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Barbosa EC, Espírito Santo PA, Baraldo S, Meine GC. Remimazolam versus propofol for sedation in gastrointestinal endoscopic procedures: a systematic review and meta-analysis. Br J Anaesth 2024; 132:1219-1229. [PMID: 38443286 DOI: 10.1016/j.bja.2024.02.005] [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: 10/16/2023] [Revised: 01/11/2024] [Accepted: 02/09/2024] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND Propofol has a favourable efficacy profile in gastrointestinal endoscopic procedures, however adverse events remain frequent. Emerging evidence supports remimazolam use in gastrointestinal endoscopy. This systematic review and meta-analysis compares remimazolam and propofol, both combined with a short-acting opioid, for sedation of adults in gastrointestinal endoscopy. METHODS We searched MEDLINE, Embase, and Cochrane databases for randomised controlled trials comparing efficacy-, safety-, and satisfaction-related outcomes between remimazolam and propofol, both combined with short-acting opioids, for sedation of adults undergoing gastrointestinal endoscopy. We performed sensitivity analyses, subgroup assessments by type of short-acting opioid used and age range, and meta-regression analysis using mean patient age as a covariate. We used R statistical software for statistical analyses. RESULTS We included 15 trials (4516 subjects). Remimazolam was associated with a significantly lower sedation success rate (risk ratio [RR] 0.991; 95% confidence interval [CI] 0.984-0.998; high-quality evidence) and a slightly longer induction time (mean difference [MD] 9 s; 95% CI 4-13; moderate-quality evidence), whereas there was no significant difference between the sedatives in other time-related outcomes. Remimazolam was associated with significantly lower rates of respiratory depression (RR 0.41; 95% CI 0.30-0.56; high-quality evidence), hypotension (RR 0.43; 95% CI 0.35-0.51; moderate-quality evidence), hypotension requiring treatment (RR 0.25; 95% CI 0.12-0.52; high-quality evidence), and bradycardia (RR 0.42; 95% CI 0.30-0.58; high-quality evidence). There was no difference in patient (MD 0.41; 95% CI -0.07 to 0.89; moderate-quality evidence) and endoscopist satisfaction (MD -0.31; 95% CI -0.65 to 0.04; high-quality evidence) between both drugs. CONCLUSIONS Remimazolam has clinically similar efficacy and greater safety when compared with propofol for sedation in gastrointestinal endoscopies.
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Affiliation(s)
| | - Paula Arruda Espírito Santo
- Diagnostic Imaging and Specialized Diagnosis Unit, University Hospital of Federal University of São Carlos, São Carlos, Brazil
| | - Stefano Baraldo
- Department of Endoscopy, Barretos Cancer Hospital, Barretos, Brazil
| | - Gilmara Coelho Meine
- Division of Gastroenterology, Internal Medicine Department, Feevale University, Novo Hamburgo, Brazil.
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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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Endoscopist-directed propofol is more efficient than anesthesiologist-administered propofol in patients at low-intermediate anesthetic risk. Eur J Gastroenterol Hepatol 2020; 32:1440-1446. [PMID: 32925498 DOI: 10.1097/meg.0000000000001820] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Endoscopist-directed propofol (EDP) sedation is becoming more popular, with a reported safety and efficacy similar to anesthesiologist-administered propofol (AAP). The aim of this study is to compare the efficiency of EDP and AAP in patients of low-intermediate anesthetic risk. METHODS A prospective cost-effectiveness comparison study was conducted. The costs of the endoscopic procedures in the EDP and AAP group were calculated using the full cost methodology after breaking down the endoscopic activity into relative value units to allocate costs in an equitable way. To determine the effectiveness, adverse events related to endoscopic sedation and the number of incomplete procedures were registered for the EDP group and compared with those published by anesthesiologists for AAP. RESULTS A total of 1165 and 18 919 endoscopic procedures were, respectively, included in the EDP and AAP groups. The average costs of EDP vs. AAP for gastroscopy, colonoscopy and endoscopic ultrasound were &OV0556; 182.81 vs. &OV0556; 332.93, &OV0556; 297.07 vs. &OV0556; 459.76, and &OV0556; 319.92 vs. &OV0556; 485.12, respectively. No significant differences were detected regarding the rate of overall adverse events (4.43 vs. 4.46%) or serious adverse events (0 vs. 0.17%); the rate of arterial hypotension was significantly lower in the EDP group: 0.34 vs. 1.78% [odds ratio (OR), 0.19; 95% confidence interval (CI), 0.08-0.46] and the desaturation rate was significantly lower in the AAP group: 3.26 vs. 1.29% (OR, 2.58; 95% CI, 1.85-3.60). No significant differences were found in terms of incomplete examinations (0.17 vs. 0.14%). CONCLUSION In patients with low-intermediate anesthetic risk referred for an endoscopic examination, EDP appears to be more efficient than AAP.
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Dossa F, Medeiros B, Keng C, Acuna SA, Baxter NN. Propofol versus midazolam with or without short-acting opioids for sedation in colonoscopy: a systematic review and meta-analysis of safety, satisfaction, and efficiency outcomes. Gastrointest Endosc 2020; 91:1015-1026.e7. [PMID: 31926966 DOI: 10.1016/j.gie.2019.12.047] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Accepted: 12/30/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Propofol is increasingly being used for sedation in colonoscopy; however, its benefits over midazolam (± short-acting opioids) are not well quantified. The objective of this study was to compare safety, satisfaction, and efficiency outcomes of propofol versus midazolam (± short-acting opioids) in patients undergoing colonoscopy. METHODS We systematically searched Medline, Embase, and the Cochrane library (to July 30, 2018) for randomized controlled trials of colonoscopies performed with propofol versus midazolam (± short-acting opioids). We pooled odds ratios for cardiorespiratory outcomes using mixed-effects conditional logistic models. We pooled standardized mean differences (SMDs) for patient and endoscopist satisfaction and efficiency outcomes using random-effects models. RESULTS Nine studies of 1427 patients met the inclusion criteria. There were no significant differences in cardiorespiratory outcomes (hypotension, hypoxia, bradycardia) between sedative groups. Patient satisfaction was high in both groups, with most patients reporting willingness to undergo a future colonoscopy with the same sedative regimen. In the meta-analysis, patients sedated with propofol had greater satisfaction than those sedated with midazolam (± short-acting opioids) (SMD, .54; 95% confidence interval [CI], .30-.79); however, there was considerable heterogeneity. Procedure time was similar between groups (SMD, .15; 95% CI, .04-.27), but recovery time was shorter in the propofol group (SMD, .41; 95% CI, .08-.74). The median difference in recovery time was 3 minutes, 6 seconds shorter in patients sedated with propofol. CONCLUSIONS Both propofol and midazolam (± short-acting opioids) result in high patient satisfaction and appear to be safe for use in colonoscopy. The marginal benefits to propofol are small improvements in satisfaction and recovery time.
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Affiliation(s)
- Fahima Dossa
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada; Department of Surgery, St Michael's Hospital, Toronto, Ontario, Canada
| | - Braeden Medeiros
- Department of Biology, Western University, London, Ontario, Canada
| | - Christine Keng
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Sergio A Acuna
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Nancy N Baxter
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada; Department of Surgery, St Michael's Hospital, Toronto, Ontario, Canada
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Sidhu R, Turnbull D, Newton M, Thomas-Gibson S, Sanders DS, Hebbar S, Haidry RJ, Smith G, Webster G. Deep sedation and anaesthesia in complex gastrointestinal endoscopy: a joint position statement endorsed by the British Society of Gastroenterology (BSG), Joint Advisory Group (JAG) and Royal College of Anaesthetists (RCoA). Frontline Gastroenterol 2019; 10:141-147. [PMID: 31205654 PMCID: PMC6540268 DOI: 10.1136/flgastro-2018-101145] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 12/05/2018] [Accepted: 12/16/2018] [Indexed: 02/04/2023] Open
Abstract
In the UK, more than 2.5 million endoscopic procedures are carried out each year. Most are performed under conscious sedation with benzodiazepines and opioids administered by the endoscopist. However, in prolonged and complex procedures, this form of sedation may provide inadequate patient comfort or result in oversedation. As a result, this may have a negative impact on procedural success and patient outcome. In addition, there have been safety concerns on the high doses of benzodiazepines and opioids used particularly in prolonged and complex procedures such as endoscopic retrograde cholangiopancreatography. Diagnostic and therapeutic endoscopy has evolved rapidly over the past 5 years with advances in technical skills and equipment allowing interventions and procedural capabilities that are moving closer to minimally invasive endoscopic surgery. It is vital that safe and appropriate sedation practices follow the inevitable expansion of this portfolio to accommodate safe and high-quality clinical outcomes. This position statement outlines the current use of sedation in the UK and highlights the role for anaesthetist-led deep sedation practice with a focus on propofol sedation although the choice of sedative or anaesthetic agent is ultimately the choice of the anaesthetist. It outlines the indication for deep sedation and anaesthesia, patient selection and assessment and procedural details. It considers the setup for a deep sedation and anaesthesia list, including the equipment required, the environment, staffing and monitoring requirements. Considerations for different endoscopic procedures in both emergency and elective setting are also detailed. The role for training, audit, compliance and future developments are discussed.
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Affiliation(s)
- Reena Sidhu
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
| | - David Turnbull
- Department of Anaesthesia, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
| | - Mary Newton
- Department of Anaesthesia, The National Hospital for Neurology and Neurosurgery, UCLH NHS Foundation Trust, London, UK
| | - Siwan Thomas-Gibson
- Imperial College, Chair Joint Advisory Group Gastrointestinal Endoscopy, St Mark’s Hospital, Harrow, UK
| | - David S Sanders
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
| | - Srisha Hebbar
- Department of Gastroenterology, Stoke University Hospital University, Hospitals of North Midlands NHS Trust, Sheffield, UK
| | - Rehan J Haidry
- Department of Gastroenterology, University College London Hospital NHS Foundation Trust, London, UK,Division of Surgery & Interventional Science, University College London (UCL), London, UK
| | - Geoff Smith
- Gastroenterology, Imperial College Healthcare NHS Trust, London, UK
| | - George Webster
- Department of Gastroenterology, University College London Hospital NHS Foundation Trust, London, UK
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Glennie RA, Barry SP, Alant J, Christie S, Oxner WM. Will cost transparency in the operating theatre cause surgeons to change their practice? J Clin Neurosci 2019; 60:1-6. [DOI: 10.1016/j.jocn.2018.09.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 09/26/2018] [Indexed: 01/07/2023]
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Allampati S, Wen S, Liu F, Kupec JT. Recovery of cognitive function after sedation with propofol for outpatient gastrointestinal endoscopy. Saudi J Gastroenterol 2019; 25:188-193. [PMID: 30618439 PMCID: PMC6526733 DOI: 10.4103/sjg.sjg_369_18] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND/AIM Most endoscopies performed in the United States utilize sedation. Anesthesia provides patient comfort and improved procedural quality but adds to the complexity of scheduling routine outpatient procedures. We aimed to assess the return of cognitive function after propofol administration in patients undergoing outpatient endoscopies. PATIENTS AND METHODS Cognitive recovery for patients undergoing endoscopy under monitored anesthesia care was evaluated using EncephalApp. Patients were tested before and after procedure and healthy controls were tested twice, 30 min apart. Results were tabulated in on state (on time) and off state (off time) and total time (on time + off time). The time difference between pre- and post-tests, "delta," was calculated for on, off, and total times. Wilcoxon rank test was used to check the difference in mean delta of all three test times between cases and controls and to check for statistical significance. RESULTS The difference in mean time between cases and controls was significant for off (P < 0.0001) and total (P = 0.0002) times. No statistically significant difference was noted in mean time for on time (P = 0.013) between cases and controls. Cognitive flexibility, a measure of on time, returned to baseline after procedural sedation even though psychomotor speed, a measure of off time and total time, had not. CONCLUSION Cognitive flexibility returns to baseline within 30-45 min after propofol sedation despite delayed return of psychomotor speed and reaction time.
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Affiliation(s)
- Sanath Allampati
- Department of Medicine, West Virginia University, WV, USA,Address for correspondence: Dr. Sanath Allampati, 1, Stadium Drive, Morgantown, WV - 26506, USA. E-mail:
| | - Sijin Wen
- Department of Biostatistics, West Virginia University, WV, USA
| | - Feiyu Liu
- Department of Biostatistics, West Virginia University, WV, USA
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The impact of water-aided methods on pain reduction and adenoma detection rate during colonoscopy. ADVANCES IN DIGESTIVE MEDICINE 2018. [DOI: 10.1002/aid2.13067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Hernán Ocaña P. Sedation assisted by an endoscopist (SAE) for complex endoscopic procedures. Is it time to change the current guidelines? REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2018; 110:261-262. [PMID: 29620410 DOI: 10.17235/reed.2018.5537/2018] [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
Currently, sedation in endoscopic procedures is considered a necessary condition and a criterion of quality in digestive endoscopy. The role of SAE in conventional endoscopic procedures is clearly established in clinical guidelines, but this is not so clear in complex endoscopic procedures, such as ERCP. In recent years, numerous studies have been published, with results similar to those noticed in this article, endorsing the safety, efficacy and efficiency of SAE, when performed by properly trained staff.
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Helmers RA, Dilling JA, Chaffee CR, Larson MV, Narr BJ, Haas DA, Kaplan RS. Overall Cost Comparison of Gastrointestinal Endoscopic Procedures With Endoscopist- or Anesthesia-Supported Sedation by Activity-Based Costing Techniques. Mayo Clin Proc Innov Qual Outcomes 2017; 1:234-241. [PMID: 30225422 PMCID: PMC6132202 DOI: 10.1016/j.mayocpiqo.2017.10.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2023] Open
Abstract
OBJECTIVE Endoscopic/colonoscopic procedures are either done with gastroenterologist-administered conscious sedation or with anesthesia-administered sedation with propofol. There are potential benefits to anesthesia-administered sedation, but the concern has been the associated increased cost. METHODS To perform this study, we used the time-derived activity-based costing (TDABC) technique to accurately assess the true cost of gastrointestinal procedures done with gastroenterologist-administered conscious sedation vs anesthesia-administered sedation in 2 areas of our practice that use predominantly conscious sedation or anesthesia-administered sedation. This type of study has never been reported using such an integrated approach. This study was performed on 2 different days in June 2015. RESULTS The true cost associated with anesthesia-administered sedation in our practice was associated with only 9% to 24% greater cost when the TDABC technique was applied. CONCLUSION Gastrointestinal procedures with anesthesia-administered sedation are not as costly when all factors are considered. Using novel approaches to cost measurement, such as the TDABC, allows a total cost measurement approach across an episode of care that existing cost measurements in health care are incapable of.
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Affiliation(s)
- Richard A. Helmers
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Scottsdale, AZ
- Correspondence: Address to Richard A. Helmers, MD, Mayo Clinic Health System, Administration Building, 1400 Bellinger St, Eau Claire, WI 54703.
| | | | | | - Mark V. Larson
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Bradly J. Narr
- Department of Anesthesiology, Mayo Clinic, Rochester, MN
| | - Derek A. Haas
- Institute for Strategy & Competitiveness, Harvard Business School, Boston, MA
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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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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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Thirumurthi S, Raju GS, Pande M, Ruiz J, Carlson R, Hagan KB, Lee JH, Ross WA. Does deep sedation with propofol affect adenoma detection rates in average risk screening colonoscopy exams? World J Gastrointest Endosc 2017; 9:177-182. [PMID: 28465784 PMCID: PMC5394724 DOI: 10.4253/wjge.v9.i4.177] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 01/02/2017] [Accepted: 01/16/2017] [Indexed: 02/05/2023] Open
Abstract
AIM To determine the effect of sedation with propofol on adenoma detection rate (ADR) and cecal intubation rates (CIR) in average risk screening colonoscopies compared to moderate sedation. METHODS We conducted a retrospective chart review of 2604 first-time average risk screening colonoscopies performed at MD Anderson Cancer Center from 2010-2013. ADR and CIR were calculated in each sedation group. Multivariable regression analysis was performed to adjust for potential confounders of age and body mass index (BMI). RESULTS One-third of the exams were done with propofol (n = 874). Overall ADR in the propofol group was significantly higher than moderate sedation (46.3% vs 41.2%, P = 0.01). After adjustment for age and BMI differences, ADR was similar between the groups. CIR was 99% for all exams. The mean cecal insertion time was shorter among propofol patients (6.9 min vs 8.2 min; P < 0.0001). CONCLUSION Deep sedation with propofol for screening colonoscopy did not significantly improve ADR or CIR in our population of average risk patients. While propofol may allow for safer sedation in certain patients (e.g., with sleep apnea), the overall effect on colonoscopy quality metrics is not significant. Given its increased cost, propofol should be used judiciously and without the implicit expectation of a higher quality screening exam.
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Schumann R, Natov NS, Rocuts-Martinez KA, Finkelman MD, Phan TV, Hegde SR, Knapp RM. High-flow nasal oxygen availability for sedation decreases the use of general anesthesia during endoscopic retrograde cholangiopancreatography and endoscopic ultrasound. World J Gastroenterol 2016; 22:10398-10405. [PMID: 28058020 PMCID: PMC5175252 DOI: 10.3748/wjg.v22.i47.10398] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 11/03/2016] [Accepted: 11/28/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To examine whether high-flow nasal oxygen (HFNO) availability influences the use of general anesthesia (GA) in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) and associated outcomes.
METHODS In this retrospective study, patients were stratified into 3 eras between October 1, 2013 and June 30, 2014 based on HFNO availability for deep sedation at the time of their endoscopy. During the first and last 3-mo eras (era 1 and 3), no HFNO was available, whereas it was an option during the second 3-mo era (era 2). The primary outcome was the percent utilization of GA vs deep sedation in each period. Secondary outcomes included oxygen saturation nadir during sedation between periods, as well as procedure duration, and anesthesia-only time between periods and for GA vs sedation cases respectively.
RESULTS During the study period 238 ERCP or EUS cases were identified for analysis. Statistical testing was employed and a P < 0.050 was significant unless the Bonferroni correction for multiple comparisons was used. General anesthesia use was significantly lower in era 2 compared to era 1 with the same trend between era 2 and 3 (P = 0.012 and 0.045 respectively). The oxygen saturation nadir during sedation was significantly higher in era 2 compared to era 3 (P < 0.001) but not between eras 1 and 2 (P = 0.028) or 1 and 3 (P = 0.069). The procedure time within each era was significantly longer under GA compared to deep sedation (P≤ 0.007) as was the anesthesia-only time (P≤ 0.001).
CONCLUSION High-flow nasal oxygen availability was associated with decreased GA utilization and improved oxygenation for ERCP and EUS during sedation.
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Abstract
Recent development and expansion of endoscopy units has necessitated similar progress in the quality assurance of procedure sedation and monitoring. The large number of endoscopic procedures performed annually underlies the need for standardized quality initiatives focused on mitigating patient risk before, during, and immediately after endoscopic sedation, as well as improving procedure outcomes and patient satisfaction. Specific standards are needed for newer sedation modalities, including propofol administration. This article reviews the current guidelines and literature concerning quality assurance and endoscopic procedure sedation.
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González-Huix Lladó F. Sedation for endoscopy in 2016 - Is endoscopist-guided sedation safe in complex situations? REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2016; 108:237-239. [PMID: 27128637 DOI: 10.17235/reed.2016.4383/2016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
The higher number of adverse events reported with anesthetist-delivered sedation are likely due to the fact that anethesia professionals induce deeper sedation as compared to sedation delivered by endoscopists. The former are trained to induce general anesthesia in their daily practice, where protective reflexes are more commonly depressed and the risk for undesired cardiopulmonary events is higher.
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Efficacy Outcome Measures for Procedural Sedation Clinical Trials in Adults: An ACTTION Systematic Review. Anesth Analg 2016; 122:152-70. [PMID: 26678470 DOI: 10.1213/ane.0000000000000934] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Successful procedural sedation represents a spectrum of patient- and clinician-related goals. The absence of a gold-standard measure of the efficacy of procedural sedation has led to a variety of outcomes being used in clinical trials, with the consequent lack of consistency among measures, making comparisons among trials and meta-analyses challenging. We evaluated which existing measures have undergone psychometric analysis in a procedural sedation setting and whether the validity of any of these measures support their use across the range of procedures for which sedation is indicated. Numerous measures were found to have been used in clinical research on procedural sedation across a wide range of procedures. However, reliability and validity have been evaluated for only a limited number of sedation scales, observer-rated pain/discomfort scales, and satisfaction measures in only a few categories of procedures. Typically, studies only examined 1 or 2 aspects of scale validity. The results are likely unique to the specific clinical settings they were tested in. Certain scales, for example, those requiring motor stimulation, are unsuitable to evaluate sedation for procedures where movement is prohibited (e.g., magnetic resonance imaging scans). Further work is required to evaluate existing measures for procedures for which they were not developed. Depending on the outcomes of these efforts, it might ultimately be necessary to consider measures of sedation efficacy to be procedure specific.
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das Neves JFNP, das Neves Araújo MMP, de Paiva Araújo F, Ferreira CM, Duarte FBN, Pace FH, Ornellas LC, Baron TH, Ferreira LEVVDC. Colonoscopy sedation: clinical trial comparing propofol and fentanyl with or without midazolam. Braz J Anesthesiol 2016; 66:231-6. [PMID: 27108817 DOI: 10.1016/j.bjane.2014.09.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Accepted: 09/17/2014] [Indexed: 01/31/2023] Open
Abstract
Colonoscopy is one of the most common procedures. Sedation and analgesia decrease anxiety and discomfort and minimize risks. Therefore, patients prefer to be sedated when undergoing examination, although the best combination of drugs has not been determined. The combination of opioids and benzodiazepines is used to relieve the patient's pain and discomfort. More recently, propofol has assumed a prominent position. This randomized prospective study is unique in medical literature that specifically compared the use of propofol and fentanyl with or without midazolam for colonoscopy sedation performed by anesthesiologists. The aim of this study was to evaluate the side effects of sedation, discharge conditions, quality of sedation, and propofol consumption during colonoscopy, with or without midazolam as preanesthetic. The study involved 140 patients who underwent colonoscopy at the University Hospital of the Federal University of Juiz de Fora. Patients were divided into two groups: Group I received intravenous midazolam as preanesthetic 5min before sedation, followed by fentanyl and propofol; Group II received intravenous anesthesia with fentanyl and propofol. Patients in Group II had a higher incidence of reaction (motor or verbal) to the colonoscope introduction, bradycardia, hypotension, and increased propofol consumption. Patient satisfaction was higher in Group I. According to the methodology used, the combination of midazolam, fentanyl, and propofol for colonoscopy sedation reduces propofol consumption and provides greater patient satisfaction.
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Affiliation(s)
| | | | | | | | | | - Fabio Heleno Pace
- Universidade Federal de Juiz de Fora (UFJF), Juiz de Fora, MG, Brazil
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Patients Prefer Propofol to Midazolam Plus Fentanyl for Sedation for Colonoscopy: Results of a Single-Center Randomized Equivalence Trial. Dis Colon Rectum 2016; 59:62-69. [PMID: 26651114 DOI: 10.1097/dcr.0000000000000512] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Common sedation options for colonoscopy include propofol alone or a combination of midazolam and fentanyl. The former usually requires the presence of an anesthesia caregiver. The strategy that optimizes patient satisfaction has not yet been determined. OBJECTIVE This study was designed to assess whether patient satisfaction at the time of colonoscopy is equivalent for propofol compared with midazolam and fentanyl. DESIGN In this prospective, single-center, parallel group, single-blind, randomized, equivalence trial (NCT-01488045), 262 patients blinded to treatment received propofol (n = 126) or midazolam plus fentanyl (n = 136) at the time of colonoscopy. A patient satisfaction survey was administered in the recovery room and 1 to 5 days postprocedure. The endoscopist completed a survey immediately postprocedure. SETTINGS This study was conducted at a tertiary academic hospital with a dedicated colon and rectal surgery division. PATIENTS Patients over the age of 18 years who were undergoing elective colonoscopy were included in this study. MAIN OUTCOME MEASURES The primary outcome was patient satisfaction with the colonoscopy. Secondary outcomes included physician and patient perception of patient pain, physician perception of patient tolerance of and difficulty of procedure, procedure duration, percentage of patients with cecal intubation, recovery time, and adverse events. RESULTS Patient overall satisfaction scores in the recovery room after using the combination of midazolam and fentanyl (n = 136) during colonoscopy were not equivalent to patient satisfaction scores after using propofol (n = 126) alone (mean = 83.9 and 98.0 visual analog scale points) because the 90% CI (-18.5 to -9.6) for the mean treatment difference (-14.1) was completely outside the prespecified range of equivalence (±5 visual analog scale points). Patient pain as reported by the patient and as perceived by the physician and difficulty of the procedure were significantly worse for the midazolam/fentanyl group (n = 136) compared with the propofol group (n = 126). Time in the colonoscopy suite was significantly shorter for the propofol group, but the difference was small (4 minutes). There were no significant differences in percentage with cecal intubation, recovery time, or adverse events. LIMITATIONS This is a single-institution, single-endoscopist study and is limited by the inability to perform blinding of the endoscopist. CONCLUSIONS The use of propofol for conscious sedation during colonoscopy is associated with greater patient satisfaction and less pain when compared with midazolam/fentanyl, as perceived by the patient and endoscopist.
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Elimination of waste: creation of a successful Lean colonoscopy program at an academic medical center. Surg Endosc 2015; 30:3071-6. [DOI: 10.1007/s00464-015-4599-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 09/22/2015] [Indexed: 10/22/2022]
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Nusrat S, Mahmood S, Bitar H, Tierney WM, Bielefeldt K, Madhoun MF. The impact of chronic opioid use on colonoscopy outcomes. Dig Dis Sci 2015; 60:1016-23. [PMID: 25822037 DOI: 10.1007/s10620-015-3639-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 03/20/2015] [Indexed: 01/15/2023]
Abstract
BACKGROUND Endoscopic procedures are frequently performed on patients chronically on opioids, raising concerns about the safety and efficacy of conventional sedation. AIMS We hypothesized that chronic opioid use is associated with longer procedure times, higher dosages of sedation medications, and an increase in adverse effects. METHODS This is a retrospective review from June 2012 to June 2013. Patients on chronic opioids (opioids use ≥ 12 weeks) were compared to randomly selected patients matched for age, race, and sex. Multivariate regression analysis was performed to identify factors that were independently predictive of longer procedure times. RESULTS Patients on chronic opioids required higher doses of fentanyl (122.0 ± 45.3 vs. 105.8 ± 47.2 µg; P < 0.0001) and midazolam (5.3 ± 5.3 vs. 4.4 ± 2 mg; P = 0.0037) and were more likely to receive diphenhydramine (42.8 vs. 22.6 %; P < 0.001). The induction period (11.3 ± 8.8 vs. 7.5 ± 4.0 min), duration of procedure (39.1 ± 17.5 vs. 33.4 ± 14.1 min), and recovery times (38.7 ± 15.3 vs. 33.8 ± 12.1 min) were significantly longer for patients on chronic opioids. In the multivariate regression analysis, opioid use was an independent predictor of longer procedure duration (P < 0.05). Hypotensive episodes did not differ between groups (2.8 vs. 2.7 %; P = 0.8). However, patients on chronic opioids experienced more pain (13.4 vs. 5.9 %; P 0.001) and hypertensive episodes (8.1 vs. 2.8 %; P 0.002). CONCLUSION Patients on chronic opioids represent a high-risk population with longer procedural times and more discomfort, despite higher dosages of sedative agents. Prospective studies are required to define the risks and benefits of more costly alternative sedation strategies for patients on chronic opioids.
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Affiliation(s)
- Salman Nusrat
- Section of Digestive Diseases, Department of Internal Medicine, University of Oklahoma Health Sciences Center, 920 Stanton Young Blvd. WP 1345, Oklahoma City, OK, 73104, USA,
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Neves JFNPD, Araújo MMPDN, Araújo FDP, Ferreira CM, Duarte FBN, Pace FH, Ornellas LC, Baron TH, Ferreira LEVVDC. [Colonoscopy sedation: clinical trial comparing propofol and fentanyl with or without midazolam]. Rev Bras Anestesiol 2015; 66:231-6. [PMID: 25818341 DOI: 10.1016/j.bjan.2014.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Accepted: 09/17/2014] [Indexed: 10/23/2022] Open
Abstract
Colonoscopy is one of the most common procedures. Sedation and analgesia decrease anxiety and discomfort and minimize risks. Therefore, patients prefer to be sedated when undergoing examination, although the best combination of drugs has not been determined. The combination of opioids and benzodiazepines is used to relieve the patient's pain and discomfort. More recently, propofol has assumed a prominent position. This randomized prospective study is unique in medical literature that specifically compared the use of propofol and fentanyl with or without midazolam for colonoscopy sedation performed by anesthesiologists. The aim of this study was to evaluate the side effects of sedation, discharge conditions, quality of sedation, and propofol consumption during colonoscopy, with or without midazolam as preanesthetic. The study involved 140 patients who underwent colonoscopy at the University Hospital of the Federal University of Juiz de Fora. Patients were divided into two groups: Group I received intravenous midazolam as preanesthetic five minutes before sedation, followed by fentanyl and propofol; Group II received intravenous anesthesia with fentanyl and propofol. Patients in Group II had a higher incidence of reaction (motor or verbal) to the colonoscope introduction, bradycardia, hypotension, and increased propofol consumption. Patient satisfaction was higher in Group I. According to the methodology used, the combination of midazolam, fentanyl, and propofol for colonoscopy sedation reduces propofol consumption and provides greater patient satisfaction.
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Affiliation(s)
| | | | | | | | | | - Fabio Heleno Pace
- Universidade Federal de Juiz de Fora (UFJF), Juiz de Fora, MG, Brasil
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Braunstein ED, Rosenberg R, Gress F, Green PHR, Lebwohl B. Development and validation of a clinical prediction score (the SCOPE score) to predict sedation outcomes in patients undergoing endoscopic procedures. Aliment Pharmacol Ther 2014; 40:72-82. [PMID: 24815064 DOI: 10.1111/apt.12786] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Revised: 04/04/2014] [Accepted: 04/17/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND Use of anaesthesia services during endoscopy has increased, increasing cost of endoscopy. AIM To identify risk factors for and develop a clinical prediction score to predict difficult conscious sedation. METHODS We performed a retrospective cross-sectional study of all patients who underwent oesophagogastroduodenoscopy (OGD) and colonoscopy with endoscopist-administered conscious sedation. The endpoint of difficult sedation was a composite of receipt of high doses (top quintile) of benzodiazepines and opioids, or the documentation of agitation or discomfort. Univariate and multivariate analyses were performed to measure association of the outcome with: age, sex, body mass index (BMI), procedure indication, tobacco use, self-reported psychiatric history, chronic use of benzodiazepines, opioids or other psychoactive medications, admission status and participation of a trainee. A clinical prediction score was constructed using statistically significant variables. RESULTS We identified 13,711 OGDs and 21,763 colonoscopies, 1704 (12.4%) and 2299 (10.6%) of which met the primary endpoint, respectively. On multivariate analysis, factors associated with difficulty during OGD were younger age, procedure indication, male sex, presence of a trainee, psychiatric history and benzodiazepine and opioid use. Factors associated with difficulty during colonoscopy were younger age, female sex, BMI <25, procedure indication, tobacco, benzodiazepine, opioid and other psychoactive medication use. A clinical prediction score was developed and validated that may be used to risk-stratify patients undergoing OGD and colonoscopy across five risk classes. CONCLUSIONS Using the Stratifying Clinical Outcomes Prior to Endoscopy (SCOPE) score, patients may be risk stratified for difficult sedation/high sedation requirement during OGD and colonoscopy.
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Affiliation(s)
- E D Braunstein
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY, USA
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Mönkemüller K, Wilcox CM. Positive domino effect, choice of conscious sedation, and endoscopic unit efficiency. Gastrointest Endosc 2013; 77:888-90. [PMID: 23684092 DOI: 10.1016/j.gie.2013.02.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Accepted: 02/26/2013] [Indexed: 02/08/2023]
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Berg BP, Murr M, Chermak D, Woodall J, Pignone M, Sandler RS, Denton BT. Estimating the cost of no-shows and evaluating the effects of mitigation strategies. Med Decis Making 2013; 33:976-85. [PMID: 23515215 DOI: 10.1177/0272989x13478194] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To measure the cost of nonattendance ("no-shows") and benefit of overbooking and interventions to reduce no-shows for an outpatient endoscopy suite. METHODS We used a discrete-event simulation model to determine improved overbooking scheduling policies and examine the effect of no-shows on procedure utilization and expected net gain, defined as the difference in expected revenue based on Centers for Medicare & Medicaid Services reimbursement rates and variable costs based on the sum of patient waiting time and provider and staff overtime. No-show rates were estimated from historical attendance (18% on average, with a sensitivity range of 12%-24%). We then evaluated the effectiveness of scheduling additional patients and the effect of no-show reduction interventions on the expected net gain. RESULTS The base schedule booked 24 patients per day. The daily expected net gain with perfect attendance is $4433.32. The daily loss attributed to the base case no-show rate of 18% is $725.42 (16.4% of net gain), ranging from $472.14 to $1019.29 (10.7%-23.0% of net gain). Implementing no-show interventions reduced net loss by $166.61 to $463.09 (3.8%-10.5% of net gain). The overbooking policy of 9 additional patients per day resulted in no loss in expected net gain when compared with the reference scenario. CONCLUSIONS No-shows can significantly decrease the expected net gain of outpatient procedure centers. Overbooking can help mitigate the impact of no-shows on a suite's expected net gain and has a lower expected cost of implementation to the provider than intervention strategies.
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Affiliation(s)
- Bjorn P Berg
- Department of Systems Engineering & Operations Research, George Mason University, Fairfax, Virginia (BPB)
| | - Michael Murr
- Edward P. Fitts Department of Industrial & Systems Engineering, North Carolina State University, Raleigh, North Carolina (MM)
| | - David Chermak
- Performance Services, Duke University Medical Center, Durham, North Carolina (DC, JW)
| | - Jonathan Woodall
- Performance Services, Duke University Medical Center, Durham, North Carolina (DC, JW)
| | - Michael Pignone
- Division of General Medicine and Clinical Epidemiology (MP) University of North Carolina, Chapel Hil
| | - Robert S Sandler
- Division of Gastroenterology and Hepatology (RSS), University of North Carolina, Chapel Hil
| | - Brian T Denton
- Department of Industrial & Operations Engineering, University of Michigan, Ann Arbor (BTD)
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Dominitz JA, Baldwin LM, Green P, Kreuter WI, Ko CW. Regional variation in anesthesia assistance during outpatient colonoscopy is not associated with differences in polyp detection or complication rates. Gastroenterology 2013; 144:298-306. [PMID: 23103615 PMCID: PMC3622787 DOI: 10.1053/j.gastro.2012.10.038] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2011] [Revised: 10/09/2012] [Accepted: 10/19/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS We investigated the rate and predictors of anesthesia assistance during outpatient colonoscopy and whether anesthesia assistance is associated with colonoscopy interventions and outcomes. METHODS We performed a retrospective cohort study using a 20% sample of Medicare administrative claims submitted during the 2003 calendar year. We analyzed data from 328,177 adults, 66 years old or older, who underwent outpatient colonoscopy examinations. RESULTS Overall, 8.7% of outpatient colonoscopies were performed with anesthesia assistance. In multivariate analysis, independent predictors of anesthesia assistance included black race, female sex, and a nonscreening indication; anesthesia assistance increased with median income and comorbidities. General and colorectal surgeons, fewer years in their practice, and nonhospital site of service were also significantly associated with anesthesia assistance. The strongest predictor of anesthesia assistance was the Medicare carrier, with odds ratios ranging from 0.22 (95% confidence interval: 0.12-0.43) for the Arkansas carrier (crude rate 0.9%) to 9.90 (95% confidence interval: 7.92-12.39) for the Empire carrier in New York area (crude rate 35.3%) compared with the Wisconsin carrier (crude rate 4.3%). There was also considerable variation among endoscopists; 75% of providers had no colonoscopies with anesthesia assistance recorded in their dataset, and 4.5% of providers had anesthesia assistance in at least three quarters of their examinations. Anesthesia assistance was not associated with the diagnosis of polyps, the performance of biopsy or polypectomy, or complications in multivariate analyses. CONCLUSIONS There are significant variations among regions and sites of service in anesthesia assistance during outpatient colonoscopies of Medicare beneficiaries. Although this variation has considerable economic implications, it was not associated with measures of patient risk or outcomes, such as polyp detection or procedure-related complications.
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Affiliation(s)
- Jason A Dominitz
- Northwest Center for Outcomes Research in Older Adults, VA Puget Sound Health Care System, Seattle, Washington; Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington.
| | - Laura-Mae Baldwin
- Department of Family Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Pamela Green
- Northwest Center for Outcomes Research in Older Adults, VA Puget Sound Health Care System, Seattle, Washington
| | - William I Kreuter
- Department of Health Services, University of Washington School of Medicine, Seattle, Washington
| | - Cynthia W Ko
- Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
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Al-Awabdy B, Wilcox CM. Use of anesthesia on the rise in gastrointestinal endoscopy. World J Gastrointest Endosc 2013; 5:1-5. [PMID: 23330047 PMCID: PMC3547114 DOI: 10.4253/wjge.v5.i1.1] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Revised: 09/25/2012] [Accepted: 12/01/2012] [Indexed: 02/05/2023] Open
Abstract
Conscious sedation has been the standard of care for many years for gastrointestinal endoscopic procedures. As procedures have become more complex and lengthy, additional medications became essential for adequate sedation. Often time's deep sedation is required for procedures such as endoscopic retrograde cholangiography which necessitates higher doses of narcotics and benzodiazepines or even use of other medications such as ketamine. Given its pharmacologic properties, propofol was rapidly adopted worldwide to gastrointestinal endoscopy for complex procedures and more recently to routine upper and lower endoscopy. Many studies have shown superiority for both the physician and patient compared to standard sedation. Nevertheless, its use remains highly controversial. A number of studies worldwide show that propofol can be given safely by endoscopists or nurses when well trained. Despite this wealth of data, at many centers its use has been prohibited unless administered by anesthesiology. In this commentary, we review the use of anesthesia support for endoscopy in the United States based on recent data and its implications for gastroenterologists worldwide.
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Affiliation(s)
- Basil Al-Awabdy
- Basil Al-Awabdy, C Mel Wilcox, Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, AL 35294, United States
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Non-anesthesiologist administered propofol with or without midazolam for moderate sedation-the problem is not "which regimen" but "who's regimen". Dig Dis Sci 2012; 57:2243-5. [PMID: 22833381 DOI: 10.1007/s10620-012-2268-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Accepted: 05/31/2012] [Indexed: 12/18/2022]
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Ngo C, Leung JW, Mann SK, Terrado C, Bowlus C, Ingram D, Leung FW. Interim report of a randomized cross-over study comparing clinical performance of novice trainee endoscopists using conventional air insufflation versus warm water infusion colonoscopy. JOURNAL OF INTERVENTIONAL GASTROENTEROLOGY 2012; 2:135-139. [PMID: 23805395 DOI: 10.4161/jig.23736] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2012] [Revised: 05/31/2012] [Accepted: 05/31/2012] [Indexed: 01/19/2023]
Abstract
BACKGROUND The applicability of water method colonoscopy in trainee education is not known. AIM To compare the water method vs. usual air method in teaching novice trainee colonoscopy. METHOD An IRB approved prospective randomized cross-over study (NCT01482546) in a university setting with diverse patient population. DESIGN Three first year GI fellows consented to participate in the study. Trainees were randomized to learn with either usual air method or the water method in performing colonoscopy with a dedicated endoscopy attending during their weekly outpatient endoscopy clinics for the initial six months of training and then cross-over to the other method for the remaining six months. PATIENTS Patients undergoing screening, surveillance or diagnostic colonoscopy. RESULTS The interim data revealed no significant difference in age, gender, and body mass index (BMI). Trainees rated the water method colonoscopy as significantly easier to learn compared to the air method (p=0.007). CONCLUSIONS The interim data demonstrate positive effects of using the water method in training novice endoscopists who reported a significant ease of learning colonoscopy using this method. Training programs could consider joining us in evaluating the use of warm water infusion in colonoscopy education.
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Paggi S, Radaelli F, Amato A, Meucci G, Spinzi G, Rondonotti E, Terruzzi V. Unsedated colonoscopy: an option for some but not for all. Gastrointest Endosc 2012; 75:392-8. [PMID: 22248607 DOI: 10.1016/j.gie.2011.09.015] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Accepted: 09/08/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND The increasing request for colonoscopy in clinical practice, coupled with the lack of time, has led to a renewed interest in unsedated procedures. OBJECTIVE To evaluate the acceptability of unsedated colonoscopy and to characterize the subset of patients more likely to undergo and complete the procedure without sedation and/or analgesia. DESIGN Prospective, population study. SETTING Nonacademic community hospital, 6-month observation period. PATIENTS Adult outpatients referred for colonoscopy were offered unsedated procedure, with the possibility of on-demand sedation. INTERVENTIONS Demographics, clinical features, and endoscopy outcomes were recorded. Data were analyzed by stepwise logistic regression analysis, and odds ratio (OR) and 95% confidence interval (CI) are given for significant variables. MAIN OUTCOME MEASUREMENTS Unsedated colonoscopy acceptance rate. Factors significantly associated with acceptance and completion of unsedated procedures. RESULTS The acceptance rate for unsedated colonoscopy was 56.2% of 964 consecutive evaluated patients. The cecal intubation rate in unsedated patients was 81.6% and increased to 97.3% with the option of on-demand sedation. At multivariate analysis, factors significantly associated with the acceptance were no previous colonoscopy (OR 1.52; 95% CI, 1.10-2.11), absent/low level of anxiety (OR 3.82; 95% CI, 2.71-5.38), and no concern about the examination (OR 1.80; 95% CI, 1.17-2.77). Fear of procedure-related pain was inversely associated with acceptance (OR 0.28; 95% CI, 0.17-0.35). Factors associated to drug-free colonoscopy completion were absence of preprocedure anxiety (OR 1.87; 95% CI, 1.08-3.21) and male sex (OR 3.59; 95% CI, 2.13-6.05). LIMITATIONS Single-center study. CONCLUSION The acceptance rate of unsedated colonoscopy is clinically relevant, and the procedure can be completed without sedation in the majority of patients. Subject-related factors may help to identify patients willing to undergo and potentially complete unsedated procedures.
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Affiliation(s)
- Silvia Paggi
- Gastroenterology Unit, Valduce Hospital, Como, Italy
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Patient-controlled analgesia and sedation with alfentanyl versus fentanyl for colonoscopy: a randomized double blind study. J Clin Gastroenterol 2011; 45:e72-5. [PMID: 21135703 DOI: 10.1097/mcg.0b013e318201fbce] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
STUDY OBJECTIVE The aim of this study was to evaluate whether sedo-analgesia with alfentanyl/fentanyl, using a patient-controlled analgesia (PCA) pump, may have positive outcomes in terms of safety, postprocedural workload, and expectations of the colonoscopist, nurse, and patients in elective colonoscopy. PATIENTS One hundred American Society of Anesthesiology physical status I and II adult patients. INTERVENTIONS Patients were randomized in a double-blind trial to receive either alfentanyl (n=50) or fentanyl (n=50) by PCA, and incremental doses of midazolam. MEASUREMENTS Patient expectations were assessed using hemodynamic variables, willingness to have a repeat colonoscopy in the same way, adverse events, discomfort scores, and patient/operator/nurse satisfaction associated with sedo-analgesia. RESULT All patients in both groups had adequate sedo-analgesia with high satisfaction and willingness scores. There were no serious adverse effects and except for a few events, no required medication. The total sedation times were shorter in the alfentanyl group compared with the fentanyl group. CONCLUSIONS PCA and sedation with alfentanyl and fentanyl for colonoscopy are safe, feasible, and acceptable to most patients. However, shorter sedation times make alfentanyl more attractive for postprocedural workload.
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European Society of Gastrointestinal Endoscopy, European Society of Gastroenterology and Endoscopy Nurses and Associates, and the European Society of Anaesthesiology Guideline: Non-anaesthesiologist administration of propofol for GI endoscopy. Eur J Anaesthesiol 2011; 27:1016-30. [PMID: 21068575 DOI: 10.1097/eja.0b013e32834136bf] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Propofol sedation by non-anaesthesiologists is an upcoming sedation regimen in several countries throughout Europe. Numerous studies have shown the efficacy and safety of this sedation regimen in gastrointestinal endoscopy. Nevertheless, this issue remains highly controversial. The aim of this evidence- and consensus-based set of guideline is to provide non-anaesthesiologists with a comprehensive framework for propofol sedation during digestive endoscopy. This guideline results from a collaborative effort from representatives of the European Society of Gastrointestinal Endoscopy (ESGE), the European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) and the European Society of Anaesthesiology (ESA). These three societies have endorsed the present guideline.The guideline is published simultaneously in the Journals Endoscopy and European Journal of Anaesthesiology.
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Maslekar S, Balaji P, Gardiner A, Culbert B, Monson JRT, Duthie GS. Randomized controlled trial of patient-controlled sedation for colonoscopy: Entonox vs modified patient-maintained target-controlled propofol. Colorectal Dis 2011; 13:48-57. [PMID: 19575742 DOI: 10.1111/j.1463-1318.2009.01988.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM Propofol sedation is often associated with deep sedation and decreased manoeuvrability. Patient-maintained sedation has been used in such patients with minimal side-effects. We aimed to compare novel modified patient-maintained target-controlled infusion (TCI) of propofol with patient-controlled Entonox inhalation for colonoscopy in terms of analgesic efficacy (primary outcome), depth of sedation, manoeuvrability and patient and endoscopist satisfaction (secondary outcomes). METHOD One hundred patients undergoing elective colonoscopy were randomized to receive either TCI propofol or Entonox. Patients in the propofol group were administered propofol initially to achieve a target concentration of 1.2 μg/ml and then allowed to self-administer a bolus of propofol (200 μg/kg/ml) using a patient-controlled analgesia pump with a handset. Entonox group patients inhaled the gas through a mouthpiece until caecum was reached and then as required. Sedation was initially given by an anaesthetist to achieve a score of 4 (Modified Observer's Assessment of Alertness and Sedation Scale), and colonoscopy was then started. Patients completed an anxiety score (Hospital Anxiety and Depression questionnaire), a baseline letter cancellation test and a pain score on a 100-mm visual analogue scale before and after the procedure. All patients completed a satisfaction survey at discharge and 24 h postprocedure. RESULTS The median dose of propofol was 174 mg, and the median number of propofol boluses was four. There was no difference between the two groups in terms of pain recorded (95% confidence interval of the difference -0.809, 5.02) and patient/endoscopist satisfaction. There was no difference between the two groups in either depth of sedation or manoeuvrability. CONCLUSION Both Entonox and the modified TCI propofol provide equally effective sedation and pain relief, simultaneously allowing patients to be easily manoeuvred during the procedures.
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Affiliation(s)
- S Maslekar
- University of Hull, Castle Hill Hospital, Hull, UK
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Leung FW. Is there a place for sedationless colonoscopy? JOURNAL OF INTERVENTIONAL GASTROENTEROLOGY 2011; 1:19-22. [PMID: 21686108 DOI: 10.4161/jig.1.1.14592] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2010] [Revised: 07/24/2010] [Accepted: 07/25/2010] [Indexed: 12/13/2022]
Abstract
Usedated colonoscopy is routinely available in many parts of the world. In the US, only educated professionals appear to be knowledgeable enough to request the unsedated option. Colonoscopists have also been willing to perform unsedated colonoscopy when a patient presents without an escort after undergoing bowel purge preparation. While the actual side-effects of sedation are minimal, the escort requirement and time burden of sedation are barriers to the uptake of screening colonoscopy in the US. The recent trend of deep sedation with propofol for screening colonoscopy increases the efficiency of the colonoscopists at significant costs (e.g. anesthetist reimbursement). The options of as needed and on demand sedation permit patients to complete colonoscopy without sedation. The latter appears to be potentially less coercive. Nurses with experience in the unsedated options recognize the benefit of the quick turn-around of the examination room and shortened occupancy of the recovery area. Discharge planning can be optimized due to absence of amnesia. Patients completing unsedated colonoscopy have given their endorsement of the options. Pain and discomfort continue to limit the success rate of cecal intubation to about 80%. A recently described water method (warm water infusion in lieu of air insufflation combined with removal of all residual colonic air by suction and residual feces by water exchange) has the potential of decreasing procedural discomfort and enhancing cecal intubation in unsedated colonoscopy. The availability of the novel water method assures colonoscopists that high success rate of cecal intubation can be achieved in the unsedated patients.
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Affiliation(s)
- Felix W Leung
- Research and Medical Services, VA Sepulveda Ambulatory Care Center, Veterans Affairs Greater Los Angeles Healthcare System, North Hills, CA, USA; and David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA
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Leung FW, Harker JO, Jackson G, Okamoto KE, Behbahani OM, Jamgotchian NJ, Aharonian HS, Guth PH, Mann SK, Leung JW. A proof-of-principle, prospective, randomized, controlled trial demonstrating improved outcomes in scheduled unsedated colonoscopy by the water method. Gastrointest Endosc 2010; 72:693-700. [PMID: 20619405 DOI: 10.1016/j.gie.2010.05.020] [Citation(s) in RCA: 112] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2010] [Accepted: 05/11/2010] [Indexed: 12/18/2022]
Abstract
BACKGROUND An observational study in veterans showed that a novel water method (water infusion in lieu of air insufflation) enhanced cecal intubation and willingness to undergo a repeat scheduled unsedated colonoscopy. OBJECTIVE To confirm these beneficial effects and significant attenuation of discomfort in a randomized, controlled trial (RCT). DESIGN Prospective RCT, intent-to-treat analysis. SETTING Veterans Affairs ambulatory care facility. PATIENTS Veterans undergoing scheduled unsedated colonoscopy. INTERVENTIONS During insertion, the water and traditional air methods were compared. MAIN OUTCOME MEASUREMENTS Discomfort and procedure-related outcomes. RESULTS Eighty-two veterans were randomized to the air (n = 40) or water (n = 42) method. Cecal intubation (78% vs 98%) and willingness to repeat (78% vs 93%) were significantly better with the water method (P < .05; Fisher exact test). The mean (standard deviation) of maximum discomfort (0 = none, 10 = most severe) during colonoscopy was 5.5 (3.0) versus 3.6 (2.1) P = .002 (Student t test), and the median overall discomfort after colonoscopy was 3 versus 2, P = .052 (Mann-Whitney U test), respectively. The method, but not patient characteristics, was a predictor of discomfort (t = -1.998, P = .049, R(2) = 0.074). The odds ratio for failed cecal intubation was 2.09 (95% CI, 1.49-2.93) for the air group. Fair/poor previous experience increased the risk of failed cecal intubation in the air group only. The water method numerically increased adenoma yield. LIMITATIONS Single site, small number of elderly men, unblinded examiner, possibility of unblinded subjects, restricted generalizability. CONCLUSIONS The RCT data confirmed that the water method significantly enhanced cecal intubation and willingness to undergo a repeat colonoscopy. The decrease in maximum discomfort was significant; the decrease in overall discomfort approached significance. The method, but not patient characteristics, was a predictor of discomfort. (Clinical trial registration number NCT00747084).
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Affiliation(s)
- Felix W Leung
- Research and Medical Services, Sepulveda Ambulatory Care Center, Veterans Affairs Greater Los Angeles Healthcare System, North Hills, California, USA.
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Radaelli F, Paggi S, Amato A, Terruzzi V. Warm water infusion versus air insufflation for unsedated colonoscopy: a randomized, controlled trial. Gastrointest Endosc 2010; 72:701-9. [PMID: 20883846 DOI: 10.1016/j.gie.2010.06.025] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2010] [Accepted: 06/14/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND Uncontrolled data suggest that warm water infusion (WWI) instead of air insufflation (AI) during the insertion phase of unsedated colonoscopy improves patient tolerance and satisfaction. OBJECTIVE We tested the hypothesis that water could increase the proportion of patients able to complete unsedated colonoscopy and improve patient tolerance compared with the conventional procedure. DESIGN Randomized, controlled trial. SETTING Single center, community hospital. PATIENTS Consecutive outpatients agreeing to start colonoscopy without premedication. METHODS Patients were randomly assigned to either WWI or AI insertion phase of colonoscopy. Sedation and/or analgesia were administered on patient request if significant pain or discomfort occurred. MAIN OUTCOME MEASUREMENTS Percentage of patients requiring sedation/analgesia. Pain and tolerance scores were assessed at discharge by using a 100-mm visual analog scale. RESULTS A total of 230 subjects (116 in the WWI group and 114 in the AI group) were enrolled. Intention-to-treat analysis showed that the proportion of patients requesting sedation/analgesia during the procedure (main outcome measurement) was 12.9% in the WWI group and 21.9% in AI group (P = .07). Cecal intubation rates were 94% in the WWI group and 95.6% in the AI group (P = .57). Median (interquartile range) scores for pain were 28 (12-44) and 39 (14-54) in WWI and AI groups, respectively (P = .05); corresponding figures for tolerance were 10 (3-18) and 14 (5-42), respectively (P = .01). The adenoma detection rates were 25% and 40.1% for the WWI and AI groups, respectively (P = .013). LIMITATIONS Single-center study, endoscopists not blinded to randomization. CONCLUSIONS WWI instead of AI is not associated with a statistically significant decrease in the number of patients requiring on-demand sedation, although it significantly improves the overall patient tolerance of colonoscopy. The finding of a lower adenoma detection rate in the WWI group calls for further evaluations. ( CLINICAL TRIAL REGISTRATION NUMBER NCT00905554).
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Affiliation(s)
- Franco Radaelli
- Division of Gastroenterology, Valduce Hospital, Como, Italy.
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Abstract
The practice of sedation for digestive endoscopy continues to evolve throughout the world. In many countries, there is a trend for increased utilization of sedation during routine endoscopic procedures. Sedation improves patient satisfaction with endoscopy and the willingness to comply with screening guidelines and it improves the quality of examination. Moderate sedation, using a benzodiazepine and an opioid, remains the standard method of sedation in most areas of the world, although propofol, a short-acting hypnotic agent, is being used increasingly in some countries. Controversy regarding the feasibility of endoscopist-directed propofol administration continues, in spite of overwhelming evidence supporting this practice. In the USA, recent revisions in policy by the Centers for Medicare and Medicaid Services may threaten the practice of endoscopist-directed propofol administration. In this article, future trends in sedation practice, including fospropofol and computer-assisted personalized sedation, are discussed.
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Leung FW, Aljebreen AM, Brocchi E, Chang EB, Liao WC, Mizukami T, Schapiro M, Triantafyllou K. Sedation-risk-free colonoscopy for minimizing the burden of colorectal cancer screening. World J Gastrointest Endosc 2010; 2:81-9. [PMID: 21160707 PMCID: PMC2998881 DOI: 10.4253/wjge.v2.i3.81] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2009] [Revised: 01/30/2010] [Accepted: 02/06/2010] [Indexed: 02/06/2023] Open
Abstract
Unsedated colonoscopy is available worldwide, but is not a routine option in the United States (US). We conducted a literature review supplemented by our experience and expert commentaries to provide data to support the use of unsedated colonoscopy for colorectal cancer screening. Medline data from 1966 to 2009 were searched to identify relevant articles on the subject. Data were summarized and co-authors provided critiques as well as accounts of unsedated colonoscopy for screening and surveillance. Diagnostic colonoscopy was initially developed as an unsedated procedure. Procedure-related discomfort led to wide adoption of sedation in the US, although unsedated colonoscopy remains the usual practice elsewhere. The increased use of colonoscopy for colorectal cancer screening in healthy, asymptomatic individuals suggests a reassessment of the burden of sedation in colonoscopy for screening is appropriate in the US for lowering costs and minimizing complications for patients. A water method developed to minimize discomfort has shown promise to enhance outcomes of unsedated colonoscopy. The use of scheduled, unsedated colonoscopy in the US appears to be feasible for colorectal cancer screening. Studies to assess its applicability in diverse practice settings deserve to be conducted and supported.
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Affiliation(s)
- Felix W Leung
- Felix W Leung, Research and Medical Services, Sepulveda Ambulatory Care Center, Veterans Affairs Greater Los Angeles Healthcare System, North Hills, CA 91343, United States
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Harris EA, Lubarsky DA, Candiotti KA. Monitored anesthesia care (MAC) sedation: clinical utility of fospropofol. Ther Clin Risk Manag 2009; 5:949-59. [PMID: 20057894 PMCID: PMC2801588 DOI: 10.2147/tcrm.s5583] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2009] [Indexed: 01/28/2023] Open
Abstract
Fospropofol, a phosphorylated prodrug version of the popular induction agent propofol, is hydrolyzed in vivo to release active propofol, formaldehyde, and phosphate. Pharmacodynamic studies show fospropofol provides clinically useful sedation and EEG/bispectral index suppression while causing significantly less respiratory depression than propofol. Pain at the injection site, a common complaint with propofol, was not reported with fospropofol; the major patient complaint was transitory perianal itching during the drug's administration. Although many clinicians believe fospropofol can safely be given by a registered nurse, the FDA mandated that fospropofol, like propofol, must be used only in the presence of a trained anesthesia provider.
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Affiliation(s)
- Eric A Harris
- Department of Anesthesiology, Perioperative Management, and Pain Medicine, University of Miami/Miller School of Medicine
| | - David A Lubarsky
- Department of Anesthesiology, Perioperative Management, and Pain Medicine, University of Miami/Miller School of Medicine
| | - Keith A Candiotti
- Department of Anesthesiology, Perioperative Management, and Pain Medicine, University of Miami/Miller School of Medicine
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Fechner J, Ihmsen H, Jeleazcov C, Schüttler J. Fospropofol disodium, a water-soluble prodrug of the intravenous anesthetic propofol (2,6-diisopropylphenol). Expert Opin Investig Drugs 2009; 18:1565-71. [PMID: 19758110 DOI: 10.1517/13543780903193063] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Today, propofol or 2,6-diisopropylphenol is the anesthetic mainly used for monitored anesthetic care sedation and during intravenous anesthesia. The formulation, a lipid macroemulsion, shows several disadvantages. Therefore, during the past years considerable scientific effort has been undertaken to find either a better formulation or a prodrug of propofol. Fospropofol is the first propofol prodrug that has been intensively studied in man. It has been licensed in 2008 by the FDA for monitored anesthetic care sedation. OBJECTIVES AND METHODS This review describes first published study results of fospropofol with regard to its pharmacokinetics/pharmacodynamics, drug safety, tolerability and drug side effects. Using a Medline search all published articles and abstracts containing the words fospropofol or GPI 15715 were included. RESULTS AND CONCLUSION As the impact of an errorness drug assay for propofol liberated from fospropofol is not exactly defined, no clear conclusions can be drawn from the first published pharmacokinetic/pharmacodynamic studies. Fospropofol was well tolerated in the first two clinical studies and no serious side effects were reported. After characterization of the true pharmacokinetic/pharmacodynamics profile, fospropofol, an aqueous solution, has the potential to favorably compare with benzodiazepines for procedural sedation and also may be used for long-term sedation and intravenous anesthesia.
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Affiliation(s)
- Jörg Fechner
- University Erlangen-Nürnberg, Department of Anesthesiology, Krankenhausstrasse 12, 91054 Erlangen, Germany.
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Vargo JJ, Cohen LB, Rex DK, Kwo PY. Position statement: Nonanesthesiologist administration of propofol for GI endoscopy. Hepatology 2009; 50:1683-9. [PMID: 19937691 DOI: 10.1002/hep.23326] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- John J Vargo
- Department of Gastroenterology and Hepatology, Cleveland Clinic Lerner College of Medicine of Case Western University, Cleveland, Ohio, USA
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Vargo JJ, Cohen LB, Rex DK, Kwo PY. Position statement: Nonanesthesiologist administration of propofol for GI endoscopy. Gastroenterology 2009; 137:2161-7. [PMID: 19961989 DOI: 10.1053/j.gastro.2009.09.050] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2009] [Accepted: 07/10/2009] [Indexed: 12/14/2022]
Affiliation(s)
- John J Vargo
- Department of Gastroenterology and Hepatology, Cleveland Clinic Lerner College of Medicine of Case Western University, Cleveland, Ohio, USA
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Vargo JJ, Cohen LB, Rex DK, Kwo PY. Position statement: nonanesthesiologist administration of propofol for GI endoscopy. Gastrointest Endosc 2009; 70:1053-9. [PMID: 19962497 DOI: 10.1016/j.gie.2009.07.020] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2009] [Accepted: 07/10/2009] [Indexed: 02/08/2023]
Affiliation(s)
- John J Vargo
- Department of Gastroenterology and Hepatology, Cleveland Clinic Lerner College of Medicine of Case Western University, Cleveland, Ohio, USA
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Moore GD, Walker AM, MacLaren R. Fospropofol: a new sedative-hypnotic agent for monitored anesthesia care. Ann Pharmacother 2009; 43:1802-8. [PMID: 19826098 DOI: 10.1345/aph.1m290] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE To summarize the published clinical data on fospropofol, critically review the safety and efficacy information, and provide pertinent information for formulary review. DATA SOURCES Data were collected from searches of MEDLINE (1966-June 30, 2009), EMBASE (1974-June 30, 2009), bibliographies of manuscripts, and www.fda.gov. Key search terms included fospropofol, Lusedra, Aquavan, sedative-hypnotic, and monitored anesthesia care. STUDY SELECTION AND DATA EXTRACTION All Phase 1, Phase 2, and Phase 3 clinical trials studying the safety and efficacy of fospropofol were reviewed. DATA SYNTHESIS Fospropofol is a water-soluble prodrug of propofol, a potent sedative-hypnotic agent. Propofol is highly lipophilic and is formulated in lipid-containing solvents, which have known disadvantages, including pain on injection, narrow therapeutic window with the potential to cause deep sedation, high lipid intake during long-term sedation, and risk of infection resulting from bacterial contamination. Due to its water solubility, fospropofol eliminates some of the known lipid emulsion-associated disadvantages of propofol and provides a more predictable peak onset of activity and more gradual recovery to a full state of consciousness. The pharmacokinetic and pharmacodynamic profiles of fospropofol make it an attractive agent for sedation for procedures of short duration. Unfortunately, the number of patients studied has been relatively small and the amount of safety data is limited. Of concern are reports of hypoxemia and hypotension; these reports are limited in number, but the episodes are serious and may require acute intervention. Although fospropofol holds promise for procedural sedation, due to limited safety data, the Food and Drug Administration has limited approval of fospropofol to monitored anesthesia care in patients undergoing diagnostic or therapeutic procedures. CONCLUSIONS Fospropofol is a viable addition to the class of sedative-hypnotic agents due to the minimization of unwanted adverse effects of propofol and maintenance of a favorable pharmacokinetic profile facilitating sedation, anxiolysis, and rapid recovery. However, there are limited safety data to justify its use without the presence of dedicated anesthesia personnel.
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Affiliation(s)
- Gina D Moore
- School of Pharmacy, University of Colorado Denver, 12631 E. 17th Ave., Mail Stop C238-L15, Aurora, CO 80045, USA.
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Leung JW, Mann SK, Siao-Salera R, Ransibrahmanakul K, Lim B, Cabrera H, Canete W, Barredo P, Gutierrez R, Leung FW. A randomized, controlled comparison of warm water infusion in lieu of air insufflation versus air insufflation for aiding colonoscopy insertion in sedated patients undergoing colorectal cancer screening and surveillance. Gastrointest Endosc 2009; 70:505-10. [PMID: 19555938 DOI: 10.1016/j.gie.2008.12.253] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2008] [Accepted: 12/23/2008] [Indexed: 02/06/2023]
Abstract
BACKGROUND Pilot studies using a novel water method to perform screening colonoscopy allowed patients to complete colonoscopy without sedation medications and also significantly increased the cecal intubation success rate. OBJECTIVE To perform a randomized, controlled trial comparing air insufflation (conventional method) and water infusion in lieu of air insufflation (study method) colonoscopy in minimally sedated patients. HYPOTHESIS Compared with the conventional method, patients examined by the study method had lower pain scores and required less medication but had a similar cecal intubation rate and willingness to undergo colonoscopy in the future. SETTING Outpatient colonoscopy in a single Veterans Affairs hospital. METHODS After informed consent and standard bowel preparation, patients received premedications administered as 0.5-increments of fentanyl (25 microg) and 0.5-increments of Versed (midazolam) (1 mg) plus 50 mg of diphenhydramine. The conventional and the study methods for colonoscopy were implemented as previously described. Additional pain medications were administered at the patients' request. MAIN OUTCOME MEASUREMENTS Increments of medications, pain scores, cecal intubation, and willingness to repeat colonoscopy. RESULTS Increments of medications used before reaching the cecum (1.6 +/- 0.2 vs 2.4 +/- 0.2, P < .0027), total increments used (1.8 +/- 0.2 vs 2.5 +/- 0.2, P < .014), and the maximum pain scores (1.3 +/- 0.3 vs 4.1 +/- 0.6, P < .0002) were significantly lower with the water method. Cecal intubation rate (100%) and willingness to undergo a repeat colonoscopy (96%) were similar. LIMITATIONS Single Veterans Affairs hospital, older male population. CONCLUSION Water infusion in lieu of air insufflation is superior to air insufflation during colonoscopy in the minimally sedated patients (ClinicalTrials.gov Identifier NCT00785889).
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Affiliation(s)
- Joseph W Leung
- Section of Gastroenterology, Sacramento Veterans Affairs Medical Center, Veterans Affairs Northern California Health Care System, Mather, California 95655, USA.
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Abstract
BACKGROUND Despite the increasing popularity of propofol for sedation in colonoscopy, the optimal regimen is still controversial. Both propofol alone and propofol in combination with meperidine are frequently used during colonoscopy, but the impact of adding meperidine has not been evaluated. This study aimed to investigate if adding meperidine to propofol offers any advantage in terms of patient tolerance, recovery time, and postcolonoscopy discomforts. METHOD Consecutive patients admitted to the physical checkup department of our hospital were randomized to receive either meperidine plus propofol (combination group, n=100) or propofol alone (propofol group, n=100) for sedated colonoscopy. The patients' tolerance and postcolonoscopy discomforts (pain, bloating, dizziness, and nausea/vomiting) were assessed with a 0-10 visual analog scale. The recovery times were assessed with 5-minute and 10-minute Aldrete scores. RESULTS The dose of propofol was less in the combination group than the propofol group (129.80+/-37.93 mg vs. 147.90+/-47.85, mean+/-SD, P=0.003). The endoscopists, anesthetists, and nurses all rated patients' tolerance in favor of the combination group than the propofol group (mean+/-SD, endoscopists, 9.17+/-1.23 vs. 8.49+/-1.60, P=0.001; anesthetists, 9.21+/-1.08 vs. 8.63+/-1.37, P=0.001; nurses, 9.18+/-1.34 vs. 8.71+/-1.47, P=0.019, respectively). Patients in the combination group recovered earlier than the placebo group (5-min Aldrete scores: 9.48+/-1.09 vs. 9.05+/-1.32, mean+/-SD, P=0.013; short intervals to speak: 4.29+/-4.05 min vs. 6.30+/-5.22 min, P=0.003; and departure: 18.62+/-5.28 min vs. 20.28+/-5.68 min, P=0.034). There was also less abdominal bloating in the combination group after colonoscopy (1.23+/-1.79 vs. 2.19+/-2.12, mean+/-SD, P=0.004). Incidences of hypoxemia, hypotension, and overall satisfaction scores were comparable between the 2 groups. CONCLUSIONS For sedated colonoscopy, propofol in combination with meperidine is better than propofol alone in improving patients' tolerance and recovery.
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Abstract
Traditionally, sedation for gastrointestinal endoscopic procedures was provided by the gastroenterologist. Increasingly, however, complex procedures are being performed on seriously ill patients. As a result, anesthesiologists now are providing anesthesia and sedation in the gastrointestinal endoscopy suite for many of these patients. This article reviews the challenges encountered in this environment and anesthetic techniques that can be used successfully for these procedures.
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Affiliation(s)
- Daniel T Goulson
- Department of Anesthesiology, University of Kentucky College of Medicine, 800 Rose Street, Lexington, KY 40536, USA.
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50
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Abstract
Non-anesthesiologist-administered propfol (NAAP) sedation for endoscopic procedures remains controversial despite the overwhelming evidence that with proper training and patient selection, NAAP is safe and results in improved time to sedation and recovery when compared with standard sedation with a combination of an opioid and benzodiazepine. Emerging data suggest that NAAP also results in an improved psychomotor recovery. Can our patients return to meaningful tasks such as driving with NAAP after recovery in the endoscopy suite?
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