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Zheng L, Ye M, Ma J, Jin C, Yang Y, Li H, Zheng R, Wang Y. Effects of adding adjuvants to propofol on the post-anesthesia cognitive function in patients undergoing gastroscopy/colonoscopy: a systematic review and meta-analysis. Expert Opin Drug Saf 2024; 23:995-1005. [PMID: 38217432 DOI: 10.1080/14740338.2024.2305705] [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: 06/08/2023] [Accepted: 11/28/2023] [Indexed: 01/15/2024]
Abstract
OBJECTIVES This study aimed to elucidate the effects of propofol plus adjuvants on postoperative cognitive dysfunction (POCD) and patient satisfaction. METHODS Studies published up to September 2023 on the Chinese National Knowledge Infrastructure (CNKI), Wanfang Data, Sinomed, PubMed, Embase, Cochrane Library, Web of Science, and Clinictrials.gov websites were searched. Binary summary of results was used for meta-analyses. RESULTS We included 18 studies (2691 patients). The combined sedation did not affect the processing speed (ES = 0.02, 95%CI: -0.01, 0.04; I2 = 79.3%, p < 0.001), attention (ES = 0.02, 95%CI: -0.02, 0.05; I2 = 95.0%, p < 0.001), nor working memory (ES = 0.02, 95%CI: -0.03, 0.06; I2 = 94.4%, p < 0.001) in CogState brief battery tool. A significant effect of combined sedation was observed in the domain of visual learning in CogState tool (ES = -0.03, 95%CI: -0.04, -0.02; I2 = 15.8%, p = 0.306). The TDT (ES = 4.96, 95%CI: 2.92, 7.00) indicates that combined sedation would increase error rates in the tests of cognitive function. The DSST (ES = 0.16, 95% CI: -0.44, 0.75) shown that combined sedation does not affect cognitive function. In addition, an insignificant difference in patient satisfaction between combined sedation and propofol alone was observed (ES = -0.03, 95%CI: -0.09, 0.02). CONCLUSION The available evidence suggests that propofol combined with adjuvants may affect POCD but not patient satisfaction. REGISTRATION NUMBER INPLASY2023110092.
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Affiliation(s)
- Liupu Zheng
- Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Mengqian Ye
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Jun Ma
- Division of Epidemiology and Biostatistics, School of Public Health and Management, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Chen Jin
- Division of Epidemiology and Biostatistics, School of Public Health and Management, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Yan Yang
- Division of Epidemiology and Biostatistics, School of Public Health and Management, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Haoqi Li
- Division of Epidemiology and Biostatistics, School of Public Health and Management, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Rongyuan Zheng
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Yi Wang
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
- Division of Epidemiology and Biostatistics, School of Public Health and Management, Wenzhou Medical University, Wenzhou, Zhejiang, China
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Sun Q, Cheng J, Lei W, Lu X, Huang Y, Sun J. The effects of remimazolam combined with sufentanil on respiration, circulation and sedation level in patients undergoing colonoscopy. BMC Anesthesiol 2024; 24:252. [PMID: 39054423 PMCID: PMC11271046 DOI: 10.1186/s12871-024-02644-0] [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: 08/09/2023] [Accepted: 07/17/2024] [Indexed: 07/27/2024] Open
Abstract
BACKGROUND The main sedative which is propofol in painless gastroenteroscopy, has a high risk of reducing blood pressure and respiratory depression. Remimazolam (a short-acting benzodiazepine) is expected to be widely used in painless gastroenteroscopy due to its rapid onset, rapid metabolism and light respiratory and circulation inhibition. METHODS A randomized, single-blind, parallel, controlled study, 123 outpatients who were undergoing painless colonoscopy and ramdomly divided into group A, B and C, in Hangzhou First People's Hospital, July-December 2021. All patients were intravenously injected with 5 µg sufentanil for analgesic preconditioning. The group A was induced by 0.2 mg/kg remimazolam besylate. The group B was induced by 0.25 mg/kg remimazolam besylate. And the group C was inducted by 2.0 mg /kg propofol. If the patients had limb movement or MOAA/S score > 3 and so on, remimazolam besylate was added at 2.5 mg/ time in group A and B, and propofol emulsion injection was added at 0.5 mg/kg/ time in group C. During the operation, according to the actual situation, remimazolam was per added 2.5 mg in the experimental group, and propofol was 0.5 mg/kg in the control group. Heart rate (HR), non-invasive blood pressure (BP), respiratory rate (RR), pulse oxygen saturation (SpO2), and improved vigilance/sedation score (MOAA/S) of patients was recorded from entering endoscopy room to get out of the anesthesia recovery room, also including perioperative adverse events, other medications or treatments, the time of patients waking up and leaving the hospital. RESULTS The successful rate of induction in three groups was 100%. There was no significant difference in the sedation completion rate among the three groups (Group A:90.2%, Group B: 92.7%, Group C: 92.7%, P = 1.000). The rate of adverse events after administration: group A(27.0%) and B(36.8%) both lower than group C(71.0%),P < 0.001;There was no significant difference between group A and group B, P > 0.744;The average time from the last drug administration to meet the discharge criteria of the subjects in three groups was as follows: The average time of group A(16.2 min) and Group B(16.5 min) both shorter than group C(19.6 min), P = 0.001; There was no significant difference between group A and group B, P = 0.742. CONCLUSIONS This study revealed that remimazolam is a safe and effective medication for colonoscopy sedation, the security of remimazolam is better than propofol, and the sedative effect with the initial dose of 0.25 mg/kg of remimazolam is optimal. TRIAL REGISTRATION China Clinical Trial Center with registration number: 2100052615,02/11/2021.
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Affiliation(s)
- Qirui Sun
- Department of Anesthesiology, Chengbei Branch of Hangzhou First People's Hospital (Hangzhou Geriatric Hospital), Hangzhou, 310000, China
- Department of Anesthesiology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, 310000, China
- School of Second Clinical Medical College, Wenzhou Medical University, Wenzhou, 310053, Zhejiang, China
| | - Jiating Cheng
- School of Second Clinical Medical College, Wenzhou Medical University, Wenzhou, 310053, Zhejiang, China
- Department of Anesthesiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, 310016, China
| | - Weiping Lei
- Department of Anesthesiology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, 310000, China
| | - Xinlei Lu
- Department of Anesthesiology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, 310000, China
| | - Yaqin Huang
- Department of Anesthesiology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, 310000, China
| | - Jianliang Sun
- Department of Anesthesiology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, 310000, China.
- School of Second Clinical Medical College, Wenzhou Medical University, Wenzhou, 310053, Zhejiang, China.
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Walayat S, Stadmeyer P, Hameed A, Sarfaraz M, Estrada P, Benson M, Soni A, Pfau P, Hayes P, Kile B, Cruz T, Gopal D. Sedation reversal trends at outpatient ambulatory endoscopic center vs in-hospital ambulatory procedure center using a triage protocol. World J Gastrointest Endosc 2024; 16:413-423. [PMID: 39072249 PMCID: PMC11271719 DOI: 10.4253/wjge.v16.i7.413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 05/22/2024] [Accepted: 06/19/2024] [Indexed: 07/08/2024] Open
Abstract
BACKGROUND Routine outpatient endoscopy is performed across a variety of outpatient settings. A known risk of performing endoscopy under moderate sedation is the potential for over-sedation, requiring the use of reversal agents. More needs to be reported on rates of reversal across different outpatient settings. Our academic tertiary care center utilizes a triage tool that directs higher-risk patients to the in-hospital ambulatory procedure center (APC) for their procedure. Here, we report data on outpatient sedation reversal rates for endoscopy performed at an in-hospital APC vs at a free-standing ambulatory endoscopy digestive health center (AEC-DHC) following risk stratification with a triage tool. AIM To observe the effect of risk stratification using a triage tool on patient outcomes, primarily sedation reversal events. METHODS We observed all outpatient endoscopy procedures performed at AEC-DHC and APC from April 2013 to September 2019. Procedures were stratified to their respective sites using a triage tool. We evaluated each procedure for which sedation reversal with flumazenil and naloxone was recorded. Demographics and characteristics recorded include patient age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, procedure type, and reason for sedation reversal. RESULTS There were 97366 endoscopic procedures performed at AEC-DHC and 22494 at the APC during the study period. Of these, 17 patients at AEC-DHC and 9 at the APC underwent sedation reversals (0.017% vs 0.04%; P = 0.06). Demographics recorded for those requiring reversal at AEC-DHC vs APC included mean age (53.5 ± 21 vs 60.4 ± 17.42 years; P = 0.23), ASA class (1.66 ± 0.48 vs 2.22 ± 0.83; P = 0.20), BMI (27.7 ± 6.7 kg/m2 vs 23.7 ± 4.03 kg/m2; P = 0.06), and female gender (64.7% vs 22%; P = 0.04). The mean doses of sedative agents and reversal drugs used at AEC-DHC vs APC were midazolam (5.9 ± 1.7 mg vs 8.9 ± 3.5 mg; P = 0.01), fentanyl (147.1 ± 49.9 μg vs 188.9 ± 74.1 μg; P = 0.10), flumazenil (0.3 ± 0.18 μg vs 0.17 ± 0.17 μg; P = 0.13) and naloxone (0.32 ± 0.10 mg vs 0.28 ± 0.12 mg; P = 0.35). Procedures at AEC-DHC requiring sedation reversal included colonoscopies (n = 6), esophagogastroduodenoscopy (EGD) (n = 9) and EGD/colonoscopies (n = 2), whereas APC procedures included EGDs (n = 2), EGD with gastrostomy tube placement (n = 1), endoscopic retrograde cholangiopancreatography (n = 2) and endoscopic ultrasound's (n = 4). The indications for sedation reversal at AEC-DHC included hypoxia (n = 13; 76%), excessive somnolence (n = 3; 18%), and hypotension (n = 1; 6%), whereas, at APC, these included hypoxia (n = 7; 78%) and hypotension (n = 2; 22%). No sedation-related deaths or long-term post-sedation reversal adverse outcomes occurred at either site. CONCLUSION Our study highlights the effectiveness of a triage tool used at our tertiary care hospital for risk stratification in minimizing sedation reversal events during outpatient endoscopy procedures. Using a triage tool for risk stratification, low rates of sedation reversal can be achieved in the ambulatory settings for EGD and colonoscopy.
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Affiliation(s)
- Saqib Walayat
- Department of Gastroenterology, University of Illinois, Peoria, IL 61605, United States
| | - Peter Stadmeyer
- Department of Gastroenterology, University of Wisconsin, Madison, WI 53792, United States
| | - Azfar Hameed
- Department of Internal Medicine, Texas Health Denton, Denton, TX 76201, United States
| | - Minahil Sarfaraz
- Department of Internal Medicine, Allama Iqbal Medical College, Lahore 042, Pakistan
| | - Paul Estrada
- Department of Gastroenterology, Texas Tech University Health Services Center, El Paso, TX 79911, United States
| | - Mark Benson
- Department of Gastroenterology and Hepatology, University of Wisconsin, Madison, WI 53705, United States
| | - Anurag Soni
- Department of Gastroenterology and Hepatology, University of Wisconsin, Madison, WI 53705, United States
| | - Patrick Pfau
- Department of Gastroenterology and Hepatology, University of Wisconsin, Madison, WI 53705, United States
| | - Paul Hayes
- Finance Business Partners UW Health, University of Wisconsin, Madison, WI 53792, United States
| | - Brittney Kile
- UW Health Digestive Health Center Endoscopy, University of Wisconsin, Madison, WI 53792, United States
| | - Toni Cruz
- UW Health Digestive Health Center Endoscopy, University of Wisconsin, Madison, WI 53792, United States
| | - Deepak Gopal
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin Hospitals and Clinics, Madison, WI 53705, United States
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Zhang J, Liu R, Bi R, Li X, Xu M, Li L, Su Y, Yan W. Comparison of ciprofol-alfentanil and propofol-alfentanil sedation during bidirectional endoscopy: A prospective, double-blind, randomised, controlled trial. Dig Liver Dis 2024; 56:663-671. [PMID: 37813808 DOI: 10.1016/j.dld.2023.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 09/05/2023] [Accepted: 09/14/2023] [Indexed: 10/11/2023]
Abstract
BACKGROUND Although propofol is widely used for gastrointestinal endoscopic sedation, cardiopulmonary adverse events remain common. Ciprofol is a new intravenous anaesthetic agent demonstrating respiratory and hemodynamic stability. AIMS This study aimed to clarify the benefits of ciprofol combined with alfentanil in bidirectional endoscopy (esophagogastroduodenoscopy followed by colonoscopy) to reduce adverse events and improve post-endoscopic recovery. METHODS A total of 185 patients scheduled to undergo bidirectional endoscopy were randomly divided into two groups: ciprofol combined with alfentanil or propofol combined with alfentanil. All patients received 7 µg/kg alfentanil intravenously before the study drugs were administered. The propofol group received a bolus of 1.2 mg/kg (0.12 ml/kg) propofol intravenously, whereas the ciprofol group received a bolus of 0.3 mg/kg (0.12 ml/kg) ciprofol intravenously. The primary outcome was the proportion of patients with cardiopulmonary adverse events (i.e., any one of the airway obstruction, apnoea, hypotension, hypertension, bradycardia, tachycardia or arrhythmias). RESULTS Compared with propofol, ciprofol reduced cardiopulmonary adverse events by 43.51 % (34.4% vs. 60.9 %, P <0.001), mitigated respiratory adverse events by 54.74 % (17.2% vs. 38.0 %, P = 0.002) overall and by 59.05 % (12.9% vs. 31.5 %, P = 0.002) during the induction period. CONCLUSIONS Ciprofol can significantly decrease respiratory depression events and provides a better sedative efficacy than propofol with higher recovery quality and satisfaction.
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Affiliation(s)
- Jiqiang Zhang
- Department of Anaesthesiology, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ruijuan Liu
- Department of Anaesthesiology, Gansu Provincial Hospital, No. 204 Dong-gang West Road, Lanzhou, Gansu 730030, China; Ningxia Medical University School of Clinical Medicine, Yinchuan, China
| | - Ruirui Bi
- Department of Anaesthesiology, Gansu Provincial Hospital, No. 204 Dong-gang West Road, Lanzhou, Gansu 730030, China
| | - Xia Li
- Department of Anaesthesiology, Gansu Provincial Hospital, No. 204 Dong-gang West Road, Lanzhou, Gansu 730030, China
| | - Mengjun Xu
- Department of Anaesthesiology, Gansu Provincial Hospital, No. 204 Dong-gang West Road, Lanzhou, Gansu 730030, China
| | - Lijuan Li
- Department of Anaesthesiology, Gansu Provincial Hospital, No. 204 Dong-gang West Road, Lanzhou, Gansu 730030, China; First School of Clinical Medicine, Lanzhou University, Lanzhou, China
| | - Yuxi Su
- Department of Anaesthesiology, Gansu Provincial Hospital, No. 204 Dong-gang West Road, Lanzhou, Gansu 730030, China
| | - Wenjun Yan
- Department of Anaesthesiology, Gansu Provincial Hospital, No. 204 Dong-gang West Road, Lanzhou, Gansu 730030, China.
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Park I, Kim J, Chung SH, Na HS, Do SH. Effects of remimazolam combined with remifentanil on quality of recovery after ambulatory hysteroscopic surgery: a prospective, observational study. Anesth Pain Med (Seoul) 2024; 19:44-53. [PMID: 38311354 PMCID: PMC10846998 DOI: 10.17085/apm.23102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 11/02/2023] [Accepted: 11/02/2023] [Indexed: 02/08/2024] Open
Abstract
BACKGROUND Remimazolam, a new benzodiazepine, is known for its quick onset of effects and recovery time. Recently, it has been licensed for general anesthesia and sedation in Korea and its use is increasing in other countries. However, less is known about its effect on postoperative recovery. We used a patient-reported outcome questionnaire to examine the effect of remimazolam on postoperative recovery. METHODS Patients who underwent hysteroscopy on day surgery basis were administered an induction dose of remimazolam 6 mg/kg/h followed by a maintenance dose of 1-2 mg/kg/h. After surgery, the translated Korean version of 15-item Quality of Recovery scale (QoR-15K) including post-discharge nausea and vomiting (PDNV) and/or pain, was surveyed 24 h after surgery to evaluate patient recovery. RESULTS Total of 38 patients were enrolled in this prospective, observational study. All patients successfully completed QoR-15K. Only one patient scored low for moderate pain and PDNV. On average, patients scored 9 and above for all QoR-15K items except for moderate pain (8.66 ± 1.68). When QoR-15K items were grouped into dimensions, all dimensions scored an average of 9 or higher on a 10-point scale. In addition, 19 out of 38 patients gave score range of 148 to 150 out of possible 150. CONCLUSIONS Psychometric evaluation based on postoperative QoR-15K among patients receiving remimazolam shows satisfactory patient recovery profiles without significant pain or PDNV. Considering its effectiveness and safety, remimazolam could be one of useful agents for general anesthesia of day surgery in terms of postoperative recovery.
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Affiliation(s)
- Insun Park
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Junkyu Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Seung Hyun Chung
- Department of Anesthesiology and Pain Medicine, Uijeongbu Eulji Medical Center, Eulji University, Uijeongbu, Korea
| | - Hyo-Seok Na
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sang-Hwan Do
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
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Kim SH, Cho JY, Kim M, Chung JM, Yang J, Seong C, Kim EG, Seok JW, Shin YM, Lee KM, Choe KH, Han JH, Yang B. Safety and efficacy of remimazolam compared with midazolam during bronchoscopy: a single-center, randomized controlled study. Sci Rep 2023; 13:20498. [PMID: 37993525 PMCID: PMC10665376 DOI: 10.1038/s41598-023-47271-w] [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: 08/21/2023] [Accepted: 11/11/2023] [Indexed: 11/24/2023] Open
Abstract
Although remimazolam is an ultra-short-acting benzodiazepine with a shorter elimination half-life and faster recovery time than midazolam, studies evaluating its safety and efficacy during bronchoscopy are limited. This study aimed to compare the safety and efficacy of remimazolam with those of midazolam for bronchoscopy. This prospective randomized parallel-group study was conducted at a single institution. The primary outcome was the time from the end of the procedure to full alertness. Other procedural time parameters, satisfaction profiles, and adverse effects were thoroughly evaluated. The time taken to reach peak sedation and the time from the end of the procedure to full alertness was significantly shorter in the remimazolam group than in the midazolam group (median [interquartile range], 2 min [1-4] vs. 3 min [2-5], P = 0.006; and median, 2 min [1-5] vs. 5 min [1-12], P = 0.035, respectively). In patients with non-biopsy procedures (n = 79), participant satisfaction was significantly higher in the remimazolam group than in the midazolam group (median rated scale, 10 vs. 7, P = 0.042). Physician satisfaction and willingness to repeat the procedure were similar between groups. Although the incidence of adverse effects was similar between the groups and there was no significant difference, the midazolam group had a higher antidote administration rate than the remimazolam group (15.7% vs. 4.1%, P = 0.092). Remimazolam is effective and safe for achieving adequate sedation, with a shorter onset time and faster neuropsychiatric recovery than midazolam. It may be a new option for sedation during bronchoscopy.Trial registration: The trial registration number is NCT05994547, and the date of first registration is 16/08/2023.
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Affiliation(s)
- Sun-Hyung Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Jun Yeun Cho
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Miyeon Kim
- Academic Cooperation Foundation, Chungbuk National University Industry, Cheongju, Korea
| | - Ji Min Chung
- Red Cross College of Nursing, Chung-Ang University, Seoul, Korea
| | - Jiyoul Yang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Changhwan Seong
- Department of Clinical Pharmacology & Therapeutics, Chungbuk National University Hospital, Cheongju, Korea
| | - Eung-Gook Kim
- Department of Biochemistry, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Jeong Won Seok
- Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Yoon Mi Shin
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Ki Man Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Kang Hyeon Choe
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Joung-Ho Han
- Division of Gastroenterology, Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea.
| | - Bumhee Yang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea.
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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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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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Xiong Y, Yan H, Qu L, Wang S, Meng X, Zhu X, Zhang P, Yuan S, Shi J. Global Trends of Gastrointestinal Endoscopy Anesthesia/Sedation: A Bibliometric Study (from 2001 to 2022). J Pain Res 2023; 16:2393-2406. [PMID: 37483407 PMCID: PMC10356960 DOI: 10.2147/jpr.s408811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 07/06/2023] [Indexed: 07/25/2023] Open
Abstract
Background Gastrointestinal (GI) endoscopy becomes more and more common now in order to diagnose and treat GI diseases, and anesthesia/sedation plays an important role. We aim to discuss the developmental trends and evaluate the research hotspots using bibliometric methods for GI endoscopy anesthesia/sedation in the past two decades. Methods The original and review articles published from 2001 to December 2022 related to GI endoscopy anesthesia/sedation were extracted from the Web of Science database. Four different softwares (CiteSpace, VOSviewer, and Bibliometrix, Online Analysis Platform of Literature Metrology (Bibliometric)) were used for this comprehensive analysis. Results According to our retrieval strategy, we found a total of 3154 related literatures. Original research articles were 2855, and reviews were 299. There has been a substantial increase in the research on GI endoscopy anesthesia/sedation in recent 22 years. These publications have been cited 66,418 times, with a mean of 21.04 citations per publication. The US maintained a leading position in global research, with the largest number of publications (29.94%), and China ranked second (19.92%). Keyword burst and concurrence showed that conscious sedation, colonoscopy and midazolam were the most frequently occurring keywords. Conclusion Our research found that GI endoscopy anesthesia/sedation was in a period of rapid development and demonstrated the improvement of medical instruments and surgical options that had significantly contributed to the field of GI endoscopy anesthesia/sedation. The US dominates this field, and the selection and dosage of sedative regimens have always been the foci of disease research to improve comfort and safety, while adverse events and risks arouse attention gradually. In the past 20 years, hotspots mainly focus on upper gastrointestinal endoscopy, gastroscopy, and esophagogastroduodenoscopy. These data would provide future directions for clinicians and researchers regarding GI endoscopy anesthesia/sedation.
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Affiliation(s)
- Yujun Xiong
- Department of Gastroenterology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
| | - Haoqi Yan
- Department of Anesthesiology, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences; Peking Union Medical College, Beijing, 100037, People’s Republic of China
| | - Lang Qu
- Department of Anesthesiology, Shanghai General Hospital, Shanghai, People’s Republic of China
| | - Shuqi Wang
- Department of Otolaryngology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, People’s Republic of China
| | - Xiangda Meng
- Department of Neurosurgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Xingyun Zhu
- Department of Endocrinology, Beijing Jishuitan Hospital, Beijing, People’s Republic of China
| | - Pan Zhang
- Department of Gastroenterology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
| | - Su Yuan
- Department of Anesthesiology, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences; Peking Union Medical College, Beijing, 100037, People’s Republic of China
| | - Jihua Shi
- Department of Gastroenterology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
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10
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Hao XW, Zhan YL, Li P, Zhang ST, Yan XD, Li XM, Xiang W. Recovery of driving skills after endoscopy under propofol sedation: a prospective pilot study to assess the driving skills after endoscopic sedation using driving simulation. BMC Anesthesiol 2023; 23:223. [PMID: 37355565 PMCID: PMC10290334 DOI: 10.1186/s12871-023-02122-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 05/03/2023] [Indexed: 06/26/2023] Open
Abstract
BACKGROUND Patients are recommended not to drive for at least the first 24 h after endoscopy with propofol sedation. However, the evidence underlying these recommendations is scarce. We hypothesized that after endoscopic procedures performed under propofol sedation, the subject's driving ability was restored in less than 24 h. METHODS We prospectively enrolled thirty patients between 20 and 70 years possessing a legitimate driver's license scheduled for endoscopy at our hospital. The sample chosen was a convenience sample. Gastroscopy or colonoscopy was performed with propofol sedation. Before and after endoscopy, the investigator drove the subjects to the laboratory to assess their driving skills using a driving simulation system, which employs 3 driving scenarios designed by professional transportation researchers. The blood propofol concentration was estimated before endoscopy, and 2 and 4 h after endoscopy. The primary outcome was the time required for subjects to recover their driving ability after propofol sedation. The secondary outcome was the blood propofol concentration before and after endoscopic procedures under propofol anesthesia. RESULTS Thirty volunteers participated in the study and 18 of them completed all the interventions. In the low-risk S-curve scene, the mean acceleration, lane deviation, and number of deviations from the path at baseline (0.016 cm/s2, 42.50 cm, and 0.83, respectively) were significantly less than that at post-2 h (0.029 cm/s2, P = 0.001; 53.80 cm, P = 0.014; 2.06, P = 0.022). In the moderate-(overtaking) and high-risk (emergency collision avoidance) scenes, the tested parameters at baseline and post-2 h were statistically comparable. In the low-, moderate-, and high-risk scenes the tested parameters at baseline and post-4 h were statistically comparable. The total range of propofol was 120-280 mg.The mean blood concentration of propofol at post-2 h was 0.81 ± 0.40 µg/mL, and at post-4 h was below the limit of detection. CONCLUSION After endoscopy performed under propofol sedation, subjects' driving abilities were completely restored at 4 h when tested on a simulator.
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Affiliation(s)
- Xiao-Wen Hao
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Beijing, 100050, China
| | - Yuan-Lin Zhan
- Psychiatry Department, Beijing Hai-Dian Hospital, Beijing, 100080, China
| | - Peng Li
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Beijing, 100050, China.
| | - Shu-Tian Zhang
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Beijing, 100050, China
| | - Xue-Dong Yan
- MOT Key Laboratory of Transport Industry of Big Data Application Technologies for Comprehensive Transport, Beijing Jiaotong University, Beijing, 100044, China
| | - Xiao-Meng Li
- Centre for Accident Research and Road Safety-Queensland (CARRS-Q), Queensland University of Technology (QUT), Kelvin Grove, QLD, 4059, Australia
| | - Wang Xiang
- School of Traffic & Transportation Engineering, Changsha University of Science & Technology, Changsha, 410114, China
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11
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Qiu Y, Gu W, Zhao M, Zhang Y, Wu J. The hemodynamic stability of remimazolam compared with propofol in patients undergoing endoscopic submucosal dissection: A randomized trial. Front Med (Lausanne) 2022; 9:938940. [PMID: 36004376 PMCID: PMC9394743 DOI: 10.3389/fmed.2022.938940] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 07/12/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveHypotension is common in propofol anesthesia. Whether remimazolam could reduce intraoperative hypotension remains unknown. We therefore tested the primary hypothesis that remimazolam reduces the incidence of intraoperative hypotension compared with propofol in adult patients undergoing endoscopic submucosal dissection (ESD) surgery.Materials and methodsWe conducted a prospective trial to compare patients who received either remimazolam or propofol bolus induction and thereafter intravenous infusion. The hemodynamic parameters were measured using CNAP® Monitor 500 system. Our primary analysis was to compare the incidence of hypotension defined as systolic blood pressure below 90 mmHg between remimazolam and propofol during the whole anesthesia period.ResultsThe incidence of hypotension decreased by 50%, from 67.9% in propofol group to 32.1% in remimazolam group (p < 0.01). Patients received less amount of intraoperative phenylephrine in the remimazolam group than the propofol group (0 [0–40] μg vs. 80 [0–200] μg, p < 0.01). Time-weighted average and cumulative time of hypotension was lower in remimazolam group compared with propofol group (p < 0.05). Cardiac output continuously measured by CNAP was preserved much better in remimazolam group compared with propofol group (p = 0.01), while systemic vascular resistance did not differ between the groups. The median time from discontinuation until full alertness was 4 [3–11.8] min in the remimazolam group compared with 15 [12.0–19.8] min in the propofol group (p < 0.01).ConclusionRemimazolam has better hemodynamic stability than propofol in adult patients undergoing ESD surgery. The benefits of remimazolam on hemodynamic stability and hypotension prevention may be partly contributed to its better preservation of cardiac output.Clinical Trial Registration[http://www.chictr.org.cn/com/25/showproj.aspx?proj=61104], identifier [ChiCTR2000037975].
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Affiliation(s)
- Yuwei Qiu
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
- Outcomes Research Consortium, Cleveland, OH, United States
| | - Wei Gu
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Mingye Zhao
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yunyun Zhang
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jingxiang Wu
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
- Outcomes Research Consortium, Cleveland, OH, United States
- *Correspondence: Jingxiang Wu,
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12
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Park I, Cho M, Nam SW, Hwang JW, Do SH, Na HS. Total intravenous anesthesia induced and maintained by a combination of remimazolam and remifentanil without a neuromuscular blocking agent: a prospective, observational pilot study. BMC Anesthesiol 2022; 22:237. [PMID: 35883039 PMCID: PMC9316331 DOI: 10.1186/s12871-022-01779-2] [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: 04/12/2022] [Accepted: 07/20/2022] [Indexed: 11/26/2022] Open
Abstract
Background A novel short-acting benzodiazepine, Remimazolam, has recently been approved for general anesthesia and sedation. Hence, we investigated the feasibility and safety of remimazolam during the induction and maintenance of general anesthesia without using a neuromuscular blocking agent (NMBA) in patients undergoing hysteroscopic surgery. Methods This prospective observational study included 38 patients undergoing hysteroscopic surgery. Remimazolam and remifentanil were the main anesthetic agents without an NMBA, and a supraglottic airway was inserted to protect the airway. The induction time, amount of each anesthetic agent used during anesthesia, intraoperative bispectral index (BIS) hemodynamic parameters, and recovery profiles were measured. Results General anesthesia was successfully administered to 37 patients using remimazolam and remifentanil without NMBA. The induction doses of remimazolam and remifentanil were 0.4 mg/kg (interquartile range [IQR] 0.34–0.47 mg/kg) and 1.07 μg/kg (IQR, 0.90–1.29 μg/kg), respectively. Additionally, the maintenance doses of remimazolam and remifentanil were 1.14 mg/kg/h (IQR, 0.88–1.55 mg/kg/h) and 0.06 μg/kg/min (IQR, 0.04–0.08 μg/kg/min), respectively. Intraoperative BIS values had risen temporarily > 60 in eight patients (21.6%) despite administration of 2 mg/kg/h of remimazolam; thus, they were treated with supplementary midazolam. The median recovery time was 7 min (IQR, 5–8 min) after 40 min (IQR, 40.0–57.5 min) of total mean anesthesia time. There was no correlation between the infusion dose of remimazolam and recovery profiles, such as recovery time, final BIS of anesthesia, modified observer assessment of alertness/sedation (OAA/S) scale or post-anesthesia recovery (PAR) score when arriving at the PACU, and length of stay in the PACU (all P > 0.05). Conclusion Remimazolam can be combined with remifentanil without an NMBA in female patients who undergo hysteroscopic surgery, during which a supraglottic airway is a feasible method to protect the airway. Trial registration The study protocol was registered at ClinicalTrials.gov (NCT05025410) on 27/08/2021.
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Affiliation(s)
- Insun Park
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, 82, Gumi 173, Bundang, Seongnam, Gyeonggi, 13620, Republic of Korea
| | - Mincheul Cho
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, 82, Gumi 173, Bundang, Seongnam, Gyeonggi, 13620, Republic of Korea
| | - Sun Woo Nam
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, 82, Gumi 173, Bundang, Seongnam, Gyeonggi, 13620, Republic of Korea
| | - Jung-Won Hwang
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, 82, Gumi 173, Bundang, Seongnam, Gyeonggi, 13620, Republic of Korea
| | - Sang-Hwan Do
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, 82, Gumi 173, Bundang, Seongnam, Gyeonggi, 13620, Republic of Korea
| | - Hyo-Seok Na
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, 82, Gumi 173, Bundang, Seongnam, Gyeonggi, 13620, Republic of Korea.
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13
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Crawford E, Sabe R, Sferra TJ, Apperson-Hansen C, Khalili AS. Pediatric endoscopy across multiple clinical settings: Efficiency and adverse events. World J Gastrointest Endosc 2022; 14:367-375. [PMID: 35978713 PMCID: PMC9265253 DOI: 10.4253/wjge.v14.i6.367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 03/29/2022] [Accepted: 05/23/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Endoscopic procedures are becoming increasingly important for the diagnosis and treatment of gastrointestinal disorders during childhood, and have evolved from a more infrequent inpatient procedure in the operating room to a routine outpatient procedure conducted in multiple care settings. Demand for these procedures is rapidly increasing and thus there is a need to perform them in an efficient manner. However, there are little data comparing the efficiency of pediatric endoscopic procedures in diverse clinical environments. We hypothesized that there are significant differences in efficiency between settings.
AIM To compare the efficiency and examine adverse effects of pediatric endoscopic procedures across three clinical settings.
METHODS A retrospective chart review was conducted on 1623 cases of esophagogastroduodenoscopy (EGD) or combined EGD and colonoscopy performed between January 1, 2014 and May 31, 2018 by 6 experienced pediatric gastroenterologists in three different clinical settings, including a tertiary care hospital operating room, community hospital operating room, and free-standing pediatric ambulatory endoscopy center at a community hospital. The following strict guidelines were used to schedule patients at all three locations: age greater than 6 mo; American Society of Anesthesiologists class 1 or 2; normal craniofacial anatomy; no anticipated therapeutic intervention (e.g., foreign body retrieval, stricture dilation); and, no planned or anticipated hospitalization post-procedure. Data on demographics, times, admission rates, and adverse events were collected. Endoscopist time (elapsed time from the endoscopist entering the operating room or endoscopy suite to the next patient entering) and patient time (elapsed time from patient registration to that patient exiting the operating room or endoscopy suite) were calculated to assess efficiency.
RESULTS In total, 58% of the cases were performed in the tertiary care operating room. The median age of patients was 12 years and the male-to-female ratio was nearly equal across all locations. Endoscopist time at the tertiary care operating room was 12 min longer compared to the community operating room (63.3 ± 21.5 min vs 51.4 ± 18.9 min, P < 0.001) and 7 min longer compared to the endoscopy center (vs 56.6 ± 19.3 min, P < 0.001). Patient time at the tertiary care operating room was 11 min longer compared to the community operating room (133.2 ± 39.9 min vs 122.3 ± 39.5 min, P < 0.001) and 9 min longer compared to the endoscopy center (vs 124.9 ± 37.9 min; P < 0.001). When comparing endoscopist and patient times for EGD and EGD/colonoscopies among the three locations, endoscopist, and patient times were again shorter in the community hospital and endoscopy center compared to the tertiary care operating room. Adverse events from procedures occurred in 0.1% (n = 2) of cases performed in the tertiary care operating room, with 2.2% (n = 35) of cases from all locations having required an unplanned admission after the endoscopy for management of a primary GI disorder.
CONCLUSION Pediatric endoscopic procedures can be conducted more efficiently in select patients in a community operating room and endoscopy center compared to a tertiary care operating room.
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Affiliation(s)
- Erin Crawford
- Department of Pediatrics, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, OH 44113, United States
| | - Ramy Sabe
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, OH 44106, United States
| | - Thomas J Sferra
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, OH 44106, United States
| | - Carolyn Apperson-Hansen
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH 44106, United States
| | - Ali S Khalili
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, OH 44106, United States
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14
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Steenholdt C, Jensen JT, Brynskov J, Møller AM, Limschou AC, Konge L, Vilmann P. Patient Satisfaction of Propofol Versus Midazolam and Fentanyl Sedation During Colonoscopy in Inflammatory Bowel Disease. Clin Gastroenterol Hepatol 2022; 20:559-568.e5. [PMID: 33371995 DOI: 10.1016/j.cgh.2020.10.037] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 08/17/2020] [Accepted: 10/20/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Colonoscopy is essential for optimal management of inflammatory bowel disease. However, many patients opt out due to unpleasantness related to this procedure. We investigated if Nurse Administered Propofol Sedation (NAPS) would improve patient satisfaction and attitude towards future colonoscopies. METHODS Randomized clinical trial of deep sedation with NAPS (n = 63) versus moderate midazolam and fentanyl sedation (n = 67). To assess the primary end point of patient satisfaction at discharge, we developed a Satisfaction Questionnaire comprising 13 items each rated by a 5-point Likert scale and with higher scores reflecting more positive outcomes (13-65 points). RESULTS Fifty-six patients (43%) with ulcerative colitis, 48 (37%) with Crohn's disease, and 26 (20%) with high suspicion of inflammatory bowel disease were included. Most (88%) had previously had a colonoscopy and pre-procedure expectations were similar between groups. Patients receiving deep sedation had significantly higher satisfaction score (mean 60.1, SD 3.4) than those receiving moderate sedation (51.2, 8.4; P < .001). This was driven especially by less pain, more amnesia, sedation more to their liking, and better experience with the current than previous sedations. Importantly, these patients significantly more often preferred the same sedation for a future colonoscopy and were also inclined to accept more frequent colonoscopies. Assistance from another colonoscopist and disruption of the procedure due to pain occurred significantly more frequent in the moderate sedation group. There were no safety signals associated with NAPS. CONCLUSIONS Patients with inflammatory bowel disease favor deep propofol sedation over moderate midazolam and fentanyl sedation. Availability of NAPS may facilitate patient adherence to endoscopy-based monitoring programs. Clinicaltrials.gov NCT01934088.
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Affiliation(s)
- Casper Steenholdt
- Department of Gastroenterology, Herlev-Gentofte University Hospital, Herlev, Denmark.
| | - Jeppe T Jensen
- Department of Gastroenterology, Herlev-Gentofte University Hospital, Herlev, Denmark
| | - Jørn Brynskov
- Department of Gastroenterology, Herlev-Gentofte University Hospital, Herlev, Denmark
| | - Ann Merete Møller
- Department of Anaesthesiology, Herlev-Gentofte University Hospital, Herlev, Denmark
| | | | - Lars Konge
- Copenhagen Academy for Medical Education and Simulation, University of Copenhagen and the Capital Region of Copenhagen, Copenhagen, Denmark
| | - Peter Vilmann
- Department of Gastroenterology, Herlev-Gentofte University Hospital, Herlev, Denmark
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15
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Fatima H, Imperiale T. Safety Profile of Endoscopist-directed Balanced Propofol Sedation for Procedural Sedation: An Experience at a Hospital-based Endoscopy Unit. J Clin Gastroenterol 2022; 56:e209-e215. [PMID: 34739402 DOI: 10.1097/mcg.0000000000001630] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 09/27/2021] [Indexed: 12/10/2022]
Abstract
BACKGROUND Nurse-administered propofol sedation was restricted to anesthesiologists in 2009, a practice that has contributed to spiraling health care costs in the United States. AIM The aim of this study was to evaluate the safety of endoscopist-directed balanced propofol sedation (EDBPS). MATERIALS AND METHODS We identified patients undergoing endoscopy with EDBPS from January 1, 2017, to June 20, 2017, and abstracted their medical records. Adverse events (AEs) included: hypoxia (oxygen saturation < 90%); hypotension [(a) systolic blood pressure < 90 mm Hg, (b) systolic blood pressure decline of >50 mm Hg, (c) decline in mean arterial pressure of >30%]; bradycardia (heart rate of < 40 beats/min). Logistic regression identified factors independently associated with AEs. RESULTS A total of 1897 patients received EDBPS during the study period [mean age: 55 y (SD=11.4 y); 56.4% women]. Patients received median doses of 50 µg fentanyl, 2 mg of midazolam, and a mean propofol dose of 160±99 mg. There were no major complications (upper 95% confidence interval, 0.19%). Overall, 334 patients (17.6%) experienced a clinically insignificant AE: 65 (3.4%) experienced transient hypoxia, 277 patients (14.6%) experienced hypotension, 2 had transient bradycardia. In bivariate analysis, older age was associated with risk for hypotension, propofol dose was associated with transient hypoxemia, and procedure duration was associated with both hypotension and transient hypoxia. In multivariate analysis, only procedure length was associated with AEs (odds ratio scale 10; odds ratio=1.07; 95% confidence interval, 1.05-1.09, P<0.001). CONCLUSIONS EDBPS is safe for endoscopic sedation. Given the higher cost of anesthesia-administered propofol, endoscopists should reinstate EDBPS by revising institutional sedation policies.
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Affiliation(s)
- Hala Fatima
- Division of Gastroenterology/Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN
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Qin Y, Chen S, Zhang Y, Liu W, Lin Y, Chi X, Chen X, Yu Z, Su D. A Bibliometric Analysis of Endoscopic Sedation Research: 2001-2020. Front Med (Lausanne) 2022; 8:775495. [PMID: 35047526 PMCID: PMC8761812 DOI: 10.3389/fmed.2021.775495] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 12/06/2021] [Indexed: 12/28/2022] Open
Abstract
Background and Aims: To evaluate endoscopic sedation research and predict research hot spots both quantitatively and qualitatively using bibliometric analysis. Methods: We extracted relevant publications from the Web of Science Core Collection (WoSCC) on 13 December 2020. We examined the retrieved data by bibliometric analysis (e.g., co-cited and cluster analysis, keyword co-occurrence) using the software CiteSpace and VOSviewer and the website of bibliometrics, the Online Analysis Platform of Literature Metrology (http://bibliometric.com/), to analyse and predict the trends and hot spots in this field. Main Results: We identified 2,879 articles and reviews on endoscopic sedation published between 2001 and 2020. Although the overall trend is increasing, with slight fluctuation in some years, there were significant increases in 2007 and 2012. In respect of the contributions on endoscopic sedation research, the United States (US) had the greatest number of publications, and it was followed by Japan and China. In addition, collaboration network analysis revealed that the most frequent collaboration was between the US and China. Six of the top ten most prolific research institutions were located in the US. The most publications on endoscopic sedation research in the past two decades were found primarily in journals on gastroenterology and hepatology. Keyword co-occurrence and co-citation cluster analysis revealed the most popular terms relating to endoscopic sedation in the manner of cluster labels; these included patient anxiety, tolerance, ketamine, propofol, hypoxia, nursing shortage, endoscopic ultrasonography, colorectal cancer, carbon dioxide insufflation, and water exchange (WE). Keyword burst detection suggested that propofol sedation, adverse event, adenoma detection rate (ADR), hypoxemia, and obesity were newly-emergent research hot spots. Conclusions: Our findings showed that hypoxia, adverse event, and ADR, along with conscious sedation and propofol sedation, have been foci of endoscopic sedation research over the past 20 years. The research focus has shifted from sedative drugs to sedative complications and endoscopy quality control, which means that there will be higher requirements and standards for sedative quality and endoscopy quality in the future.
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Affiliation(s)
- Yi Qin
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Sifan Chen
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuanyuan Zhang
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wanfeng Liu
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuxuan Lin
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaoying Chi
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xuemei Chen
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhangjie Yu
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Diansan Su
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Teo EK. Ensuring safe sedation during gastroendoscopy. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2022; 51:1-2. [PMID: 35091723 DOI: 10.47102/annals-acadmedsg.20228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Affiliation(s)
- Eng Kiong Teo
- Department of Medicine, Sengkang General Hospital, Singapore
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18
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Ang TL, Seet E, Goh YC, Ng WK, Koh CJ, Lui HF, Li JW, Oo AM, Lim KBL, Ho KS, Chew MH, Quan WL, Tan DMY, Ng KH, Goh HS, Cheong WK, Tseng P, Ling KL. Academy of Medicine, Singapore clinical guideline on the use of sedation by non-anaesthesiologists during gastrointestinal endoscopy in the hospital setting. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2022; 51:24-39. [PMID: 35091728 DOI: 10.47102/annals-acadmedsg.2021306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
INTRODUCTION In Singapore, non-anaesthesiologists generally administer sedation during gastrointestinal endoscopy. The drugs used for sedation in hospital endoscopy centres now include propofol in addition to benzodiazepines and opiates. The requirements for peri-procedural monitoring and discharge protocols have also evolved. There is a need to develop an evidence-based clinical guideline on the safe and effective use of sedation by non-anaesthesiologists during gastrointestinal endoscopy in the hospital setting. METHODS The Academy of Medicine, Singapore appointed an expert workgroup comprising 18 gastroenterologists, general surgeons and anaesthesiologists to develop guidelines on the use of sedation during gastrointestinal endoscopy. The workgroup formulated clinical questions related to different aspects of endoscopic sedation, conducted a relevant literature search, adopted Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology and developed recommendations by consensus using a modified Delphi process. RESULTS The workgroup made 16 recommendations encompassing 7 areas: (1) purpose of sedation, benefits and disadvantages of sedation during gastrointestinal endoscopy; (2) pre-procedural assessment, preparation and consent taking for sedation; (3) Efficacy and safety of drugs used in sedation; (4) the role of anaesthesiologist administered sedation during gastrointestinal endoscopy; (5) performance of sedation; (6) post-sedation care and discharge after sedation; and (7) training in sedation for gastrointestinal endoscopy for non-anaesthesiologists. CONCLUSION These recommendations serve to guide clinical practice during sedation for gastrointestinal endoscopy by non-anaesthesiologists in the hospital setting.
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Affiliation(s)
- Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
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Sneyd JR, Absalom AR, Barends CRM, Jones JB. Hypotension during propofol sedation for colonoscopy: an exploratory analysis. Br J Anaesth 2021; 128:610-622. [PMID: 34916051 PMCID: PMC9008870 DOI: 10.1016/j.bja.2021.10.044] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 10/11/2021] [Accepted: 10/17/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Intraoperative and postoperative hypotension occur commonly and are associated with organ injury and poor outcomes. Changes in arterial blood pressure (BP) during procedural sedation are not well described. METHODS Individual patient data from five trials of propofol sedation for colonoscopy and a clinical database were pooled and explored with logistic and linear regression. A literature search and focused meta-analysis compared the incidence of hypotension with propofol and alternative forms of procedural sedation. Hypotensive episodes were characterised by the original authors' definitions (typically systolic BP <90 mm Hg). RESULTS In pooled individual patient data (n=939), 36% of procedures were associated with episodes of hypotension. Longer periods of propofol sedation and larger propofol doses were associated with longer-lasting and more-profound hypotension. Amongst 380 patients for whom individual BP measurements were available, 107 (28%) experienced systolic BP <90 mm Hg for >5 min, and in 89 (23%) the episodes exceeded 10 min. Meta-analysis of 18 RCTs identified an increased risk ratio for the development of hypotension in procedures where propofol was used compared with the use of etomidate (two studies; n=260; risk ratio [RR] 2.0 [95% confidence interval: 1.37-2.92]; P=0.0003), remimazolam (one study; n=384; RR 2.15 [1.61-2.87]; P=0.0001), midazolam (14 studies; n=2218; RR 1.46 [1.18-1.79]; P=0.0004), or all benzodiazepines (15 studies; n=2602; 1.67 [1.41-1.98]; P<0.00001). Hypotension was less likely with propofol than with dexmedetomidine (one study; n=60; RR 0.24 [0.09-0.62]; P=0.003). CONCLUSIONS Hypotension is common during propofol sedation for colonoscopy and of a magnitude and duration associated with harm in surgical patients.
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Affiliation(s)
- J Robert Sneyd
- Faculty of Medicine and Dentistry, University of Plymouth, Plymouth, UK.
| | - Anthony R Absalom
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Clemens R M Barends
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Jordan B Jones
- College of Osteopathic Medicine, Rocky Vista University, Ivins, UT, USA
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McKenzie P, Fang J, Davis J, Qiu Y, Zhang Y, Adler DG, Gawron AJ. Safety of endoscopist-directed nurse-administered balanced propofol sedation in patients with severe systemic disease (ASA class III). Gastrointest Endosc 2021; 94:124-130. [PMID: 33309879 DOI: 10.1016/j.gie.2020.11.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 11/28/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS The safety of endoscopist-directed nurse-administered propofol sedation (EDNAPS) has been demonstrated in low-risk patients (American Society of Anesthesiologists [ASA] class I and II). There are limited data regarding the safety of EDNAPS for endoscopic procedures in ASA class III patients. The purpose of this study was to determine the safety of EDNAPS for routine outpatient endoscopy in this population. METHODS We retrospectively reviewed all outpatient EGDs and colonoscopies performed with EDNAPS at the University of Utah from January 2015 to November 2018. Exclusion criteria were inpatient procedures, combined procedures, ASA IV or higher, use of continuous or bilevel positive airway pressure at the start of the procedure, or procedures performed by a nongastroenterologist. Major adverse events were defined as intubation or death. Minor adverse events were defined as hypoxia, hypotension, bradycardia, or need for airway interventions. Patients were stratified by procedure type and ASA I/II status and were compared with patients with ASA III status and matched according to age, gender, and the involvement of a fellow in a 3 to 1 fashion. RESULTS The final sample size was 18,910 colonoscopy procedures (17,205 patients) and 9178 EGD procedures (6827 patients). In both colonoscopy and EGD procedures, there were no major adverse events such as intubation, need for resuscitation, or death. The rates of any airway intervention, jaw thrust, oral nasal airway, or use of positive pressure ventilation were low in both procedure types and not different between ASA I/II and ASA III patients. CONCLUSION EDNAPS is safe in both ASA I/II and ASA class III patients undergoing routine outpatient endoscopy.
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Affiliation(s)
| | - John Fang
- University of Utah, Salt Lake City, Utah, USA
| | | | - Yuqing Qiu
- University of Utah, Salt Lake City, Utah, USA
| | - Yue Zhang
- University of Utah, Salt Lake City, Utah, USA
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Gururatsakul M, Lee R, Ponnuswamy SK, Gilhotra R, McGowan C, Whittaker D, Ombiga J, Boyd P. Prospective audit of the safety of endoscopist-directed nurse-administered propofol sedation in an Australian referral hospital. J Gastroenterol Hepatol 2021; 36:490-497. [PMID: 33448489 DOI: 10.1111/jgh.15204] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/29/2020] [Accepted: 07/21/2020] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Endoscopist directed nurse administered propofol sedation (EDNAPS) is widely considered to be safe and efficient, but there are limited data from the Australian health-care setting, and Australian sedation guidelines do not support the practice. Thus, we report data from a prospective audit of EDNAPS over a 6.5-year period in an Australian referral hospital. METHODS Consecutive endoscopic procedures performed between January 2013 and June 2019. Sedation protocol was an initial dose of midazolam 1-3 mg intravenously (i.v.) and propofol 10-50 mg i.v.. Further aliquots of propofol 10-30 mg i.v. were given as required. ProvationMD® endoscopic reporting system was used to prospectively record patient demographics, medication and dose, American Society of Anesthesiologist's (ASA) class, and sedation-related complications. RESULTS During the 78-month period, 28 051 eligible procedures were performed; 3093 procedures performed with anesthetic support or without EDNAPS were excluded. In total, 24 958 procedures with EDNAPS were analyzed including 7563 gastroscopies, 12 941 colonoscopies, 2932 gastroscopy and colonoscopy, 1440 flexible sigmoidoscopies, and 82 combined gastroscopy and flexible sigmoidoscopy. Of these, 9539 were ASA 1 (38.2%), 13 680 were ASA 2 (54.8%), 1733 were ASA 3 (6.9%), and 4 were ASA 4 (0.02%). Sedation-related complications occurred in 66 patients (0.26%), predominantly transient hypoxic episodes. No patient required intubation for an airway emergency, and there was no sedation-related mortality. Sedation-related complications increased with ASA class and were significantly more common with gastroscopy. CONCLUSIONS Endoscopist directed nurse administered propofol sedation is a safe way of performing endoscopic sedation in low-risk patients in the hospital setting.
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Affiliation(s)
- Montri Gururatsakul
- Department of Gastroenterology and Hepatology, Cairns Hospital, Cairns, Queensland, Australia
| | - Richard Lee
- Department of Gastroenterology and Hepatology, Cairns Hospital, Cairns, Queensland, Australia
| | | | - Rajit Gilhotra
- Department of Gastroenterology and Hepatology, Cairns Hospital, Cairns, Queensland, Australia
| | - Cathal McGowan
- Department of Gastroenterology and Hepatology, Cairns Hospital, Cairns, Queensland, Australia
| | - Debra Whittaker
- Department of Gastroenterology and Hepatology, Cairns Hospital, Cairns, Queensland, Australia
| | - John Ombiga
- Department of Gastroenterology and Hepatology, Cairns Hospital, Cairns, Queensland, Australia
| | - Peter Boyd
- Department of Gastroenterology and Hepatology, Cairns Hospital, Cairns, Queensland, Australia
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Schoonjans C, Tate DJ. Endoscopist-administered propofol sedation during colonoscopy: Time to take over the syringe? Gastrointest Endosc 2021; 93:209-211. [PMID: 33353617 DOI: 10.1016/j.gie.2020.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 07/07/2020] [Indexed: 02/08/2023]
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Kim DB, Kim JS, Huh CW, Ma DW, Ji JS, Kim BW, Choi H. Propofol compared with bolus and titrated midazolam for sedation in outpatient colonoscopy: a prospective randomized double-blind study. Gastrointest Endosc 2021; 93:201-208. [PMID: 32504701 DOI: 10.1016/j.gie.2020.05.045] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 05/07/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS The safest and most efficient method of sedation for outpatient colonoscopy remains unclear. This study aimed to compare the efficiency and safety of bolus administration of midazolam compared with titrated administration and propofol administration for patients undergoing outpatient colonoscopy. METHODS We randomly divided patients undergoing colonoscopy into the propofol group, bolus midazolam group, and titrated midazolam group. We compared total procedure time, induction time, recovery time, and discharge time among the 3 groups. We also compared patient satisfaction and the incidence of adverse events. RESULTS In total, 267 patients (89 in each study group) were enrolled during the study period. Patients in the propofol group had a shorter total procedure time (39.5 vs 59.4 vs 58.1 minutes; P < .001), induction time (4.6 vs 6.3 vs 7.6 minutes; P < .001), recovery time (11.5 vs 29.5 vs 29.2 minutes; P < .001), and discharge time (20.6 vs 34.9 vs 34.7 minutes; P < .001) than patients in the bolus midazolam group and titrated midazolam group. Patients in the propofol group reported higher degrees of satisfaction than patients in the bolus or titrated midazolam plus meperidine groups (9.9 vs 9.6 vs 9.6 [P = .007] and 4.9 vs 4.7 vs 4.8 [P = .008], respectively). Adverse events were not significantly different between groups. CONCLUSIONS In this randomized trial, propofol was superior to bolus or titrated midazolam in terms of endoscopy unit efficiency and patient satisfaction during outpatient colonoscopy. (Clinical trial registration number: KCT0002805.).
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Affiliation(s)
- Dae Bum Kim
- Division of Gastroenterology, Department of Internal Medicine, St Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Joon Sung Kim
- Division of Gastroenterology, Department of Internal Medicine, Incheon St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Cheal Wung Huh
- Division of Gastroenterology, Department of Internal Medicine, Incheon St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dae Won Ma
- Division of Gastroenterology, Department of Internal Medicine, Incheon St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jeong-Seon Ji
- Division of Gastroenterology, Department of Internal Medicine, Incheon St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Byung-Wook Kim
- Division of Gastroenterology, Department of Internal Medicine, Incheon St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hwang Choi
- Division of Gastroenterology, Department of Internal Medicine, Incheon St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Kanno Y, Ohira T, Harada Y, Koshita S, Ogawa T, Kusunose H, Koike Y, Yamagata T, Sakai T, Masu K, Yonamine K, Miyamoto K, Tanaka M, Shimada T, Kozakai F, Endo K, Okano H, Komabayashi D, Shimizu T, Suzuki S, Ito K. Safety and Recipient Satisfaction of Propofol Sedation in Outpatient Endoscopy: A 24-Hour Prospective Investigation Using a Questionnaire Survey. Clin Endosc 2020; 54:340-347. [PMID: 33302328 PMCID: PMC8182244 DOI: 10.5946/ce.2020.138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 07/06/2020] [Indexed: 12/16/2022] Open
Abstract
Background/Aims The aim of this study was to evaluate the safety of sedation with propofol as an alternative to benzodiazepine drugs in outpatient endoscopy.
Methods In this prospective study, examinees who underwent outpatient endoscopy under propofol sedation and submitted a nextday questionnaire with providing informed consent were evaluated. Periprocedural acute responses, late adverse events within 24 hours, and examinee satisfaction were evaluated.
Results Among the 4,122 patients who received propofol in the 17,978 outpatient-based endoscopic examinations performed between November 2016 and March 2018, 2,305 eligible examinees (esophagogastroduodenoscopy for 1,340, endoscopic ultrasonography for 945, and total colonoscopy for 20) were enrolled, and their responses to a questionnaire were analyzed. The mean propofol dose was 69.6±24.4 mg (range, 20–200 mg). Diazepam, midazolam, and/or pentazocine in combination with propofol was administered to 146 examinees. Mild oxygen desaturation was observed in 59 examinees (2.6%); and mild bradycardia, in 2 (0.09%). Other severe reactions or late events did not occur. After eliminating 181 invalid responses, 97.7% (2,065/2,124) of the patients desired propofol sedation in future examinations.
Conclusions Propofol sedation was found to be safe-without severe adverse events or accidents-for outpatient endoscopy on the basis of the patients’ next-day self-evaluation. Given the high satisfaction level, propofol sedation might be an ideal tool for painless endoscopic screening.
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Affiliation(s)
- Yoshihide Kanno
- Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan
| | - Tetsuya Ohira
- Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan
| | - Yoshihiro Harada
- Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan
| | - Shinsuke Koshita
- Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan
| | - Takahisa Ogawa
- Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan
| | - Hiroaki Kusunose
- Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan
| | - Yoshiki Koike
- Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan
| | - Taku Yamagata
- Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan
| | - Toshitaka Sakai
- Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan
| | - Kaori Masu
- Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan
| | - Keisuke Yonamine
- Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan
| | - Kazuaki Miyamoto
- Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan
| | - Megumi Tanaka
- Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan
| | - Tomohiro Shimada
- Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan
| | - Fumisato Kozakai
- Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan
| | - Kazuki Endo
- Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan
| | - Haruka Okano
- Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan
| | - Daichi Komabayashi
- Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan
| | - Takeshi Shimizu
- Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan
| | - Shohei Suzuki
- Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan
| | - Kei Ito
- Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan
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Yaghoobi M. Propofol Use for Sedation in Endoscopic Procedures: Too Many Physicians in the Room? J Can Assoc Gastroenterol 2020; 3:151-152. [PMID: 32671322 PMCID: PMC7338842 DOI: 10.1093/jcag/gwz021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Mohammad Yaghoobi
- Division of Gastroenterology, Michael G. DeGroote School of Medicine, McMaster University and McMaster University Medical Center, Hamilton, Ontario, Canada
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Review on colorectal endoscopic submucosal dissection focusing on the technical aspect. Surg Endosc 2020; 34:3766-3787. [PMID: 32342217 DOI: 10.1007/s00464-020-07599-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 04/23/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) enables removal of broad-based colorectal polyps or lateral spreading tumors with a higher rate of en bloc resection and a lower risk of local recurrence. However, it is technically demanding. Over the past 20 years, various equipment and innovative techniques have been developed to reduce the difficulty of ESD. The information in the literature is scattered. Our aim is to provide a comprehensive review on the setup and technical aspects of colorectal ESD. METHODS We searched the PubMed database and systemically reviewed all original and review articles related to colorectal ESD. Further manual search according to reference lists of identified articles were done. The selected articles were categorized and reviewed. Original figures were created to help readers understand some of the ESD techniques. RESULTS A total of 216 articles were identified, in which 25 of them were review articles and 191 of them were original articles. They were categorized and reviewed. An in-depth appraisal of the setting, equipment, and technical aspects of colorectal ESD was performed. CONCLUSIONS Although ESD is a technically demanding procedure that requires expert endoscopic skills, it can be mastered. With good peri-procedural preparation, sufficient knowledge of the equipment, and thorough understanding of the useful endoscopic tricks and maneuvers, colorectal ESD can be performed smoothly and safely.
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McCain JD, Stancampiano FF, Bouras EP, DeVault KR, Gilbert EL, Ryan T, Maillis A, Heckman MG, Diehl NN, Palmer WC. Creation of a score to predict risk of high conscious sedation requirements in patients undergoing endoscopy. Gastrointest Endosc 2020; 91:595-605.e3. [PMID: 31756314 DOI: 10.1016/j.gie.2019.11.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 11/03/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS The administration of intravenous conscious sedation to patients undergoing GI endoscopy carries a risk of cardiopulmonary adverse events. Our study aim was to create a score that stratifies the risk of occurrence of either high-dose conscious sedation requirements or a failed procedure. METHODS Patients receiving endoscopy via endoscopist-directed conscious sedation were included. The primary outcome was occurrence of sedation failure, which was defined as one of the following: (1) high-dose sedation, (2) the need for benzodiazepine/narcotic reversal agents, (3) nurse-documented poor patient tolerance to the procedure, or (4) aborted procedure. High-dose sedation was defined as >10 mg of midazolam and/or >200 μg of fentanyl or the meperidine equivalent. Patients with sedation failure (n = 488) were matched to controls (n = 976) without a sedation failure by endoscopist and endoscopy date. RESULTS Significant associations with sedation failure were identified for age, sex, nonclonazepam benzodiazepine use, opioid use, and procedure type (EGD, colonoscopy, or both). Based on these 5 variables, we created the high conscious sedation requirements (HCSR) score, which predicted the risk of sedation failure with an area under the curve of 0.70. Compared with the patients with a risk score of 0, risk of a sedation failure was highest for patients with a score ≥3.5 (odds ratio, 17.31; P = 2 × 10-14). Estimated area under the curve of the HCSR score was 0.68 (95% confidence interval, 0.63-0.72) in a validation series of 250 cases and 250 controls. CONCLUSIONS The HCSR risk score, based on 5 key patient and procedure characteristics, can function as a useful tool for physicians when discussing sedation options with patients before endoscopy.
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Affiliation(s)
- Josiah D McCain
- Division of Community Internal Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | | | - Ernest P Bouras
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Kenneth R DeVault
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Emily L Gilbert
- Division of Community Internal Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Taylor Ryan
- CRISP Student Program, Mayo Clinic, Jacksonville, Florida, USA
| | - Alex Maillis
- CRISP Student Program, Mayo Clinic, Jacksonville, Florida, USA
| | - Michael G Heckman
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, Florida, USA
| | - Nancy N Diehl
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, Florida, USA
| | - William C Palmer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
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Medical, Political, and Economic Considerations for the Use of MAC for Endoscopic Sedation: Big Price, Little Justification? Dig Dis Sci 2020; 65:2466-2472. [PMID: 32671589 PMCID: PMC7363687 DOI: 10.1007/s10620-020-06464-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The last few decades of gastrointestinal (GI) endoscopy have seen phenomenal growth. In many aspects, GI endoscopy has led the field of nonsurgical interventional medicine. In many aspects, this growth is facilitated by advancements in sedation-both drugs and techniques. Unfortunately, the topic of GI endoscopy sedation is also mired in many controversies, mainly emanating from the cost of anesthesia providers. While no one debates their role in the majority of advanced endoscopic procedures, the practice of universal propofol sedation in the USA, delivered by anesthesia providers, needs a closer look. In this review, medical, political, and economic considerations of this important topic are discussed in a very frank and honest way. While such ubiquitous propofol use has increased satisfaction of both patients and gastroenterologists, there is little justification. More importantly, going by the evidence, there is even less justification for the mandated anesthesia providers use for such delivery. Unfortunately, the FDA could not be convinced otherwise. The new drug fospropofol met the same fate. Approval of SEDASYS®, the first computer-assisted personalized sedation system, was a step in the right direction, nevertheless an insufficient step that failed to takeoff. As a result, in spite of years of research and efforts of many august societies, the logjam of balancing cost and justification of propofol sedation has continued. We hope that recent approval of remimazolam, a novel benzodiazepine, and potential approval of oliceridine, a novel short-acting opioid, might be able to contain the cost without compromising the quality of sedation.
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Delgado AADA, de Moura DTH, Ribeiro IB, Bazarbashi AN, dos Santos MEL, Bernardo WM, de Moura EGH. Propofol vs traditional sedatives for sedation in endoscopy: A systematic review and meta-analysis. World J Gastrointest Endosc 2019; 11:573-588. [PMID: 31839876 PMCID: PMC6885729 DOI: 10.4253/wjge.v11.i12.573] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 08/17/2019] [Accepted: 09/11/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Propofol is commonly used for sedation during endoscopic procedures. Data suggests its superiority to traditional sedatives used in endoscopy including benzodiazepines and opioids with more rapid onset of action and improved post-procedure recovery times for patients. However, Propofol requires administration by trained healthcare providers, has a narrow therapeutic index, lacks an antidote and increases risks of cardio-pulmonary complications.
AIM To compare, through a systematic review of the literature and meta-analysis, sedation with propofol to traditional sedatives with or without propofol during endoscopic procedures.
METHODS A literature search was performed using MEDLINE, Scopus, EMBASE, the Cochrane Library, Scopus, LILACS, BVS, Cochrane Central Register of Controlled Trials, and The Cumulative Index to Nursing and Allied Health Literature databases. The last search in the literature was performed on March, 2019 with no restriction regarding the idiom or the year of publication. Only randomized clinical trials with full texts published were included. We divided sedation therapies to the following groups: (1) Propofol versus benzodiazepines and/or opiate sedatives; (2) Propofol versus Propofol with benzodiazepine and/or opioids; and (3) Propofol with adjunctive benzodiazepine and opioid versus benzodiazepine and opioid. The following outcomes were addressed: Adverse events, patient satisfaction with type of sedation, endoscopists satisfaction with sedation administered, dose of propofol administered and time to recovery post procedure. Meta-analysis was performed using RevMan5 software version 5.39.
RESULTS A total of 23 clinical trials were included (n = 3854) from the initial search of 6410 articles. For Group I (Propofol vs benzodiazepine and/or opioids): The incidence of bradycardia was not statistically different between both sedation arms (RD: -0.01, 95%CI: −0.03–+0.01, I2: 22%). In 10 studies, the incidence of hypotension was not statistically difference between sedation arms (RD: 0.01, 95%CI: −0.02–+0.04, I2: 0%). Oxygen desaturation was higher in the propofol group but not statistically different between groups (RD: −0.03, 95%CI: −0.06–+0.00, I2: 25%). Patients were more satisfied with their sedation in the benzodiazepine + opioid group compared to those with monotherapy propofol sedation (MD: +0.89, 95%CI: +0.62–+1.17, I2: 39%). The recovery time after the procedure showed high heterogeneity even after outlier withdrawal, there was no statistical difference between both arms (MD: -15.15, 95%CI: −31.85–+1.56, I2: 99%). For Group II (Propofol vs propofol with benzodiazepine and/or opioids): Bradycardia had a tendency to occur in the Propofol group with benzodiazepine and/or opioid-associated (RD: -0.08, 95%CI: −0.13–−0.02, I2: 59%). There was no statistical difference in the incidence of bradycardia (RD: -0.00, 95%CI: −0.08–+0.08, I2: 85%), desaturation (RD: −0.00, 95%CI: −0.03–+0.02, I2: 44%) or recovery time (MD: -2.04, 95%CI: −6.96–+2.88, I2: 97%) between sedation arms. The total dose of propofol was higher in the propofol group with benzodiazepine and/or opiates but with high heterogeneity. (MD: 70.36, 95%CI: +53.11–+87.60, I2: 61%). For Group III (Propofol with benzodiazepine and opioid vs benzodiazepine and opioid): Bradycardia and hypotension was not statistically significant between groups (RD: -0.00, 95%CI: −0.002–+0.02, I2: 3%; RD: 0.04, 95%CI: −0.05–+0.13, I2: 77%). Desaturation was evaluated in two articles and was higher in the propofol + benzodiazepine + opioid group, but with high heterogeneity (RD: 0.15, 95%CI: 0.08–+0.22, I2: 95%).
CONCLUSION This meta-analysis suggests that the use of propofol alone or in combination with traditional adjunctive sedatives is safe and does not result in an increase in negative outcomes in patients undergoing endoscopic procedures.
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Affiliation(s)
- Aureo Augusto de Almeida Delgado
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403000, Brazil
| | - Diogo Turiani Hourneaux de Moura
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403000, Brazil
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Igor Braga Ribeiro
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403000, Brazil
| | - Ahmad Najdat Bazarbashi
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Marcos Eduardo Lera dos Santos
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403000, Brazil
| | - Wanderley Marques Bernardo
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403000, Brazil
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Julián Gómez L, Fuentes Coronel A, López Ramos C, Ochoa Sangrador C, Fradejas Salazar P, Martín Garrido E, Conde Gacho P, Bailador Andrés C, García-Alvarado M, Rascarachi G, Castillo Trujillo R, Rodríguez Gómez SJ. A clinical trial comparing propofol versus propofol plus midazolam in diagnostic endoscopy of patients with a low anesthetic risk. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2019; 110:691-698. [PMID: 30318893 DOI: 10.17235/reed.2018.5289/2017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND OBJECTIVES propofol and midazolam are two of the most commonly used sedatives in upper gastrointestinal endoscopy (UGE). The objective of this study was to evaluate these two sedation regimens administered to patients who underwent an UGE with regard to security, efficiency, quality of exploration and patient response. PATIENTS AND METHODS a prospective, randomized and double-blind study was performed which included 83 patients between 18 and 80 years of age of a low anesthetic risk (ASA - American Society of Anesthesiologists- I-II) who underwent a diagnostic UGE. Patients were randomized to receive sedation with either placebo plus propofol (group A) or midazolam plus propofol (group B). RESULTS in group A, 42 patients received a placebo bolus (saline solution) and on average up to 115 mg of propofol in boluses of 20 mg. In group B, 41 patients received 3 mg of midazolam and an average of up to 83 mg of propofol in boluses of 20 mg. There were no significant differences in the adverse effects observed in either group and all adverse events were treated conservatively. The patients in group B (midazolam plus propofol) entered the desired sedated state more quickly with no variation in the overall time of the exploration. The quality of the endoscopic evaluation was similar in both groups and the patients were equally satisfied regardless of the sedatives they received. CONCLUSIONS the use of midazolam plus propofol as a sedative does not affect the overall exploration time, a lower dose of propofol can be used and it is as safe as administering propofol as a monotherapy while providing the same level of both exploration quality and patient approval.
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Kim JH, Kim DH, Kim JH. Low-dose midazolam and propofol use for conscious sedation during diagnostic endoscopy. Kaohsiung J Med Sci 2019; 35:160-167. [PMID: 30887720 DOI: 10.1002/kjm2.12028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Accepted: 11/22/2018] [Indexed: 01/26/2023] Open
Abstract
To find the right sedation technique for different types of treatment methods and the right amount of sedatives so the chances of side effects happening can be reduced. This was a retrospective cohort analysis conducted on prospectively collected data. Patients who underwent esophagogastroduodenoscopy only (E group) were sub-divided into two subgroups: (a) Those who received 0.5 mg/kg of propofol (E-a), (b) Those who received 0.025 mg/kg of midazolam and 0.5 mg/kg of propofol (E-b). Patients who underwent esophagogastroduodenoscopy with colonoscopy (EC group) were also sub-divided into three subgroups: (a) Those who received 0.5 mg/kg of propofol (EC-a), (b) Those who received 0.025 mg/kg of midazolam and 0.5 mg/kg of propofol (EC-b), (c) Those who received 25 mg (12.5 mg if body weight < 50 kg or age > 70) of meperidine and 0.025 mg/kg of midazolam along with 0.5 mg/kg of propofol (EC-c). When the level of target was not reached, 10-20 mg of propofol was additionally injected. Sedation efficacy and safety were then compared among groups. E-b and EC-b decreased the overall amount of propofol and reduced side effect of temporary hypoxemia compared to E-a and EC-a. EC-b shortened patient recovery time compared to EC-c and reduced paradoxical reaction. In terms of the patient satisfaction and patient cooperation by endoscopists, there were no significant differences between EC-b and EC-c. Concomitant use of low dosages of both propofol and midazolam is found to be useful and safe when endoscopy needs to be performed.
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Affiliation(s)
- Joo Hyung Kim
- Department of Surgery, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Dae Hyun Kim
- Department of Health Services Administration, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jin Hong Kim
- Department of Internal Medicine, Ajou University School of Medicine, Suwon, Republic of Korea
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Abstract
Abstract
Editor’s Perspective
What We Already Know about This Topic
What This Article Tells Us That Is New
Background
Enhanced recovery protocols employ various approaches to minimize detrimental side effects of anesthetizing agents. The authors tested the hypothesis that adding low-dose dexmedetomidine to propofol for anesthesia in ambulatory colonoscopies, compared with propofol alone, would lower the propofol requirement, improve the intra-procedure hemodynamic state, and not increase time-to-discharge.
Methods
In this noninferiority, double-blind, randomized controlled trial, patients having colonoscopies received total IV anesthesia either with propofol and placebo (n = 50), or propofol and a bolus dose of dexmedetomidine, 0.3 μg/kg (n = 51). Additional propofol was administered to maintain a Bispectral Index score of 60. Following the procedure, readiness for discharge was assessed regularly using the Modified Post Anesthetic Discharge Scoring System until discharge criteria were met. The primary outcome was the percentage of patients meeting discharge criteria within 30 min from procedure end-time.
Results
Twenty-six of 51 (51%) patients receiving propofol-dexmedetomidine were ready for discharge by 30 min from procedure end time, compared with 44 of 50 (88%) receiving propofol (P < 0.001). Propofol consumption was lower in subjects receiving propofol–dexmedetomidine (140 μg · kg-1 · min-1) compared to those receiving propofol (180 μg · kg-1 · min-1) with P = 0.011. The lowest mean arterial pressure decreased further from baseline in those receiving propofol–dexmedetomidine (−30%; mean decrease −30 ±10.5 mmHg) compared to propofol (−21%; mean decrease, −22 ± 14.2 mmHg) with P = 0.003. There was no difference in incidence of bradycardia, with sustained bradycardia occurring in 3 of 51 (6%) patients receiving propofol–dexmedetomidine compared to 1 of 50 (2%) patients receiving propofol (P = 0.62). No apnea episodes requiring positive-pressure ventilation occurred in either group.
Conclusions
For anesthesia in ambulatory colonoscopy, combining low-dose dexmedetomidine with propofol delayed discharge readiness and provoked hypotension compared to propofol alone.
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Baudet JS, Aguirre-Jaime A. Effect of conscious sedation with midazolam and fentanyl on the overall quality of colonoscopy: a prospective and randomized study. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2019; 111:507-513. [PMID: 31117800 DOI: 10.17235/reed.2019.5735/2018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION a prospective, randomized study was performed to assess the influence of conscious sedation on the overall quality of colonoscopy, simultaneously quantifying its effect on the scientific quality, perceived quality and patient safety. METHODS patients referred for a colonoscopy were included in the study and were randomized to receive or not receive sedation. Demographic data, indication for colonoscopy, cecal intubation, introduction and withdrawal time, resected adenomas and complications during the exploration were collected. Thirty days later, a satisfaction questionnaire was performed (GHAA 9-me) and patients were asked about complications after the examination. RESULTS a total of 5,328 patients were included, the average age was 62 ± 15.22 years, 47% were male, 3,734 were sedated and 1,594 were not sedated. The sedated patients had a shorter endoscope insertion time (7'20 ± 2'15 min vs 6'15 ± 3'12 min, p < 0.019), a higher rate of cecal intubations (96% vs 88%, p < 0.05), longer withdrawal time (7'20 ± 2'15 min vs 6'15 ± 3'12 min, p < 0.01) and higher adenoma detection rates (22% vs 17%, p < 0.05). The use of sedation reduced discomfort during and after the exploration, without increasing the complications. The satisfaction questionnaire score was higher (23.6 ± 1.5 vs 16.6 ± 4.8, p < 0.001) in the sedated patients. CONCLUSIONS superficial sedation not only reduces patient discomfort but also improves the overall quality of the colonoscopy. Therefore, we must consider the use of sedation as an essential part of colonoscopy.
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Sato M, Horiuchi A, Tamaki M, Ichise Y, Kajiyama M, Yamamoto Y, Tanaka N. Safety and Effectiveness of Nurse-Administered Propofol Sedation in Outpatients Undergoing Gastrointestinal Endoscopy. Clin Gastroenterol Hepatol 2019; 17:1098-1104.e1. [PMID: 29933097 DOI: 10.1016/j.cgh.2018.06.025] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 06/02/2018] [Accepted: 06/15/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Esophagogastroduodenoscopy (EGD) and colonoscopy are common outpatient gastrointestinal endoscopic procedures that frequently use sedation. We aimed to identify a protocol that combines safety with cost effectiveness. METHODS We collected data from consecutive outpatients (age, 20-98 y) who underwent diagnostic EGD (n = 117,661) or colonoscopy (n = 32,550) with propofol sedation from January 2006 through December 2016. Propofol was administered by a nurse via bolus injection using an age-adjusted standard protocol, up to a total of 200 mg. The primary outcome measure was occurrence of adverse events within 24 hours. Secondary outcome measures included rates of procedure success, respiratory depression, and other procedure-related adverse events. RESULTS The median dose of propofol administered for EGD was 77 mg (range, 20-160 mg) and for colonoscopy was 99 mg (range, 40-200 mg). Among patients undergoing EGD, those younger than 41 years required 1.5-fold more propofol than patients 61-80 years old. The only adverse event was the transient need for supplemental oxygen supply, required by 1950 patients (1.3%): 1689 undergoing EGD (1.4%) and 261 undergoing colonoscopy (0.8%). Patients were discharged after 60 minutes and at least 66,250 patients (44%) drove themselves from the hospital. None experienced a traffic accident within 24 hours after receiving propofol sedation. CONCLUSIONS Nurse-administered propofol monosedation using an age-adjusted standard protocol up to a maximal of 200 mg is safe and practical for outpatient gastrointestinal endoscopy.
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Affiliation(s)
- Masamichi Sato
- Digestive Disease Center, Showa Inan General Hospital, Komagane, Japan; Department of Pediatrics, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Akira Horiuchi
- Digestive Disease Center, Showa Inan General Hospital, Komagane, Japan.
| | - Michio Tamaki
- Digestive Disease Center, Showa Inan General Hospital, Komagane, Japan
| | - Yasuyuki Ichise
- Digestive Disease Center, Showa Inan General Hospital, Komagane, Japan
| | - Masashi Kajiyama
- Digestive Disease Center, Showa Inan General Hospital, Komagane, Japan
| | - Yuta Yamamoto
- Digestive Disease Center, Showa Inan General Hospital, Komagane, Japan
| | - Naoki Tanaka
- Digestive Disease Center, Showa Inan General Hospital, Komagane, Japan
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Vargo JJ. Is Driving Home After Endoscopy Ready for Prime Time? Clin Gastroenterol Hepatol 2019; 17:1033-1034. [PMID: 30583049 DOI: 10.1016/j.cgh.2018.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Revised: 12/17/2018] [Accepted: 12/17/2018] [Indexed: 02/07/2023]
Affiliation(s)
- John J Vargo
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
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Daza JF, Tan CM, Fielding RJ, Brown A, Farrokhyar F, Yang I. Propofol administration by endoscopists versus anesthesiologists in gastrointestinal endoscopy: a systematic review and meta-analysis of patient safety outcomes. Can J Surg 2019; 61:8117. [PMID: 30067180 DOI: 10.1503/cjs.008117] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND With a growing demand for endoscopic services, the role of anesthesiologists in endoscopy units must be reassessed. The aim of this study was to compare patient outcomes in non-anesthesiologist-administered propofol (NAAP) versus anesthesiologist-administered propofol (AAP) during routine endoscopy. METHODS We systematically searched MEDLINE, CINAHL, Embase, Web of Science, CENTRAL and the grey literature for studies comparing NAAP and AAP. Primary outcomes included endoscopy- and sedation-related complications. Secondary outcomes included measures of endoscopy quality and of patient and endoscopist satisfaction. We reported treatment effects using random-effects models. RESULTS Of 602 articles identified, 5 met the inclusion criteria. Most studies included only patients with an American Society of Anesthesiologists (ASA) classification of I or II. Non-anesthesiologist-administered propofol did not result in increased rates of airway intervention (odds ratio [OR] 1.07, 95% confidence interval [CI] 0.29 to 3.95; 3443 patients) or hypotension (OR 1.47, 95% CI 0.40 to 5.41; 17 978 patients) but did result in higher rates of bradycardia (OR 3.68, 95% CI 1.65 to 8.17; 17 978 patients). Nonanesthesiologists administered lower propofol dosages than anesthesiologists (mean difference -61.79, 95% CI -114.46 to -9.12; 3443 patients), and their patients more commonly experienced awareness with recall (OR 19.99, 95% CI 7.88 to 50.76; 2090 patients). However, NAAP neither compromised patient willingness to repeat the procedure (OR 0.42, 95% CI 0.10 to 1.83; 2367 patients) nor lengthened total procedure time (mean difference -0.08, 95% CI -3.51 to 3.34; 2367 patients). CONCLUSION Endoscopists may safely administer propofol without compromising procedural quality in patients classified as ASA I or II undergoing routine endoscopy. The results of this meta-analysis are limited by a lack of available high-quality studies. Further, large-scale studies are needed for definitive conclusions.
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Affiliation(s)
- Julian F Daza
- From the Michael G. DeGroote School of Medicine - Niagara Regional Campus, McMaster University, St. Catharines, Ont.(Daza, Tan, Brown); the Department of Surgery, McMaster University, Hamilton, Ont. (Fielding, Farrokhyar, Yang); and the Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ont. (Brown, Farrokhyar)
| | - Carolyn M Tan
- From the Michael G. DeGroote School of Medicine - Niagara Regional Campus, McMaster University, St. Catharines, Ont.(Daza, Tan, Brown); the Department of Surgery, McMaster University, Hamilton, Ont. (Fielding, Farrokhyar, Yang); and the Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ont. (Brown, Farrokhyar)
| | - Ryan J Fielding
- From the Michael G. DeGroote School of Medicine - Niagara Regional Campus, McMaster University, St. Catharines, Ont.(Daza, Tan, Brown); the Department of Surgery, McMaster University, Hamilton, Ont. (Fielding, Farrokhyar, Yang); and the Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ont. (Brown, Farrokhyar)
| | - Allison Brown
- From the Michael G. DeGroote School of Medicine - Niagara Regional Campus, McMaster University, St. Catharines, Ont.(Daza, Tan, Brown); the Department of Surgery, McMaster University, Hamilton, Ont. (Fielding, Farrokhyar, Yang); and the Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ont. (Brown, Farrokhyar)
| | - Forough Farrokhyar
- From the Michael G. DeGroote School of Medicine - Niagara Regional Campus, McMaster University, St. Catharines, Ont.(Daza, Tan, Brown); the Department of Surgery, McMaster University, Hamilton, Ont. (Fielding, Farrokhyar, Yang); and the Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ont. (Brown, Farrokhyar)
| | - Ilun Yang
- From the Michael G. DeGroote School of Medicine - Niagara Regional Campus, McMaster University, St. Catharines, Ont.(Daza, Tan, Brown); the Department of Surgery, McMaster University, Hamilton, Ont. (Fielding, Farrokhyar, Yang); and the Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ont. (Brown, Farrokhyar)
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Cadoni S, Hassan C, Frazzoni L, Ishaq S, Leung FW. Impact of water exchange colonoscopy on endoscopy room efficiency: a systematic review and meta-analysis. Gastrointest Endosc 2019; 89:159-167.e13. [PMID: 30048649 DOI: 10.1016/j.gie.2018.07.020] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 07/14/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Separate randomized controlled trials (RCTs) showed water exchange (WE) colonoscopy outperformed other techniques in minimizing insertion pain and optimizing adenoma detection rate. Longer insertion time required for removal of infused water, residual air, and feces might have hampered its wider adoption. We evaluate the impact of WE compared with air or carbon dioxide insufflation (GAS) on room turnaround efficiency measured by cecal intubation, withdrawal, and total procedure times. METHODS With a systematic search in PubMed, Embase, and Cochrane Library, we identified RCTs (published before March 18, 2018) that compared WE with GAS. We focused on parameters of turnaround efficiency and patient-centered outcomes. RESULTS We analyzed 8371 subjects from 17 studies. Demographics and indications were comparable. Mean cecal intubation time (± standard deviation) was WE 12.5 ± 6.1 minutes versus GAS 11.1 ± 7.0 minutes, with a mean difference of 1.4 ± 3.4 minutes. Six studies showed significant differences in insertion time, with mean cecal intubation times of 11.6 ± 5.1 minutes for WE versus 7.7 ± 5.2 minutes for GAS, with a mean difference of 3.9 ± 1.1 minutes. Mean withdrawal time was similar. Mean total procedure time was WE 26.0 ± 9.7 versus GAS 24.2 ± 9.6, with a mean difference of 1.8 ± 6.2 minutes. All mean procedure times were significantly different. Patient-centered outcomes revealed that patients examined with WE had significantly lower real-time insertion pain score, less need for sedation, and higher willingness to repeat the procedure. CONCLUSIONS Based on parameters of procedural time, the impact of WE colonoscopy on endoscopy room turnaround yields an increase in total procedure time of about 2 minutes and is associated with significant improvement in specific patient-centered outcomes.
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Affiliation(s)
- Sergio Cadoni
- Digestive Endoscopy Unit, CTO Hospital, Iglesias, Italy
| | - Cesare Hassan
- Digestive Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy
| | - Leonardo Frazzoni
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Sauid Ishaq
- Department of Gastroenterology, Dudley Group Hospitals NHS Foundation Trust, Dudley, United Kingdom; Department of Health and Sciences, Birmingham City University, Birmingham, United Kingdom
| | - Felix W Leung
- Sepulveda Ambulatory Care Center, Veterans Affairs Greater Los Angeles Healthcare System, North Hills, California, USA; David Geffen School of Medicine at University of California at Los Angeles, Los Angeles, California, USA
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Kayaaltı S, Kayaaltı Ö. Safety of applying midazolam-ketamine-propofol sedation combination under the supervision of endoscopy nurse with patient-controlled analgesia pump in colonoscopy. World J Clin Cases 2018; 6:1146-1154. [PMID: 30613673 PMCID: PMC6306640 DOI: 10.12998/wjcc.v6.i16.1146] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 11/09/2018] [Accepted: 11/23/2018] [Indexed: 02/05/2023] Open
Abstract
AIM To compare the results of midazolam-ketamine-propofol sedation performed by an endoscopy nurse and anaesthetist during colonoscopy in terms of patient satisfaction and safety. METHODS American Statistical Association (ASA) I-II 60 patients who underwent colonoscopy under sedation were randomly divided into two groups: sedation under the supervision of an anaesthetist (SSA) and sedation under the supervision of an endoscopy nurse (SSEN). Both groups were initially administered 1 mg midazolam, 50 mg ketamine and 30-50 mg propofol. Continuation of sedation was performed by the anaesthetist in the SSA group and the nurse with a patient-controlled analgesia (PCA) pump in the SSEN group. The total propofol consumption, procedure duration, recovery times, pain using the visual analogue scale (VAS) and satisfaction score of the patients, and side effects were recorded. In addition, the patients were asked whether they remembered the procedure and whether they would prefer the same method in the case of re-endoscopy. RESULTS Total propofol consumption in the SSEN group was significantly higher (P < 0.05) than that in the SSA group. When the groups were compared in terms of VAS score, recovery time, patient satisfaction, recall of the procedure, re-preference for the same method in case of re-endoscopy, and side effects, there were no significant differences (P > 0.05) between the two groups. No long-term required intervention side effects were observed in either group. CONCLUSION Colonoscopy sedation in ASA I-II patients can be safely performed by an endoscopy nurse using PCA pump with the incidence of side effects and patient satisfaction levels similar to sedation under anaesthetist supervision.
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Affiliation(s)
- Selda Kayaaltı
- Division of Anaesthesiology and Reanimation, Develi Public Hospital, Develi, Kayseri 38400, Turkey
| | - Ömer Kayaaltı
- Computer Technology, Kayseri University, Develi Huseyin Sahin Vocational College, Develi, Kayseri 38400, Turkey
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Zhang W, Zhu Z, Zheng Y. Effect and safety of propofol for sedation during colonoscopy: A meta-analysis. J Clin Anesth 2018; 51:10-18. [DOI: 10.1016/j.jclinane.2018.07.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 07/23/2018] [Accepted: 07/23/2018] [Indexed: 02/08/2023]
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The Comparison of Midazolam and Propofol in Gastrointestinal Endoscopy: A Systematic Review and Meta-analysis. Surg Laparosc Endosc Percutan Tech 2018; 28:153-158. [PMID: 29738382 DOI: 10.1097/sle.0000000000000532] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Midazolam and propofol are both used for sedation in gastrointestinal endoscopy. We conducted a systematic review and meta-analysis to compare the efficacy and safety of midazolam and propofol in gastrointestinal endoscopy. MATERIALS AND METHODS PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases were systematically searched. Randomized controlled trials assessing the effect of midazolam versus propofol on sedation in gastrointestinal endoscopy are included. Two investigators have independently searched for articles, extracted data, and assessed the quality of included studies. This meta-analysis was performed using the random-effect model. RESULTS Five randomized controlled trials involving 552 patients were included in the meta-analysis. Overall, compared with midazolam sedation during gastrointestinal endoscopy, propofol sedation results in higher endoscopist satisfaction scores during gastrointestinal endoscopy than midazolam [standard mean difference (Std. MD)=-0.71; 95% confidence interval (CI)=-1.05 to -0.37; P<0.0001), but the comparison shows no remarkable influence on patient satisfaction scores between midazolam and propofol (Std. MD=-0.34; 95% CI=-0.88 to 0.20; P=0.21), procedure time (Std. MD=0.14; 95% CI=-0.13 to 0.42; P=0.31), hypoxia [risk ratio (RR)=0.86; 95% CI=0.53-1.38; P=0.53), and bradycardia (RR=1.05; 95% CI=0.54-2.06; P=0.89). In addition, propofol shows higher incidence of hypotension than midazolam (RR=0.58; 95% CI=0.34-0.99; P=0.04). CONCLUSIONS When compared with midazolam sedation for gastrointestinal endoscopy, propofol sedation results in higher endoscopist satisfaction scores, but may increase the incidence of hypotension.
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Watanabe K, Hikichi T, Takagi T, Suzuki R, Nakamura J, Sugimoto M, Kikuchi H, Konno N, Takasumi M, Sato Y, Hashimoto M, Irie H, Obara K, Ohira H. Propofol is a more effective and safer sedative agent than midazolam in endoscopic injection sclerotherapy for esophageal varices in patients with liver cirrhosis: a randomized controlled trial. Fukushima J Med Sci 2018; 64:133-141. [PMID: 30344206 DOI: 10.5387/fms.2018-21] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE The efficacy of sedation during endoscopic injection sclerotherapy (EIS) for esophageal varices (EVs) in patients with liver cirrhosis remains unclear. The aim of this study is to compare the efficacy and safety between propofol- and midazolam-based sedation for EIS. METHODS Twenty-three patients with EVs were prospectively and randomly assigned to midazolam-based (Midazolam group) or propofol-based (Propofol group) sedation. All patients underwent a number connection test (NCT) to evaluate minimal hepatic encephalopathy (MHE) on the day before and at 2 and 24 hours following EIS. The primary endpoint was exacerbation of MHE after EIS, which was defined as deterioration of the NCT. The secondary endpoints were postoperative awareness, technical success rate, frequency of body movement, patient and operator satisfaction, cardiorespiratory dynamics during EIS, and adverse events. RESULTS Exacerbations of MHE at 2 hours after EIS compared with those before EIS were not significantly different between the two groups. In both groups, the deterioration of NCT scores before and 2 hours after EIS was observed (Propofol group: 60.0 vs. 70.0 s, P = 0.026; Midazolam group: 42.5 vs. 67.0 s, P = 0.002). There were no significant differences in awareness, technical success rate, or patient satisfaction. However, the frequency of body movement in the Propofol group was significantly lower than that in the Midazolam group (1 vs. 4, P = 0.045), and operator satisfaction in the Propofol group was significantly higher than that in the Midazolam group (P = 0.016). No adverse events were observed. CONCLUSIONS Propofol-based sedation exacerbated MHE after EIS similarly to midazolam-based sedation in patients with liver cirrhosis. However, propofol-based sedation provided stable sedation with a lower frequency of body movements and high operator satisfaction.
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Affiliation(s)
- Ko Watanabe
- Department of Endoscopy, Fukushima Medical University Hospital.,Department of Gastroenterology, Fukushima Medical University School of Medicine
| | - Takuto Hikichi
- Department of Endoscopy, Fukushima Medical University Hospital
| | - Tadayuki Takagi
- Department of Gastroenterology, Fukushima Medical University School of Medicine
| | - Rei Suzuki
- Department of Gastroenterology, Fukushima Medical University School of Medicine
| | - Jun Nakamura
- Department of Endoscopy, Fukushima Medical University Hospital.,Department of Gastroenterology, Fukushima Medical University School of Medicine
| | - Mitsuru Sugimoto
- Department of Gastroenterology, Fukushima Medical University School of Medicine
| | - Hitomi Kikuchi
- Department of Endoscopy, Fukushima Medical University Hospital.,Department of Gastroenterology, Fukushima Medical University School of Medicine
| | - Naoki Konno
- Department of Endoscopy, Fukushima Medical University Hospital.,Department of Gastroenterology, Fukushima Medical University School of Medicine
| | - Mika Takasumi
- Department of Gastroenterology, Fukushima Medical University School of Medicine
| | - Yuki Sato
- Department of Gastroenterology, Fukushima Medical University School of Medicine
| | - Minami Hashimoto
- Department of Endoscopy, Fukushima Medical University Hospital.,Department of Gastroenterology, Fukushima Medical University School of Medicine
| | - Hiroki Irie
- Department of Gastroenterology, Fukushima Medical University School of Medicine
| | - Katsutoshi Obara
- Department of Advanced Gastrointestinal Endoscopy, Fukushima Medical University
| | - Hiromasa Ohira
- Department of Gastroenterology, Fukushima Medical University School of Medicine
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Rex DK, Bhandari R, Desta T, DeMicco MP, Schaeffer C, Etzkorn K, Barish CF, Pruitt R, Cash BD, Quirk D, Tiongco F, Sullivan S, Bernstein D. A phase III study evaluating the efficacy and safety of remimazolam (CNS 7056) compared with placebo and midazolam in patients undergoing colonoscopy. Gastrointest Endosc 2018; 88:427-437.e6. [PMID: 29723512 DOI: 10.1016/j.gie.2018.04.2351] [Citation(s) in RCA: 141] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 04/18/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Remimazolam is an ultrashort-acting benzodiazepine. METHODS We performed a randomized double-blind comparison of remimazolam to placebo for outpatient colonoscopy. This study design was a requirement of the U.S. Food and Drug Administration. An additional group was randomized to open-label midazolam administered according to its package insert instructions (the randomization ratio for remimazolam:placebo:midazolam was 30:6:10). Study medications were administered under the supervision of the endoscopist, without any involvement of an anesthesia specialist. Patients were given 50 to 75 μg of fentanyl before receiving study medications. Patients who failed to achieve adequate sedation in any arm were rescued with midazolam dosed at the investigator's discretion. The primary endpoint was a composite that required 3 criteria be met: completion of the colonoscopy, no need for rescue medication, and ≤5 doses of remimazolam or placebo in any 15-minute interval (≤3 doses of midazolam in any 12-minute interval in the open-label midazolam arm). RESULTS There were 461 randomized patients in 12 U.S. sites. The primary endpoint was met for remimazolam, placebo, and midazolam in 91.3%, 1.7%, and 25.2% of patients, respectively (P < .0001 for remimazolam vs placebo). Patients administered remimazolam received less fentanyl, had faster recovery of neuropsychiatric function, were ready for discharge earlier, and felt back to normal sooner than patients with both placebo and midazolam. Hypotension was less frequent with remimazolam, and hypoxia occurred in 1% of patients with remimazolam or midazolam. There were no treatment-emergent serious adverse events. CONCLUSION Remimazolam can be administered safely under the supervision of endoscopists for outpatient colonoscopy, and it allows faster recovery of neuropsychiatric function compared with placebo (midazolam rescue) and midazolam. (Clinical trial registration number: NCT02290873.).
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Affiliation(s)
- Douglas K Rex
- Indiana University School of Medicine, Indianapolis, Indianapolis
| | | | | | | | | | | | | | - Ronald Pruitt
- Nashville Medical Research Institute, Nashville, Tennessee
| | | | - Daniel Quirk
- Thomas Jefferson Medical College, Philadelphia, Pennsylvania
| | - Felix Tiongco
- Gastroenterology Associates of Tidewater, Chesapeake, Virginia
| | - Shelby Sullivan
- Department of Medicine, University of Colorado, Denver, Colorado
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Eschenfeldt PC, Kartoun U, Heberle CR, Kong CY, Nishioka NS, Ng K, Kamarthi S, Hur C. Analysis of factors associated with extended recovery time after colonoscopy. PLoS One 2018; 13:e0199246. [PMID: 29927978 PMCID: PMC6013091 DOI: 10.1371/journal.pone.0199246] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 04/20/2018] [Indexed: 01/09/2023] Open
Abstract
Background & aims A common limiting factor in the throughput of gastrointestinal endoscopy units is the availability of space for patients to recover post-procedure. This study sought to identify predictors of abnormally long recovery time after colonoscopy performed with procedural sedation. In clinical research, this type of study would be performed using only one regression modeling approach. A goal of this study was to apply various “machine learning” techniques to see if better prediction could be achieved. Methods Procedural data for 31,442 colonoscopies performed on 29,905 adult patients at Massachusetts General Hospital from 2011 to 2015 were analyzed to identify potential predictors of long recovery times. These data included the identities of hospital personnel, and the initial statistical analysis focused on the impact of these personnel on recovery time via multivariate logistic regression. Secondary analyses included more information on patient vitals both to identify secondary predictors and to predict long recoveries using more complex techniques. Results In univariate analysis, the endoscopist, procedure room nurse, recovery room nurse, and surgical technician all showed a statistically significant relationship to long recovery times, with p-value below 0.0001 in all cases. In the multivariate logistic regression, the most significant predictor of a long recovery time was the identity of the recovery room nurse, with the endoscopist also showing a statistically significant relationship with a weaker effect. Complex techniques led to a negligible improvement over simple techniques in prediction of long recovery periods. Conclusion The hospital personnel involved in performing a colonoscopy show a strong association with the likelihood of a patient spending an abnormally long time recovering from the procedure, with the most pronounced effect for the nurse in the recovery room. The application of more advanced approaches to improve prediction in this clinical data set only yielded modest improvements.
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Affiliation(s)
- Patrick C Eschenfeldt
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA, United States of America.,Gastrointestinal Unit, Massachusetts General Hospital, Boston, MA, United States of America.,Harvard Medical School, Boston, MA, United States of America
| | - Uri Kartoun
- Center for Computational Health, IBM Research, Cambridge, MA, United States of America
| | - Curtis R Heberle
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA, United States of America.,Gastrointestinal Unit, Massachusetts General Hospital, Boston, MA, United States of America
| | - Chung Yin Kong
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA, United States of America.,Harvard Medical School, Boston, MA, United States of America
| | - Norman S Nishioka
- Gastrointestinal Unit, Massachusetts General Hospital, Boston, MA, United States of America.,Harvard Medical School, Boston, MA, United States of America
| | - Kenney Ng
- Center for Computational Health, IBM Research, Cambridge, MA, United States of America
| | - Sagar Kamarthi
- Northeastern University College of Engineering, Boston, MA, United States of America
| | - Chin Hur
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA, United States of America.,Gastrointestinal Unit, Massachusetts General Hospital, Boston, MA, United States of America.,Harvard Medical School, Boston, MA, United States of America
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Abstract
PURPOSE OF REVIEW To assess the trends in nonoperating room anesthesia (NORA) for gastrointestinal endoscopy over the past few years, and to describe alternative methods of delivering propofol sedation in selected low-risk patients. RECENT FINDINGS The use of NORA for routine gastrointestinal endoscopic procedures has been rising steadily over the past decade in the United States, considerably increasing healthcare costs. Because of this, there have been attempts to develop nonanesthesiologist-administered propofol sedation methods in low-risk patients. There is controversy as to whether properly trained nonanesthesia personnel can use propofol safely via the modalities of nurse-administered propofol sedation, computer-assisted propofol sedation or nurse-administered continuous propofol sedation SUMMARY: The deployment of nonanesthesia-administered propofol sedation for low-risk procedures allows for optimal allocation of scarce anesthesia resources, which can be more appropriately used for more complex cases. This can address some of the current shortages in anesthesia provider supply, and can potentially reduce overall healthcare costs without sacrificing sedation quality. We also address the realm of anesthesia provider care for advanced endoscopic procedures including setup for administration of anesthesia, decision-making regarding placement of an endotracheal tube, and the potential need to move a challenging case to the operating room.
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Xue M, Tian J, Zhang J, Zhu H, Bai J, Zhang S, Wang Q, Wang S, Song X, Ma D, Li J, Zhang Y, Li W, Wang D. No increased risk of perforation during colonoscopy in patients undergoing propofol versus traditional sedation: A meta-analysis. Indian J Gastroenterol 2018. [PMID: 29520582 DOI: 10.1007/s12664-017-0814-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS The safety of propofol sedation during colonoscopy remains unclear, and we performed a meta-analysis to assess the risk of perforation in patients undergoing propofol vs. traditional sedation. METHODS MEDLINE, CBM, VIP, CNKI, and Wanfang databases were searched up to December 2016. Two reviewers independently assessed abstract of those searched articles. Data about perforation condition in propofol and traditional sedation groups were extracted and combined using the random effects model. RESULTS A total of 19 studies were included in the current meta-analysis. Compared to traditional sedation, propofol sedation did not increase the risk of perforation (RD = - 0.00, 95% CI - 0.00~0.00, p = 0.98; subgroup analysis: OR = 1.30, 95% CI 0.83~2.05, p = 0.25). CONCLUSION This meta-analysis suggested that propofol sedation did not increase the risk of perforation compared to traditional sedation during colonoscopy.
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Affiliation(s)
- Minmin Xue
- Department of Gastroenterology, Chinese People's Liberation Army 254 Hospital, Tianjin, 300070, People's Republic of China
| | - Jian Tian
- Department of Gastroenterology, Chinese People's Liberation Army 254 Hospital, Tianjin, 300070, People's Republic of China
| | - Jing Zhang
- Department of Gastroenterology, Chinese People's Liberation Army 254 Hospital, Tianjin, 300070, People's Republic of China
| | - Hongbin Zhu
- Department of Gastroenterology, Chinese People's Liberation Army 254 Hospital, Tianjin, 300070, People's Republic of China
| | - Jun Bai
- Department of Gastroenterology, Chinese People's Liberation Army 254 Hospital, Tianjin, 300070, People's Republic of China
| | - Sujuan Zhang
- Department of Gastroenterology, Chinese People's Liberation Army 254 Hospital, Tianjin, 300070, People's Republic of China
| | - Qili Wang
- Department of Gastroenterology, Chinese People's Liberation Army 254 Hospital, Tianjin, 300070, People's Republic of China
| | - Shuge Wang
- Department of Gastroenterology, Chinese People's Liberation Army 254 Hospital, Tianjin, 300070, People's Republic of China
| | - Xuzheng Song
- Department of Gastroenterology, Chinese People's Liberation Army 254 Hospital, Tianjin, 300070, People's Republic of China
| | - Donghong Ma
- Department of Gastroenterology, Chinese People's Liberation Army 254 Hospital, Tianjin, 300070, People's Republic of China
| | - Jia Li
- Department of Gastroenterology, Chinese People's Liberation Army 254 Hospital, Tianjin, 300070, People's Republic of China
| | - Yongmin Zhang
- Department of Gastroenterology, Chinese People's Liberation Army 254 Hospital, Tianjin, 300070, People's Republic of China
| | - Wei Li
- Department of Gastroenterology, Chinese People's Liberation Army 254 Hospital, Tianjin, 300070, People's Republic of China
| | - Dongxu Wang
- Department of Gastroenterology, Chinese People's Liberation Army 254 Hospital, Tianjin, 300070, People's Republic of China.
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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: 290] [Impact Index Per Article: 48.3] [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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Kikuchi H, Hikichi T, Watanabe K, Nakamura J, Takagi T, Suzuki R, Sugimoto M, Waragai Y, Konno N, Asama H, Takasumi M, Sato Y, Obara K, Ohira H. Efficacy and safety of sedation during endoscopic submucosal dissection of gastric cancers using a comparative trial of propofol versus midazolam. Endosc Int Open 2018; 6:E51-E57. [PMID: 29340298 PMCID: PMC5766337 DOI: 10.1055/s-0043-122225] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Accepted: 09/11/2017] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Proper sedation is necessary for the safe and satisfactory completion of endoscopic submucosal dissection (ESD) for early gastric cancer. This study was conducted as a comparative trial of efficacy and safety, comparing propofol-based sedation and midazolam-based sedation during ESD of early gastric cancer patients. PATIENTS AND METHODS This study examined 64 lesions in 58 patients treated using ESD with midazolam plus pentazocine between July 2013 and January 2014 (group M) and 237 lesions in 216 patients treated by ESD using propofol plus pentazocine between February 2014 and December 2015 (group P). The two groups were compared in terms of the frequency of body movement during ESD as the primary outcome and in terms of the procedure time, en bloc resection rate, intraoperative change in cardiorespiratory dynamics, and postoperative awareness as the secondary outcomes. Body movement was defined as movement by a patient that required interruption of the procedure or restraint of the patient's body trunk, and addition of a sedative agent. RESULTS The median frequency of body movement during ESD was significantly lower in group P (0 times) than in group M (3 times) ( P < 0.001). No significant difference was found for the mean procedure time (117 min in group P; 127 min in group M). Although no significant difference was found in the incidence of hypoxemia, bradycardia, or bradypnea, the incidence of hypotension was significantly higher in group P (31.5 %) than in group M (6.9 %) ( P = 0.004). Patients in group P had significantly higher postoperative awareness immediately after ESD and at 1 hour after ESD ( P = 0.002 and 0.022, respectively). CONCLUSION These results demonstrate the efficacy and safety of propofol-based sedation for gastric ESD.
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Affiliation(s)
- Hitomi Kikuchi
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan,Department of Gastroenterology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Takuto Hikichi
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan,Corresponding author Takuto Hikichi, MD, PhD Director and Associate ProfessorDepartment of EndoscopyFukushima Medical University Hospital1 HikarigaokaFukushima, Japan, 960-1295+81-24-547-1586
| | - Ko Watanabe
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan,Department of Gastroenterology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Jun Nakamura
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan,Department of Gastroenterology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Tadayuki Takagi
- Department of Gastroenterology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Rei Suzuki
- Department of Gastroenterology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Mitsuru Sugimoto
- Department of Gastroenterology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Yuichi Waragai
- Department of Gastroenterology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Naoki Konno
- Department of Gastroenterology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Hiroyuki Asama
- Department of Gastroenterology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Mika Takasumi
- Department of Gastroenterology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Yuki Sato
- Department of Gastroenterology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Katsutoshi Obara
- Department of Advanced Gastrointestinal Endoscopy, Fukushima Medical University, Fukushima, Japan
| | - Hiromasa Ohira
- Department of Gastroenterology, Fukushima Medical University School of Medicine, Fukushima, Japan
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Lin OS. Sedation for routine gastrointestinal endoscopic procedures: a review on efficacy, safety, efficiency, cost and satisfaction. Intest Res 2017; 15:456-466. [PMID: 29142513 PMCID: PMC5683976 DOI: 10.5217/ir.2017.15.4.456] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 08/03/2017] [Accepted: 08/03/2017] [Indexed: 02/07/2023] Open
Abstract
Most gastrointestinal endoscopic procedures are now performed with sedation. Moderate sedation using benzodiazepines and opioids continue to be widely used, but propofol sedation is becoming more popular because its unique pharmacokinetic properties make endoscopy almost painless, with a very predictable and rapid recovery process. There is controversy as to whether propofol should be administered only by anesthesia professionals (monitored anesthesia care) or whether properly trained non-anesthesia personnel can use propofol safely via the modalities of nurse-administered propofol sedation, computer-assisted propofol sedation or nurse-administered continuous propofol sedation. The deployment of non-anesthesia administered propofol sedation for low-risk procedures allows for optimal allocation of scarce anesthesia resources, which can be more appropriately used for more complex cases. This can address some of the current shortages in anesthesia provider supply, and can potentially reduce overall health care costs without sacrificing sedation quality. This review will discuss efficacy, safety, efficiency, cost and satisfaction issues with various modes of sedation for non-advanced, non-emergent endoscopic procedures, mainly esophagogastroduodenoscopy and colonoscopy.
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Affiliation(s)
- Otto S Lin
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
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Kim MG, Park SW, Kim JH, Lee J, Kae SH, Jang HJ, Koh DH, Choi MH. Etomidate versus propofol sedation for complex upper endoscopic procedures: a prospective double-blinded randomized controlled trial. Gastrointest Endosc 2017; 86:452-461. [PMID: 28284883 DOI: 10.1016/j.gie.2017.02.033] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 02/23/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Although a growing body of evidence demonstrates that propofol-induced deep sedation can be effective and performed safely, cardiopulmonary adverse events have been observed frequently. Etomidate is a new emerging drug that provides hemodynamic and respiratory stability, even in high-risk patient groups. The objective of this study was to compare safety and efficacy profiles of etomidate and propofol for endoscopic sedation. METHODS A total of 128 patients undergoing EUS were randomized to receive either etomidate or propofol blinded administered by a registered nurse. The primary outcome was the proportion of patients with any cardiopulmonary adverse events. RESULTS Overall cardiopulmonary adverse events were identified in 22 patients (34.38%) of the etomidate group and 33 patients (51.56%) of the propofol group, without significant difference (P = .074). However, the incidence of oxygen desaturation (4/64 [6.25%] vs 20/64 [31.25%]; P =.001) and respiratory depression (5/64 [7.81%] vs 21/64 [32.81%]; P =.001) was significantly lower in the etomidate group than in the propofol group. The frequency of myoclonus was significantly higher in the etomidate group (22/64 [34.37%]) compared with the propofol group (8/64 [12.50%]) (P =.012). Repeated measure analysis of variance revealed significant effects of sedation group and time on systolic blood pressure (etomidate group greater than propofol group). Physician satisfaction was greater in the etomidate group than in the propofol group. CONCLUSIONS Etomidate administration resulted in fewer respiratory depression events and had a better sedative efficacy than propofol; however, it was more frequently associated with myoclonus and increased blood pressure during endoscopic procedures. (Clinical trial registration number: KCT0001701.).
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Affiliation(s)
- Mi Gang Kim
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
| | - Se Woo Park
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
| | - Jae Hyun Kim
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
| | - Jin Lee
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
| | - Sea Hyub Kae
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
| | - Hyun Joo Jang
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
| | - Dong Hee Koh
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
| | - Min Ho Choi
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
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Finn RT, Boyd A, Lin L, Gellad ZF. Bolus Administration of Fentanyl and Midazolam for Colonoscopy Increases Endoscopy Unit Efficiency and Safety Compared With Titrated Sedation. Clin Gastroenterol Hepatol 2017; 15:1419-1426.e2. [PMID: 28365484 DOI: 10.1016/j.cgh.2017.03.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 02/23/2017] [Accepted: 03/02/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Guidelines recommend slow titration of sedatives for moderate sedation. Bolus sedation, in which a larger weight-based dose of medication is given upfront, has been shown in a single trial to be beneficial. We evaluated the effects of bolus sedation on procedural safety, efficiency, and patient experience. METHODS We performed a retrospective analysis of colonoscopies performed between April 2010 and April 2011 at Duke Medical Center. Colonoscopies before October 2010 were performed with nurse-directed titration of sedative (n = 966); colonoscopies performed after October 2010 were performed with physician-directed administration of bolus sedative (n = 699). We compared sedation and recovery times, medication doses, and adverse events between groups. We also compared patient satisfaction in a subset of patients from each group. Data were compared using the chi-square test for categorical variables and Wilcoxon rank sum test for continuous and ordinal categorical variables. RESULTS Patients in the bolus group had a shorter sedation time (6.0 min) than patients in the titration group (13.0 min; P < .01) and a slightly longer colonoscopy time (25.0 min vs 24.0 min in the titration group; P < .01). Recovery time did not differ significantly between groups (53.0 min in the bolus group vs 52.1 min in the titration group; P = .07). Patients in the bolus group received lower weight-adjusted doses of fentanyl (1.71 μg/kg vs 1.89 μg/kg in the titration group) and midazolam (0.065 mg/kg vs 0.075 mg/kg in the titration group). A smaller proportion of patients in the bolus sedative group developed hypotension (12.7% vs 17.9% in the titration group; P < .01). These findings persisted even after adjustment for baseline patient age, race, sex, smoking status, alcohol use, body mass index, and American Society of Anesthesiologists' classification. CONCLUSIONS In a retrospective study of patients undergoing colonoscopy, we found that compared with titrated administration of sedative, bolus dosing improves endoscopy unit efficiency and safety and decreases the amount of sedative required. This benefit does not come at the expense of the patient experience.
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Affiliation(s)
- R Thomas Finn
- Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina
| | - Amanda Boyd
- Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina
| | - Li Lin
- Duke Clinical Research Institute, Durham, North Carolina
| | - Ziad F Gellad
- Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina; Durham VA Medical Center, Durham, North Carolina.
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