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Tobin SC. Continuous Capnography for Early Detection of Respiratory Compromise During Gastroenterological Procedural Sedation and Analgesia. Gastroenterol Nurs 2024; 47:291-298. [PMID: 39087995 DOI: 10.1097/sga.0000000000000839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 05/15/2024] [Indexed: 08/02/2024] Open
Abstract
Gastroenterology nurses working across a variety of clinical settings are responsible for periprocedural monitoring during moderate to deep procedural sedation and analgesia (PSA) to identify signs of respiratory compromise and intervene to prevent cardiorespiratory events. Pulse oximetry is the standard of care for respiratory monitoring, but it may delay or fail to detect abnormal ventilation during PSA. Continuous capnography, which measures end-tidal CO2 as a marker of alveolar ventilation, has been endorsed by a number of clinical guidelines. Large clinical trials have demonstrated that the addition of continuous capnography to pulse oximetry during PSA for various gastroenterological procedures reduces the incidence of hypoxemia, severe hypoxemia, and apnea. Studies have shown that the cost of adding continuous capnography is offset by the reduction in adverse events and hospital length of stay. In the postanesthesia care unit, continuous capnography is being evaluated for monitoring opioid-induced respiratory depression and to guide artificial airway removal. Studies are also examining the utility of continuous capnography to predict the risk of opioid-induced respiratory depression among patients receiving opioids for primary analgesia. Continuous capnography monitoring has become an essential tool to detect early signs of respiratory compromise in patients receiving PSA during gastroenterological procedures. When combined with pulse oximetry, it can help reduce cardiorespiratory adverse events, improve patient outcomes and safety, and reduce health care costs.
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Affiliation(s)
- Stacey C Tobin
- Stacey C. Tobin, PhD, is a Senior Medical Writer at The Tobin Touch, Inc., Arlington Heights, Illinois
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2
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Michael FA, Hessz D, Graf C, Zimmer C, Nour S, Jung M, Kloka J, Knabe M, Welsch C, Blumenstein I, Dultz G, Finkelmeier F, Walter D, Mihm U, Lingwal N, Zeuzem S, Bojunga J, Friedrich-Rust M. Thoracic impedance pneumography in propofol-sedated patients undergoing percutaneous endoscopic gastrostomy (PEG) placement in gastrointestinal endoscopy: A prospective, randomized trial. J Clin Anesth 2024; 94:111403. [PMID: 38368798 DOI: 10.1016/j.jclinane.2024.111403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 11/25/2023] [Accepted: 01/23/2024] [Indexed: 02/20/2024]
Abstract
STUDY OBJECTIVE To assess the efficacy of an ECG-based method called thoracic impedance pneumography to reduce hypoxic events in endoscopy. DESIGN This was a single center, 1:1 randomized controlled trial. SETTING The trial was conducted during the placement of percutaneous endoscopic gastrostomy (PEG). PATIENTS 173 patients who underwent PEG placement were enrolled in the present trial. Indication was oncological in most patients (89%). 58% of patients were ASA class II and 42% of patients ASA class III. INTERVENTIONS Patients were randomized in the standard monitoring group (SM) with pulse oximetry and automatic blood pressure measurement or in the intervention group with additional thoracic impedance pneumography (TIM). Sedation was performed with propofol by gastroenterologists or trained nurses. MEASUREMENTS Hypoxic episodes defined as SpO2 < 90% for >15 s were the primary endpoint. Secondary endpoints were minimal SpO2, apnea >10s/>30s and incurred costs. MAIN RESULTS Additional use of thoracic impedance pneumography reduced hypoxic episodes (TIM: 31% vs SM: 49%; p = 0.016; OR 0.47; NNT 5.6) and elevated minimal SpO2 per procedure (TIM: 90.0% ± 8.9; SM: 84.0% ± 17.6; p = 0.007) significantly. Apnea events >10s and > 30s were significantly more often detected in TIM (43%; 7%) compared to SM (1%; 0%; p < 0.001; p = 0.014) resulting in a time advantage of 17 s before the occurrence of hypoxic events. As a result, adjustments of oxygen flow were significantly more often necessary in SM than in TIM (p = 0.034) and assisted ventilation was less often needed in TIM (2%) compared with SM (9%; p = 0.053). Calculated costs for the additional use of thoracic impedance pneumography were 0.13$ (0.12 €/0.11 £) per procedure. CONCLUSIONS Additional thoracic impedance pneumography reduced the quantity and extent of hypoxic events with less need of assisted ventilation. Supplemental costs per procedure were negligible. KEY WORDS thoracic impedance pneumography, capnography, sedation, monitoring, gastrointestinal endoscopy, percutaneous endoscopic gastrostomy.
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Affiliation(s)
- F A Michael
- Goethe University Frankfurt, University Hospital, Department of Internal Medicine 1, Frankfurt am Main, Germany.
| | - D Hessz
- Goethe University Frankfurt, University Hospital, Department of Internal Medicine 1, Frankfurt am Main, Germany
| | - C Graf
- Goethe University Frankfurt, University Hospital, Department of Internal Medicine 1, Frankfurt am Main, Germany
| | - C Zimmer
- Goethe University Frankfurt, University Hospital, Department of Internal Medicine 1, Frankfurt am Main, Germany
| | - S Nour
- Goethe University Frankfurt, University Hospital, Department of Internal Medicine 1, Frankfurt am Main, Germany
| | - M Jung
- Goethe University Frankfurt, University Hospital, Department of Internal Medicine 1, Frankfurt am Main, Germany
| | - J Kloka
- Goethe University Frankfurt, University Hospital, Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Frankfurt am Main, Germany
| | - M Knabe
- Goethe University Frankfurt, University Hospital, Department of Internal Medicine 1, Frankfurt am Main, Germany
| | - C Welsch
- Goethe University Frankfurt, University Hospital, Department of Internal Medicine 1, Frankfurt am Main, Germany
| | - I Blumenstein
- Goethe University Frankfurt, University Hospital, Department of Internal Medicine 1, Frankfurt am Main, Germany
| | - G Dultz
- Goethe University Frankfurt, University Hospital, Department of Internal Medicine 1, Frankfurt am Main, Germany
| | - F Finkelmeier
- Goethe University Frankfurt, University Hospital, Department of Internal Medicine 1, Frankfurt am Main, Germany
| | - D Walter
- Goethe University Frankfurt, University Hospital, Department of Internal Medicine 1, Frankfurt am Main, Germany
| | - U Mihm
- Goethe University Frankfurt, University Hospital, Department of Internal Medicine 1, Frankfurt am Main, Germany
| | - N Lingwal
- Goethe University Frankfurt, University Hospital, Institute of Biostatistics and Mathematical Modeling, Frankfurt am Main, Germany
| | - S Zeuzem
- Goethe University Frankfurt, University Hospital, Department of Internal Medicine 1, Frankfurt am Main, Germany
| | - J Bojunga
- Goethe University Frankfurt, University Hospital, Department of Internal Medicine 1, Frankfurt am Main, Germany
| | - M Friedrich-Rust
- Goethe University Frankfurt, University Hospital, Department of Internal Medicine 1, Frankfurt am Main, Germany
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Kim SH, Moon YJ, Chae MS, Lee YJ, Karm MH, Joo EY, Min JJ, Koo BN, Choi JH, Hwang JY, Yang Y, Kwon MA, Koh HJ, Kim JY, Park SY, Kim H, Chung YH, Kim NY, Choi SU. Korean clinical practice guidelines for diagnostic and procedural sedation. Korean J Anesthesiol 2024; 77:5-30. [PMID: 37972588 PMCID: PMC10834708 DOI: 10.4097/kja.23745] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 11/16/2023] [Indexed: 11/19/2023] Open
Abstract
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.
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Affiliation(s)
- Sang-Hyun Kim
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Young-Jin Moon
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Min Suk Chae
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yea-Ji Lee
- Department of Anesthesiology and Pain Medicine, Konkuk University Medical Center, Seoul, Korea
| | - Myong-Hwan Karm
- Department of Dental Anesthesiology, School of Dentistry and Dental Research Institute, Seoul National University, Seoul, Korea
| | - Eun-Young Joo
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong-Jin Min
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Bon-Nyeo Koo
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jeong-Hyun Choi
- Department of Anesthesiology and Pain Medicine, Kyung Hee University College of Medicine, Seoul, Korea
| | - Jin-Young Hwang
- Department of Anesthesiology and Pain Medicine, SMG-SNU Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Yeonmi Yang
- Department of Pediatric Dentistry, Jeonbuk National University School of Dentistry, Jeonju, Korea
| | - Min A Kwon
- Department of Anesthesiology and Pain Medicine, Dankook University Hospital, Cheonan, Korea
| | - Hyun Jung Koh
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jong Yeop Kim
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Sun Young Park
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Hyunjee Kim
- Department of Anesthesiology and Pain Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Yang-Hoon Chung
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Na Young Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Uk Choi
- Department of Anesthesiology and Pain Medicine, Korea University College of Medicine, Seoul, Korea
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Mostafa MF, Mamdouh Osman A, Reda Mohamed Abdallah A, Mostafa Thabet A, Abbas Hassan S. Non-invasive carbon dioxide monitoring during moderate sedation at different oxygen flow rates in patients undergoing endoscopic retrograde cholangio-pancreatography. EGYPTIAN JOURNAL OF ANAESTHESIA 2023. [DOI: 10.1080/11101849.2023.2168848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Affiliation(s)
- Mohamed F. Mostafa
- Anesthesia and Intensive Care Department, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ayman Mamdouh Osman
- Anesthesia and Intensive Care Department, Faculty of Medicine, Assiut University, Assiut, Egypt
| | | | - Ahmed Mostafa Thabet
- Anesthesia and Intensive Care Department, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Shimaa Abbas Hassan
- Anesthesia and Intensive Care Department, Faculty of Medicine, Assiut University, Assiut, Egypt
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Wehrmann T, Riphaus A, Eckardt AJ, Klare P, Kopp I, von Delius S, Rosien U, Tonner PH. Updated S3 Guideline "Sedation for Gastrointestinal Endoscopy" of the German Society of Gastroenterology, Digestive and Metabolic Diseases (DGVS) - June 2023 - AWMF-Register-No. 021/014. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:e654-e705. [PMID: 37813354 DOI: 10.1055/a-2165-6388] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Affiliation(s)
- Till Wehrmann
- Clinic for Gastroenterology, DKD Helios Clinic Wiesbaden, Wiesbaden, Germany
| | - Andrea Riphaus
- Internal Medicine, St. Elisabethen Hospital Frankfurt Artemed SE, Frankfurt, Germany
| | - Alexander J Eckardt
- Clinic for Gastroenterology, DKD Helios Clinic Wiesbaden, Wiesbaden, Germany
| | - Peter Klare
- Department Internal Medicine - Gastroenterology, Diabetology, and Hematology/Oncology, Hospital Agatharied, Hausham, Germany
| | - Ina Kopp
- Association of the Scientific Medical Societies in Germany e.V. (AWMF), Berlin, Germany
| | - Stefan von Delius
- Medical Clinic II - Internal Medicine - Gastroenterology, Hepatology, Endocrinology, Hematology, and Oncology, RoMed Clinic Rosenheim, Rosenheim, Germany
| | - Ulrich Rosien
- Medical Clinic, Israelite Hospital, Hamburg, Germany
| | - Peter H Tonner
- Anesthesia and Intensive Care, Clinic Leer, Leer, Germany
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Cukierman DS, Perez M, Guerra-Londono JJ, Carlson R, Hagan K, Ghebremichael S, Hagberg C, Ge PS, Raju GS, Rhim A, Cata JP. Nasal continuous positive pressure versus simple face mask oxygenation for adult obese and obstructive sleep apnea patients undergoing colonoscopy under propofol-based general anesthesia without tracheal intubation: A randomized controlled trial. J Clin Anesth 2023; 89:111196. [PMID: 37406462 DOI: 10.1016/j.jclinane.2023.111196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 06/21/2023] [Accepted: 06/27/2023] [Indexed: 07/07/2023]
Abstract
STUDY OBJECTIVE To determine if a nasal positive airway pressure (nasal CPAP) mask would decrease the number of hypoxemic events in obese and obstructive sleep apnea patients undergoing colonoscopy. DESIGN Single-center prospective randomized controlled trial. SETTING Tertiary academic center. PATIENTS We enrolled 109 patients with diagnosis of obesity and/or obstructive sleep apnea scheduled to undergo colonoscopy under propofol general anesthesia without planned tracheal intubation. INTERVENTION Patients were randomly allocated (1:1 ratio) to receive supplementary oxygen at a flow of 10 L/min, either through a nasal CPAP or a simple facemask. MEASUREMENTS The primary endpoint was the difference in the mean percentage of time spent with oxygen saturation below 90% between the two groups. Secondary outcomes included the need for airway maneuvers/interventions, average SpO2 during the case, duration and severity of oxygen desaturation, incidence and duration of procedural interruptions, and satisfaction and tolerance scores. MAIN RESULTS 54 were allocated to the simple face mask and 55 to the nasal CPAP mask arms, respectively. A total of 6 patients experienced a hypoxemic event. Among these patients, the difference in the percentage of time spent with oxygen saturation below 90% was not clinically relevant (p = 1.0). However, patients in the nasal CPAP group required less chin lift (20% vs. 42.6%; p = 0.01) and oral cannula insertion (12.7% vs.29.6%; p = 0.03). The percentage of patients with at least one airway maneuver was higher in the simple face mask arm (68.5% vs. 41.8%; p = 0.005). Patient tolerance to device score was lower in the nasal CPAP group (8.85 vs. 9.56; p = 0.003). CONCLUSIONS A nasal CPAP did not prevent hypoxemia and should not be used routinely for colonoscopy in obese or OSA patients if a simple face mask is an alternative therapy. However, potential advantages of its use include fewer airway maneuvers or interventions, which may be desirable in certain clinical settings. TRIAL REGISTRATION Clinicaltrials.gov, identifier: NCT05175573.
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Affiliation(s)
- Daniel S Cukierman
- Department of Anesthesiology, Hospital Bernardino Rivadavia, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Manuel Perez
- Department of Anesthesiology and Perioperative Medicine, The University of Texas - MD Anderson Cancer Center, Houston, TX, USA; Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas - MD Anderson Cancer Center, Houston, TX, USA
| | - Juan J Guerra-Londono
- Department of Anesthesiology and Perioperative Medicine, The University of Texas - MD Anderson Cancer Center, Houston, TX, USA; Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas - MD Anderson Cancer Center, Houston, TX, USA
| | - Richard Carlson
- Department of Anesthesiology and Perioperative Medicine, The University of Texas - MD Anderson Cancer Center, Houston, TX, USA
| | - Katherine Hagan
- Department of Anesthesiology and Perioperative Medicine, The University of Texas - MD Anderson Cancer Center, Houston, TX, USA
| | - Semhar Ghebremichael
- Department of Anesthesiology and Perioperative Medicine, The University of Texas - MD Anderson Cancer Center, Houston, TX, USA
| | - Carin Hagberg
- Department of Anesthesiology, Hospital Bernardino Rivadavia, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Phillip S Ge
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas - MD Anderson Cancer Center, Houston, TX, USA
| | - Gottumukkala S Raju
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas - MD Anderson Cancer Center, Houston, TX, USA
| | - Andrew Rhim
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas - MD Anderson Cancer Center, Houston, TX, USA
| | - Juan P Cata
- Department of Anesthesiology and Perioperative Medicine, The University of Texas - MD Anderson Cancer Center, Houston, TX, USA; Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas - MD Anderson Cancer Center, Houston, TX, USA; Anesthesiology and Surgical Oncology Research Group, Houston, TX, USA.
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Lorenz P, Wehrmann T, Riphaus A, Eckardt AJ, Klare P, Koop I, Fischer N, Jansen PL. Leitlinienreport der aktualisierten S3-Leitlinie „Sedierung in der gastrointestinalen Endoskopie“ der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS). ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:e628-e653. [PMID: 37678314 DOI: 10.1055/a-2124-5746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Affiliation(s)
- Pia Lorenz
- Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS), Berlin, Deutschland
| | - Till Wehrmann
- Klinik für Gastroenterologie, DKD Helios Klinik Wiesbaden, Wiesbaden, Deutschland
| | - Andrea Riphaus
- Innere Medizin, St. Elisabethen Krankenhaus Frankfurt Artemed SE, Frankfurt, Deutschland
| | - Alexander J Eckardt
- Klinik für Gastroenterologie, DKD Helios Klinik Wiesbaden, Wiesbaden, Deutschland
| | - Peter Klare
- Abteilung Innere Medizin Gastroenterologie, Diabetologie und Hämato-/Onkologie, Krankenhaus Agatharied, Hausham, Deutschland
| | - Ina Koop
- AWMF-Institut für Medizinisches Wissensmanagement, Marburg, Deutschland
| | - Nadine Fischer
- Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS), Berlin, Deutschland
| | - Petra Lynen Jansen
- Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS), Berlin, Deutschland
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Wehrmann T, Riphaus A, Eckardt AJ, Klare P, Kopp I, von Delius S, Rosien U, Tonner PH. Aktualisierte S3-Leitlinie „Sedierung in der gastrointestinalen Endoskopie“ der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS). ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:1246-1301. [PMID: 37678315 DOI: 10.1055/a-2124-5333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Affiliation(s)
- Till Wehrmann
- Klinik für Gastroenterologie, DKD Helios Klinik Wiesbaden, Wiesbaden, Deutschland
| | - Andrea Riphaus
- Innere Medizin, St. Elisabethen Krankenhaus Frankfurt Artemed SE, Frankfurt, Deutschland
| | - Alexander J Eckardt
- Klinik für Gastroenterologie, DKD Helios Klinik Wiesbaden, Wiesbaden, Deutschland
| | - Peter Klare
- Abteilung Innere Medizin - Gastroenterologie, Diabetologie und Hämato-/Onkologie, Krankenhaus Agatharied, Hausham, Deutschland
| | - Ina Kopp
- Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V. (AWMF), Berlin, Deutschland
| | - Stefan von Delius
- Medizinische Klinik II - Innere Medizin - Gastroenterologie, Hepatologie, Endokrinologie, Hämatologie und Onkologie, RoMed Klinikum Rosenheim, Rosenheim, Deutschland
| | - Ulrich Rosien
- Medizinische Klinik, Israelitisches Krankenhaus, Hamburg, Deutschland
| | - Peter H Tonner
- Anästhesie- und Intensivmedizin, Klinikum Leer, Leer, Deutschland
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Wang Y, Liu F, Zhang Y, Yang X, Wu J. The effect of capnography on the incidence of hypoxia during sedation for EGD and colonoscopy in mildly obese patients: a randomized, controlled study. BMC Anesthesiol 2023; 23:188. [PMID: 37259022 DOI: 10.1186/s12871-023-02151-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 05/24/2023] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND By continually monitoring end-tidal carbon dioxide concentrations, capnography can detect abnormal ventilation or apnoea early. This randomized, controlled study explored the effect of early intervention with capnography on the incidence of hypoxia in mildly obese patients undergoing sedation for esophagogastroduodenoscopy (EGD) and colonoscopy. METHODS This is a single-center, randomized, single-blind, parallel-assignment, controlled trial. Mildly obese patients (28 kg/m2 ≤ BMI < 40 kg/m2) undergoing sedation for EGD and colonoscopy were randomly assigned to either the standard or capnography group. Standard cardiopulmonary monitoring equipment was used in both groups, and additional capnography was performed in the capnography group. In the event of inadequate alveolar ventilation during sedation, five interventions were administered in sequence (a-e) : a: increasing oxygen flow (5 L/min); b: a chin lift or jaw thrust maneuver; c: placement of the nasopharyngeal airway and chin lift; d: mask positive-pressure ventilation, and e: ventilator-assisted ventilation with tube insertion. The primary outcome was the incidence of hypoxia (SpO2 < 90%, ≥ 10 s) in each group. The secondary outcomes included the incidence of severe hypoxia (SpO2 ≤ 85%), subclinical respiratory depression (90% ≤ SpO2 < 95%), interventions, minimum SpO2 during operation, patient satisfaction, endoscopist satisfaction, and other adverse events of anesthesia sedation. RESULTS 228 patients were included (capnography group = 112; standard group = 113; three patients were excluded) in this study. The incidence of hypoxia was significantly lower in the capnography group than in the standard group (13.4% vs. 30.1%, P = 0.002). Subclinical respiratory depression in the capnography group was higher than that of the standard group (30.4% vs. 17.7%, P = 0.026). There was only a 5.4% incidence of severe hypoxia in the capnography group compared with 14.2% in the standard group (P = 0.026). During sedation, 96 and 34 individuals in the capnography and standard groups, respectively, underwent the intervention. There was a statistically significant difference (P < 0.0001) in the number of the last intraoperative intervention between the two groups ( a:47 vs. 1, b:46 vs. 26, c:2 vs. 5, d:1 vs. 2, e:0 vs. 0 ). No significant differences were found between the two groups in terms of minimum SpO2 during operation, patient satisfaction, or endoscopist satisfaction rating. There was no statistically significant difference in adverse events of anesthesia sedation between the two groups. CONCLUSION Capnography during sedation for EGD and colonoscopy allows for the detection of apnea and altered breathing patterns in mildly obese patients before SpO2 is reduced. Effective intervention measures are given to patients within this time frame, which reduces the incidence of hypoxia and severe hypoxia in patients. TRIAL REGISTRATION Ethical approval was granted by the Medical Ethics Committee (Chairperson Professor Tian Hui) of Qilu Hospital, Shandong University ((Ke) Lun Audit 2021 (186)) on 15/07/2021. The study was registered ( https://www.chictr.org.cn ) on 23/10/2021(ChiCTR2100052234). Designed and reported using CONSORT statements.
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Affiliation(s)
- Yingjie Wang
- Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan, 250012, China
- School of Medicine, Cheeloo College of Medicine, Shandong University, Jinan, 250012, China
| | - Fang Liu
- Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan, 250012, China
- School of Medicine, Cheeloo College of Medicine, Shandong University, Jinan, 250012, China
| | - Yuan Zhang
- Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan, 250012, China
- School of Medicine, Cheeloo College of Medicine, Shandong University, Jinan, 250012, China
| | - Xiaomei Yang
- Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan, 250012, China.
- School of Medicine, Cheeloo College of Medicine, Shandong University, Jinan, 250012, China.
- Department of Cardiology, the Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, the State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012, China.
| | - Jianbo Wu
- Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan, 250012, China.
- Department of Anesthesiology and Perioperative Medicine, Qilu Hospital Dezhou Hospital, Shandong University, Dezhou, 253000, China.
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10
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Sun H, Zhang L, Liu Z, Zhang Y, Li J, Pang K. Study on different sequences of painless gastroenteroscopy in patients with difficult airway. Biotechnol Genet Eng Rev 2023:1-10. [PMID: 36966443 DOI: 10.1080/02648725.2023.2193774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/27/2023]
Abstract
The selection of different examination sequences of painless gastroscopy in patients with difficult airway risk was explored in this study. A total of 45 patients undergoing painless gastroscopy with Mallampati airway score of III-IV were randomly assigned into two groups (A group and B group) according to the sequence of colonoscopy and gastroscopy. Group A was first examined by gastroscopy after anesthesia, and then by colonoscopy. Group B was examined in the opposite order, first by colonoscopy, and then by gastroscopy. Ramsay Sedation scores were evaluated every five minutes when gastroscopy was performed in the two groups. The dosage of propofol, blood pressure, heart rate, blood oxygen saturation, recovery time, hospital leaving time, and adverse reactions after induction and endoscopy were recorded. The dosage of propofol and change of vital signs in B group was less than that in A group. Operation time, recovery time, hospital leaving time and postoperative adverse reactions have no significant difference between two groups. For patients at risk of difficult airway, colonoscopy followed by gastroscopy has more stable intraoperative vital signs and less propofol consumption.
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Affiliation(s)
- Huirui Sun
- Hiser Medical Center of Qingdao, Qingdao Hiser Hospital Affiliated to Qingdao University, Qingdao, China
| | - Linghua Zhang
- Hiser Medical Center of Qingdao, Qingdao Hiser Hospital Affiliated to Qingdao University, Qingdao, China
| | - Zhixian Liu
- Hiser Medical Center of Qingdao, Qingdao Hiser Hospital Affiliated to Qingdao University, Qingdao, China
| | - Yanping Zhang
- Hiser Medical Center of Qingdao, Qingdao Hiser Hospital Affiliated to Qingdao University, Qingdao, China
| | - Jieping Li
- Hiser Medical Center of Qingdao, Qingdao Hiser Hospital Affiliated to Qingdao University, Qingdao, China
| | - Kunfang Pang
- Hiser Medical Center of Qingdao, Qingdao Hiser Hospital Affiliated to Qingdao University, Qingdao, China
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11
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Nagashima H, Mikata R, Isono S, Ogasawara S, Sugiyama H, Ohno I, Yasui S, Matsumura T, Koroki K, Kusakabe Y, Miura Y, Kan M, Maruta S, Yamada T, Takemura R, Sato Y, Kato J, Kato N. Phase II study comparing nasal pressure monitoring with capnography during invasive endoscopic procedures: a single-center, single-arm trial. Sci Rep 2023; 13:1265. [PMID: 36690708 PMCID: PMC9871023 DOI: 10.1038/s41598-023-28213-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 01/16/2023] [Indexed: 01/24/2023] Open
Abstract
Nasal pressure signal is commonly used to evaluate obstructive sleep apnea. This study aimed to assess its safety for respiratory monitoring during sedation. A total of 45 adult patients undergoing sedation with propofol and fentanyl for invasive endoscopic procedures were enrolled. While both nasal pressure and capnograph signals were continuously recorded, only the nasal pressure signal was displayed. The primary outcome was the incidence of oxygen desaturation below 90%. The secondary outcomes were the ability to predict the desaturation and incidence of harmful events and false alarms, defined as an apnea waveform lasting more than 3 min without desaturation. Of the 45 participants, 43 completed the study. At least one desaturation event occurred in 12 patients (27.9%; 95% confidence interval 15.3-43.7%). In these 12 patients, more than half of the desaturation events were predictable in 9 patients by capnography and 11 patients by nasal pressure monitoring (p = 0.59). In the 43 patients, false alarms were detected in 7 patients with capnography and 11 patients with nasal pressure monitoring (p = 0.427). Harmful events unrelated to nasal pressure monitoring occurred in 2 patients. Nasal pressure monitoring is safe and possibly useful for respiratory monitoring despite false alarms during sedation.
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Affiliation(s)
- Hiroki Nagashima
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
| | - Rintaro Mikata
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan.
| | - Shiroh Isono
- Department of Anesthesiology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Sadahisa Ogasawara
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
- Translational Research and Development Center, Chiba University Hospital, Chiba, Japan
| | - Harutoshi Sugiyama
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
| | - Izumi Ohno
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
| | - Shin Yasui
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
| | - Tomoaki Matsumura
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
| | - Keisuke Koroki
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
| | - Yuko Kusakabe
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
| | - Yoshifumi Miura
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
| | - Motoyasu Kan
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
| | - Shikiko Maruta
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
| | - Toshihito Yamada
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
| | - Ryo Takemura
- Clinical and Translational Research Center, Keio University Hospital, Tokyo, Japan
| | - Yasunori Sato
- Department of Preventive Medicine and Public Health, Keio University School of Medicine, Tokyo, Japan
| | - Jun Kato
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
| | - Naoya Kato
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
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12
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Festa R, Del Vicario M, Antonicelli F, Amato A. Improving anesthesia patient safety in NORA settings: utility of high-flow nasal cannula in the management of superobese patients undergoing deep sedation for gastrointestinal endoscopic procedures. Minerva Anestesiol 2023; 89:104-105. [PMID: 36383080 DOI: 10.23736/s0375-9393.22.16677-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Rossano Festa
- Department of Anesthesia and Intensive Care Medicine, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Miryam Del Vicario
- Department of Anesthesia and Intensive Care Medicine, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy -
| | - Federica Antonicelli
- Department of Anesthesia and Intensive Care Medicine, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Arianna Amato
- Department of Anesthesia and Intensive Care Medicine, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
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13
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Hayashi Y, Hosoe N, Takabayashi K, Limpias Kamiya KJL, Tojo A, Sakurai H, Kinoshita S, Sujino T, Nakayama A, Kato M, Yahagi N, Ogata H, Kanai T. Efficacy of capnographic and bispectral index monitoring on trans-oral therapeutic endoscopy: A prospective observational study. J Gastroenterol Hepatol 2022; 37:2004-2010. [PMID: 35772179 DOI: 10.1111/jgh.15932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 05/06/2022] [Accepted: 06/18/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Oral therapeutic and invasive endoscopy requires deep sedation to reduce patient distress due to prolonged examination and procedures. The usefulness of capnography and bispectral index (BIS) monitoring in the early hypoxia detection in oral therapeutic and invasive endoscopy has yet to be evaluated. This study aimed to investigate the clinical impact of capnography and BIS monitoring on hypoxic events during oral therapeutic and invasive endoscopic procedures. METHODS This is a prospective observational study. Trans-oral non-intubated therapeutic and/or invasive endoscopic procedures were performed with conventional monitoring (pulse oximetry, pulse, and blood pressure) as well as additional monitoring (BIS and end-tidal CO2 concentration). Hypoxia is defined as oxygen saturation of <90% that lasts >15 s. The clinical impact of capnography and BIS monitoring on hypoxic events during oral therapeutic and invasive endoscopic procedures were investigated with the risk factors for hypoxia in each patient. RESULTS Patients with hypoxia had significantly more apneas detected using capnography than other patients. The multivariate analysis revealed the detected apnea by capnography as an independent risk factor for hypoxia (odds ratio: 3.48[95% confidence interval: 1.24-9.78], P = 0.02). The BIS was not significantly different as a risk factor for hypoxia; however, per-event analysis revealed significantly decreased BIS values over time in 3 min before hypoxic events. CONCLUSIONS Apnea detected by capnography was an independent predictor of hypoxia. The BIS value was not associated with hypoxia events; however, it showed a significant downward trend before hypoxia events.
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Affiliation(s)
- Yukie Hayashi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Naoki Hosoe
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo, Japan
| | - Kaoru Takabayashi
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo, Japan
| | - Kenji J L Limpias Kamiya
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Anna Tojo
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Hinako Sakurai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Satoshi Kinoshita
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo, Japan
| | - Tomohisa Sujino
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo, Japan
| | - Atsushi Nakayama
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Motohiko Kato
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Naohisa Yahagi
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Haruhiko Ogata
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo, Japan
| | - Takanori Kanai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
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14
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Capnography for Monitoring of the Critically Ill Patient. Clin Chest Med 2022; 43:393-400. [PMID: 36116809 DOI: 10.1016/j.ccm.2022.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Capnography has been widely adopted in multiple clinical areas. The capnogram and end-tidal carbon dioxide offer a wealth of information, in the right clinical setting, and when properly interpreted. In this article, the authors aim to review the most common clinical scenarios during which capnography has been shown to be of benefit. This includes the areas of fluid responsiveness, cardiopulmonary resuscitation, and conscious sedation. They review the published literature, highlighting its pitfalls and identifying its limitations.
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15
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Urdaneta F, Wardhan R, Wells G, White JD. Prevention of pulmonary complications in sedated patients undergoing interventional procedures in the nonoperating room anesthesia setting. Curr Opin Anaesthesiol 2022; 35:493-501. [PMID: 35787534 DOI: 10.1097/aco.0000000000001158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW Nonoperating room anesthesia (NORA) procedures have expanded in number, variety, and complexity. NORA involves all age groups, including frail older adults and patients often considered too sick to tolerate traditional surgical interventions. Postoperative pulmonary complications are a significant source of adverse events in the perioperative setting. We present a review focused on preventing pulmonary complications in the interventional NORA setting. RECENT FINDINGS NORA locations should function as independent, autonomous ambulatory units. We discuss a strategic plan involving a thorough preoperative evaluation of patients, including recognizing high-risk patients and their anesthetic management. Finally, we offer guidance on the challenges of conducting sedation and anesthesia in patients with coronavirus disease 2019 (COVID-19) or a history of COVID-19. SUMMARY The demands on the interventional NORA anesthesia team are increasing. Strategic planning, checklists, consistent staffing assignments, and scheduled safety drills are valuable tools to improve patient safety. In addition, through quality improvement initiatives and reporting, NORA anesthetists can achieve reductions in periprocedural pulmonary complications.
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Affiliation(s)
- Felipe Urdaneta
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida, USA
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16
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Fung BM, Leon DJ, Beck LN, Tabibian JH. Pre-procedural Preparation and Sedation for Gastrointestinal Endoscopy in Patients with Advanced Liver Disease. Dig Dis Sci 2022; 67:2739-2753. [PMID: 34169430 DOI: 10.1007/s10620-021-07111-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 06/10/2021] [Indexed: 12/09/2022]
Abstract
Gastrointestinal endoscopy in patients with advanced liver disease poses various challenges, a major one being procedural sedation and its associated considerations. While sedation during endoscopy can improve patient comfort, decrease anxiety, and facilitate procedural completion, in patients with advanced liver disease, it is also associated with substantial and unique risks due to alterations in drug metabolism and other factors. As such, the choice of sedative agent(s) and related logistics may require careful inter-disciplinary planning and individualized considerations. Furthermore, a large proportion of agents require dose reductions and particular monitoring of the vital signs, level of consciousness, and other indices. In the present review, we provide a contemporary overview of procedural sedation considerations, commonly used intravenous sedatives, and second-line as well as novel sedatives for gastrointestinal endoscopy in patients with advanced liver disease.
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Affiliation(s)
- Brian M Fung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA. .,Banner - University Medical Center Phoenix, Internal Medicine, LL2, 1111 E McDowell Road, Phoenix, AZ, 85006, USA.
| | - Deanna J Leon
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Lauren N Beck
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - James H Tabibian
- Division of Gastroenterology, Department of Medicine, Olive View-UCLA Medical Center, Sylmar, CA, USA.,David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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17
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Godoroja-Diarto D, Constantin A, Moldovan C, Rusu E, Sorbello M. Efficacy and Safety of Deep Sedation and Anaesthesia for Complex Endoscopic Procedures—A Narrative Review. Diagnostics (Basel) 2022; 12:diagnostics12071523. [PMID: 35885429 PMCID: PMC9323178 DOI: 10.3390/diagnostics12071523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 06/18/2022] [Accepted: 06/20/2022] [Indexed: 11/30/2022] Open
Abstract
Propofol sedation for advanced endoscopic procedures is a widespread technique at present, which generates controversy worldwide when anaesthetic or non-anaesthetic personnel administer this form of sedation. There is some evidence for safe administered propofol sedation by non-anaesthetic personnel in patients undergoing endoscopy procedures, but there are only few randomised trials addressing the safety and efficacy of propofol in patients undergoing advanced procedures. A serious possible consequence of propofol sedation is the rapid and unpredictable progression from deep sedation to general anaesthesia mostly when elderly and frail patients are involved in the diagnosis or treatment of various neoplasia. This situation requires rescue measures with skilled airway management. The aim of this paper is to review the safety and efficacy aspects of sedation techniques, with special reference to propofol administration covering the whole patient journey, including preassessment, sedation options and discharge when advanced endoscopic procedures are performed.
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Affiliation(s)
- Daniela Godoroja-Diarto
- Department Anaesthesia and Intennsive Care, Ponderas Academic Hospital, 014142 Bucharest, Romania
- Correspondence: (D.G.-D.); (C.M.); Tel.: +40-756026125 (D.G.-D.); +40-723504207 (C.M.)
| | - Alina Constantin
- Department Gastroenterology, Ponderas Academic Hospital, 014142 Bucharest, Romania;
| | - Cosmin Moldovan
- Faculty of Medicine, University Titu Maiorescu, 040441 Bucharest, Romania;
- Department of General Surgery, Hospital Clinic CF1 Witting, 010243 Bucharest, Romania
- Correspondence: (D.G.-D.); (C.M.); Tel.: +40-756026125 (D.G.-D.); +40-723504207 (C.M.)
| | - Elena Rusu
- Faculty of Medicine, University Titu Maiorescu, 040441 Bucharest, Romania;
| | - Massimilliano Sorbello
- Department Anaesthesia and Intennsive Care, AOU Policlinico San Marco, 95121 Catania, Italy;
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18
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Dike CR, Bishop WP, Titler SS, Rahhal R. Transient End-Tidal Carbon Dioxide Elevation During Pediatric Upper Endoscopy With Carbon Dioxide Insufflation: Is It True Hypercapnia? J Pediatr Gastroenterol Nutr 2022; 74:413-418. [PMID: 34856563 DOI: 10.1097/mpg.0000000000003363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Endoscopic insufflation, long performed using air, is being replaced by carbon dioxide (CO2) at many pediatric centers, despite limited published data on its use in children. We have previously demonstrated that CO2 use during esophagogastroduodenoscopy (EGD) in non-intubated children is associated with transient elevations of end-tidal CO2 (EtCO2). This observation raised concerns about possible CO2 inhalation and systemic absorption. Here, we investigate this concern by concurrently measuring both EtCO2 and transcutaneous CO2 (tCO2) during upper endoscopic procedures in children. AIM To determine if elevations in EtCO2 levels seen in non-intubated children undergoing CO2 insufflation during EGD are associated with elevated systemic CO2 levels. METHODS Double-blinded, prospective, randomized clinical trial. Children were randomized 1:1 to receive either CO2 or air for endoscopic insufflation. EtCO2 was sampled with a CO2-sampling nasal cannula and tCO2 was monitored using the Radiometer transcutaneous monitoring device. RESULTS Fifty nine patients were enrolled; 30 patients in the CO2 insufflation group and 29 in the air group. All patients underwent a procedure involving an EGD. Transient elevations in EtCO2 (defined as >60 mmHg) were observed only in the CO2 insufflation group. This contrasted with the similar elevations of tCO2 between the CO2 and air insufflation groups. None of these events were of clinically significant magnitude or duration. CONCLUSION This study demonstrates that the observed transient elevations in EtCO2 seen during EGD in non-intubated children receiving CO2 insufflation are most likely measurements of eructated CO2 without evidence of excessive systemic absorption of CO2.
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Affiliation(s)
- Chinenye R Dike
- Division of Pediatric Gastroenterology, Hepatology, Pancreatology and Nutrition, Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Nebraska Medical Center, and Children's Hospital and Medical Center Omaha, NE
| | - Warren P Bishop
- Division of Pediatric Gastroenterology, Hepatology, Pancreatology and Nutrition, Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA
| | - Sarah S Titler
- Department of Anesthesiology; Division of Pediatric Anesthesia, University of Iowa, Iowa City, IA
| | - Riad Rahhal
- Division of Pediatric Gastroenterology, Hepatology, Pancreatology and Nutrition, Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA
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19
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Michael FA, Peveling-Oberhag J, Herrmann E, Zeuzem S, Bojunga J, Friedrich-Rust M. Evaluation of the Integrated Pulmonary Index® during non-anesthesiologist sedation for percutaneous endoscopic gastrostomy. J Clin Monit Comput 2021; 35:1085-1092. [PMID: 32734356 PMCID: PMC8497449 DOI: 10.1007/s10877-020-00563-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 07/21/2020] [Indexed: 12/22/2022]
Abstract
Standard monitoring of heart rate, blood pressure and arterial oxygen saturation during endoscopy is recommended by current guidelines on procedural sedation. A number of studies indicated a reduction of hypoxic (art. oxygenation < 90% for > 15 s) and severe hypoxic events (art. oxygenation < 85%) by additional use of capnography. Therefore, U.S. and the European guidelines comment that additional capnography monitoring can be considered in long or deep sedation. Integrated Pulmonary Index® (IPI) is an algorithm-based monitoring parameter that combines oxygenation measured by pulse oximetry (art. oxygenation, heart rate) and ventilation measured by capnography (respiratory rate, apnea > 10 s, partial pressure of end-tidal carbon dioxide [PetCO2]). The aim of this paper was to analyze the value of IPI as parameter to monitor the respiratory status in patients receiving propofol sedation during PEG-procedure. Patients reporting for PEG-placement under sedation were randomized 1:1 in either standard monitoring group (SM) or capnography monitoring group including IPI (IM). Heart rate, blood pressure and arterial oxygen saturation were monitored in SM. In IM additional monitoring was performed measuring PetCO2, respiratory rate and IPI. Capnography and IPI values were recorded for all patients but were only visible to the endoscopic team for the IM-group. IPI values range between 1 and 10 (10 = normal; 8-9 = within normal range; 7 = close to normal range, requires attention; 5-6 = requires attention and may require intervention; 3-4 = requires intervention; 1-2 requires immediate intervention). Results on capnography versus standard monitoring of the same study population was published previously. A total of 147 patients (74 in SM and 73 in IM) were included in the present study. Hypoxic events occurred in 62 patients (42%) and severe hypoxic events in 44 patients (29%), respectively. Baseline characteristics were equally distributed in both groups. IPI = 1, IPI < 7 as well as the parameters PetCO2 = 0 mmHg and apnea > 10 s had a high sensitivity for hypoxic and severe hypoxic events, respectively (IPI = 1: 81%/81% [hypoxic/severe hypoxic event], IPI < 7: 82%/88%, PetCO2: 69%/68%, apnea > 10 s: 84%/84%). All four parameters had a low specificity for both hypoxic and severe hypoxic events (IPI = 1: 13%/12%, IPI < 7: 7%/7%, PetCO2: 29%/27%, apnea > 10 s: 7%/7%). In multivariate analysis, only SM and PetCO2 = 0 mmHg were independent risk factors for hypoxia. IPI (IPI = 1 and IPI < 7) as well as the individual parameters PetCO2 = 0 mmHg and apnea > 10 s allow a fast and convenient conclusion on patients' respiratory status in a morbid patient population. Sensitivity is good for most parameters, but specificity is poor. In conclusion, IPI can be a useful metric to assess respiratory status during propofol-sedation in PEG-placement. However, IPI was not superior to PetCO2 and apnea > 10 s.
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Affiliation(s)
- Florian Alexander Michael
- Department of Internal Medicine 1, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany.
| | - Jan Peveling-Oberhag
- Department of Internal Medicine 1, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
- Department of Internal Medicine 1, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Eva Herrmann
- Institute of Biostatistic and Mathematical Modelling, Goethe-University, Frankfurt, Germany
| | - Stefan Zeuzem
- Department of Internal Medicine 1, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Jörg Bojunga
- Department of Internal Medicine 1, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Mireen Friedrich-Rust
- Department of Internal Medicine 1, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
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20
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Strohleit D, Galetin T, Kosse N, Lopez-Pastorini A, Stoelben E. Guidelines on analgosedation, monitoring, and recovery time for flexible bronchoscopy: a systematic review. BMC Pulm Med 2021; 21:198. [PMID: 34112130 PMCID: PMC8193886 DOI: 10.1186/s12890-021-01532-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 05/10/2021] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Patients undergoing bronchoscopy in spontaneous breathing are prone to hypoxaemia and hypercapnia. Sedation, airway obstruction, and lung diseases impair respiration and gas exchange. The restitution of normal respiration takes place in the recovery room. Nonetheless, there is no evidence on the necessary observation time. We systematically reviewed current guidelines on bronchoscopy regarding sedation, monitoring and recovery. METHODS This review was registered at the PROSPERO database (CRD42020197476). MEDLINE and awmf.org were double-searched for official guidelines, recommendation or consensus statements on bronchoscopy from 2010 to 2020. The PICO-process focussed on adults (Patients), bronchoscopy with maintained spontaneous breathing (Interventions), and recommendations regarding the intra- and postprocedural monitoring and sedation (O). The guideline quality was graded. A catalogue of 54 questions was answered. Strength of recommendation and evidence levels were recorded for each recommendation. RESULTS Six guidelines on general bronchoscopy and three expert statements on special bronchoscopic procedures were identified. Four guidelines were evidence-based. Most guidelines recommend sedation to improve the patient's tolerance. Midazolam combined with an opioid is preferred. The standard monitoring consists of non-invasive blood pressure, and pulse oximetry, furthermore electrocardiogram in cardiac patients. Only one guideline discusses hypercapnia and capnometry, but without consensus. Two guidelines discuss a recovery time of two hours, but a recommendation was not given because of lack of evidence. CONCLUSION Evidence for most issues is low to moderate. Lung-diseased patients are not represented by current guidelines. Capnometry and recovery time lack evidence. More primary research in these fields is needed so that future guidelines may address these issues, too.
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Affiliation(s)
- Daniel Strohleit
- Lung Clinic Cologne-Merheim, Thoracic Surgery, Hospital of Cologne, University of Witten/Herdecke, Ostmerheimer Str. 200, 51109, Cologne, Germany
| | - Thomas Galetin
- Lung Clinic Cologne-Merheim, Thoracic Surgery, Hospital of Cologne, University of Witten/Herdecke, Ostmerheimer Str. 200, 51109, Cologne, Germany.
| | - Nils Kosse
- Lung Clinic Cologne-Merheim, Thoracic Surgery, Hospital of Cologne, University of Witten/Herdecke, Ostmerheimer Str. 200, 51109, Cologne, Germany
| | - Alberto Lopez-Pastorini
- Lung Clinic Cologne-Merheim, Thoracic Surgery, Hospital of Cologne, University of Witten/Herdecke, Ostmerheimer Str. 200, 51109, Cologne, Germany
| | - Erich Stoelben
- Lung Clinic Cologne-Merheim, Thoracic Surgery, Hospital of Cologne, University of Witten/Herdecke, Ostmerheimer Str. 200, 51109, Cologne, Germany
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21
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Shin R, Lee S, Han KS, Sohn DK, Moon SH, Choi DH, Kye BH, Son HJ, Lee SI, Si S, Kang WK. Guidelines for accreditation of endoscopy units: quality measures from the Korean Society of Coloproctology. Ann Surg Treat Res 2021; 100:154-165. [PMID: 33748029 PMCID: PMC7943281 DOI: 10.4174/astr.2021.100.3.154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 11/29/2020] [Accepted: 12/09/2020] [Indexed: 11/30/2022] Open
Abstract
Purpose Colonoscopy is an effective method of screening for colorectal cancer (CRC), and it can prevent CRC by detection and removal of precancerous lesions. The most important considerations when performing colonoscopy screening are the safety and satisfaction of the patient and the diagnostic accuracy. Accordingly, the Korean Society of Coloproctology (KSCP) herein proposes an optimal level of standard performance to be used in endoscopy units and by individual colonoscopists for screening colonoscopy. These guidelines establish specific criteria for assessment of safety and quality in screening colonoscopy. Methods The Colonoscopy Committee of the KSCP commissioned this Position Statement. Expert gastrointestinal surgeons representing the KSCP reviewed the published evidence to identify acceptable quality indicators and indicators that lacked sufficient evidence. Results The KSCP recommends an optimal standard list for quality control of screening colonoscopy in the following 6 categories: training and competency of the colonoscopist, procedural quality, facilities and equipment, performance indicators and auditable outcomes, disinfection of equipment, and sedation and recovery of the patient. Conclusion The KSCP recommends that endoscopy units performing CRC screening evaluate 6 key performance measures during daily practice.
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Affiliation(s)
- Rumi Shin
- The Colonoscopy Committee, The Korean Society of Coloproctology (KSCP), Seoul, Korea.,Department of Surgery, SMG-SNU Boramae Medical Center, Seoul, Korea
| | - Seongdae Lee
- The Colonoscopy Committee, The Korean Society of Coloproctology (KSCP), Seoul, Korea
| | - Kyung-Su Han
- The Colonoscopy Committee, The Korean Society of Coloproctology (KSCP), Seoul, Korea
| | - Dae Kyung Sohn
- The Colonoscopy Committee, The Korean Society of Coloproctology (KSCP), Seoul, Korea
| | - Sang Hui Moon
- The Colonoscopy Committee, The Korean Society of Coloproctology (KSCP), Seoul, Korea
| | - Dong Hyun Choi
- The Colonoscopy Committee, The Korean Society of Coloproctology (KSCP), Seoul, Korea
| | - Bong-Hyeon Kye
- The Colonoscopy Committee, The Korean Society of Coloproctology (KSCP), Seoul, Korea
| | - Hae-Jung Son
- The Colonoscopy Committee, The Korean Society of Coloproctology (KSCP), Seoul, Korea
| | - Sun Il Lee
- The Colonoscopy Committee, The Korean Society of Coloproctology (KSCP), Seoul, Korea
| | - Sumin Si
- The Colonoscopy Committee, The Korean Society of Coloproctology (KSCP), Seoul, Korea
| | - Won-Kyung Kang
- The Colonoscopy Committee, The Korean Society of Coloproctology (KSCP), Seoul, Korea.,Department of Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Gotoda T, Akamatsu T, Abe S, Shimatani M, Nakai Y, Hatta W, Hosoe N, Miura Y, Miyahara R, Yamaguchi D, Yoshida N, Kawaguchi Y, Fukuda S, Isomoto H, Irisawa A, Iwao Y, Uraoka T, Yokota M, Nakayama T, Fujimoto K, Inoue H. Guidelines for sedation in gastroenterological endoscopy (second edition). Dig Endosc 2021; 33:21-53. [PMID: 33124106 DOI: 10.1111/den.13882] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 10/12/2020] [Accepted: 10/21/2020] [Indexed: 12/14/2022]
Abstract
Sedation in gastroenterological endoscopy has become an important medical option in routine clinical care. Here, the Japan Gastroenterological Endoscopy Society and the Japanese Society of Anesthesiologists together provide the revised "Guidelines for sedation in gastroenterological endoscopy" as a second edition to address on-site clinical questions and issues raised for safe examination and treatment using sedated endoscopy. Twenty clinical questions were determined and the strength of recommendation and evidence quality (strength) were expressed according to the "MINDS Manual for Guideline Development 2017." We were able to release up-to-date statements related to clinical questions and current issues relevant to sedation in gastroenterological endoscopy (henceforth, "endoscopy"). There are few reports from Japan in this field (e.g., meta-analyses), and many aspects have been based only on a specialist consensus. In the current scenario, benzodiazepine drugs primarily used for sedation during gastroenterological endoscopy are not approved by national health insurance in Japan, and investigations regarding expense-related disadvantages have not been conducted. Furthermore, including the perspective of beneficiaries (i.e., patients and citizens) during the creation of clinical guidelines should be considered. These guidelines are standardized based on up-to-date evidence quality (strength) and supports on-site clinical decision-making by patients and medical staff. Therefore, these guidelines need to be flexible with regard to the wishes, age, complications, and social conditions of the patient, as well as the conditions of the facility and discretion of the physician.
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Affiliation(s)
- Takuji Gotoda
- Japanese Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Takuji Akamatsu
- Japanese Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Seiichiro Abe
- Japanese Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Yousuke Nakai
- Japanese Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Waku Hatta
- Japanese Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Naoki Hosoe
- Japanese Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Yoshimasa Miura
- Japanese Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Ryoji Miyahara
- Japanese Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Naohisa Yoshida
- Japanese Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Shinsaku Fukuda
- Japanese Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Hajime Isomoto
- Japanese Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Atsushi Irisawa
- Japanese Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Yasushi Iwao
- Japanese Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Toshio Uraoka
- Japanese Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Takeo Nakayama
- Department of Health Informatics, Kyoto University School of Public Health, Kyoto, Japan
| | - Kazuma Fujimoto
- Japanese Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Haruhiro Inoue
- Japanese Gastroenterological Endoscopy Society, Tokyo, Japan
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23
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Chen Y, Gong Y, Huai X, Gu X, Su D, Yu W, Xie H. Effects of transcutaneous electrical acupuncture point stimulation on peripheral capillary oxygen saturation in elderly patients undergoing colonoscopy with sedation: a prospective randomized controlled trial. Acupunct Med 2020; 39:292-298. [PMID: 33256456 DOI: 10.1177/0964528420960479] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION This study investigated whether transcutaneous electrical acupuncture point stimulation (TEAS) at PC6 can reduce the proportion of elderly patients experiencing a drop of ⩾4% in peripheral capillary oxygen saturation (SpO2) while undergoing colonoscopy under sedation. METHODS A total of 32 elderly patients (aged ⩾ 65 years) scheduled for colonoscopy were randomly assigned in a 1:1 ratio to receive either real or sham TEAS (treatment or control groups, respectively). Each patient received oxygen (2 L/min) delivered routinely via nasal cannula. The treatment group was given TEAS at PC6 for 20 min at 2 Hz frequency and 6 mA intensity; the control group underwent the same procedures but with zero frequency/intensity. SpO2 and other physiological parameters were measured prior to sedation and colonoscopy (baseline) and at seven other timepoints through departure from recovery. Depth of anesthesia was measured using a Narcotrend monitor. RESULTS Significantly fewer patients in the treatment group experienced a ⩾4% decrease from baseline SpO2 (2/16) than patients in the control group (10/16; p = 0.004). The two groups were comparable with regard to respiratory rate, systolic and diastolic blood pressures, mean arterial pressure, and heart rate. CONCLUSION TEAS applied at PC6 with 2 Hz frequency was feasible and may be helpful in reducing the rate of hypoxia in elderly patients during colonoscopy.Trial registration number: NCT03775122 (ClinicalTrials.gov).
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Affiliation(s)
- Yongming Chen
- Department of Anesthesiology, The Second Affiliated Hospital of Soochow University, Suzhou, China.,Department of Anesthesiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Yin Gong
- Department of Anesthesiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Xiaorong Huai
- Department of Anesthesiology, The Second Affiliated Hospital of Soochow University, Suzhou, China.,Department of Anesthesiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Xiyao Gu
- Department of Anesthesiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Diansan Su
- Department of Anesthesiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Weifeng Yu
- Department of Anesthesiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Hong Xie
- Department of Anesthesiology, The Second Affiliated Hospital of Soochow University, Suzhou, China
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24
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Capnography monitoring in procedural intravenous sedation: a systematic review and meta-analysis. Clin Oral Investig 2020; 24:3761-3770. [PMID: 32556657 DOI: 10.1007/s00784-020-03395-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 06/04/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Currently, procedural sedation in the clinical setting relies heavily on the use of pulse oximetry to monitor hypoxemia. Different studies suggest that incidence of hypoxemia and incidence of arterial oxygen desaturation are reduced by early intervention via capnography monitoring. The aim of this article was to discuss the importance of implementing capnography monitoring during procedural sedations performed in a dental setting and determine whether additional capnographic monitoring reduces the incidence of arterial oxygen desaturation and the overall complications rate. MATERIALS AND METHODS Two independent reviewers conducted electronic (PubMed and EMBASE) and manual searches up to February 2020. Randomized clinical trials (RCTs), including both patients under procedural sedation monitored by capnography and oximetry, and reporting the incidence of hypoxemia or episodes of oxygen desaturation were included. Risk ratio was used to compare the outcomes (i.e., the incidence of hypoxemia, the episodes of oxygen desaturation, the detection of apnea, the reduction of events of bradycardia, and hypotension) between patients monitored by capnography and standard approach. RESULTS Fourteen randomized clinical trials fulfilling the inclusion criteria were selected. The analysis revealed that capnography monitoring group showed the lower incidence of hypoxemia (RR 0.76, 95%CI 0.70 to 0.83, p < 0.001) and the episodes of oxygen desaturation (RR 0.79, 95%CI 0.71 to 0.87, p < 0.001) compared with the oximetry monitoring group. Apnea was detected in capnography monitoring earlier than standard monitoring (RR 2.60, 95%CI 2.30 to 2.93, p < 0.001). No significant difference was found between capnography and standard monitoring groups in terms of reduction of events of bradycardia (RR 1.17, 95%CI 0.91 to 1.50, p = 0.225) and hypotension (RR 0.96, 95%CI 0.76 to 1.21, p = 0.746). CONCLUSION Capnography monitoring reduced incidence of hypoxemia during procedural sedations. Within the limitations of this review, we suggest that the application of capnography during procedural sedation would decrease the frequency of oxygen desaturation events and incidence of hypoxemia. CLINICAL RELEVANCE Training and instructing dental providers on using capnography monitoring would help in reducing adverse events during intravenous sedation.
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25
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Eugene A, Fromont L, Auvet A, Baert O, Mfam WS, Remerand F, Boulain T, Nay MA. High-flow nasal oxygenation versus standard oxygenation for gastrointestinal endoscopy with sedation. The prospective multicentre randomised controlled ODEPHI study protocol. BMJ Open 2020; 10:e034701. [PMID: 32075842 PMCID: PMC7045106 DOI: 10.1136/bmjopen-2019-034701] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Hypoxaemia is a major complication during gastrointestinal endoscopy (GIE) procedures (upper/lower) when performed under deep sedation in the procedure room. Standard oxygen therapy (SOT) is used to prevent hypoxaemia. Data suggest that risk factors for hypoxaemia under deep sedation during GIE are obstructive sleep apnoea syndrome, a body mass index above 30 kg/m², high blood pressure, diabetes, heart disease, age over 60 years old, high American Society of Anesthesiologists physical status class and the association of upper and lower GIE. High-flow nasal oxygenation (HFNO) may potentially improve oxygenation during GIE under deep sedation. We hypothesised that HFNO could decrease the incidence of hypoxaemia in comparison with SOT. METHODS AND ANALYSIS The ODEPHI (High-flow nasal oxygenation versus standard oxygenation for gastrointestinal endoscopy with sedation. The prospective multicentre randomised controlled) study is a multicentre randomised controlled trial comparing HFNO to SOT during GIE (upper and/or lower) under deep sedation administered by anaesthesiologists in the procedure room. Three hundred and eighty patients will be randomised with a 1:1 ratio in two parallel groups.The primary outcome is the occurrence of hypoxaemia, defined by a pulse oximetry measurement of peripheral capillary oxygen saturation (SpO2) below or equal to 92% during the GIE procedure. Secondary outcomes include prolonged hypoxaemia, severe hypoxaemia, need for manoeuvres to maintain upper airway patency and other adverse events. ETHICS AND DISSEMINATION This study has been approved by the ethics committee (CPP Sud Est Paris V, France), and patients are included after informed consent. The results will be submitted for publication in peer-reviewed journals. As provided for by French law, patients participating in the study are informed that they have the possibility to ask the investigators, once the study is completed, to be informed of the overall results of the study. Thus, a summary of the results will be sent by post to the participants on request. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT03829293).
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Affiliation(s)
- Axelle Eugene
- Anaesthesiology and Critical Care Medicine, Centre Hospitalier Régional Universitaire de Tours, Tours, France
| | - Lucie Fromont
- Anaesthesiology and Critical Care Medicine, Centre Hospitalier Régional Universitaire de Tours, Tours, France
| | - Adrien Auvet
- Medical Intensive Care Unit, Hospital Dax Côte d'Argent, Dax, France
| | - Olivier Baert
- Anaesthesiology, Oréliance Health Centre, Saran, France
| | - Willy-Serge Mfam
- Anaesthesiology and Critical Care Medicine, Centre Hospitalier Régional d'Orleans, Orleans, France
| | - Francis Remerand
- Anaesthesiology and Critical Care Medicine, Centre Hospitalier Régional Universitaire de Tours, Tours, France
| | - Thierry Boulain
- Medical Intensive Care Unit, Centre Hospitalier Régional d'Orleans, Orleans, France
| | - Mai-Anh Nay
- Medical Intensive Care Unit, Centre Hospitalier Régional d'Orleans, Orleans, France
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Monitoring standards in sedation and analgesia: the odyssey of capnography in sedation for gastroenterology procedures. Curr Opin Anaesthesiol 2019; 32:453-456. [PMID: 31169549 DOI: 10.1097/aco.0000000000000756] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW Capnography is an excellent tool for early detection of hypoxemia and apnea in patients undergoing sedation for gastrointestinal endoscopy. The current American Society of Anesthesiology (ASA) guidelines recommend the use of capnography in any patient undergoing moderate sedation. The purpose of this review was to compile the most recent data available on capnography use in gastrointestinal endoscopy with the focus primarily on the use of capnography in moderate sedation cases. RECENT FINDINGS Recent high-quality studies have evaluated the utility of capnography in low risk patients undergoing moderate sedation and have found no benefit with addition of capnography. SUMMARY Capnography is beneficial when used for patients who are at a higher risk for sedation-related complications. There is no benefit when capnography is used in low risk patients undergoing routine upper endoscopy and colonoscopy under moderate sedation but there is benefit when used in advanced endoscopic procedures that require deeper sedation and have longer procedure times.
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27
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Parker W, Estrich CG, Abt E, Carrasco-Labra A, Waugh JB, Conway A, Lipman RD, Araujo MWB. Benefits and harms of capnography during procedures involving moderate sedation: A rapid review and meta-analysis. J Am Dent Assoc 2019; 149:38-50.e2. [PMID: 29304910 DOI: 10.1016/j.adaj.2017.08.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 08/22/2017] [Accepted: 08/26/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patient safety is a priority in dentistry. Evaluating the benefits and harms associated with the addition of capnography to standard monitoring during moderate sedation for adult patients in the dental practice setting is needed. TYPES OF STUDIES REVIEWED The authors used rapid review methodology to identify relevant systematic reviews, which they updated through a systematic search by using the same search strategy as the identified reviews. The authors searched PubMed and Google Scholar and through the references of the identified systematic reviews, which yielded 2,892 studies. Inclusion criteria were that the article was available in English, was original research in adult humans who had undergone moderate procedural sedation, and involved comparing standard monitoring with the addition of capnography. RESULTS Sixteen studies were eligible, involving 3,866 adults undergoing procedural sedation. The authors used the Grading of Recommendations Assessment, Development and Evaluation approach to evaluate the evidence and rate it as being of moderate to low quality because of high risk of bias and heterogeneous effects for the outcomes of hypoxemia and adverse respiratory events. Capnography had higher sensitivity to detect adverse respiratory events than did standard monitoring alone (0.92; 95% confidence interval, 0.65 to 0.99) and may reduce the risk of developing hypoxemia by 31% (risk ratio, 0.69; 95% confidence interval, 0.57 to 0.82). Capnography did not affect the risk of developing serious adverse events, procedure time, sedation quality, or patient satisfaction. CONCLUSIONS AND PRACTICAL IMPLICATIONS Adding capnography to standard monitoring of adults during moderate sedation may reduce the risk of developing hypoxemia, increase detection of adverse respiratory events, and is not associated with additional harms. These findings suggest routine use of capnography during moderate sedation has the potential to reduce adverse anesthetic outcomes in dental practice.
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Conway A, Collins P, Chang K, Mafeld S, Sutherland J, Fingleton J. Sequence analysis of capnography waveform abnormalities during nurse-administered procedural sedation and analgesia in the cardiac catheterization laboratory. Sci Rep 2019; 9:10214. [PMID: 31308455 PMCID: PMC6629622 DOI: 10.1038/s41598-019-46751-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 07/04/2019] [Indexed: 11/17/2022] Open
Abstract
Identifying common patterns in capnography waveform abnormalities and the factors that influence these patterns could yield insights to optimize responses to sedation-induced respiratory depression. Respiratory state sequences for 102 patients who had a procedure in a cardiac catheterisation laboratory with procedural sedation and analgesia were developed by classifying each second of procedures into a state of normal breathing or other capnography waveform abnormalities based on pre-specified cut-offs for respiratory rate and end-tidal CO2 concentration. Hierarchical clustering identified four common patterns in respiratory state sequences, which were characterized by a predominance of the state assigned normal breathing (n = 42; 41%), hypopneic hypoventilation (n = 38; 38%), apnea (n = 15; 15%) and bradypneic hypoventilation (n = 7; 7%). A multivariable distance matrix regression model including demographic and clinical variables explained 28% of the variation in inter-individual differences in respiratory state sequences. Obstructive sleep apnea (R2 = 2.4%; p = 0.02), smoking status (R2 = 2.8%; p = 0.01), Charlson comorbidity index score (R2 = 2.5%; p = 0.021), peak transcutaneous carbon dioxide concentration (R2 = 4.1%; p = 0.002) and receiving an intervention to support respiration (R2 = 5.6%; p = 0.001) were significant covariates but each explained only small amounts of the variation in respiratory state sequences. Oxygen desaturation (SpO2 < 90%) was rare (n = 3; 3%) and not associated with respiratory state sequence trajectories.
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Affiliation(s)
- Aaron Conway
- Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Canada.
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada.
- Institute of Health and Biomedical Innovation, School of Nursing, Queensland University of Technology, Brisbane, Australia.
| | - Peter Collins
- Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Kristina Chang
- Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Sebastian Mafeld
- Interventional Radiology, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Joanna Sutherland
- Department of Anaesthesia, Coffs Harbour Health Campus, Coffs Harbour, Australia
| | - James Fingleton
- Medical Research Institute of New Zealand, Wellington, New Zealand
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Abstract
Conscious sedation is a commonly used approach to provide pain relief during transvaginal oocyte retrieval. It has been shown to be effective with high levels of acceptability and patient satisfaction. Fundamental Standards and Development Standards in safe sedation practice have been set out by the Royal College of Anaesthetists and they recommend that Royal Colleges, in association with the relevant sub-specialty organizations, should develop guidelines on sedation methods appropriate to clinical practice in their sphere of influence. This Policy and Practice paper outlines the human resources and equipment necessary to optimize patients' safety for the administration of intravenous (I.V.) sedation in assisted conception units, based on the most current evidence and guidance available.
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Takimoto Y, Iwasaki E, Masaoka T, Fukuhara S, Kawasaki S, Seino T, Katayama T, Minami K, Tamagawa H, Machida Y, Ogata H, Kanai T. Novel mainstream capnometer system is safe and feasible even under CO 2 insufflation during ERCP-related procedure: a pilot study. BMJ Open Gastroenterol 2019; 6:e000266. [PMID: 30899539 PMCID: PMC6398869 DOI: 10.1136/bmjgast-2018-000266] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 01/18/2019] [Accepted: 02/01/2019] [Indexed: 11/29/2022] Open
Abstract
Background and aims There is a need to safely achieve conscious sedation during endoscopic retrograde cholangiopancreatography (ERCP). We evaluated the safety and feasibility of a mainstream capnometer system to monitor apnoea during ERCP under CO2 insufflation. Methods Non-intubated adult patients undergoing ERCP-related procedures with intravenous sedation were enrolled. End-tidal CO2 (EtCO2) was continuously monitored during the procedure under CO2 insufflation using a mainstream capnometer system, comprising a capnometer and a specially designed bite block for upper gastrointestinal endoscopy and ERCP. Oxygen saturation (SpO2) was also monitored continuously during the procedure. In this study, we evaluated the safety and feasibility of the capnometer system. Results Eleven patients were enrolled. Measurement of EtCO2 concentration was possible from the beginning to the end of the procedure in all 11 cases. There was no measurement failure, dislocation of the bite block, or adverse event related to the bite block. Apnoea linked to hypoxaemia occurred five times (mean duration, 174.4 s). Conclusion This study confirmed that apnoea was detected earlier than when using a percutaneous oxygen monitor. Measurement of EtCO2 concentration using the newly developed mainstream capnometer system was feasible and safe even under CO2 insufflation.
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Affiliation(s)
- Yoichi Takimoto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Eisuke Iwasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Tatsuhiro Masaoka
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Seiichiro Fukuhara
- Center for Diagnostic and Therapeutic Endoscopy, KeioUniversity School of Medicine, Tokyo, Japan
| | - Shintaro Kawasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Takashi Seino
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Tadashi Katayama
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Kazuhiro Minami
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Hiroki Tamagawa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yujiro Machida
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Haruhiko Ogata
- Center for Diagnostic and Therapeutic Endoscopy, KeioUniversity School of Medicine, Tokyo, Japan
| | - Takanori Kanai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
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Nasal positive pressure with the SuperNO 2VA™ device decreases sedation-related hypoxemia during pre-bariatric surgery EGD. Surg Endosc 2019; 33:3828-3832. [PMID: 30805788 DOI: 10.1007/s00464-019-06721-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 02/20/2019] [Indexed: 01/29/2023]
Abstract
INTRODUCTION Pre-operative esophagogastroduodenoscopy (EGD) is becoming routine practice in patients undergoing bariatric surgery. Many patients with morbid obesity have obstructive sleep apnea (OSA), which can worsen hypoxia during an EGD. In this study, we report our outcomes using the SuperNO2VA™ device, a sealed nasal positive airway pressure mask designed to deliver high-fraction inhaled oxygen and titratable positive pressure compared to conventional nasal cannula. METHODS Between June 2016 and August 2017, we conducted a prospective observational study that included 56 consecutive patients who presented for EGD prior to bariatric surgery. Airway management was done using either the SuperNO2VA™ (N = 26) device or conventional nasal cannula (N = 30). Patient demographics, procedure details, and outcomes were compared between the two groups. RESULTS The SuperNO2VA™ group had a lower median age compared to the control group (38.5 vs. 48.5 years, p = 0.04). These patients had a higher body mass index (BMI) (47.4 vs. 40.5, IQR, p < 0.0001), higher ASA class (p = 0.03), and were more likely to have OSA (53.9% vs. 26.7%, p = 0.04). Desaturation events were significantly lower in the SuperNO2VA™ group (11.5% vs. 46.7%, p = 0.004) and the median lowest oxygen saturation was higher in the SuperNO2VA™ group (100% vs. 90.5%, p < 0.0001). DISCUSSION This is the first study to report on the use of the SuperNO2VA™ device in bariatric patients undergoing pre-operative screening EGD. The use of the SuperNO2VA™ device offers a clinical advantage compared to the current standard of care. Our data demonstrate that patients with higher BMI, higher ASA classification, and OSA were more likely to have the SuperNO2VA™ device used; yet, paradoxically, these patients were less likely to have issues with desaturation events. Use of this device can optimize care in this challenging patient population by minimizing the risks of hypoventilation.
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Capnography Monitoring for Patients Undergoing Moderate Sedation: An SGNA Fellowship Project. Gastroenterol Nurs 2019; 42:49-54. [PMID: 30688708 DOI: 10.1097/sga.0000000000000426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The purpose of this Society of Gastroenterology Nurses and Associates Fellowship project was to determine whether capnography is more accurate than oximetry in identifying symptoms of respiratory depression in patients undergoing moderate sedation. Capnography provides an early warning of respiratory depression and airway compromise, especially when the medications used for sedation include opiates and benzodiazepines. It is a standard of care according to the American Society of Anesthesiologists that should be adopted in order to provide the safest possible environment for the delivery of moderate sedation. During this project, the nursing staff were educated on the importance and usage of capnography. Evidence was gathered that helped show that by using capnography, nurses were able to identify signs of respiratory depression earlier and more frequently than with the use of oximetry and cardiac monitoring alone.
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Kim SH, Park M, Lee J, Kim E, Choi YS. The addition of capnography to standard monitoring reduces hypoxemic events during gastrointestinal endoscopic sedation: a systematic review and meta-analysis. Ther Clin Risk Manag 2018; 14:1605-1614. [PMID: 30233196 PMCID: PMC6132492 DOI: 10.2147/tcrm.s174698] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background The use of capnography monitoring devices has been shown to lower the rates of hypoxemia via early detection of respiratory depression, and facilitate more accurate titration of sedatives during procedures. The aim of the current meta-analysis was to compare the incidence of hypoxemia associated with standard monitoring alone during gastrointestinal endoscopy to that associated with standard monitoring with the addition of capnography. Methods The MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials scientific databases were searched to identify relevant studies. We performed a meta-analysis of randomized controlled trials undertaken up to January 2018 that met our predefined inclusion criteria. The study outcome measures were incidence of hypoxemia, severe hypoxemia, apnea, the use of assisted ventilation, the use of supplemental oxygen, and change in vital signs. Results We included nine trials assessing a total of 3,088 patients who underwent gastrointestinal procedural sedation. Meta-analysis of study outcome revealed that capnography significantly reduced the incidence of hypoxemia (odds ratio 0.61, 95% CI 0.49–0.77) and severe hypoxemia (odds ratio 0.53, 95% CI 0.35–0.81). However, there were no significant differences in other outcomes including incidence of apnea, assisted ventilation, supplemental oxygen, and changes in vital signs. Early procedure termination and patient satisfaction-related outcomes did not differ significantly in the capnography group and the standard monitoring group. Conclusion This study indicates that capnography monitoring is an important addition with regard to the detection of hypoxemia during gastrointestinal procedural sedation, and should be considered in routine monitoring during gastrointestinal endoscopy.
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Affiliation(s)
- Seung Hyun Kim
- Department of Anesthesiology and Pain Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Minsu Park
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Korea
| | - Jinae Lee
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Korea
| | - Eungjin Kim
- Department of Anesthesiology and Pain Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Seon Choi
- Department of Anesthesiology and Pain Medicine, Severance Hospital, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea,
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Pella L, Lambert C, McArthur B, West C, Hernandez M, Green K, Sousa M, Brast S, Long M. Systematic Review to Develop the Clinical Practice Guideline for the Use of Capnography During Procedural Sedation in Radiology and Imaging Settings: A Report of the Association for Radiologic & Imaging Nursing Capnography Task Force. ACTA ACUST UNITED AC 2018. [DOI: 10.1016/j.jradnu.2018.07.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Supplemental Digital Content is available in the text.
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Saunders R, Davis JA, Kranke P, Weissbrod R, Whitaker DK, Lightdale JR. Clinical and economic burden of procedural sedation-related adverse events and their outcomes: analysis from five countries. Ther Clin Risk Manag 2018. [PMID: 29535525 PMCID: PMC5836671 DOI: 10.2147/tcrm.s154720] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
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.
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Affiliation(s)
| | | | - Peter Kranke
- Department of Anaesthesia and Critical Care, University of Würzburg, Würzburg, Germany
| | | | - David K Whitaker
- Department of Anaesthesia, Manchester Royal Infirmary, Manchester, UK
| | - Jenifer R Lightdale
- Pediatric Gastroenterology, Hepatology and Nutrition, University of Massachusetts, Worcester, MA, USA
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Early DS, Lightdale JR, Vargo JJ, Acosta RD, Chandrasekhara V, Chathadi KV, Evans JA, Fisher DA, Fonkalsrud L, Hwang JH, Khashab MA, Muthusamy VR, Pasha SF, Saltzman JR, Shergill AK, Cash BD, DeWitt JM. Guidelines for sedation and anesthesia in GI endoscopy. Gastrointest Endosc 2018; 87:327-337. [PMID: 29306520 DOI: 10.1016/j.gie.2017.07.018] [Citation(s) in RCA: 288] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 07/13/2017] [Indexed: 02/08/2023]
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Parida S, Kundra P, Mohan VK, Mishra SK. Standards of care for procedural sedation: Focus on differing perceptions among societies. Indian J Anaesth 2018; 62:493-496. [PMID: 30078850 PMCID: PMC6053889 DOI: 10.4103/ija.ija_201_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Adherence to established standards of care is important for anaesthesiologists to avoid undesirable legal consequences of their actions. The judiciary lays stress on the need to perpetuate healthy doctor–patient correspondence, good documentation, and to bestow a justifiable standard of care. But what defines standard of care and who delineates such standards is something that lacks clarity. The American Society for Gastrointestinal Endoscopy (ASGE) has recently released updated guidelines on the use of sedation and anaesthesia for gastrointestinal endoscopic procedures. Almost simultaneously, the American Society of Anesthesiologists (ASA) has brought out practice guidelines for moderate sedation and analgesia. In contrast to the ASA recommendations, ASGE does not view capnography as an essential monitoring modality for endoscopic procedures with moderate sedation because it has apparently not been shown to improve patient safety. However, they do agree that evidence supports its deployment during deep sedation. These differences in views between guidelines published by societies of substantial academic and clinical standing can confuse the agreement over what constitutes standard of care for the particular speciality. It is the expectation that guidelines and consensus statements in anaesthesiology be preferably issued by national or international organizations of the same speciality.
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Affiliation(s)
- Satyen Parida
- Department of Anesthesiology and Critical Care, JIPMER, Puducherry, India
| | - Pankaj Kundra
- Department of Anesthesiology and Critical Care, JIPMER, Puducherry, India
| | - V K Mohan
- Department of Anesthesiology and Critical Care, JIPMER, Puducherry, India
| | - Sandeep K Mishra
- Department of Anesthesiology and Critical Care, JIPMER, Puducherry, India
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Brady P, Iohom G, O'Halloran KD, McCreary C, Cronin M. Microstream capnography during conscious sedation with midazolam for oral surgery: a randomised controlled trial. BDJ Open 2017; 3:17019. [PMID: 29607089 PMCID: PMC5842831 DOI: 10.1038/bdjopen.2017.19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 08/06/2017] [Accepted: 08/09/2017] [Indexed: 11/30/2022] Open
Abstract
Objectives/Aims: There has been no dentistry-specific published data supporting the use of monitoring with capnography for dental sedation. Our aim was to determine if adding capnography to standard monitoring during conscious sedation with midazolam would decrease the incidence of hypoxaemia. Materials and Methods: A randomised controlled trial was conducted in which all patients (ASA I and II) received standard monitoring and capnography, but were randomised to whether staff could view the capnography (intervention) or were blinded to it (control). The primary outcome was the incidence of hypoxaemia (SpO2⩽94%). Results: We enrolled 190 patients, mean age 31 years (range, 14–62 years). There were 93 patients in the capnography group and 97 in the control group. The mean cumulative dose of midazolam titrated was 6.94 mg (s.d., 2.31; range, 3–20 mg). Six (3%) patients, three in each group, required temporary supplemental oxygen. There was no statistically significant difference between the capnography and control groups for the incidence of hypoxaemia: 34.4 vs 39.2% (P=0.4962, OR=0.81, 95% CI: 0.45–1.47). Conclusions: We were unable to confirm an additive role for capnography to prevent hypoxaemia during conscious sedation with midazolam for patients not routinely administered supplemental oxygen.
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Affiliation(s)
- Paul Brady
- Department of Dental Surgery, University College Cork, Cork, Ireland
| | - Gabriella Iohom
- Department of Anaesthesia, University College Cork, Cork, Ireland
| | - Ken D O'Halloran
- Department of Physiology, University College Cork, Cork, Ireland
| | | | - Michael Cronin
- Department of Statistics, University College Cork, Cork, Ireland
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Saunders R, Struys MMRF, Pollock RF, Mestek M, Lightdale JR. Patient safety during procedural sedation using capnography monitoring: a systematic review and meta-analysis. BMJ Open 2017; 7:e013402. [PMID: 28667196 PMCID: PMC5734204 DOI: 10.1136/bmjopen-2016-013402] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 03/22/2017] [Accepted: 03/23/2017] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE To evaluate the effect of capnography monitoring on sedation-related adverse events during procedural sedation and analgesia (PSA) administered for ambulatory surgery relative to visual assessment and pulse oximetry alone. DESIGN AND SETTING Systematic literature review and random effects meta-analysis of randomised controlled trials (RCTs) reporting sedation-related adverse event incidence when adding capnography to visual assessment and pulse oximetry in patients undergoing PSA during ambulatory surgery in the hospital setting. Searches for eligible studies published between 1 January 1995 and 31 December 2016 (inclusive) were conducted in PubMed, the Cochrane Library and EMBASE without any language constraints. Searches were conducted in January 2017, screening and data extraction were conducted by two independent reviewers, and study quality was assessed using a modified Jadad scale. INTERVENTIONS Capnography monitoring relative to visual assessment and pulse oximetry alone. PRIMARY AND SECONDARY OUTCOME MEASURES Predefined endpoints of interest were desaturation/hypoxaemia (the primary endpoint), apnoea, aspiration, bradycardia, hypotension, premature procedure termination, respiratory failure, use of assisted/bag-mask ventilation and death during PSA. RESULTS The literature search identified 1006 unique articles, of which 13 were ultimately included in the meta-analysis. Addition of capnography to visual assessment and pulse oximetry was associated with a significant reduction in mild (risk ratio (RR) 0.77, 95% CI 0.67 to 0.89) and severe (RR 0.59, 95% CI 0.43 to 0.81) desaturation, as well as in the use of assisted ventilation (OR 0.47, 95% CI 0.23 to 0.95). No significant differences in other endpoints were identified. CONCLUSIONS Meta-analysis of 13 RCTs published between 2006 and 2016 showed a reduction in respiratory compromise (from respiratory insufficiency to failure) during PSA with the inclusion of capnography monitoring. In particular, use of capnography was associated with less mild and severe oxygen desaturation, which may have helped to avoid the need for assisted ventilation.
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Affiliation(s)
- Rhodri Saunders
- Coreva Scientific GmbH & Co. KG., Freiburg, Germany
- Ossian Health Economics and Communications, Basel, Switzerland
| | - Michel M R F Struys
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Anesthesia, Ghent University, Ghent, Belgium
| | | | - Michael Mestek
- Minimally Invasive Therapies Group, Medtronic, Boulder, Colorado, USA
| | - Jenifer R Lightdale
- Division of Pediatric Gastroenterology, UMass Memorial Children’s Medical Center, Westborough, Massachusetts, USA
- Department of Pediatrics, University of Massachusetts Medical School, Worcester, Massachusetts, USA
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Mehta JH, Williams GW, Harvey BC, Grewal NK, George EE. The relationship between minute ventilation and end tidal CO2 in intubated and spontaneously breathing patients undergoing procedural sedation. PLoS One 2017; 12:e0180187. [PMID: 28662195 PMCID: PMC5491149 DOI: 10.1371/journal.pone.0180187] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 06/12/2017] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Monitoring respiratory status using end tidal CO2 (EtCO2), which reliably reflects arterial PaCO2 in intubated patients under general anesthesia, has often proven both inaccurate and inadequate when monitoring non-intubated and spontaneously breathing patients. This is particularly important in patients undergoing procedural sedation (e.g., endoscopy, colonoscopy). This can be undertaken in the operating theater, but is also often delivered outside the operating room by non-anesthesia providers. In this study we evaluated the ability for conventional EtCO2 monitoring to reflect changes in ventilation in non-intubated surgical patients undergoing monitored anesthesia care and compared and contrasted these findings to both intubated patients under general anesthesia and spontaneously breathing volunteers. METHODS Minute Ventilation (MV), tidal volume (TV), and respiratory rate (RR) were continuously collected from an impedance-based Respiratory Volume Monitor (RVM) simultaneously with capnography data in 160 patients from three patient groups: non-intubated surgical patients managed using spinal anesthesia and Procedural Sedation (n = 58); intubated surgical patients under General Anesthesia (n = 54); and spontaneously breathing Awake Volunteers (n = 48). EtCO2 instrument sensitivity was calculated for each patient as the slope of a Deming regression between corresponding measurements of EtCO2 and MV and expressed as angle from the x-axis (θ). All data are presented as mean ± SD unless otherwise indicated. RESULTS While, as expected, EtCO2 and MV measurements were negatively correlated in most patients, we found gross systematic differences across the three cohorts. In the General Anesthesia patients, small changes in MV resulted in large changes in EtCO2 (high sensitivity, θ = -83.6 ± 9.9°). In contrast, in the Awake Volunteers patients, large changes in MV resulted in insignificant changes in EtCO2 (low sensitivity, θ = -24.7 ± 19.7°, p < 0.0001 vs General Anesthesia). In the Procedural Sedation patients, EtCO2 sensitivity showed a bimodal distribution, with an approximately even split between patients showing high EtCO2 instrument sensitivity, similar to those under General Anesthesia, and patients with low EtCO2 instrument sensitivity, similar to the Awake Volunteers. CONCLUSIONS When monitoring non-intubated patients undergoing procedural sedation, EtCO2 often provides inadequate instrument sensitivity when detecting changes in ventilation. This suggests that augmenting standard patient care with EtCO2 monitoring is a less than optimal solution for detecting changes in respiratory status in non-intubated patients. Instead, adding direct monitoring of MV with an RVM may be preferable for continuous assessment of adequacy of ventilation in non-intubated patients.
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Affiliation(s)
- Jaideep H. Mehta
- Department of Anesthesiology, The University of Texas Health Science Center at Houston, Houston, Texas, United States of America
| | - George W. Williams
- Department of Anesthesiology, The University of Texas Health Science Center at Houston, Houston, Texas, United States of America
| | - Brian C. Harvey
- Respiratory Motion, Inc. Waltham, Massachusetts, United States of America
| | - Navneet K. Grewal
- Department of Anesthesiology, The University of Texas Health Science Center at Houston, Houston, Texas, United States of America
| | - Edward E. George
- Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
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Oral capnography is more effective than nasal capnography during sedative upper gastrointestinal endoscopy. J Clin Monit Comput 2017; 32:321-326. [DOI: 10.1007/s10877-017-0029-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 05/06/2017] [Indexed: 01/08/2023]
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Affiliation(s)
- Amit Rastogi
- University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Sachin Wani
- University of Colorado, Aurora, Colorado, USA
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Kochhar GS, Gill A, Vargo JJ. On the Horizon: The Future of Procedural Sedation. Gastrointest Endosc Clin N Am 2016; 26:577-92. [PMID: 27372779 DOI: 10.1016/j.giec.2016.03.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Sedation plays an integral part in endoscopy. By achieving patient comfort, it allows for a better examination and enhances patient satisfaction. Various medications have been used, propofol being the current favorite. With emphasis on patient safety and quality of endoscopy, various new medications in different combinations are being used to achieve adequate sedation and not escalate the cost of the procedure. With the advent of newer medications and newer modalities to administer these medications, there is need for more specialized training for the endoscopist to feel comfortable while using these medications.
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Affiliation(s)
- Gursimran S Kochhar
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Anant Gill
- Saraswathi Institute of Medical Sciences, Anwarpur, Uttar Pradesh, India
| | - John J Vargo
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic, Cleveland Clinic Foundation, A-30, 9500 Euclid Avenue, Cleveland, OH, USA.
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