Adverse events during monitored anesthesia care for GI endoscopy: an 8-year experience

A machine learning stacking model accurately estimating gastric fluid volume in patients undergoing elective sedated gastrointestinal endoscopy

BACKGROUND

The current point-of-care ultrasound (POCUS) assessment of gastric fluid volume primarily relies on the traditional linear approach, which often suffers from moderate accuracy. This study aimed to develop an advanced machine learning (ML) model to estimate gastric fluid volume more accurately.

METHODS

We retrospectively analyzed the clinical data and POCUS data (D1: craniocaudal diameter, D2: anteroposterior diameter) of 1386 patients undergoing elective sedated gastrointestinal endoscopy (GIE) at Nanjing First Hospital to predict gastric fluid volume using ML techniques, including six different ML models and a stacking model. We evaluated the models using the adjusted Coefficient of Determination (R2), mean absolute error (MAE) and root mean square error (RMSE). The SHapley Additive exPlanations (SHAP) method was used to interpret the importance of the variables. Finally, a web calculator was constructed to facilitate its clinical application.

RESULTS

The stacking model (Linear regression + Multilayer perceptron) performed best, with the highest adjusted R2 of 0.718 (0.632 to 0.804). The mean prediction bias was 4 ml (MAE: 4.008 (3.68 to 4.336)), which is better than that of the linear model. D1 and D2 ranked high in the SHAP plot and performed better in the right lateral decubitus (RLD) than in the supine position. The web calculator can be accessed at https://cheason.shinyapps.io/Stacking_regressor/.

CONCLUSION

The stacking model and its web calculator can serve as practical tools for accurately estimating gastric fluid volume in patients undergoing elective sedated GIE. It is recommended that anesthesiologists measure D1 and D2 in the patient's RLD position.

Predictors and impact of aspiration pneumonia in patients undergoing esophagogastroduodenoscopy: national inpatient sample 2016-2020

OBJECTIVES

Aspiration pneumonia is a rare but feared complication among patients undergoing esophagogastroduodenoscopy (EGD). Our study aims to assess the incidence as well as risk factors for aspiration pneumonia in patients undergoing EGD.

METHODS

National Inpatient Sample 2016-2020 was used to identify adult patients undergoing EGD. Patients were stratified into two groups based on the presence of aspiration pneumonia. Multivariate logistic regression analysis was performed to identify the risk factors associated with aspiration pneumonia. We adjusted for patient demographics, Elixhauser comorbidities and hospital characteristics.

RESULTS

Of the 1.8 million patients undergoing EGD, 1.9% of the patients developed aspiration pneumonia. Patients with aspiration pneumonia were mostly males (59.54%), aged >65 years old (66.19%), White (72.2%), had Medicare insurance (70.5%) and were in the lowest income quartile (28.7%). On multivariate analysis, the age >65 group, White race, congestive heart failure (CHF), neurological disorders and chronic obstructive pulmonary disease were associated with higher odds of aspiration pneumonia. This complication was associated with higher in-hospital mortality (9% vs. 0.8%; P  < 0.001) and longer length of stay (10.54 days vs. 4.85 days; P  < 0.001).

CONCLUSION

Our study found that rates of post-EGD aspiration pneumonia are increasing. We found a significant association between various comorbidities and aspiration pneumonia. Our data suggests that we need to optimize these patients before EGD, as the development of aspiration is associated with worsened outcomes. Further prospective studies are needed to clarify these associations.

Effect of Remimazolam Supplementation on Propofol Requirements During Hysteroscopy: A Double-Blind, Dose-Response Study

BACKGROUND

Propofol is commonly used for procedural sedation but may increase side effects in a dose-dependent manner. Remimazolam, an ultrashort-acting benzodiazepine, has been approved for procedural sedation but may delay awakening. This study tested the hypothesis that remimazolam as a supplement reduces effect-site propofol concentration (Ceprop) required to suppress response to cervical dilation in patients undergoing hysteroscopy.

METHODS

One hundred and fifty patients who were scheduled for hysteroscopy were randomized to receive 0, 0.05, 0.1, 0.15, or 0.2 mg·kg-1 intravenous remimazolam, followed by a bolus of sufentanil 0.15 μg⋅kg-1, and a target-controlled propofol infusion. The initial target Ceprop was 3.5 μg·mL-1 and was increased or decreased in subsequent patients by steps of 0.5 μg·mL-1 according to whether there was loss of response to cervical dilation in the previous patient. We used up-down sequential analysis to determine values of Ceprop that suppressed response to cervical dilation in 50% of patients (EC50).

RESULTS

The EC50 of propofol for suppressing response to cervical dilation was lower in patients given 0.1 mg·kg-1 (2.08 [95% confidence interval, CI, 1.88-2.28] μg·mL-1), 0.15 mg⋅kg-1 (1.83 [1.56-2.10] μg·mL-1), and 0.2 mg⋅kg-1 (1.43 [1.27-1.58] μg·mL-1) remimazolam than those given 0 mg⋅kg-1 (3.67 [3.49-3.86] μg·mL-1) or 0.05 mg⋅kg-1 (3.47 [3.28-3.67] μg·mL-1) remimazolam (all were P < .005). Remimazolam at doses of 0.1, 0.15, and 0.2 mg·kg-1 decreased EC50 of propofol by 43.3% (95% CI, 41.3%-45.5%), 50.3% (48.0%-52.8%), and 61.2% (58.7%-63.8%), respectively, from baseline (remimazolam 0 mg⋅kg-1). Propofol consumption was lower in patients given 0.1 mg⋅kg-1 (4.15 [3.51-5.44] mg·kg-1), 0.15 mg⋅kg-1 (3.54 [3.16-4.46] mg·kg-1), and 0.2 mg⋅kg-1 (2.74 [1.73-4.01] mg·kg-1) remimazolam than those given 0 mg⋅kg-1 (6.09 [4.99-7.35] mg·kg-1) remimazolam (all were P < .005). Time to anesthesia emergence did not differ significantly among the 5 groups.

CONCLUSIONS

For women undergoing hysteroscopic procedures, remimazolam at doses from 0.1 to 0.2 mg·kg-1 reduced the EC50 of propofol inhibiting response to cervical dilation and the total propofol requirement. Whether the combination could improve perioperative outcomes deserves further investigation.

Development and validation of a novel nomogram model to assess the risk of gastric contents in outpatients undergoing elective sedative gastrointestinal endoscopy procedures

BACKGROUND

Gastric contents may contribute to patients' aspiration during anesthesia. Ultrasound can accurately assess the risk of gastric contents in patients undergoing sedative gastrointestinal endoscopy (GIE) procedures, but its efficiency is limited. Therefore, developing an accurate and efficient model to predict gastric contents in outpatients undergoing elective sedative GIE procedures is greatly desirable.

METHODS

This study retrospectively analyzed 1501 patients undergoing sedative GIE procedures. Gastric contents were observed under direct gastroscopic vision and suctioned through the endoscope. High-risk gastric contents were defined as having solid content or liquid volume > 25 ml and pH < 2.5; otherwise, they were considered low-risk gastric contents. Univariate analysis and multivariate analysis were used to select the independent risk factors to predict high-risk gastric contents. Based on the selected independent risk factors, we assigned values to each independent risk factor and established a novel nomogram. The performance of the nomogram was verified in the testing cohort by the metrics of discrimination, calibration, and clinical usefulness. In addition, an online accessible web calculator was constructed.

RESULTS

We found BMI, cerebral infarction, cirrhosis, male, age, diabetes, and gastroesophageal reflux disease were risk factors for gastric contents. The AUROCs were 0.911 and 0.864 in the development and testing cohort, respectively. Moreover, the nomogram showed good calibration ability. Decision curve analysis and Clinical impact curve demonstrated that the predictive nomogram was clinically useful. The website of the nomogram was https://medication.shinyapps.io/dynnomapp/.

CONCLUSIONS

This study demonstrates that clinical variables can be combined with algorithmic techniques to predict gastric contents in outpatients. Nomogram was constructed from routine variables, and the web calculator had excellent clinical applicability to assess the risk of gastric contents accurately and efficiently in outpatients, assist anesthesiologists in assessment and identify the most appropriate patients for ultrasound.

Korean clinical practice guidelines for diagnostic and procedural sedation

Safe and effective sedation depends on various factors, such as the choice of sedatives, sedation techniques used, experience of the sedation provider, degree of sedation-related education and training, equipment and healthcare worker availability, the patient's underlying diseases, and the procedure being performed. The purpose of these evidence-based multidisciplinary clinical practice guidelines is to ensure the safety and efficacy of sedation, thereby contributing to patient safety and ultimately improving public health. These clinical practice guidelines comprise 15 key questions covering various topics related to the following: the sedation providers; medications and equipment available; appropriate patient selection; anesthesiologist referrals for high-risk patients; pre-sedation fasting; comparison of representative drugs used in adult and pediatric patients; respiratory system, cardiovascular system, and sedation depth monitoring during sedation; management of respiratory complications during pediatric sedation; and discharge criteria. The recommendations in these clinical practice guidelines were systematically developed to assist providers and patients in sedation-related decision making for diagnostic and therapeutic examinations or procedures. Depending on the characteristics of primary, secondary, and tertiary care institutions as well as the clinical needs and limitations, sedation providers at each medical institution may choose to apply the recommendations as they are, modify them appropriately, or reject them completely.

Propofol sedation in routine endoscopy: A case series comparing target controlled infusion vs manually controlled bolus concept

BACKGROUND

Many studies have addressed safety and effectiveness of non-anaesthesiologist propofol sedation (NAPS) for gastrointestinal (GI) endoscopy Target controlled infusion (TCI) is claimed to provide an optimal sedation regimen by avoiding under- or oversedation.

AIM

To assess safety and performance of propofol TCI sedation in comparison with nurse-administered bolus-sedation.

METHODS

Fouty-five patients undergoing endoscopy under TCI propofol sedation were prospectively included from November 2016 to May 2017 and compared to 87 patients retrospectively included that underwent endoscopy with NAPS. Patients were matched for age and endoscopic procedure. We recorded time of sedation and endoscopy, dosage of medication and adverse events.

RESULTS

There was a significant reduction in dose per time of propofol administered in the TCI group, compared to the NAPS group (8.2 ± 2.7 mg/min vs 9.3 ± 3.4 mg/min; P = 0.046). The time needed to provide adequate sedation levels was slightly but significantly lower in the control group (5.3 ± 2.7 min vs 7.7 ± 3.3 min; P < 0.001), nonetheless the total endoscopy time was similar in both groups. No differences between TCI and bolus-sedation was observed for mean total-dosage of propofol rate as well as adverse events.

CONCLUSION

This study indicates that sedation using TCI for GI endoscopy reduces the dose of propofol necessary per minute of endoscopy. This may translate into less adverse events. However, further and randomized trials need to confirm this trend.

Feasibility and Utility of Routine Point-of-Care Gastric Ultrasonography in Patients Undergoing Upper Gastrointestinal Endoscopy Procedures: A Prospective Cohort Study

OBJECTIVES

Previous studies have indicated that point-of-care ultrasonography (POCUS) of the gastric antrum can predict the adequacy of fasting before surgery and anesthesia. The aim of this study was to evaluate the utility of gastric POCUS in patients undergoing upper gastrointestinal (GI) endoscopy procedures.

METHODS

We performed a single-center cohort study in patients undergoing upper GI endoscopy. Consenting patient's gastric antrum was scanned before anesthetic care for endoscopy to determine the cross-sectional area (CSA) and qualitatively determine safe and unsafe contents. Further, an estimate of residual gastric volume was determined using the formula and the nomogram methods. Subsequently, gastric secretions aspirated during endoscopy were quantified and further correlated with nomogram and formula-based assessments. No patient required a change in the primary anesthetic plan except for using rapid sequence induction in those with unsafe contents on POCUS scans.

RESULTS

Qualitative ultrasound measurements consistently determined safe and unsafe gastric residual contents in 83 patients enrolled in the study. Unsafe contents were determined by qualitative scans in 4 out of 83 cases (5%) despite adequate fasting status. Quantitatively, only a moderate correlation was demonstrated between measured gastric volumes and nomogram (r = .40, 95% CI: 0.20, 0.57; P = .0002) or formula-based (r = .38, 95% CI: 0.17, 0.55; P = .0004) determinations of residual gastric volumes.

CONCLUSION

In daily clinical practice, qualitative POCUS determination of residual gastric content is a feasible and useful technique to identify patients at risk of aspiration before upper GI endoscopy procedures.

Propofol-remifentanil patient-controlled sedation for endoscopic procedures: a prospective service audit

PURPOSE

Following demand, we established a patient-controlled propofol-remifentanil sedation service for endoscopy overseen by an anesthesiologist. To assess the effectiveness of the intervention of this service and any complications, we prospectively audited the service. Our primary outcomes of interest were adequacy of sedation and patient satisfaction. Secondary outcomes included any adverse events associated with the sedation.

METHODS

Patients were referred for failure of procedure under endoscopist-administered sedation, refusal of procedure without general anesthesia (GA), or planned complex procedure. We included all 670 procedures performed between 2017 and 2021. We used a mixture of 8.9 mg·mL-1 propofol and 5.4 µg·mL-1 remifentanil with a 1-mL bolus and 20-sec lockout. We assessed the adequacy of sedation using the Modified Gloucester Scale and categorized adverse events according to the Tracking and Reporting Outcomes of Procedural Sedation.

RESULTS

All 670 procedures were accomplished with adequate sedation without the need for ventilation or GA, and all patients were satisfied with the sedation. The complication rate was low, with no sentinel airway or respiratory events. Nineteen out of 670 patients (2.8%) had an incidence of airway obstruction (requiring a simple airway maneuver). The body mass index (BMI) was documented in 18/19 of these patients and the average BMI in this group was 35 kg·m-2. Seven of the 670 patients (1%) had self-terminating apnea, 3/670 patients (0.4%) vomited, no patients aspirated, and 17/665 patients (2.6%) required a vasopressor to maintain blood pressure within 20% of preprocedure values.

CONCLUSION

The results from our prospective service audit indicate that propofol-remifentanil patient-controlled sedation is a safe and reliable technique in patients undergoing endoscopic procedures.

Effect of inspiratory muscle training on hypoxemia in obese patients undergoing painless gastroscopy: protocol for a single-center, double-blind, randomized controlled trial

Introduction

Obese patients who undergo painless gastroscopy are particularly prone to suffer from upper airway obstruction, respiratory depression, and subsequent hypoxemia. Despite adequate preoxygenation, the incidence of hypoxemia remains high. Recently, inspiratory muscle training (IMT) has been considered to be a promising strategy to increase respiratory muscle strength and endurance with the attendant improvement of pulmonary function. However, it remains unclear whether IMT is associated with a lower rate of hypoxemia in obese patients during this sedative procedure. This study aims to investigate the effectiveness of IMT used in obese patients who are scheduled for selective painless gastroscopy.

Methods and analysis

This prospective, randomized controlled trial (RCT) will enroll 232 obese patients with a body mass index (BMI) of 35-39.9 kg·m-2 who undergo painless gastroscopy at the First Affiliated Hospital of Xiamen University. Subjects will be randomly assigned to two groups with a 1:1 ratio. Participants in both groups will receive IMT for 4 weeks prior to gastroscopy. The intervention group will receive IMT with a load of 30% of the maximal inspiratory pressure (Pi(max)) in the first week, with an increase of 10% per week since the following week, while the counterparts in the control group will not receive any load during the 4-week IMT. The primary outcome is the incidence of hypoxemia during painless gastroscopy. Secondary outcomes include the need for airway maneuvers, blood pressure changes, sleep quality assessment, pro-inflammatory cytokines levels, and monitoring of adverse events.

Discussions

The outcomes of this study will offer invaluable guidance for the clinical implementation of IMT as a potential non-invasive preventive measure. Additionally, it stands to enrich our comprehension of anesthesia management and airway-related challenges in obese patients undergoing procedural sedation, which we anticipate will further contribute to addressing the turnaround concerns within high-volume, swiftly paced ambulatory endoscopy centers.

Ethics and dissemination

This study has been approved by the Ethics Committee of the First Affiliated Hospital of Xiamen University (2022, No.091). The results will be submitted for publication in peer-reviewed journals.

Trial registration number

China Clinical Trial Center (ChiCTR2200067041).

Effect of ciprofol on swallowing function in patients undergoing painless gastrointestinal endoscopy

BACKGROUND

Gastroscopy is one of the most commonly used diagnostic modalities for upper gastrointestinal disorders. This study compared the effect of ciprofol and propofol on swallowing function during painless gastroenteroscopy.

METHODS

This was a single-center, placebo-controlled randomized trial. Three hundred sixty-eight patients undergoing painless gastroscopy were included in this study and randomly divided into 2 groups: the propofol group (PRO group, n = 183) and the ciprofol group (CIP group, n = 185). Sufentanil, ciprofol, and propofol are used to anesthetize the patients, and the effects of different solutions on these patients are compared and analyzed. The patient's general condition, vocal cord adduction reflex, dysphagia severity score, penetration and aspiration scale score, vital signs at different times, complications, recovery time (minutes), residence time in the resuscitation room (minutes), and adverse reactions were recorded.

RESULTS

During the examination, the incidence of severe swallowing dysfunction in CIP group was lower than that in PRO group (P < .05). The BP in CIP group was higher than that in PRO Group (P < .05). The HR of CIP group was lower than that of PRO Group (P < .05). SpO2 in CIP group was higher than that in PRO Group (P < .05). The recovery time of CIP group was longer than that of PRO Group, and the postanesthesia care unit stay time of PRO group was longer than that of CIP group(P < .05). The incidence of respiratory depression, hypotension and cough in CIP group was lower than that in PRO Group (P < .05). The incidence of injection pain in CIP group was lower than that in PRO Group (P < .05).

CONCLUSION

Compared with propofol, ciprofol has less inhibition on swallowing function, less impact on hemodynamics, less respiratory depression, and less injection pain, which is more suitable for painless gastroscopy.

Ultrasonographic Assessment of Gastric Volume in Fasted Patients Undergoing Gastrointestinal Endoscopy Under Sedation

Purpose

In this prospective observational study, an ultrasonographic measurement of antral cross-sectional area (ACSA) was conducted to evaluate the gastric content and volume as well as to identify high-risk stomach in non-pregnant adult surgical patients adhering to preanesthetic fasting guidelines.

Patients and Methods

Fasted patients undergoing gastrointestinal endoscopy under sedation were included. Ultrasonographic measurements of ACSA were conducted in both semi-recumbent and right lateral decubitus positions before endoscopic procedures. Gastroscopy was employed to guide the measurement of suctioned gastric volume (GV). Ultrasonography was performed to assess gastric contents and identify patients with high-risk stomach. The relationship between ACSA and suctioned GV was also evaluated.

Results

ACSA was evaluated in 736 out of 782 patients. A significant positive correlation was discovered between ACSA in the right lateral decubitus position and suctioned GV, which was more reliable than in the semi-recumbent position. To analyze high-risk stomach with a GV > 100 mL, the cutoff value of ACSA in the right lateral decubitus was found to be 7.5 cm2, with the AUC, sensitivity and specificity of 0.80 (95% CI, 0.76-0.82; P<0.001), 82.4% and 67.3%, respectively. A novel mathematical model based on ACSA to estimate GV in non-pregnant fasted adults was presented.

Conclusion

Ultrasonographic measurement of ACSA can assist anesthesiologists in estimating the risk of pulmonary aspiration of gastric contents during general anesthesia and sedation.

Use of artificial intelligence in paediatric anaesthesia: a systematic review

Objectives

Although the development of artificial intelligence (AI) technologies in medicine has been significant, their application to paediatric anaesthesia is not well characterised. As the paediatric operating room is a data-rich environment that requires critical clinical decision-making, this systematic review aims to characterise the current use of AI in paediatric anaesthesia and to identify barriers to the successful integration of such technologies.

Methods

This review was registered with PROSPERO (CRD42022304610), the international registry for systematic reviews. The search strategy was prepared by a librarian and run in five electronic databases (Embase, Medline, Central, Scopus, and Web of Science). Collected articles were screened by two reviewers. Included studies described the use of AI for paediatric anaesthesia (<18 yr old) within the perioperative setting.

Results

From 3313 records identified in the initial search, 40 were included in this review. Identified applications of AI were described for patient risk factor prediction (24 studies; 60%), anaesthetic depth estimation (2; 5%), anaesthetic medication/technique decision guidance (2; 5%), intubation assistance (1; 2.5%), airway device selection (3; 7.5%), physiological variable monitoring (6; 15%), and operating room scheduling (2; 5%). Multiple domains of AI were discussed including machine learning, computer vision, fuzzy logic, and natural language processing.

Conclusion

There is an emerging literature regarding applications of AI for paediatric anaesthesia, and their clinical integration holds potential for ultimately improving patient outcomes. However, multiple barriers to their clinical integration remain including a lack of high-quality input data, lack of external validation/evaluation, and unclear generalisability to diverse settings.

Systematic review protocol

CRD42022304610 (PROSPERO).

Advances in Analgosedation and Periprocedural Care for Gastrointestinal Endoscopy

The number and complexity of endoscopic gastrointestinal diagnostic and therapeutic procedures is globally increasing. Procedural analgosedation during gastrointestinal endoscopic procedures has become the gold standard of gastrointestinal endoscopies. Patient satisfaction and safety are important for the quality of the technique. Currently there are no uniform sedation guidelines and protocols for specific gastrointestinal endoscopic procedures, and there are several challenges surrounding the choice of an appropriate analgosedation technique. These include categories of patients, choice of drug, appropriate monitoring, and medical staff providing the service. The ideal analgosedation technique should enable the satisfaction of the patient, their maximum safety and, at the same time, cost-effectiveness. Although propofol is the gold standard and the most used general anesthetic for endoscopies, its use is not without risks such as pain at the injection site, respiratory depression, and hypotension. New studies are looking for alternatives to propofol, and drugs like remimazolam and ciprofol are in the focus of researchers' interest. New monitoring techniques are also associated with them. The optimal technique of analgosedation should provide good analgesia and sedation, fast recovery, comfort for the endoscopist, patients' safety, and will have financial benefits. The future will show whether these new drugs have succeeded in these goals.

High-flow nasal oxygenation during gastrointestinal endoscopy. Systematic review and meta-analysis

Background

The use of high-flow nasal oxygen (HFNO) has the potential to improve patient safety by limiting hypoxaemia during gastrointestinal endoscopy. The degree of benefit is not adequately established.

Methods

English language literature searches of PubMed, Scopus, Web of Science, and Cochrane Library electronic databases were performed to identify randomised controlled trials comparing HFNO and conventional oxygen therapy (COT) for patients undergoing gastrointestinal endoscopy under deep sedation. The primary endpoint was the incidence of hypoxic events observed during endoscopic procedures. The secondary endpoints were the incidence of recourse to rescue manoeuvres, procedure interruption, and adverse events. A meta-analysis and a post hoc trial sequence analysis were performed.

Results

A total of 2867 patients from six randomised controlled trials were considered. Desaturation was observed in 5.2% and 27.2% of patients receiving HFNO and COT, respectively. Desaturation <90% was observed in 1.8% and 12.6% of the patients receiving HFNO and COT, respectively. In the subgroup analysis, desaturation occurrence was lower during HFNO than during COT in non-obese patients (2.2% vs 25.2%) and obese patients (22.9% vs 43.3%). Desaturation occurrence was lower during maximum (3.6% vs 26.9%) and minimum (15.9% vs 29.8%) HFNO therapy than during COT. HFNO showed a lower recurrence to rescue manoeuvres rate (4.7% vs 34.3%), a lower procedure interruption rate (0.4% vs 6.7%), and a lower adverse events rate (18.7% vs 21%) than COT. A high level of heterogeneity between the studies precluded confidence in drawing inference from the meta-analysis.

Conclusions

The evidence reviewed suggests that compared with COT, HFNO has fewer hypoxaemic events during gastrointestinal endoscopy, but this may not apply to all patients and clinical scenarios.

Magnetic resonance cholangiopancreatography versus endoscopic ultrasound for diagnosis of choledocholithiasis: an updated systematic review and meta-analysis

INTRODUCTION

Both endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP) are used for the diagnosis of choledocholithiasis (CDL). Previous studies have shown conflicting results regarding the optimal diagnostic strategy for suspected CDL; hence, this meta-analysis was conducted.

METHODS

A comprehensive search of literature from 1990 till April 2022 was done of three databases for studies comparing EUS and MRCP to diagnose CDL.

RESULTS

A total of 12 studies were identified. The pooled sensitivity and specificity for EUS were 0.96 [95% confidence interval (CI) 0.92-0.98], and 0.92 (95% CI 0.85-0.96), respectively. The pooled sensitivity and specificity for MRCP were 0.85 (95% CI 0.78-0.90) and 0.90 (95% CI 0.79-0.96), respectively. EUS had a higher relative sensitivity [Relative risk (RR) 1.12, 95% CI 1.05-1.19], a higher diagnostic accuracy (Odds ratio 1.98, 95% CI 1.35-2.90) but comparable specificity (RR 1.02, 95% CI 0.96-1.08) with MRCP.

CONCLUSION

There is little difference concerning specificity, although EUS likely provides a higher sensitivity and accuracy for diagnosing CDL, compared to MRCP.

Identification of Patient-Related and Procedure-Related Factors Contributing to Hypoxemia in Adult Outpatients Undergoing Esophagogastroduodenoscopy (EGD)

PURPOSE

To assess which patient factors and procedure-related factors contribute to hypoxemia during esophagogastroduodenoscopy (EGD) and determine whether prophylactic oropharyngeal suctioning reduces the rate of hypoxemia when compared to oropharyngeal suctioning when clinically indicated by patient's coughing or secretions.

DESIGN

This was a single-site study taking place at a private practice, outpatient facility with no anesthesia trainees present. Patients were randomized to one of two groups based on birth month. After the administration of sedating medications but before the insertion of the endoscope, Group A was oropharyngeal suctioned by either the anesthesia provider or the proceduralist. Group B was oropharyngeal suctioned only when clinically indicated by coughing or visible copious secretions.

METHODS

Data were collected on a variety of patient and procedure-related factors. Associations between these factors and hypoxemia during esophagogastroduodenoscopy were analyzed using the statistical analysis system application JMP. After analysis and literature review, a protocol for prevention and treatment of hypoxemia during EGD was proposed.

FINDINGS

This study found that chronic obstructive pulmonary disease increases the risk for hypoxemia during esophagogastroduodenoscopy. There were no other statistically significant associations between other factors and hypoxemia.

CONCLUSIONS

This study highlights factors that should be evaluated in the future when considering the risk of hypoxemia during EGD. Although not statistically significant, this study's results indicated that prophylactic oropharyngeal suctioning may reduce rates of hypoxemia, as only 1 of 4 cases of hypoxemia occurred in Group A. Additionally, future studies on hypoxemia during monitored anesthesia care for EGD should include an evaluation of the impact of American Society of Anesthesiologists class, history of chronic obstructive pulmonary disease or asthma, body mass index, obstructive sleep apnea, and opioid administration on hypoxemia risk.

Validity Analysis of Neck Circumference as a Screening Test for Hypoxia Occurrence in Patients Undergoing Sedative Endoscopy

This study was performed to check the validity of and propose a cutoff point for measuring the neck circumference for screening hypoxia occurrence in patients undergoing sedative endoscopy. Data were collected from 168 patients who visited the Endoscopy Center of G University Hospital between 27 April 2020 and 12 June 2020 to undergo sedative endoscopy. Hypoxia occurrences were measured using sleep questionnaires (STOP-BANG and Berlin questionnaires), and the neck circumference measurements of the patients were compared. Neck circumference as a predictor of hypoxia and its sensitivity and specificity according to the cutoff values were high; thus, it is a valid screening test for hypoxia in patients undergoing sedative endoscopy. The most appropriate cutoff values for sitting neck circumference and lying neck circumference in men were 40.5 and 40.3, respectively, and those for women were 35.3 and 35.8, respectively. Hypoxia can be predicted in patients undergoing sedative endoscopy by measuring their neck circumference.

Outcomes of colonoscopy with non-anesthesiologist-administered propofol (NAAP): an equivalence trial

Background and study aims  Efficacy and safety of NAAP for gastrointestinal endoscopy have been widely documented, although there is no information about the outcomes of colonoscopy when the endoscopist supervises the sedation. In this context, the aim of this trial was to determine the equivalence of adenoma detection rate (ADR) in colorectal cancer (CRC) screening colonoscopies performed with non-anesthesiologist-administered propofol (NAAP) and performed with monitored anesthesia care (MAC). Patients and methods  This was a single-blind, non-randomized controlled equivalence trial that enrolled adults from a national CRC screening program (CRCSP). Patients were blindly assigned to undergo either colonoscopy with NAAP or MAC. The main outcome measure was the ADR in CRCSP colonoscopies performed with NAAP. Results  We included 315 patients per group. The median age was 59.76 ± 5.81 years; 40.5 % of patients were women. The cecal intubation rate was 97 %, 81.8 % of patients had adequate bowel preparation, withdrawal time was > 6 minutes in 98.7 %, and the median global exploration time was 24.25 ± 8.86 minutes (range, 8-70 minutes). The ADR was 62.9 % and the complication rate (CR) was 0.6 %. Analysis by intention-to-treat showed an ADR in the NAAP group of 64.13 % compared with 61.59 % in the MAC group, a difference (δADR) of 2.54 %, 95 %CI: -0.10 to 0.05. Analysis by per-protocol showed an ADR in the NAAP group of 62.98 %, compared with 61.94 % in the MAC group, δADR: 1.04 %, 95 %CI: -0.09 to 0.07. There was no difference in CR (NAAP: 0,63 vs. MAC: 0.63); P  = 1.0. Conclusions  ADR in colorectal cancer screening colonoscopies performed with NAAP was equivalent to that in those performed with MAC. Similarly, there was no difference in complication rates.

Risk of adverse events in gastrointestinal endoscopy: Zero-inflated Poisson regression mixture model for count data and multinomial logit model for the type of event

BACKGROUND AND AIMS

We analyze the possible predictive variables for Adverse Events (AEs) during sedation for gastrointestinal (GI) endoscopy.

METHODS

We consider 23,788 GI endoscopies under sedation on adults between 2012 and 2019. A Zero-Inflated Poisson Regression Mixture (ZIPRM) model for count data with concomitant variables is applied, accounting for unobserved heterogeneity and evaluating the risks of multi-drug sedation. A multinomial logit model is also estimated to evaluate cardiovascular, respiratory, hemorrhagic, other AEs and stopping the procedure risk factors.

RESULTS

In 7.55% of cases, one or more AEs occurred, most frequently cardiovascular (3.26%) or respiratory (2.77%). Our ZIPRM model identifies one population for non-zero counts. The AE-group reveals that age >75 years yields 46% more AEs than age <66 years; Body Mass Index (BMI) ≥27 27% more AEs than BMI <21; emergency 11% more AEs than routine. Any one-point increment in the American Society of Anesthesiologists (ASA) score and the Mallampati score determines respectively a 42% and a 16% increment in AEs; every hour prolonging endoscopy increases AEs by 41%. Regarding sedation with propofol alone (the sedative of choice), adding opioids to propofol increases AEs by 43% and adding benzodiazepines by 51%. Cardiovascular AEs are increased by age, ASA score, smoke, in-hospital, procedure duration, midazolam/fentanyl associated with propofol. Respiratory AEs are increased by BMI, ASA and Mallampati scores, emergency, in-hospital, procedure duration, midazolam/fentanyl associated with propofol. Hemorrhagic AEs are increased by age, in-hospital, procedure duration, midazolam/fentanyl associated with propofol. The risk of suspension of the endoscopic procedure before accomplishment is increased by female gender, ASA and Mallampati scores, and in-hospital, and it is reduced by emergency and procedure duration.

CONCLUSIONS

Age, BMI, ASA score, Mallampati score, in-hospital, procedure duration, other sedatives with propofol increase the risk for AEs during sedation for GI endoscopy.

Comparative evaluation of efficacy of oxygenation using high flow nasal cannula vs. conventional nasal cannula during procedural sedation for endoscopic ultrasound: A pilot study

Background and Aims:

High flow nasal cannula (HFNC) has numerous advantages against conventional oxygen therapy delivery systems. However, there is limited evidence supporting the use of HFNC in endoscopic ultrasound (EUS) under procedural sedation. The aims of this study is to evaluate the efficacy of two different oxygen delivery devices, that is,HFNCand conventional nasal cannula on the oxygenation status of patients during procedural sedation for EUS.

Material and Methods:

Sixty adult patients undergoing EUS for various ailments were randomized to two groups group HFNC (n=30) and group nasal cannula [NC (n = 30)]. HFNC (AIRVO2, Fisher and Paykel Healthcare, New Zealand) was used on patients in the group HFNC. Respiratory status of the patients was assessed using pulse oximetry, respiratory rate, procedural airway complications, and oxygen therapy adjustments. The endoscopist assessed the ease of performing EUS at the end of the procedure and patient satisfaction score (PSS) was assessed by using a Likert score in the post-anesthesia care unit.

Results:

SpO2 measurements in the HFNC group during the procedure were marginally better compared to the NC group but this failed to reach statistical significance. Also, no significant association was found between both groups while comparing desaturation events (P = 0.499), patient satisfaction score (PSS) and endendoscopist’s satisfaction score (ESS) (P = 0.795). Both the groups were comparable in terms of airway manipulation, use of airway adjuncts, need to increase oxygen flow rate, endoscope removal, apneic episodes, hypotension, and bradycardia. No major complications were observed in either group.

Conclusion:

HFNC use in patients undergoing EUS is not superior when compared to conventional nasal cannula oxygen therapy. HFNC failed to show any significant impact on decreasing the risk of desaturation events and airway manipulation during the procedure.

Variation in Pediatric Anesthesiologist Sedation Practices for Pediatric Gastrointestinal Endoscopy

Background: Despite a worldwide shift toward anesthesiologist-administered sedation for gastrointestinal endoscopy in children, ideal sedation regimens remain unclear and best practices undefined. Aim: The aim of our study was to document variation in anesthesiologist-administered sedation for pediatric endoscopy. Outcomes of interest included coefficients of variation, procedural efficiency, as well as adverse events. Methods: IRB approval was obtained to review electronic health records of children undergoing routine endoscopy at our medical center during a recent calendar year. Descriptive and multivariate analyses were used to examine predictors of sedation practices. Results: 258 healthy children [2-21 years (median 15, (Q1-Q3 = 10-17)] underwent either upper and/or lower endoscopies with sedation administered by anesthesiologists (n = 21), using different sedation regimens (29) that ranged from a single drug administered to 6 sedatives in combination. Most patients did not undergo endotracheal tube intubation for the procedure (208, 81%), and received propofol (255, 89%) either alone or in combination with other sedatives. A total of 10 (3.8%) adverse events (9 sedation related) were documented to occur. The coefficient of variation (CV) for sedation times was high at 64.2%, with regression analysis suggesting 8% was unexplained by procedure time. Multivariable model suggested that longer procedure time (p < 0.0001), younger age (p < 0.0001), and use of endotracheal tube intubation (p = 0.02) were associated with longer sedation time. Discussion: We found great variation in anesthesiologist administered regimens for pediatric endoscopy at our institution that may be unwarranted, presenting may opportunities for minimizing patient risk, as well as for optimizing procedural efficiency.

Diagnostic disagreement between clinical standard histopathological- and retrospective assessment of histopathology-based gastrointestinal graft-versus-host disease in children

BACKGROUND

No previous paediatric study has evaluated the frequency of diagnostic disagreement between clinical standard histopathological assessment (CSHA) and retrospective, independent, histopathological assessment (RIHA) of gastrointestinal Graft-Versus-Host Disease (GI-GVHD) METHODS: In a retrospective cohort study, based on gastrointestinal biopsies collected from allogeneic HSCT-treated children (<18 years) with symptom-based GI-GVHD, we evaluated; disagreement of histopathology-based GI-GVHD diagnosis in CSHA vs RIHA, and potential clinical consequences of differences between the assessments. The CSHA-based diagnoses were retrieved from histopathology reports. The RIHA was performed by one pathologist, blinded to the CSHA outcomes and based on the minimal criteria for histopathology-based GI-GVHD diagnosis by the NIH 2014.

RESULTS

Seventy children with 92 endoscopic occasions (including 22 re-endoscopies) were enrolled. GI-GVHD was observed in 73% (67/92) of the endoscopies in the RIHA and in 54% (50/92) in the CSHA (P = .014). The RIHA confirmed 94% (47/50) with GI-GVHD and 52% (22/42) with non-GI-GVHD diagnoses, established in the CSHA. Disagreement, that is endoscopic occasions with GI-GVHD solely detected in RIHA or detection of GI-GVHD in CSHA but not in RIHA, was observed in 20/42 (48%) and 3/50 (6%), respectively (McNemar's test, P = .0008). The risk of a subsequent re-endoscopy was higher in endoscopic occasions with GI-GVHD detected in RIHA but not in CSHA vs if non-GI-GVHD were detected in both readings (P = .005).

CONCLUSION

Our results suggest that in children with symptom-based GI-GVHD without histopathological confirmation in CSHA, a second, NIH 2014 based histopathological assessment should be considered before performing a re-endoscopy.

Procedural sedation in Belgium : guideline for safe patient care

Guideline produced by the Society for Anesthesia and Resuscitation of Belgium Working Group on Procedural Sedation (SARB-WG-PS).

Pulmonary aspiration during procedural sedation for colonoscopy resulting from positional change managed without oral endotracheal intubation

Background

Pulmonary aspiration under anaesthesia is a feared complication. It is likely that the incidence of aspiration occurring during procedural sedation is underreported; although rare, fatalities do occur. The supine position increases the risk of pulmonary aspiration in gastrointestinal endoscopy during procedural sedation. Immediate oral endotracheal intubation has traditionally been the cornerstone of management for aspiration during anaesthesia; however, this may not be always beneficial when aspiration occurs during procedural sedation. To my knowledge, this is the first case report of aspiration pneumonitis resulting from surgical repositioning during colonoscopy under procedural sedation.

Case presentation

A 72-year-old female underwent elective outpatient diagnostic colonoscopy. Intravenous propofol infusion was commenced for the procedural sedation. A large amount of non-particulate vomitus was expelled from the oropharynx as the patient was repositioned from the left lateral to supine position. Oxygen saturation on pulse oximetry immediately dropped to below 90% during the event. The patient was managed successfully without oral endotracheal intubation.

Conclusions

Anaesthesiologists need to be mindful of factors that raise the risk of aspiration during procedural sedation. Gastrointestinal endoscopy poses a higher risk of aspiration than other procedures, and positional change may be a precipitant. Aspiration that occurs during procedural sedation may be more safely managed by avoiding immediate oral endotracheal intubation.

Endoscopist-directed propofol is more efficient than anesthesiologist-administered propofol in patients at low-intermediate anesthetic risk

OBJECTIVE

Endoscopist-directed propofol (EDP) sedation is becoming more popular, with a reported safety and efficacy similar to anesthesiologist-administered propofol (AAP). The aim of this study is to compare the efficiency of EDP and AAP in patients of low-intermediate anesthetic risk.

METHODS

A prospective cost-effectiveness comparison study was conducted. The costs of the endoscopic procedures in the EDP and AAP group were calculated using the full cost methodology after breaking down the endoscopic activity into relative value units to allocate costs in an equitable way. To determine the effectiveness, adverse events related to endoscopic sedation and the number of incomplete procedures were registered for the EDP group and compared with those published by anesthesiologists for AAP.

RESULTS

A total of 1165 and 18 919 endoscopic procedures were, respectively, included in the EDP and AAP groups. The average costs of EDP vs. AAP for gastroscopy, colonoscopy and endoscopic ultrasound were &OV0556; 182.81 vs. &OV0556; 332.93, &OV0556; 297.07 vs. &OV0556; 459.76, and &OV0556; 319.92 vs. &OV0556; 485.12, respectively. No significant differences were detected regarding the rate of overall adverse events (4.43 vs. 4.46%) or serious adverse events (0 vs. 0.17%); the rate of arterial hypotension was significantly lower in the EDP group: 0.34 vs. 1.78% [odds ratio (OR), 0.19; 95% confidence interval (CI), 0.08-0.46] and the desaturation rate was significantly lower in the AAP group: 3.26 vs. 1.29% (OR, 2.58; 95% CI, 1.85-3.60). No significant differences were found in terms of incomplete examinations (0.17 vs. 0.14%).

CONCLUSION

In patients with low-intermediate anesthetic risk referred for an endoscopic examination, EDP appears to be more efficient than AAP.

Clinical Outcomes of a Modified Laryngeal Mask Airway (LMA® Gastro™ Airway) During Esophagogastroduodenoscopy in Children and Adolescents: A Randomized Study

Introduction

During esophagogastroduodenoscopy (EGD), general anesthesia (GA) may be provided using a laryngeal mask airway (LMA) with the endoscope inserted behind the cuff of the LMA into the esophagus. Passage of the endoscope may increase the intracuff of the LMA. We evaluated a newly designed LMA (LMA^® Gastro™ Airway) which has an internal channel exiting from its distal end to facilitate EGD. The current study compared the change of LMA cuff pressure between this new LMA and a standard clinical LMA (Ambu^® AuraOnce™) during EGD.

Methods

Patients less than 21 years of age and weighing more than 30 kg were randomized to receive airway management with one of the two LMAs during EGD. After anesthetic induction and successful LMA placement, the intracuff pressure of the LMAs was continuously monitored during the procedure. The primary outcome was the change of intracuff pressure of the LMAs.

Results

The study cohort included 200 patients (mean age 13.6 years and weight 56.6 kg) who were randomized to the LMA^® Gastro™ Airway (n=100) or the Ambu^® AuraOnce™ LMA (n=100). Average intracuff pressures during the study period (before and after endoscope insertion) were not different between the two LMAs. Ease of the procedure was slightly improved with the LMA^® Gastro™ Airway (p<0.001).

Discussion

The LMA^® Gastro™ Airway blunted, but did not prevent an increase in intracuff pressure during EGD when compared to the Ambu^® AuraOnce™ LMA. Throat soreness was generally low, and complications were infrequent in both groups. The ease of the procedure was slightly improved with the LMA^® Gastro™ Airway compared to the Ambu^® AuraOnce™ LMA.

Oxygenation before Endoscopic Sedation Reduces the Hypoxic Event during Endoscopy in Elderly Patients: A Randomized Controlled Trial

Background: Sedation endoscopy increases patient and examiner satisfaction but involves complications. The most serious complication is hypoxia, the risk factors for which are old age, obesity, and American Society of Anesthesiologists physical status of 3 or greater. However, clear evidence of oxygenation during sedation endoscopy for elderly people is lacking in US, European, and Korean guidelines. Method: This study was conducted for 1 year starting in August 2018 to evaluate whether pre-oxygenation use 1 min before sedation endoscopy could reduce the incidence of hypoxia in patients older than 65 years of age. A total of 70 patients were divided into the non-oxygenated group (n = 35; control group) and oxygen-treated group (n = 35; experimental group) during endoscopy. Result: The incidence of hypoxia was 28 (80%) in the control group versus 0 (0%) in the pre-oxygenated group. Factors related to hypoxia in the non-oxygenated group were a relatively high dose of midazolam and concomitant injection with narcotic analgesics such as pethidine. Conclusion: The incidence of hypoxia during sedation endoscopy is high in patients over 65 years, but oxygenation during endoscopic sedation in elderly people can significantly reduce the incidence of intraprocedural hypoxic events.

Pediatric Anesthesia Outside the Operating Room: Case Management

Anesthesiology teams care for children in diverse locations, including diagnostic and interventional radiology, gastroenterology and pulmonary endoscopy suites, radiation oncology units, and cardiac catheterization laboratories. To provide safe, high-quality care, anesthesiologists working in these environments must understand the unique environmental and perioperative considerations and risks involved with each remote location and patient population. Once these variables are addressed, anesthesia and procedural teams can coordinate to ensure that patients and families receive the same high-quality care that they have come to expect in the operating room. This article also describes some of the considerations for anesthetic care in outfield locations.

Sedation and Analgesia for Adult Outpatient Burn Dressing Change: A Survey of American Burn Association Centers

The management of pain and sedation during burn dressing change is challenging. Previous reviews and studies have identified wide variability in such practices in hospitalized burn patients. This survey-based study aimed to determine the most commonly utilized sedation and analgesia practices in adult burn patients treated in the outpatient setting. The goal was to identify opportunities for improvement and to assist burn centers in optimizing sedation procedures. A 23-question survey was sent to members of the American Burn Association. Nonpharmacological interventions including music, television, games, and virtual reality were used by 68% of survey respondents. Eighty-one percent reported premedicating with oral opioids, 32% with intravenous opioids, and 45% with anxiolytics. Fifty-nine percentage of respondents indicated that the initial medication regimen for outpatient dressing changes consisted of the patient's existing oral pain medications. Forty-three percent indicated that there were no additional options if this regimen provided inadequate analgesia. Fifty-six percentage of respondents felt that pain during dressing change was adequately controlled 75% to 100% of the time, and 32% felt it was adequately controlled 50% to 75% of the time. Nitrous oxide was used by 8%. Anesthesia providers and an acute pain service are available in a minority of cases (13.7% and 28%, respectively) and are rarely consulted. Procedural burn pain remains significantly undertreated in the outpatient setting and the approach to treatment is variable among burn centers in the United States. Such variation likely represents an opportunity for identifying and implementing optimal practices and developing guidelines for burn pain management in the outpatient setting.

Effect of electroacupuncture on sedation requirements during colonoscopy: a prospective placebo-controlled randomised trial

INTRODUCTION

Propofol provides excellent sedation during colonoscopy. However, its application, namely when used together with an opioid, is associated with cardiopulmonary depression. Acupuncture is used nowadays for the treatment of pain and anxiety, and also to induce sedation. We hypothesised that electroacupuncture (EA) during colonoscopy would have sedative effects, thereby reducing propofol requirements to achieve an adequate level of sedation.

METHOD

The study was designed and conducted as a single centre, patient and observer blinded, sham- and placebo-controlled randomised trial. Patients scheduled for elective colonoscopy under deep propofol/alfentanil sedation were randomly assigned to receive unilateral EA, sham-acupuncture (SA) or placebo-acupuncture (PA) at ST36, PC6 and LI4. The primary outcome parameter was the total dosage of propofol. Secondary outcomes included the patients' and endoscopists' satisfaction levels evaluated by questionnaires.

RESULTS

The dosage of propofol required (median [IQR]) was not significantly different between the three groups (EA group 147 μg/kg/min [109-193] vs SA group 141 μg/kg/min [123- 180] vs PA group 141 μg/kg/min [112-182]; P=0.776). There was also no significant difference in alfentanil consumption (P=0.634). Global satisfaction (median [IQR]) among patients (EA group 6.6 [6.0-7.0] vs SA group 6.8 [6.0-7.0] vs PA group 6.5 [6.0-7.0]; P=0.481) and endoscopists (6.0 [5.0-6.0] for all groups; P=0.773) did not significantly differ between the three groups. There was no significant difference in the number of cardiorespiratory events.

CONCLUSION

For colonoscopy, the applied mode of EA did not show any propofol-sparing sedative effect compared with sham or placebo acupuncture.

TRIAL REGISTRATION

The trial is registered in the Netherland's Trial Registry (NTR4325).

Unscheduled Procedural Sedation: A Multidisciplinary Consensus Practice Guideline

The American College of Emergency Physicians (ACEP) organized a multidisciplinary effort to create a clinical practice guideline specific to unscheduled, time-sensitive procedural sedation, which differs in important ways from scheduled, elective procedural sedation. The purpose of this guideline is to serve as a resource for practitioners who perform unscheduled procedural sedation regardless of location or patient age. This document outlines the underlying background and rationale, and issues relating to staffing, practice, and quality improvement.

An international multidisciplinary consensus statement on fasting before procedural sedation in adults and children

The multidisciplinary International Committee for the Advancement of Procedural Sedation presents the first fasting and aspiration prevention recommendations specific to procedural sedation, based on an extensive review of the literature. These were developed using Delphi methodology and assessment of the robustness of the available evidence. The literature evidence is clear that fasting, as currently practiced, often substantially exceeds recommended time thresholds and has known adverse consequences, for example, irritability, dehydration and hypoglycaemia. Fasting does not guarantee an empty stomach, and there is no observed association between aspiration and compliance with common fasting guidelines. The probability of clinically important aspiration during procedural sedation is negligible. In the post-1984 literature there are no published reports of aspiration-associated mortality in children, no reports of death in healthy adults (ASA physical status 1 or 2) and just nine reported deaths in adults of ASA physical status 3 or above. Current concerns about aspiration are out of proportion to the actual risk. Given the lower observed frequency of aspiration and mortality than during general anaesthesia, and the theoretical basis for assuming a lesser risk, fasting strategies in procedural sedation can reasonably be less restrictive. We present a consensus-derived algorithm in which each patient is first risk-stratified during their pre-sedation assessment, using evidence-based factors relating to patient characteristics, comorbidities, the nature of the procedure and the nature of the anticipated sedation technique. Graded fasting precautions for liquids and solids are then recommended for elective procedures based upon this categorisation of negligible, mild or moderate aspiration risk. This consensus statement can serve as a resource to practitioners and policymakers who perform and oversee procedural sedation in patients of all ages, worldwide.

ASGE review of adverse events in colonoscopy

Colonoscopy is the most commonly performed endoscopic procedure and overall is considered a low-risk procedure. However, adverse events (AEs) related to this routinely performed procedure for screening, diagnostic, or therapeutic purposes are an important clinical consideration. The purpose of this document from the American Society for Gastrointestinal Endoscopy's Standards of Practice Committee is to provide an update on estimates of AEs related to colonoscopy in an evidence-based fashion. A systematic review and meta-analysis of population-based studies was conducted for the 3 most common and important serious AEs (bleeding, perforation, and mortality). In addition, this document includes an updated systematic review and meta-analysis of serious AEs (bleeding and perforation) related to EMR and endoscopic submucosal dissection for large colon polyps. Finally, a narrative review of other colonoscopy-related serious AEs and those related to specific colonic interventions is included.

Doxapram alleviates low SpO2 induced by the combination of propofol and fentanyl during painless gastrointestinal endoscopy

BACKGROUND

Painless gastrointestinal endoscopy under intravenous propofol anesthesia is widely applied in the clinical scenario. Despite the good sedation and elimination of anxiety that propofol provides, low SpO2 may also result. Doxapram is a respiratory stimulant with a short half-life. The primary aim of this study was to investigate the effects of doxapram on alleviating low SpO2 induced by the combination of propofol and fentanyl during painless gastrointestinal endoscopy.

METHODS

In this prospective study, patients scheduled for painless gastrointestinal endoscopy were randomly assigned to group D or S with 55 patients per group. Initially, both groups received a combination of propofol and fentanyl. Patients in group D received 50 mg doxapram after propofol injection, while patients in group S received an equal volume of saline. Vital signs of the patients, propofol dose, examination duration, and incidences of low SpO2 were recorded.

RESULTS

There were no statistical differences in propofol consumption and examination duration between the two groups. Twenty-six patients in group S experienced low SpO2 versus 10 in group D (P = 0.001). Nineteen patients in group S underwent oxygenation with a face mask in contrast to 8 in group D (P = 0.015). Eighteen patients in group S were treated with jaw lifting compared to 5 in group D (P = 0.002). Four patients in group S underwent assisted respiration compared to 2 in group D (without statistical difference). The average oxygen saturation in group S was significantly lower than that in group D at 1, 2 and 3 min after propofol injection (P < 0.001, P = 0.001 and P = 0.020, respectively). There were no statistical differences in oxygen saturation at other time points. There were no statistical differences in MAP and HR (except for the time point of 1 min after the induction) between the two groups.

CONCLUSIONS

Low dose of doxapram can effectively alleviate low SpO2 in painless gastrointestinal endoscopy with intravenous propofol, without affecting propofol consumption, examination duration, MAP, or HR.

TRAIL REGISTRATION

The study was approved by the Institutional Ethics Committee of Clinical and New Technology of Wuxi People's Hospital on 20th July, 2018 (KYLLH2018029) and registered in the Chinese Clinical Trial Register on 16th August, 2018 (ChiCTR1800017832).

[Practical aspects of sedation in dentistry]

In modern dental practice, the use of sedation to eliminate the fear and anxiety of the patient has become frequent. Unfortunately, according to the legislation, the concept of sedation is inseparable from anesthesia and it can only be performed by an anesthesiologist in a group or Department of Anesthesiology and Resuscitation. The article is devoted to a detailed comprehensive review of sedation in dental and surgical interventions in the maxillofacial area. It details the physiological and pathophysiological data of stress and psycho-emotional discomfort. The article indicates drugs for sedation, methods of their administration, features of application, possible complications. Such methods of parenteral sedation as intranasal, inhalation, intravenous are described in detail. Specific problems of sedation, for example, psychomotor agitation in the application of propofol or cough in deep sedation are indicated. It describes the modern data on intraoperative monitoring as an important component of patient safety during sedation. In addition to the Harvard standard the use of capnography and monitoring the depth of sedation by using bispectral index (BIS) is recommended.

Adverse events of conscious sedation using midazolam for gastrointestinal endoscopy

Background

This study was conducted to identify the types and incidence of adverse events associated with midazolam, which is the most widely used drug to induce conscious sedation during gastrointestinal endoscopy, and to analyze the factors associated with hypoxemia and sedation failure.

Methods

Of 87,740 patients who underwent gastrointestinal endoscopy between February 2015 and May 2017, the electronic medical records of 335 who reportedly developed adverse events were retrospectively reviewed, and analysis was performed to determine the risk factors for hypoxemia and sedation failure, the two most frequent adverse events among those manifested during gastrointestinal endoscopy.

Results

The overall adverse event rate was 0.38% (n = 335); hypoxemia was most frequent, accounting for 40.7% (n = 90), followed by sedation failure (34.8%, n = 77), delayed discharge from the recovery room (22.1%, n = 49), and hypotension (2.2%, n = 5). Compared with the control group, the hypoxemia group did not show any significant differences in sex and body weight, but mean age was significantly older (P < 0.001) and a significantly lower dose of midazolam was administered (P < 0.001). In the group with sedation failure, the mean rate was higher in men (P < 0.001) and a significantly higher dose of midazolam was administered (P < 0.001), but no age difference was found.

Conclusions

Midazolam-based conscious sedation during gastrointestinal endoscopy can lead to various adverse events. In particular, as elderly patients are at higher risk of developing hypoxemia, midazolam dose adjustment and careful monitoring are required in this group.

Airway rescue during sedation: a proposed airway rescue pathway for nonanesthesiologists

PURPOSE OF REVIEW

This review summarizes key features of adverse airway and respiratory events for which sedation providers must be prepared to diagnose and treat in a timely manner. Key features include elements of the presedation patient evaluation that predict adverse airway and respiratory events; patient profiles, target sedation levels, and procedure types that should prompt a consult with an anesthesiologist; necessary clinical skills, essential equipment, and reversal drugs necessary to manage adverse airway and respiratory events; and a proposed airway rescue pathway that describes a sequence of interventions and prompts to call for help when encountering an adverse airway or respiratory event.

RECENT FINDINGS

Several studies have reported adverse events from sedation. Although the overall rate can approach 4.5%, the incidence of events associated with severe harm is low (e.g., <0.5%). Some that are most harmful are prolonged ventilatory compromise leading to hypoxic brain injury or death. Inadequate clinical skills that contribute to these poor outcomes include undetected or delayed detection of hypopnea, apnea, and partial or complete airway obstruction, inadequate rescue skills to manage drug-induced ventilatory depression or airway obstruction, and/or a delay or no attempt to call for expert help followed by a timely response and intervention from that expert help.

SUMMARY

To improve outcomes in detecting and managing adverse airway and respiratory events, nonanesthesiologists sedation practitioners must be trained in patient selection, monitoring, pharmacology, physiology, and airway management. One gap in sedation training curriculum is a roadmap to use when managing an adverse airway or respiratory events. This review puts forth a suggested airway rescue pathway for nonanesthesiologist sedation practitioners to use as a decision aid during an adverse airway or respiratory event associated with procedural sedation.

Safety and Acceptability of Esophageal Cytosponge Cell Collection Device in a Pooled Analysis of Data From Individual Patients

BACKGROUND & AIMS

Diagnosis and surveillance of Barrett's esophagus (BE) and eosinophilic esophagitis (EoE) have become emerging public health issues. Cytosponge is a novel, minimally invasive esophageal cell collection device. We aimed to assess the data on safety and acceptability of this device.

METHODS

We performed a patient-level review of 5 prospective trials assessing Cytosponge performance in patients with reflux disease, BE and EoE in primary and secondary care. Acceptability of Cytosponge and subsequent endoscopy were recorded with visual analogue scale (VAS), wherein 0 and 10 denoted lowest and highest acceptability. Median VAS scores were compared using a Mann-Whitney test. The number of attempts, failures in swallowing the device and occurrence of adverse events were analyzed. Risk factors for failure in swallowing were analyzed using a multivariate regression model.

RESULTS

In total, 2672 Cytosponge procedures were performed, in 2418 individuals from 2008 through 2017. There were 2 adverse events related to the device: a minor pharyngeal bleed and a case of detachment (<1:2000). The median acceptability score for the Cytosponge was 6.0 (interquartile range [IQR], 5.0-8.0), which was higher than the score for endoscopy without sedation (median 5.0; IQR, 3.0-7.0; P < .001) and lower than the score for endoscopy with sedation (median 8.0; IQR, 5.0-9.0; P < .001). Nearly all patients (91.1%) successfully swallowed the Cytosponge, most on the first attempt (90.1%). Failure to swallow the device was more likely to occur in secondary care (odds ratio, 5.13; 95% CI, 1.48-17.79; P < .01).

CONCLUSIONS

The Cytosponge test is a safe procedure with good acceptability ratings in a variety of health care settings.

Effectiveness and safety of gastrointestinal endoscopy during a specific sedation training program for non-anesthesiologists

INTRODUCTION

sedation is a key component for the improvement of sedation quality. A correct administration requires appropriate training. We performed a study to compare sedation effectiveness, safety and patient satisfaction when administered by gastroenterologists, with and without specific training.

METHODS

a training program enrolled a group of gastroenterologists (trained group, n = 4) and their results were compared to those from a non-trained group (n = 3). ASA 1-3 patients who had undergone sedation by a gastroenterologist using midazolam and fentanyl were included over a period of 30 months. Safety was assessed in terms of the complication rate, effectiveness was assessed via the rate of completed endoscopic procedures and patient satisfaction was evaluated via a phone interview the day after the procedure.

RESULTS

a total of 3,475 patients were sedated by gastroenterologists during the study period. Significant differences were found that favored the trained group for completed procedures (5.6% vs 8.9%). A lower rate of excessive sedation (1.3% vs 8.61%), hypoxemia (0.72% vs 2.49%) and post-procedural pain (1.8% vs 4.3%) were also achieved. Patient satisfaction surpassed 99.5% and there were no significant differences between groups.

CONCLUSIONS

our sedation training program improved the effectiveness and safety outcomes when compared to sedation administered by gastroenterologists without this specific training.

Pulmonary aspiration during procedural sedation: a comprehensive systematic review

Background

Although pulmonary aspiration complicating operative general anaesthesia has been extensively studied, little is known regarding aspiration during procedural sedation.

Methods

We performed a comprehensive, systematic review to identify and catalogue published instances of aspiration involving procedural sedation in patients of all ages. We sought to report descriptively the circumstances, nature, and outcomes of these events.

Results

Of 1249 records identified by our search, we found 35 articles describing one or more occurrences of pulmonary aspiration during procedural sedation. Of the 292 occurrences during gastrointestinal endoscopy, there were eight deaths. Of the 34 unique occurrences for procedures other than endoscopy, there was a single death in a moribund patient, full recovery in 31, and unknown recovery status in two. We found no occurrences of aspiration in non-fasted patients receiving procedures other than endoscopy.

Conclusions

This first systematic review of pulmonary aspiration during procedural sedation identified few occurrences outside of gastrointestinal endoscopy, with full recovery typical. Although diligent caution remains warranted, our data indicate that aspiration during procedural sedation appears rare, idiosyncratic, and typically benign.

Safety of sedation for gastrointestinal endoscopy in a group of university-affiliated hospitals: a prospective cohort study

BACKGROUND

Service models for gastrointestinal endoscopy sedation must be safe, as endoscopy is the most common procedure performed under sedation in many countries. The aim of this prospective cohort study was to determine the patient risk profile, and incidence of and risk factors for significant unplanned events, in adult patients presenting for gastrointestinal endoscopy in a group of university-affiliated hospitals where most sedation is managed by anaesthetists.

METHODS

Patients aged ≥18 yr presenting for elective and emergency gastrointestinal endoscopy under anaesthetist-managed sedation at nine hospitals affiliated with the University of Melbourne, Australia, were included. Outcomes included significant airway obstruction, hypoxia, hypotension and bradycardia; unplanned tracheal intubation; abandoned procedure; advanced life support; prolonged post-procedure stay; unplanned over-night admission and 30-day mortality.

RESULTS

2,132 patients were included. Fifty percent of patients were aged >60 yr, 50% had a BMI >27 kg m ^-2, 42% were ASA physical status III-V and 17% were emergency patients. The incidence of significant unplanned events was 23.0% (including significant hypotension 11.8%). Significant unplanned intraoperative events were associated with increasing age, BMI <18.5 kg m ^-2, ASA physical status III-V, colonoscopy and planned tracheal intubation. Thirty-day mortality was 1.2% (0.2% in electives and 6.0% in emergencies) and was associated with ASA physical status IV-V and emergency status.

CONCLUSIONS

Patients presenting for gastrointestinal endoscopy at a group of public university-affiliated hospitals where most sedation is managed by anaesthetists, had a high risk profile and a substantial incidence of significant unplanned intraoperative events and 30-day mortality.

Comparison of two supplement oxygen methods during gastroscopy with intravenous propofol anesthesia in obese patients: study protocol for a randomized controlled trial

BACKGROUND

Hypoxemia is a major complication in obese patients undergoing gastrointestinal endoscopy under intravenous anesthesia or sedation due to altered airway anatomy. We design this randomized controlled trial (RCT) to compare efficacy and safety of the Wei nasal jet tube (WNJT) and nasal prongs for supplement oxygen during gastroscopy with intravenous propofol anesthesia in obese patients.

METHODS

The study will be a single-center, prospective RCT. A total of 308 obese patients will be recruited and randomly assigned to receive either the WNJT (group A) or nasal prongs (group B). During gastroscopy with intravenous propofol anesthesia, 5 L/min of oxygen will be delivered through the jet port of the WNJT in the group A and via the nasal prongs in the group B. The primary outcome is the incidence of hypoxemia and severe hypoxemia. The secondary outcomes are adverse events during the gastroscopy, postoperative complications, and satisfaction of the anesthetist, physician, and patient.

DISCUSSION

This RCT aims to clarify whether the WNJT can result in reduced incidences of hypoxemia and complications and provide improved satisfaction to the anesthetist, physician, and patient. Thus, it can be determined if the WNJT is a useful tool for supplement oxygen in obese patients undergoing gastroscopy with intravenous propofol anesthesia. The results will provide the evidence for anesthesiologists to make a decision regarding the choice of supplementary oxygen methods in this condition.

TRIAL REGISTRATION

Chinese Clinical Trial, ChiCTR-IOR-17013089 . Registered on 23 October 2017.

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.

Clinical and economic burden of procedural sedation-related adverse events and their outcomes: analysis from five countries

Background

Studies have reported on the incidence of sedation-related adverse events (AEs), but little is known about their impact on health care costs and resource use.

Methods

Health care providers and payers in five countries were recruited for an online survey by independent administrators to ensure that investigators and respondents were blinded to each other. Surveys were conducted in the local language and began with a “screener” to ensure that respondents had relevant expertise and experience. Responses were analyzed using Excel and R, with the Dixon’s Q statistic used to identify and remove outliers. Global and country-specific average treatment patterns were calculated via bootstrapping; costs were mean values. The sum product of costs and intervention probability gave a cost per AE.

Results

Responses were received from 101 providers and 26 payers, the majority having >5 years of experience. At a minimum, the respondents performed a total of 3,430 procedural sedations per month. All AEs detailed occurred in clinical practice in the last year and were reported to cause procedural delays and cancellations in some patients. Standard procedural sedation costs ranged from €74 (Germany) to $2,300 (US). Respondents estimated that AEs would increase costs by between 16% (Italy) and 179% (US). Hypotension was reported as the most commonly observed AE with an associated global mean cost (interquartile range) of $43 ($27–$68). Other frequent AEs, including mild hypotension, bradycardia, tachycardia, mild oxygen desaturation, hypertension, and brief apnea, were estimated to increase health care spending on procedural sedation by $2.2 billion annually in the US.

Conclusion

All sedation-related AEs can increase health care costs and result in substantial delays or cancellations of subsequent procedures. The prevention of even minor AEs during procedural sedation may be crucial to ensuring its value as a health care service.