Premedication for upper gastrointestinal endoscopy

Effect of remimazolam vs propofol in high-risk patients undergoing upper gastrointestinal endoscopy: a non-inferiority randomized controlled trial

BACKGROUND

Procedural sedation is essential for optimizing upper gastrointestinal endoscopy, particularly in high-risk patients with multiple underlying diseases. Respiratory and circulatory complications present significant challenges for procedural sedation in this population. This non-inferiority randomized controlled trial aims to investigate the safety and comfort of remimazolam compared to propofol for procedural sedation during upper gastrointestinal endoscopy in high-risk patients.

METHODS

A total of 576 high-risk patients scheduled to undergo upper gastrointestinal endoscopy are planned to be enrolled in this study and randomly allocated to either the remimazolam or propofol group. The primary outcome measure is a composite endpoint, which includes (1) achieving a Modified Observer's Alertness/Sedation scale (MOAA/S) score ≤ 3 before endoscope insertion, (2) successful completion of the endoscopic procedure, (3) the absence of significant respiratory instability during the endoscopy and treatment, and (4) the absence of significant circulatory instability during the examination. The noninferiority margin was 10%. Any adverse events (AEs) that occur will be reported.

DISCUSSION

This trial aims to determine whether remimazolam is non-inferior to propofol for procedural sedation during upper gastrointestinal endoscopy in high-risk patients, regarding success rate, complication incidence, patient comfort, and satisfaction. TRIAL REGISTRATION {2A AND 2B}: Chinese Clinical Trial Registry ClinicalTrials.gov ChiCTR2200066527. Registered on 7 December 2022.

The effect of pre-procedure anxiety on sedative requirements for sedation during upper gastrointestinal endoscopy

Objectives

Sedation for upper gastrointestinal endoscopy, commonly used for diagnosis and treatment of gastrointestinal diseases, has been increasing widespread. Sedative agent requirements during sedation or anesthesia can be affected by many factors such as age and sex. In the present study, we aimed to evaluate the effects of pre-procedural anxiety levels on sedative requirements during upper gastrointestinal endoscopy.

Material and Methods

300 patients between the ages of 18-70 years were studied. Baseline anxiety levels were measured before the procedure using Spielberger's State-Trait Anxiety Inventory (STAI) form X1. Propofol was administered to have BIS values between 65-85 during sedation. Doses of propofol, total procedure time, satisfaction of the patients and endoscopists and BIS values were recorded.

Results

Pre-procedural anxiety was 44 (40-48 [20-70]). We found significant correlations between pre-procedure anxiety and the usage of propofol (mg, mg/kg, mg/kg/dk) at BIS values between 65-85, [respectively, (p= 0.451, p <0.001), (p= 0.455, p <0.001), (p= 0.428, p <0.001)]. No correlation was found between pre-procedure anxiety and procedural or sedation complications (respectively p= 0.111, p= 0.424 and p= 0.408, p= 0.363). We found significant negative correlations between pre-procedure anxiety and the satisfaction of the patients/endoscopist [respectively, (p= -0.477, p <0.001), (p= -0.495, p <0.001)].

Conclusion

Based on the results of this study, we suggest that there is a significant association between the pre-procedural anxiety levels and use of sedative drugs in patients undergoing upper gastrointestinal endoscopy.

Efficacy of Sedation by Midazolam in Association With Meperidine or Fentanyl and Role of Patient Distress During Elective Colonoscopy

Meperidine and fentanyl are opioids currently used in addition to midazolam for sedation and analgesia during colonoscopy in Italy. The aim of the study was to assess the impact of patients' psychological state before elective colonoscopy on the efficacy of the sedation regimens. Eighty outpatients who underwent an elective colonoscopy were included in our study. The Hospital Anxiety and Depression Scale questionnaire was self-administered to evaluate basal anxiety and depression state. The rate of baseline discomfort was evaluated by a standard 100-mm visual analog scale. Sedation was obtained alternatively with a midazolam-meperidine or midazolam-fentanyl combination. There were no statistically significant differences between the fentanyl and meperidine groups on body mass index, age, and gender composition. Patients in the meperidine group reported less pain during colonoscopy than patients in the fentanyl group. There were statistically significant positive correlations in the meperidine group with the distress, anxiety, and depression. Our study has pointed out greater effectiveness of the midazolam plus meperidine regimen, equal recovery times, and no significant differences in the duration of the endoscopic examinations. The evaluation of patients' psychological status seems to predict the efficacy of sedation when the nociceptive component of pain is well controlled.

Dexmedetomidine is safe and reduces the additional dose of midazolam for sedation during endoscopic retrograde cholangiopancreatography in very elderly patients

Background

Endoscopic retrograde cholangiopancreatography (ERCP) often requires deep sedation. Dexmedetomidine, a highly selective α2-adrenoceptor agonist with sedative activity and minimal effects on respiration, has recently been widely used among patients in the intensive care unit. However, its use in endoscopic procedures in very elderly patients is unclear. In this study, we retrospectively investigated the safety and efficacy of dexmedetomidine sedation during ERCP.

Methods

The study included 62 very elderly patients (aged over 80 years) who underwent ERCP from January 2014, with sedation involving dexmedetomidine (i.v. infusion at 3.0 μg/kg/h over 10 min followed by continuous infusion at 0.4 μg/kg/h) along with midazolam. For comparison, the study included 78 patients who underwent ERCP before January 2014, with midazolam alone. We considered additional administration of midazolam as needed to maintain a sedation level of 3–4, according to the Ramsay sedation scale. The outcome measures were amount of midazolam, adverse events associated with sedation, and hemodynamics.

Results

The incidence of decreased SpO₂ and median dose of additional midazolam were significantly lower in the dexmedetomidine group than in the conventional group. The minimum systolic blood pressure and minimum heart rate during and after examination was significantly lower in the dexmedetomidine group than in the conventional group. However, serious acute heart failure or arrhythmia was not noted.

Conclusions

Dexmedetomidine can decrease the incidence of respiratory complications and the total dose of other sedative agents. It can be used as an alternative to conventional methods with midazolam for adequate sedation during ERCP in very elderly patients.

A prospective randomized study comparing transnasal and peroral 5-mm ultrathin endoscopy

BACKGROUND/PURPOSE

Differences in patient tolerance, acceptance, and satisfaction of esophagogastroduodenoscopy (EGD) between transnasal (TN) and peroral (PO) routes using a 5-mm video endoscope.

METHODS

A total of 220 enrolled patients were assigned randomly to two groups undergoing EGD-110 patients each for TN and PO. The successful rate, procedure time, and adverse events were recorded. After the procedure, patients answered a validated questionnaire of tolerance, acceptance, and satisfaction.

RESULTS

There were 6 failures (5.7%) of nasal intubation and two nasal bleeding (2%) among 105 TN-EGD procedures. All PO patients (n=102) completed EGD successfully without adverse event. Compared to PO, the procedure of TN achieved lower successful rate (94% vs. 100%, p=0.01), was complicated with epistaxis (2% vs. 0%) and took longer (mean ± SD 19.9 ± 6.1 min vs. 16.8 ± 6.4 min, p=0.0001). The patients undergoing TN-EGD indicated less discomfort during passing pharynx (scores of 2.1 ± 2.0 vs. 3.1 ± 2.6, p=0.011) but more pain during inserting scope (scores of 2.2 ± 1.6 vs. 1.5 ± 1.8, p=0.0001). Eventually, there were no significant differences between TN and PO regarding the overall procedure discomfort (scores of 10.7 ± 6.6 vs. 11.1 ± 7.8 scores, p=0.9), satisfaction (scores of 41.2 ± 4.2 vs. 41.3 ± 4.6, p=0.91), and acceptability (87.8% vs. 94.2%, p=0.91).

CONCLUSION

PO intubation seems an excellent alternative method when using a 5-mm ultrathin endoscopy because it achieves comparable patient tolerance, acceptance, and satisfaction as TN intubation, takes less time and causes lower intubation failure and epistaxis.

Value and Safety of Midazolam Anesthesia during Transrectal Ultrasound-Guided Prostate Biopsy

PURPOSE

Although transrectal ultrasound-guided prostate biopsy is useful for diagnosing prostate cancer, it is a painful procedure. There are many methods for providing pain relief and for treating discomfort during the procedure, but occasionally these are reported to be of limited use. We aimed to evaluate the value and safety of midazolam-induced anesthetic transrectal ultrasound-guided prostate biopsy.

MATERIALS AND METHODS

From August 2008 to December 2009, 104 male patients, who were examined with transrectal ultrasound-guided prostate 12-core biopsy, were randomly assigned to two groups. Group 1 (n=51) received ketorolac (Tarasyn®) 30 mg. Group 2 (n=53) was treated with midazolam (Dormicum®) 3 mg, which was increased to 5 mg if necessary. Immediately after the procedure, the patients were asked to rate their comfort level by using a 10-point visual analog self-assessment pain scale.

RESULTS

The pain scale in group 2 was significantly lower than that in group 1 (p<0.05). The patients assigned to group 2 experienced no side-effects from midazolam and were more satisfied than the patients in group 1 (p<0.05).

CONCLUSIONS

Midazolam anesthesia relieves pain effectively, and the patient's satisfaction is better than with conventional transrectal ultrasound-guided prostate biopsy. Midazolam-induced anesthetic transrectal ultrasound-guided prostate biopsy is useful and safe.

Midazolam anesthesia during rigid and flexible cystoscopy

The objective of this study was to investigate the usefulness and safety of midazolam-induced anesthesia for cystoscopy. From September 2005 to March 2006, 80 patients scheduled for regular outpatient follow-up cystoscopy participated in this study. The patients were randomized and classified according to the cystoscope type and midazolam use as follows: group 1 (10 men and 10 women), flexible cystoscopy + midazolam; group 2 (10 men and 10 women), flexible cystoscopy + no midazolam; group 3 (10 men and 10 women), rigid cystoscopy + midazolam; and group 4 (10 men and 10 women), rigid cystoscopy + no midazolam. Immediately after the procedure, the patients were asked to rate their comfort level using a ten-point visual linear analog self-assessment pain scale. The patients assigned in the midazolam group experienced no side-effects from the midazolam. Blood pressure and pulse rate did not change significantly during the procedure. The degree of pain experienced by group 1 was lower than other groups (P < 0.05) and group 4 had a significantly greater pain score than other groups (P < 0.05). No difference was evident between group 2 and 3 regarding the pain score. Midazolam anesthesia may relieve pain during rigid and flexible cystoscopy. Our findings suggest that midazolam anesthesia during cystoscopy is useful and safe.

Evaluation of topical pharyngeal anaesthesia by benzocaine lozenge for upper endoscopy

BACKGROUND

Among the randomized controlled trials evaluating the effect of pharyngeal anaesthesia only some suggest benefit. Spray is irritating for some people and leaves bitter taste in the throat. We hypothesized that delivering the local anaesthetic as a sucking lozenge would benefit the patients in terms of decreasing anxiety and will improve procedure performance and patient tolerance.

AIM

To determine whether benzocaine/tyrothricin sucking lozenges with conscious sedation is superior to conscious sedation alone, with respect to procedure performance and tolerance in patients undergoing upper endoscopy.

METHODS

One hundred and seventy-four adult patients undergoing upper endoscopy with conscious sedation completed the study. They were randomized to receive sucking lozenge containing benzocaine or placebo before the procedure. Patients were asked to rate prestudy anxiety, tolerance for topical pharyngeal anaesthesia, comfort during endoscopy, degree of difficulty of intubation, postprocedure throat discomfort and willingness to undergo subsequent examinations using a 10-cm visual analogue scale. Endoscopists were asked to estimate the ease of oesophageal intubation and procedure performance.

RESULTS

No significant statistical differences regarding all the points studied were found between the groups.

CONCLUSIONS

Topical pharyngeal anaesthesia with benzocaine/tyrothricin lozenges with conscious sedation has no advantages over conscious sedation alone in patients undergoing upper endoscopy.

Paradoxical Reactions to Benzodiazepines: Literature Review and Treatment Options

Benzodiazepines frequently are administered to patients to induce sedation. Paradoxical reactions to benzodiazepines, characterized by increased talkativeness, emotional release, excitement, and excessive movement, are relatively uncommon and occur in less than 1% of patients. The exact mechanism of paradoxical reactions remains unclear. Most cases are idiosyncratic; however, some evidence suggests that these reactions may occur secondary to a genetic link, history of alcohol abuse, or psychological disturbances. This review evaluates the numerous cases of paradoxical reactions to benzodiazepines in adult and pediatric patients that have been reported in the biomedical literature. It also explores the advantages and disadvantages of the various available treatment options.

Sedation versus no sedation in the performance of diagnostic upper gastrointestinal endoscopy: a Canadian randomized controlled cost-outcome study

BACKGROUND

Sedation is not required to perform a technically adequate gastroscopy (EGDE), but does improve patient satisfaction, comfort, and willingness to repeat particularly in the elderly and those with decreased pharyngeal sensitivity. The comparative cost-efficacy of sedation versus no sedation remains poorly characterized.

AIM

To compare the cost-efficacy of diagnostic EGDE with and without sedation in an adult ambulatory Canadian population.

METHODS

A double-blind randomized controlled trial assigned patients to sedation versus placebo. "Successful endoscopy" was considered an EGDE rated 4/4 in technical adequacy (1 = inadequate to 4 = totally adequate), and 1-2/5 in patient self-reported comfort (1 = acceptable to 5 = unacceptable). Secondary outcomes included recovery room time, patient satisfaction alone, and willingness to repeat the procedure. Cost data were obtained using a published, institutional activity-based costing methodology. Analysis was intention to treat using standard univariate and multivariate methods.

RESULTS

419 patients (mean age 54.5, 48% male) were randomized (N = 210 active vs N = 209 placebo). Among patients randomized to active medication 76% of procedures were "successful" (placebo 46%), 79% were satisfied with their level of comfort (placebo 47%), and willingness to repeat was 81% (placebo 65%). We observed a 10% crossover rate from placebo to active medications. The use of sedation was the major determinant of successful endoscopy (OR = 3.8; 95% CI: 2.5-5.7), but contributed to an increased recovery room time (29 vs 15 min; p < 0.0001). The expected cost of an additional successful endoscopy using sedation was $90.06 (CDN). In a planned subgroup analysis, among the elderly (>75; N = 53) unsedated endoscopy became the dominant approach. Indeed, in this population, a trend was observed favoring the effectiveness of placebo (63%) versus active medication (57%) (OR = 0.75; 95% CI: 0.25-2.3) and was less costly resulting in $450 savings/unsedated EGDE.

CONCLUSIONS

In the average Canadian ambulatory adult population, sedated diagnostic EGDE is more costly but remains an efficacious strategy by increasing the rate of successful endoscopies, patient satisfaction, and willingness to repeat. However, among the elderly (>75 yr), an unsedated strategy may be more cost-efficacious.

Predicting which patients can undergo upper endoscopy comfortably without conscious sedation

BACKGROUND

Eliminating conscious sedation for diagnostic endoscopy may be advantageous for patient safety and cost containment. The aim of this study was to identify and validate independent predictors of a comfortable, technically adequate, unsedated diagnostic upper endoscopy in Canadian patients.

METHODS

Patients were consecutively enrolled in a prospective fashion. Data collected on an initial cohort of 268 patients included demographics, a validated anxiety questionnaire, use of sedatives/analgesics, upper endoscopy experience, pharyngeal sensitivity, technical adequacy, and patient assessment of comfort after the procedure. The main outcome measure was "satisfactory upper endoscopy," a composite of optimal scores for patient comfort and technical adequacy. Univariate and multivariate analyses were performed to identify the optimal predictive model of a satisfactory unsedated diagnostic upper endoscopy. Once identified, 68 additional patients were enrolled in a similar fashion from an independent prospective sample for purposes of outcome validation. Multivariate analysis was then repeated with the total cohort (N = 336). These results were then compared for concordance with those obtained from the initial cohort.

RESULTS

Among the initial 268 patients (54.3% women; mean age 51 +/- 17 years), 49% were anxious, 15% regularly used sedatives and analgesics, 28% experienced increased pharyngeal sensitivity, and 41% had previously undergone upper endoscopy. Endoscopy was completed in 94.7% of patients without sedation and was technically adequate in 97%, and 80.1% were willing to repeat the procedure under similar conditions. Satisfactory upper endoscopy was achieved in only 59% of the initial cohort. The only independent and significant predictors of a satisfactory upper endoscopy were advancing age (OR 1.2: 95% CI [1.1, 1.4]) and decreased pharyngeal sensitivity (OR 0.5: 95% CI [0.27, 0.93]). Concordance of results were noted after validation with the second cohort. Satisfactory endoscopy was achieved in only 59.5% of the total cohort (n = 336); only 61% reported a comfortable procedural experience.

CONCLUSIONS

The proportion of patients who can comfortably undergo technically adequate unsedated upper endoscopy is modest. Unsedated upper endoscopy is most likely to be successful under these procedural conditions in patients of advancing age with decreased pharyngeal sensitivity. The generalizability of these findings to an American population requires further study and may assist in identifying a subgroup of patients in whom it is cost-effective to perform upper endoscopy comfortably without sedation.

Factors influencing patient satisfaction with GI endoscopy

BACKGROUND

A modified Group Health Association of America-9 survey (mGHAA-9) was recently proposed for measurement of patient satisfaction with endoscopy. It is unknown whether the mGHAA-9 addresses the issues most important to this outcome.

METHODS

A 15-item survey of factors potentially important to patient satisfaction with endoscopy was developed, including the 6 core mGHAA-9 items. Respondents were asked to rank the factors from 1 to 15 (1 = most important to l5 = least important to satisfaction). Two groups were surveyed: (1) patients with prior endoscopy experience and (2) physician endoscopists. Item rank distributions overall and by patient age, gender, and procedure experience were examined.

RESULTS

Of 559 outpatients surveyed, 437 (78%) provided complete responses. The mean patient age was 59 years (48.7% female, 45.3% male, 6% not stated). The number 1 ranked factor was the endoscopist's technical skills (median ranking (mr) = 1), an item included in the mGHAA-9. Pain control, a factor not assessed by the mGHAA-9, was second (mr = 4), and ranked number 1 by 16% of patients. Item rankings were consistent across patient subgroups. Relative to patients, endoscopists underprioritized preprocedure and postprocedure communication.

CONCLUSIONS

The mGHAA-9 has inadequate content validity for measurement of patient satisfaction with endoscopy because it does not assess pain control. However, endoscopy satisfaction measurement with a single, universally applied instrument appears feasible.

Limited benefit of atropine as premedication for colonoscopy

A prospective double-blind trial was performed comparing atropine (0.5 mg) by slow intravenous administration to placebo as premedication for colonoscopy, to assess the possible beneficial effects of this vagolytic agent on the performance and safety of the procedure. A total of 77 patients was randomly assigned to receive atropine (38 patients) or placebo (39 patients) before colonoscopy in conjunction with our standard initial medications for conscious sedation (meperidine, 0.4 mg/kg and midazolam, 0.03 mg/kg). Total procedure time was 31 min for the atropine group and 35 min for the placebo group (p greater than 0.05), and there was no overall difference in the total amount of intra-procedural medications required. No statistically significant differences were observed relative to the number or severity of vagal episodes, and neither the endoscopist nor the patients noted any differences in the ease or tolerance of the procedure (p greater than 0.05). Although these results fail to demonstrate a significant benefit of atropine when given routinely as premedication for colonoscopy, this study does not rule out the potential usefulness of atropine in counteracting vagal episodes when they occur.

The role of gamma-scintigraphy in oral drug delivery

The gastrointestinal tract is usually the preferred site of absorption for most therapeutic agents, as seen from the standpoints of convenience of administration, patient compliance and cost. In recent years there has been a tendency to employ sophisticated systems that enable controlled or timed release of a drug, thereby providing a better dosing pattern and greater convenience to the patient. Although much about the performance of a system can be learned from in vitro release studies using conventional and modified dissolution methods, evaluation in vivo is essential in product development. The non-invasive technique of gamma-scintigraphy has been used to follow the gastrointestinal transit and release characteristics of a variety of pharmaceutical dosage forms. Such studies provide an insight into the fate of the delivery system and its integrity and enable the relationship between in vivo performance and resultant pharmacokinetics to be examined (pharmacoscintigraphy).

Comparison of the sedation and recovery profiles of Ro 48-6791, a new benzodiazepine, and midazolam in combination with meperidine for outpatient endoscopic procedures

In this randomized, double-blinded study, we compared the onset and recovery characteristics of an investigational benzodiazepine, Ro 48-6791 (when administered alone or combined with meperidine), a midazolam-meperidine combination for sedation during gastrointestinal (GI) endoscopic procedures. Ninety consenting outpatients scheduled for upper or lower GI procedures were randomly assigned as follows: Group I received midazolam 1 mg IV and meperidine 50 mg; Group II received Ro 48-6791 0.5 mg IV and meperidine 50 mg; or Group III received Ro 48-6791 1.0 mg IV alone. If the level of sedation did not achieve an Observer's Assessment of Alertness/Sedation (OAA/S) score of 4 (where 5 = awake/alert to 1 = asleep) in < or = 2 min, a second bolus dose, equal to half of the original dose of midazolam or Ro 48-6791, was administered. The onset time was defined as the time to achieve an OAA/S score of 4. During the procedure, a bolus dose equal to half of the total induction dose was given to maintain an OAA/S score of 4. The induction and maintenance dosages, as well as recovery times to an OAA/S score of 5, were recorded. A heel-toe line walk (HTLW) test used to determine the time to "fitness for discharge." Although the onset times were similar in all three groups, the induction dosages were significantly reduced in Group II compared with Groups I and III. There were significantly more patients requiring supplemental sedative boluses and "rescue" analgesia with Ro 48-6791 than with midazolam. The Ro 48-6791 groups also experienced more dizziness after the procedures. Ro 48-6791 was associated with a higher incidence of inadequate sedation (18% vs 3%) without the opioid. The time for the HTLW test to return to baseline values after the procedure was similar among the three groups. However, the Ro 48-6791 groups had significantly reduced times to return to an OAA/S score of 5 and to achieve the baseline HTLW value after the last dose of the benzodiazepine. In conclusion, compared with midazolam, Ro 48-6791 is more potent and may be associated with a more rapid early recovery after endoscopic GI procedures. However, sedation with Ro 48-6791 required more supplemental bolus doses and "rescue" analgesic medication and was associated with a higher incidence of dizziness.

IMPLICATIONS

The investigational water-soluble benzodiazepine, Ro 48-6791, is a more potent sedative than midazolam, which appears to have a slightly shorter duration of action. Unfortunately, use of Ro 48-6791 increased the requirement for supplemental doses of the sedative medication and the need for "rescue" analgesics during the procedure and was associated with more dizziness after the procedure.

Hypnotic technique for sedation of patients during upper gastrointestinal endoscopy

A method of sedation of patients undergoing upper gastrointestinal endoscopy is described. This technique employs a variety of elements, including "pacing and leading," metaphors, use of physiological reactions to deepen the relaxation, imagery, and post hypnotic suggestions. It is a simple and effective method which does not require any preparation. It spares the need for a pharmacological sedation and obviates the possible hazards of such a sedation. The author has successfully used this technique to sedate more than 200 patients undergoing upper gastrointestinal endoscopy. The duration of examinations performed this way compares with that using conventional pharmacological sedation. However, unlike the case of pharmacological sedation, no further monitoring is needed after the completion of the examination and the patients can leave the clinic immediately to resume their activities.

A randomized, prospective, double-blind comparison of midazolam (Versed) and emulsified diazepam (Dizac) for opioid-based, conscious sedation in endoscopic procedures

OBJECTIVE

We completed a prospective, randomized, double-blinded clinical trial to compare the quality of sedation with two benzodiazepines (emulsified diazepam and midazolam) for endoscopic procedures.

METHODS

Adult patients undergoing esophagogastroduodenoscopy or colonoscopy were eligible. Exclusion criteria included: drug allergies, altered mental status, untreated glaucoma, active pancreatitis, hyperlipidemia, resident physician training, or cases done outside the Endoscopy unit. Nurses began the sedation process by administering an opioid followed immediately by administering study drugs until patients were adequately sedated. At completion of the procedure, both the physician and the nurse rated whether the patient's sedation appeared to be adequate. In addition, before discharge, patients were asked to rate the quality of sedation.

RESULTS

A total of 111 patients were randomized to the emulsified diazepam group and 100 to the midazolam group. There was no difference in the physician's assessment of quality of sedation between the groups (p > 0.05). The length of time to sedation, total procedure time, and recovery time were similar between both groups. The estimated cost of using emulsified diazepam was approximately 50% less than that of midazolam, with an equal quality of sedation.

CONCLUSION

Neither the physicians, nurses, nor the patients could detect a difference between sedation produced by the drugs. We conclude that both drugs were equally effective for sedation for both upper and lower endoscopic procedures. Based on the results of this trial, we suggest that increased use of emulsified diazepam would markedly reduce the cost without altering the quality of sedation. The cost savings would be at least $50,000/yr at our institution.

Flumazenil reversal of psychomotor impairment due to midazolam or diazepam for conscious sedation for upper endoscopy

BACKGROUND

Flumazenil is a competitive benzodiazepine antagonist that acts to reverse their sedative and hypnotic effects. It is indicated in the management of benzodiazepine overdose, but its role in the routine reversal of endoscopic conscious sedation has not been defined.

METHODS

Patients undergoing diagnostic upper endoscopy who received sedation with either diazepam or midazolam alone were given flumazenil 0.2 mg incrementally immediately following the procedure until awake. They were then asked to repeat three psychomotor tests measuring cognitive and motor skills, with their baseline scores compared with postprocedure scores over a 3-hour period.

RESULTS

Full psychomotor function was restored to baseline values within 30 minutes after flumazenil in 79% of patients, with no differences in the reversal of psychomotor skill impairment observed between diazepam and midazolam sedation. There was no evidence of rebound sedation seen for up to 3 hours. No significant anterograde amnesia was evident in 78% of individuals.

CONCLUSIONS

These results demonstrate that flumazenil's effects on reversing psychomotor impairment are similar when midazolam or diazepam are used for conscious sedation. However, the potential usefulness of routine flumazenil reversal of conscious sedation will require further evaluation of specific psychomotor performance skills (such as driving a car) before we lift the admonition against leaving the endoscopic suite unattended, driving a vehicle, or operating complicated machinery for several hours.

Oxygen desaturation and cardiac arrhythmias in children during esophagogastroduodenoscopy using conscious sedation

To determine whether oxygen desaturation and cardiac arrhythmias occur in children during esophagogastroduodenoscopy with the use of conscious sedation, we prospectively studied 34 consecutive patients between the ages of 2 months and 18 years. Patients with pulmonary, cardiac, and neurologic disorders were defined as high risk and those without were defined as normal. All patients received intravenous sedation with meperidine, diazepam, or midazolam, used alone or in combination. Pulse oximetry, respiratory rate, and lead II electrocardiogram were recorded throughout all episodes of desaturation and tachycardia. Oxygen desaturation to less than 90% occurred in 68% of normal patients and in 58% of high-risk patients during esophagogastroduodenoscopy. Seventy-five percent of the high-risk patients and 82% of the normal patients had an arrhythmia during esophagogastroduodenoscopy usually associated with oxygen desaturation. Sinus tachycardia was the most common arrhythmia, although other arrhythmias were identified. Despite the frequency of oxygen desaturation and cardiac arrhythmias, no adverse outcome was observed in any patient. Most episodes of oxygen desaturation and cardiac arrhythmia resolved spontaneously. Subdivision of patients into high-risk groups by age, sex, weight, or diameter of endoscope used did not allow prediction of oxygen desaturation or cardiac arrhythmia. Our data suggest that conscious sedation in children undergoing esophagogastroduodenoscopy is safe and free of significant adverse clinical problems. However, conscious sedation during esophagogastroduodenoscopy continues to have certain inherent risks. Therefore we strongly advocate the routine use of continuous cardiac rhythm and pulse oximetry monitoring of all children during esophagogastroduodenoscopy performed with the use of conscious sedation.

Venous complications of midazolam versus diazepam

Although some studies have suggested fewer venous complications are associated with midazolam than with diazepam for endoscopic procedures, this variable has not been well documented. We prospectively evaluated the incidence of venous complications after intravenous injection of diazepam or midazolam in 122 consecutive patients undergoing colonoscopy and esophagogastroduodenoscopy. Overall, venous complications were more frequent with diazepam (22 of 62 patients) than with midazolam (4 of 60 patients) (p < 0.001). A palpable venous cord was present in 23% (14 of 62) of patients in the diazepam group, compared with 2% (1 of 60 patients) in the midazolam group (p < 0.002). Pain at the injection site occurred in 35% (22 of 62) of patients in the diazepam group compared with 7% (4 of 60 patients) in the midazolam group (p < 0.001). Swelling and warmth at the injection site were not significantly different between the two groups. Smoking, nonsteroidal anti-inflammatory drug use, intravenous catheter site, dwell time of the needle, alcohol use, and pain during the injection had no effect on the incidence of venous complications.

Age, anemia, and obesity-associated oxygen desaturation during upper gastrointestinal endoscopy

Although upper gastrointestinal endoscopy is generally a safe procedure, it is known to be associated with arterial oxygen desaturation. We studied 82 patients undergoing diagnostic upper gastrointestinal endoscopy following a standard premedication consisting of xylocaine throat spray and intravenous midazolam. The mean duration of endoscopy was 8.5 +/- 0.42 min and the mean dose of midazolam was 6.3 +/- 0.15 mg. The baseline SaO2 was 94.91 +/- 0.27% and it decreased after pre-medication to 92.84 +/- 0.40% (p < 0.001) and after intubation to 91.21 +/- 0.40% (p < 0.001). A fall greater than 4% saturation occurred for 15.68% of the total endoscopy time. SaO2 < 90% was seen for 16.7% and SaO2 < 85% occurred for 2.33% total endoscopy time. In patients > 65 years old, hemoglobin < 10 g/dl, or body mass index > 28, the baseline saturation was significantly lower and a reduced SaO2 was seen throughout the procedure. We identify old age, anemia, and obesity as independent risk factors for arterial oxygen desaturation. We recommend continuous monitoring before sedation, and giving supplemental oxygen to patients with these risk factors from the outset of upper gastrointestinal endoscopy.

Diazepam versus midazolam for colonoscopy: a prospective evaluation of predicted versus actual dosing requirements

We performed a prospective, randomized, double-blind study to evaluate the efficacy of the currently recommended low doses of midazolam for conscious sedation compared with diazepam for colonoscopy. Each agent was administered in a fixed ratio dose in combination with meperidine, and titrated incrementally to allow for adequate sedation prior to initiating and during the procedure. The currently recommended starting dose of midazolam (0.03 mg/kg) proved to be very appropriate for pre-medication. In contrast, the currently recommended starting dose of diazepam (0.10 mg/kg) proved excessive in 21% of patients (especially in those aged > 65). The low initial and incremental doses of midazolam compared favorably with diazepam in all efficacy parameters studied and exceeded diazepam in post-procedure amnesia scores (p = 0.01). Moreover, the sedative effects of midazolam at these lower doses were not lost despite long duration procedures (> 40 min). We conclude that midazolam, given in small incremental doses, in combination with meperidine, produces effective conscious sedation for colonoscopy and exceeds diazepam in its amnestic effect.

Patient attitudes to sedation for diagnostic upper endoscopy

The presumed need for sedation in upper gastrointestinal endoscopy differs widely between countries and between endoscopists. Very little is known about patient attitudes and the factors that influence patient discomfort. We investigated all ambulatory patients scheduled for diagnostic upper GI endoscopy during a 4-month period (n = 1169) for their attitudes to sedation. One week before the examination they were asked whether they wanted sedation in addition to topical throat anesthesia. A brief description of the endoscopic procedure was given together with an explanation of presumed advantages and disadvantages of sedation. Only 399 patients (34.1%) wanted sedation. The two groups of patients were comparable as to age, gender, and previous experience of endoscopy. Of the 399 patients wanting sedative medication 54.2% were afraid of the diagnosis and 45.8% of the procedure. Male sex and young age were associated with a lower rate of preferring sedation. Patient discomfort during endoscopy was negatively correlated with age (r = -0.309; p = 0.000). Patients who had had more than one previous endoscopy had less discomfort than those without endoscopy experience (p = 0.0069). Men had less discomfort than women (p = 0.0014). The vast majority of our patients preferred 'a normal afternoon to endoscopy sedation'. Young women not previously endoscoped potentially benefit most from sedation.

Monitoring and safety in endoscopy

Over 50% of the complications and 60% of the deaths associated with upper GI endoscopy are cardiopulmonary in type. Oxygen desaturation and cardiac arrhythmias at the time of endoscopy are common. Ways of trying to prevent hypoxia occurring are discussed. The most effective of these is the use of supplemental oxygen. Pulse oximeters are being used increasingly frequently by endoscopists. The way in which oximeters work is described in some depth, as are some of the potential errors that may result from their use. The author believes that, as in anaesthetic practice, pulse oximeters will be used ever more frequently by endoscopists and finally become standard equipment in all endoscopy units. The case for using continuous ECG monitoring and blood pressure measurement is briefly discussed. The ASGE have recently published their recommendations on monitoring patients undergoing GI endoscopic procedures. The BSG's own working party on safety and monitoring is in the process of finalizing its recommendations, and the final part of the chapter discusses the views of this working party and gives some insight into what its final recommendations are likely to be.

Evaluation of safe, effective intravenous sedation for utilization in endoscopic procedures

The prevention of anesthetic mishaps during endoscopic procedures is of great importance to physicians in training. With the large number of such procedures performed each year, even infrequent adverse anesthetic reactions may result in a significant number of problems. To establish the safety and efficacy of an anesthetic regimen using intravenous meperidine and diazepam, all endoscopic procedures performed at one teaching institution in a 4-month period were retrospectively analyzed with regard to: (1) type and dosage of sedation/anesthesia, (2) endoscopic procedure involved, (3) effect of any underlying disease state, (4) side effects, (5) endoscopic complications, and (6) overall patient acceptance. A total of 716 patients underwent 913 endoscopic procedures with 876 separate anesthetic/intravenous sedations. General anesthesia was utilized in 44% of the 155 pediatric procedures. In the adult patients, intravenous sedation was administered by a physician-in-training under supervision except in 9% of cases (66 patients) when intravenous sedation utilizing alternative agents was given by the anesthesia department. The dose of sedation used (per body weight) declined with increasing age in the pediatric group (0-19 years). The adult dose remained constant for the next eight decades of life (meperidine 0.76 +/- 0.33 mg/kg: diazepam 0.12 +/- 0.08 mg/kg). In the adult group, 758 procedures were performed: 371 patients underwent esophago-gastroduodenoscopy, 258 colonoscopy, 36 endoscopic retrograde cholangiopancreatography, 40 flexible sigmoidoscopy, and 51 percutaneous endoscopic gastrostomy. Anesthetic-related complications (transient apnea and itching), were noted in two patients, and naloxone was utilized to reverse oversedation in a further 17 (2.56%).(ABSTRACT TRUNCATED AT 250 WORDS)

Review article: premedication and intravenous sedation for upper gastrointestinal endoscopy

Upper gastrointestinal endoscopy can be performed without intravenous sedation but the evidence suggests that, in the United Kingdom and United States, most patients and endoscopists prefer that some form of premedication is given. Intravenous diazepam or midazolam are used by the majority of endoscopists. In the UK, the ratio of diazepam to midazolam users is approximately 2:1, while in the USA more endoscopists are now using midazolam. Midazolam is approximately twice as potent as diazepam but, when allowance is made for this, there is probably little or no difference in the propensity of the two drugs to produce respiratory depression. The antegrade amnesic effect of midazolam is significantly superior to that of diazepam. A benzodiazepine/narcotic combination can achieve a smoother and more rapid induction with less gagging and choking, but the incidence of adverse outcomes--particularly respiratory depression--is increased significantly. Over 50% of the deaths that are associated with upper gastrointestinal endoscopy are due to cardiopulmonary problems. Hypoxia is very common if measured using non-invasive monitoring equipment, such as a pulse oximeter. Methods of preventing oxygen desaturation and thus, by inference, most cardiac arrhythmias associated with endoscopy are discussed, as is the role of flumazenil, the new benzodiazepine antagonist.

Utility of droperidol for conscious sedation in gastrointestinal endoscopic procedures

Although narcotics and benzodiazepines are widely used as premedications for gastrointestinal endoscopic procedures, we have found a significant number of patients in whom this combination is either inadequate for sedation or results in paradoxical agitation. Over the last 54 months, we have administered droperidol, a neuroleptic, as an adjunct to narcotics and benzodiazepines in 764 patients undergoing 1,102 procedures. The most common indication for droperidol usage was active alcohol abuse or withdrawal (45%). The most frequent dose administered was 2.5 mg (41.1%) followed by 3.75 mg (25.8%). The level of sedation and cooperation was adequate in all but 22 procedures (2.0%). Complications related to droperidol use were infrequent, occurring in 17 procedures (1.5%). There was no mortality or major morbidity resulting from droperidol usage. In our endoscopic population, we find droperidol to be a safe and efficacious adjunctive agent for conscious sedation.

Therapeutic upper gastrointestinal endoscopy. Past, present, and future

Therapeutic procedures in upper gastrointestinal endoscopy are usually performed with the patient under sedation, and there is a clear advantage with video endoscopy. The endoscopy assistant needs full training on the appropriate and safe use of equipment and accessories. Complications of procedures should be detected early and managed appropriately. Indications, results, and perspectives of endoscopic procedures are reviewed for the following situations: gastrointestinal bleeding, caustic injury, foreign bodies, advanced and superficial cancer, dysplasia, reflux esophagitis, motility disorders, and nutritional assistance. Consolidation of current methods and systematic evaluation of the results of therapeutic endoscopy are important tasks for the near future.