%) of 805 endoscopies were documented. No endoscopic complication occurred in the lung and heart transplant candidates.

CONCLUSION

Diagnostic and therapeutic endoscopies can be safely performed after lung and heart transplantation and in patients on the waiting list for these organs.

Etomidate-remifentanil is more suitable for monitored anesthesia care during gastroscopy in older patients than propofol-remifentanil

Background

This prospective and randomized study was designed to compare safety, potential complications, and patient and examiner satisfaction of 2 anesthetic combinations – etomidate-remifentanil and propofol-remifentanil – in elderly patients undergoing diagnostic gastroscopy.

Material/Methods

A group of 720 patients, aged 60–80 years, scheduled for diagnostic gastroscopy under sedation were prospectively randomized. After 0.4–0.6 μg kg⁻¹ of remifentanil was infused, etomidate or propofol was administered. Patients in the etomidate group received doses of etomidate at 0.1–0.15 mg kg⁻¹ followed by 4–6 mg. Patients in the propofol group received doses of propofol at 1–2 mg kg⁻¹ followed by 20–40 mg. Physiological indexes were evaluated for the 715 of 720 patients that completed the treatment. The onset time, duration time, and discharge time were recorded. Physicians, anesthetists, and patients were surveyed to assess their satisfaction.

Results

Systolic pressure and diastolic pressure decreased significantly after the procedure in the propofol group (P<0.001). The average heart rate was significantly lower in the propofol group (P<0.05). No periods of desaturation (SpO₂ <95%) were observed in either group. The onset time was earlier in the etomidate group (P=0.00). All adverse events, with the exception of myoclonus, were greater in the propofol group, and physician and patient satisfaction in both groups was similar.

Conclusions

Etomidate-remifentanil administration for sedation and analgesia during gastroscopy resulted in more stable hemodynamic responses and less adverse events in older patients.

Assessment of the effects of ketamine-fentanyl combination versus propofol-remifentanil combination for sedation during endoscopic retrograde cholangiopancreatography

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) as a diagnostic and treatment procedure is used in most biliary tract and pancreatic. Either sedation or general anesthesia could be considered for this procedure. Combining a sedative with an opioid agent can provide effective moderate sedation. This study compared the impact of ketamine-fentanyl (KF) versus propofol-remifentanil (PR) on sedation scale in patients undergoing ERCP.

MATERIALS AND METHODS

As a double-blinded randomized clinical trial, 80 patients selected by convenient sampling, allocated randomly into two groups. KF group received ketamine 0.5 mg/kg body weight intravenously over 60 s and then fentanyl 1 mcg/kg body weight intravenously. PR group received propofol l mg/kg body weight intravenously over 60 s and then remifentanil 0.05 mcg/kg body weight/min intravenously. Intravenous (IV) infusion of propofol was maintained by 50 mcg/kg body weight/min throughout ERCP. Ramsay Sedation Score, vital signs, oxygen saturation (SpO2), recovery score (modified Aldrete score) and visual analog scales of pain intensity, and endoscopist's satisfaction were considered as measured outcomes. All analysis were analyzed by SPSS Statistics version 22 and using t-test, Chi-square and repeated measured ANOVA and Mann-Whitney tests for data analysis.

RESULTS

Respiratory rate and SpO2 level during the time intervals were lower in PR group (P < 0.001). Sedation score at intervals was not significantly different (P = 0.07). The frequency of apnea in PR group was significantly higher than the KF group (P = 0.003). The percentage of need to supplemental oxygen in PR group was 35.1% that was also significantly higher than 8.8% in the KF group (P = 0.008), but the dosage frequency was significantly higher in KF group (P < 0.001). The KF and PR groups average length of stay in the recovery room were 50.71 standard deviation (SD = 9.99) and 42.57 (SD = 11.99) minutes, respectively, indicating a significant difference (P = 0.003). The mean severity of nausea in KF and PR groups was, respectively, 2.74 confidence interval (CI = 1.68-3.81) and 0.43 (CI = 0.11-0.75), that was significantly higher in KF group (P < 0.001). The average score of surgeon satisfaction in both KF and PR groups were 7.69 (CI = 7.16-8.21) and 8.65 (CI = 8.25-9.05), respectively, which was higher in KF group (P = 0.004), but the average level of patients satisfaction in KF group was 8.86 (CI = 8.53-9.19) and in PR group was 8.95 (CI - 8.54-9.35) that were not significantly different (P = 0.074).

CONCLUSION

There is no statistically significant difference between KF and PR combinations in sedation score, but PR combination provides better pain control, with less nausea and shorter recovery time while causing more respiratory side effects, that is, apnea and need to oxygen.

In vivo endomicroscopy of donor duodenum improves early detection of pancreas rejection in a recipient of simultaneous duodenum-drained pancreas-kidney transplantation: a case report

Confocal laser endomicroscopy (CLE) is a new technique, which allows subsurface histological diagnosis at a cellular and subcellular level in vivo and could provide histological diagnosis during endoscopic examination. Up to now histological examination of the tissue sample is the only definitive way of diagnosis and monitoring organ rejection after transplantation. In case of pancreas transplantation percutaneous pancreas biopsy under imaging control is still the method of choice for obtaining tissue samples. However in 73–89% of biopsy attempts, it was shown that the duodenal histology predicts the initial diagnosis of rejection of the pancreas, usefulness of transplanted duodenum biopsies for graft rejection monitoring was also described. The histology technique is time consuming, and the therapeutic decision could not be made quickly, in spite of clinical necessity. In this paper we described feasibility of visualization and biopsy of donor duodenum and detection of microscopic changes in 2 cases of transplanted duodenum, expressed as destruction of the villi and dispersed goblet cells in comparison to a microscopic view of their own healthy duodenum No or only small, endoscopically non-significant macroscopic changes in transplanted duodenum in those patients were observed. In both cases, the histological examination confirmed acute organ rejection. We demonstrated for the first time that CLE is promising and effective method to detect acute phase of organ rejection and also for follow up in those patients.