Falls in hemoglobin saturation during ERCP and upper gastrointestinal endoscopy

Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018

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Prospective comparative study on the acceptability of unsedated transnasal endoscopy in younger versus older patients

GOALS

The aim of this prospective study was to compare the acceptance and tolerance for unsedated transnasal esophagogastroduodenoscopy (EGD) between younger and older patients.

BACKGROUND

Little information is available on comparisons of younger and older patients with regard to acceptance and tolerance of transnasal EGD.

STUDY

A total of 260 patients were referred for unsedated transnasal EGD and divided into 2 groups according to their age: less than 60 years of age (group A, n=160) and 60 years of age and older (group B, n=100). A questionnaire for tolerance was completed by each patient (a validated 0 to 10 scale where "0" represents no discomfort/well tolerated and "10" represents severe discomfort/poorly tolerated).

RESULTS

In 94.4% of group A and 95.0% of group B, insertions were successfully completed (P>0.05). Between groups A and B, discomfort during nasal anesthesia (1.7+/-0.2 vs. 1.6+/-0.2) and overall tolerance during procedure (1.7+/-0.2 vs. 1.5+/-0.2) were similar (P>0.05). However, discomfort during insertion was significantly greater in group A than in group B (2.5+/-0.2 vs. 1.9+/-0.2, P=0.02). Of all, 97.4% of group A and 94.7% of group B were willing to undergo unsedated transnasal EGD in the future (P>0.05).

CONCLUSIONS

There was no significant difference in acceptability between younger and older patients for unsedated transnasal EGD. Otherwise, younger patients experienced significantly more discomfort during insertion than did older patients.

Prospective randomized trial of transnasal versus peroral endoscopy using an ultrathin videoendoscope in unsedated patients

AIM

The aim of this study was to compare the acceptance and tolerance of transnasal and peroral esophagogastroduodenoscopy (EGD) using an ultrathin videoendoscope in unsedated patients.

METHODS

A total of 124 patients referred for diagnostic endoscopy were assigned randomly to have an unsedated transnasal EGD (n = 64) or peroral EGD (n = 60) with local anesthesia. An ultrathin videoendoscope with a diameter of 5.9 mm was used in this study. A questionnaire for tolerance was completed by the patient (a validated 0-10 scale where '0' represents no discomfort/well tolerated and '10' represents severe discomfort/poorly tolerated).

RESULTS

Of the 64 transnasal EGD patients, 60 patients (94%) had a complete examination. Four transnasal EGD examinations failed for anatomical reasons; all four patients were successfully examined when switched to the peroral EGD. All 60 peroral EGD patients had a complete examination. Between the transnasal and peroral groups, there was a statistically significant difference in scores for discomfort during local anesthesia (1.5 +/- 0.2 vs 2.6 +/- 0.3, P = 0.003), discomfort during insertion (2.3 +/- 0.3 vs 4.3 +/- 0.3, P = 0.001), and overall tolerance during procedure (1.6 +/- 0.2 vs 3.8 +/- 0.2, P = 0.001). In all, 95% of transnasal EGD patients and 75% of peroral EGD patients (P = 0.002) were willing to undergo the same procedure in the future. Four patients in the transnasal EGD group experienced mild epistaxis.

CONCLUSION

For unsedated endoscopy using an ultrathin videoendoscope, transnasal EGD is well tolerated and considerably reduces patient discomfort compared with peroral EGD.

Guidelines for sedation by nonanesthesiologists during diagnostic and therapeutic procedures. The Risk Management Committee of the Department of Anaesthesia of Harvard Medical School

The increasing use of sedation to enhance patient comfort during diagnostic and therapeutic procedures has been noted by the Joint Commission of Accredited Healthcare Organizations, specialty societies, and the public. Although anesthesiologists, by virtue of training and experience, possess unique qualifications to provide such sedation services, their availability remains somewhat limited by primary commitments to the operating room, intensive care unit, or pain service. The Risk Management Committee of the Department of Anaesthesia of Harvard Medical School has made specific recommendations to the Harvard-affiliated hospitals for anesthesiologists who participate in institutional-level committees in setting guidelines for such services when they are provided by nonanesthesiologists. Specific consideration is given to facilities, backup emergency services, equipment, education and training, issues of informed consent, documentation, and release of patients from medical care. These recommendations emphasize the collaboration of the department of anesthesia and other departments that provide sedation services in formulating policies and procedures that reflect values intrinsic to the practice of anesthesiology.

Safety of fibreoptic endoscopy: analysis of cardiorespiratory events

Cardiorespiratory function during upper gastrointestinal endoscopy and colonoscopy was studied prospectively in 164 patients. Cardiorespiratory events, which were defined as oxygen saturation < 90 per cent, electrocardiographic changes, heart rate < 50 or > 100 beats/min and systolic blood pressure < 100 mmHg, occurred in 111 patients. In 24 of these, changes were attributed solely to intravenous sedation. In the remaining 140 patients, events were noted in 34 (52 per cent) of 66 upper gastrointestinal endoscopies and during 53 (72 per cent) of 74 colonoscopies. One patient suffered a myocardial infarction during colonoscopy. Although cardiorespiratory events were common (111 of 164; 68 per cent), the actual morbidity rate was low (one of 164; 0.6 per cent). Cardiorespiratory events were significantly more common in patients with a history of cardiac disease for both upper gastrointestinal endoscopy and colonoscopy (overall chi 2 = 7.41, 1 d.f., P < 0.05) and more common for oesophageal dilatation than for diagnostic endoscopy (chi 2 = 5.56, 1 d.f., P < 0.05). It is recommended that patients with a history of cardiac problems undergoing upper gastrointestinal endoscopy or colonoscopy and all those requiring therapeutic endoscopy should be monitored carefully to allow early detection of cardiorespiratory events, and that oxygen should be administered routinely.

Hemodynamic monitoring and pulse oximetry during percutaneous gastrostomy and jejunostomy: necessity or nuisance?

Hemoglobin desaturation and arrhythmias have been reported during diagnostic gastroscopy and colonoscopy. During endoscopic placement of percutaneous gastrostomy tubes (PEG), the gastroscope is inserted twice and the stomach is markedly distended, thus increasing the potential risk of complications. Also, the procedure is frequently performed in patients exhibiting underlying systemic disease or little respiratory reserve. Patients undergoing PEG or percutaneous endoscopic jejunostomy (PEJ) were studied prospectively. Blood pressure, pulse, pulse oximetry, and lead II ECG tracings were obtained. Measurements were made before sedation, after sedation, at gastroscope insertion, at gastrostomy placement, at gastroscope reinsertion, and at 5 min after the procedure. In all, 50 patients (mean age, 56.8 years; 16 women, 26 men) underwent PEG only (39 cases) or PEG/PEJ (11 cases). The endoscopy suite was the site for the procedure in 38 cases and the intensive care unit was used in 12 cases. The mean time required for PEG and PEG/PEJ was 14.7 +/- 1.1 and 18.9 +/- 2 min, respectively. Blood pressure remained stable throughout the procedure. Sinus tachycardia was observed in 72% of patients. Arterial oxygen saturation decreased after the administration of intravenous sedation but remained constant during the procedure. We reached the following conclusions: (1) desaturation occurs during sedation, (2) saturation remains constant during PEG/PEJ, (3) the mean blood pressure remains constant during PEG/PEJ, and (4) PEG/PEJ are safe procedures and monitoring should be individualized.