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Wehrmann T, Riphaus A, Eckardt AJ, Klare P, Kopp I, von Delius S, Rosien U, Tonner PH. Updated S3 Guideline "Sedation for Gastrointestinal Endoscopy" of the German Society of Gastroenterology, Digestive and Metabolic Diseases (DGVS) - June 2023 - AWMF-Register-No. 021/014. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:e654-e705. [PMID: 37813354 DOI: 10.1055/a-2165-6388] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Affiliation(s)
- Till Wehrmann
- Clinic for Gastroenterology, DKD Helios Clinic Wiesbaden, Wiesbaden, Germany
| | - Andrea Riphaus
- Internal Medicine, St. Elisabethen Hospital Frankfurt Artemed SE, Frankfurt, Germany
| | - Alexander J Eckardt
- Clinic for Gastroenterology, DKD Helios Clinic Wiesbaden, Wiesbaden, Germany
| | - Peter Klare
- Department Internal Medicine - Gastroenterology, Diabetology, and Hematology/Oncology, Hospital Agatharied, Hausham, Germany
| | - Ina Kopp
- Association of the Scientific Medical Societies in Germany e.V. (AWMF), Berlin, Germany
| | - Stefan von Delius
- Medical Clinic II - Internal Medicine - Gastroenterology, Hepatology, Endocrinology, Hematology, and Oncology, RoMed Clinic Rosenheim, Rosenheim, Germany
| | - Ulrich Rosien
- Medical Clinic, Israelite Hospital, Hamburg, Germany
| | - Peter H Tonner
- Anesthesia and Intensive Care, Clinic Leer, Leer, Germany
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Wehrmann T, Riphaus A, Eckardt AJ, Klare P, Kopp I, von Delius S, Rosien U, Tonner PH. Aktualisierte S3-Leitlinie „Sedierung in der gastrointestinalen Endoskopie“ der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS). ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:1246-1301. [PMID: 37678315 DOI: 10.1055/a-2124-5333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Affiliation(s)
- Till Wehrmann
- Klinik für Gastroenterologie, DKD Helios Klinik Wiesbaden, Wiesbaden, Deutschland
| | - Andrea Riphaus
- Innere Medizin, St. Elisabethen Krankenhaus Frankfurt Artemed SE, Frankfurt, Deutschland
| | - Alexander J Eckardt
- Klinik für Gastroenterologie, DKD Helios Klinik Wiesbaden, Wiesbaden, Deutschland
| | - Peter Klare
- Abteilung Innere Medizin - Gastroenterologie, Diabetologie und Hämato-/Onkologie, Krankenhaus Agatharied, Hausham, Deutschland
| | - Ina Kopp
- Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V. (AWMF), Berlin, Deutschland
| | - Stefan von Delius
- Medizinische Klinik II - Innere Medizin - Gastroenterologie, Hepatologie, Endokrinologie, Hämatologie und Onkologie, RoMed Klinikum Rosenheim, Rosenheim, Deutschland
| | - Ulrich Rosien
- Medizinische Klinik, Israelitisches Krankenhaus, Hamburg, Deutschland
| | - Peter H Tonner
- Anästhesie- und Intensivmedizin, Klinikum Leer, Leer, Deutschland
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Motamed C, Servin F, Billard V. Adding Low-Dose Propofol to Limit Anxiety during Target-Controlled Infusion of Remifentanil for Gastrointestinal Endoscopy: Respiratory Issues and Safety Recommendations. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58091285. [PMID: 36143961 PMCID: PMC9502783 DOI: 10.3390/medicina58091285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 09/08/2022] [Accepted: 09/14/2022] [Indexed: 11/16/2022]
Abstract
Backgroundand Objectives: Remifentanil-based sedation is one of many protocols proposed for endoscopy procedures in spontaneous ventilation, alone or in combination with propofol. However, the effect of these small doses of propofol on the efficacy and safety of remifentanil target-controlled infusion (TCI) deserves to be examined in this context. The objective of this study was to assess the adverse respiratory and cardiovascular effects of small boluses of propofol combined with remifentanil, in comparison with remifentanil alone, and balanced with the quality of sedation and recovery. Materials andMethods: This was an observational bicenter study, representing a subgroup of a larger study describing remifentanil-based procedural sedation. In center 1, patients scheduled for gastrointestinal (GI) endoscopy had remifentanil TCI alone. In center 2, patients had a 10 mg propofol bolus before TCI and other boluses were allowed during the procedure. Remifentanil TCI was started at a target of 2 ng/mL then adapted by 0.5 ng/mL steps according to patient response to endoscopy stimulations. Results: Center 1 included 29 patients, while center 2 included 60 patients. No difference was found in the patients’ characteristics, incidence of success, average remifentanil consumption, or cardiovascular variables. Light sedation was achieved when propofol was added. The incidence of respiratory events, such as bradypnea, desaturation < 90%, and apnea requiring rescue maneuvers, were significantly higher with propofol. Conclusions: Adding propofol boluses to a remifentanil TCI for GI endoscopy ensures light sedation that may be necessary for anxiolysis but increases respiratory events, even after administration of small-dose boluses. Its safety is acceptable if the procedure is performed in an equipped environment with sedation providers trained to manage respiratory events and drugs titrated to minimal doses.
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Affiliation(s)
- Cyrus Motamed
- Department of Anesthesia, Institut Gustave Roussy, 94805 Villejuif, France
- Correspondence:
| | | | - Valerie Billard
- Department of Anesthesia, Institut Gustave Roussy, 94805 Villejuif, France
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Palmisano P, Ziacchi M, Angeletti A, Guerra F, Forleo GB, Bertini M, Notarstefano P, Accogli M, Lavalle C, Bisignani G, Landolina M, Zanotto G, D’Onofrio A, Ricci RP, De Ponti R, Boriani G. The Practice of Deep Sedation in Electrophysiology and Cardiac Pacing Laboratories: Results of an Italian Survey Promoted by the AIAC (Italian Association of Arrhythmology and Cardiac Pacing). J Clin Med 2021; 10:jcm10215035. [PMID: 34768557 PMCID: PMC8584354 DOI: 10.3390/jcm10215035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 10/23/2021] [Accepted: 10/26/2021] [Indexed: 01/23/2023] Open
Abstract
The aim of this survey, which was open to all Italian cardiologists involved in arrhythmia, was to assess common practice regarding sedation and analgesia in interventional electrophysiology procedures in Italy. The survey consisted of 28 questions regarding the approach to sedation used for elective direct-current cardioversion (DCC), subcutaneous implantable cardioverter-defibrillator (S-ICD) implantation, atrial fibrillation (AF) ablation, ventricular tachycardia (VT) ablation, and transvenous lead extraction procedures. A total of 105 cardiologists from 92 Italian centres took part in the survey. The rate of centres where DCC, S-ICD implantation, AF ablation, VT ablation and lead extraction procedures were performed without anaesthesiologic assistance was 60.9%, 23.6%, 51.2%, 37.3%, and 66.7%, respectively. When these procedures were performed without anaesthesiologic assistance, the drugs (in addition to local anaesthetics) commonly administered were benzodiazepines (from 64.3% to 79.6%), opioids (from 74.4% to 88.1%), and general anaesthetics (from 7.1% to 30.4%). Twenty-three (21.9%) of the 105 cardiologists declared that they routinely administered propofol, without the supervision of an anaesthesiologist, in at least one of the above-mentioned procedures. In current Italian clinical practice, there is a lack of uniformity in the sedation/analgesia approach used in interventional electrophysiology procedures.
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Affiliation(s)
- Pietro Palmisano
- Cardiology Unit, “Card. G. Panico” Hospital, 73039 Tricase, Italy;
- Correspondence:
| | - Matteo Ziacchi
- Institute of Cardiology, S. Orsola-Malpighi University Hospital, University of Bologna, 40138 Bologna, Italy; (M.Z.); (A.A.)
| | - Andrea Angeletti
- Institute of Cardiology, S. Orsola-Malpighi University Hospital, University of Bologna, 40138 Bologna, Italy; (M.Z.); (A.A.)
| | - Federico Guerra
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital Umberto I-Lancisi-Salesi, 60126 Ancona, Italy;
| | | | - Matteo Bertini
- Cardiology Unit, Azienda Ospedaliero-Universitaria Di Ferrara “Arcispedale S. Anna”, 44124 Cona, Ferrara, Italy;
| | | | - Michele Accogli
- Cardiology Unit, “Card. G. Panico” Hospital, 73039 Tricase, Italy;
| | - Carlo Lavalle
- Department of Cardiology, Policlinico Universitario Umberto I, 00161 Roma, Italy;
| | - Giovanni Bisignani
- Cardiology Division, Castrovillari Hospital, ASP Cosenza, 87012 Castrovillari, Italy;
| | | | - Gabriele Zanotto
- Department of Cardiology, Mater Salutis Hospital, 37045 Legnago, Verona, Italy;
| | - Antonio D’Onofrio
- Departmental Unit of Electrophysiology, Evaluation and Treatment of Arrhythmias, Monaldi Hospital, 80131 Naples, Italy;
| | | | - Roberto De Ponti
- Department of Heart and Vessels, Ospedale Di Circolo-University of Insubria, 21100 Varese, Italy;
| | - Giuseppe Boriani
- Department of Biomedical, Metabolic and Neural Sciences, Cardiology Division, University of Modena and Reggio Emilia, Policlinico Di Modena, 41121 Modena, Italy;
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Tonner PH. [The Guideline "Sedation for Gastrointestinal Endoscopy"]. Anasthesiol Intensivmed Notfallmed Schmerzther 2021; 56:201-209. [PMID: 33725740 DOI: 10.1055/a-1017-9138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The guideline "Sedation for gastrointestinal endoscopy" (AWMF-register-no. 021/014) was published initially in 2008. Because of new and developing evidence, the guideline was updated in 2015. The aim of the guideline is to define the necessary structural, equipment and personnel requirements that contribute to minimizing the risk of sedation for endoscopy. In view of the high and increasing significance of gastrointestinal endoscopy, the guideline will remain highly relevant in the future. Essential aspects are the selection of sedatives/hypnotics, structural requirements, personnel requirements with regard to number, availability and training, management of complications and quality assurance. In this article, the development and evaluation of the evidence and its influence on the practical implementation, in particular for anaesthesia, are highlighted.
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Capnography monitoring in procedural intravenous sedation: a systematic review and meta-analysis. Clin Oral Investig 2020; 24:3761-3770. [PMID: 32556657 DOI: 10.1007/s00784-020-03395-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 06/04/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Currently, procedural sedation in the clinical setting relies heavily on the use of pulse oximetry to monitor hypoxemia. Different studies suggest that incidence of hypoxemia and incidence of arterial oxygen desaturation are reduced by early intervention via capnography monitoring. The aim of this article was to discuss the importance of implementing capnography monitoring during procedural sedations performed in a dental setting and determine whether additional capnographic monitoring reduces the incidence of arterial oxygen desaturation and the overall complications rate. MATERIALS AND METHODS Two independent reviewers conducted electronic (PubMed and EMBASE) and manual searches up to February 2020. Randomized clinical trials (RCTs), including both patients under procedural sedation monitored by capnography and oximetry, and reporting the incidence of hypoxemia or episodes of oxygen desaturation were included. Risk ratio was used to compare the outcomes (i.e., the incidence of hypoxemia, the episodes of oxygen desaturation, the detection of apnea, the reduction of events of bradycardia, and hypotension) between patients monitored by capnography and standard approach. RESULTS Fourteen randomized clinical trials fulfilling the inclusion criteria were selected. The analysis revealed that capnography monitoring group showed the lower incidence of hypoxemia (RR 0.76, 95%CI 0.70 to 0.83, p < 0.001) and the episodes of oxygen desaturation (RR 0.79, 95%CI 0.71 to 0.87, p < 0.001) compared with the oximetry monitoring group. Apnea was detected in capnography monitoring earlier than standard monitoring (RR 2.60, 95%CI 2.30 to 2.93, p < 0.001). No significant difference was found between capnography and standard monitoring groups in terms of reduction of events of bradycardia (RR 1.17, 95%CI 0.91 to 1.50, p = 0.225) and hypotension (RR 0.96, 95%CI 0.76 to 1.21, p = 0.746). CONCLUSION Capnography monitoring reduced incidence of hypoxemia during procedural sedations. Within the limitations of this review, we suggest that the application of capnography during procedural sedation would decrease the frequency of oxygen desaturation events and incidence of hypoxemia. CLINICAL RELEVANCE Training and instructing dental providers on using capnography monitoring would help in reducing adverse events during intravenous sedation.
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Weinberg L, Grover H, Cowie D, Langley E, Heland M, Story DA. Attitudes of anesthetists towards an anesthesia-led nurse practitioner model for low-risk colonoscopy procedures: a cross-sectional survey. HUMAN RESOURCES FOR HEALTH 2020; 18:20. [PMID: 32183813 PMCID: PMC7076960 DOI: 10.1186/s12960-020-0458-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 02/17/2020] [Indexed: 06/10/2023]
Abstract
BACKGROUND The mounting pressure on the Australian healthcare system is driving a continual exploration of areas to improve patient care and access and to maximize utilization of our workforce. We hypothesized that there would be support by anesthetists employed at our hospital for the design, development, and potential implementation of an anesthesia-led nurse practitioner (NP) model for low-risk colonoscopy patients. METHODS We conducted a cross-sectional, mixed methods study to ascertain the attitudes and acceptability of anesthetists towards a proposed anesthesia-led NP model for low-risk colonoscopy patients. An online survey using commercial software and theoretical questions pertaining to participants' attitudes towards an anesthesia-led NP model was e-mailed to consultant anesthetists. Participants were also invited to participate in a voluntary 20-min face-to-face interview. RESULTS A total of 60 survey responses were received from a pool of 100 anesthetists (response rate = 60%, accounting for 8.04% margin of error). Despite the theoretical benefits of improved patient access to colonoscopy services, most anesthetists were not willing to participate in the supervision and training of NPs. The predominant themes underlying their lack of support for the program were a perception that patient safety would be compromised compared to the current model of anesthesia-led care, the model does not meet the Australian and New Zealand College of Anesthetists guidelines for procedural sedation and analgesia, and the program may be a public liability prone to litigation in the event of an adverse outcome. Concerns about consumer acceptance and cost-effectiveness were also raised. Finally, participants thought the model should be pilot tested to better understand consumer attitudes, logistical feasibility, patient and proceduralist attitudes, clinical governance, and, importantly, patient safety. CONCLUSIONS Most anesthetists working in a single-center university hospital did not support an anesthesia-led NP model for low-risk colonoscopy patients. Patient safety, violations of the current Australian and New Zealand College of Anesthetists guidelines on procedural sedation, and logistical feasibility were significant barriers to the acceptance of the model. TRIAL REGISTRATION Australian and New Zealand Clinical Trials Registry, 12619001036101.
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Affiliation(s)
- L. Weinberg
- Department of Anesthesia, Austin Hospital, 145 Studley Road, Heidelberg, Victoria 3084 Australia
- Department of Surgery, The University of Melbourne, Melbourne, Victoria Australia
| | - H. Grover
- Department of Anesthesia, Austin Hospital, 145 Studley Road, Heidelberg, Victoria 3084 Australia
| | - D. Cowie
- Department of Anesthesia, Austin Hospital, 145 Studley Road, Heidelberg, Victoria 3084 Australia
| | - E. Langley
- Department of Anesthesia Perioperative and Pain Medicine Unit, The University of Melbourne, Melbourne, Victoria Australia
| | - M. Heland
- Department of Anesthesia Perioperative and Pain Medicine Unit, The University of Melbourne, Melbourne, Victoria Australia
| | - D. A. Story
- Centre for Integrated Critical Care, The University of Melbourne, Melbourne, Victoria Australia
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Julián Gómez L, Fuentes Coronel A, López Ramos C, Ochoa Sangrador C, Fradejas Salazar P, Martín Garrido E, Conde Gacho P, Bailador Andrés C, García-Alvarado M, Rascarachi G, Castillo Trujillo R, Rodríguez Gómez SJ. A clinical trial comparing propofol versus propofol plus midazolam in diagnostic endoscopy of patients with a low anesthetic risk. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2019; 110:691-698. [PMID: 30318893 DOI: 10.17235/reed.2018.5289/2017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND OBJECTIVES propofol and midazolam are two of the most commonly used sedatives in upper gastrointestinal endoscopy (UGE). The objective of this study was to evaluate these two sedation regimens administered to patients who underwent an UGE with regard to security, efficiency, quality of exploration and patient response. PATIENTS AND METHODS a prospective, randomized and double-blind study was performed which included 83 patients between 18 and 80 years of age of a low anesthetic risk (ASA - American Society of Anesthesiologists- I-II) who underwent a diagnostic UGE. Patients were randomized to receive sedation with either placebo plus propofol (group A) or midazolam plus propofol (group B). RESULTS in group A, 42 patients received a placebo bolus (saline solution) and on average up to 115 mg of propofol in boluses of 20 mg. In group B, 41 patients received 3 mg of midazolam and an average of up to 83 mg of propofol in boluses of 20 mg. There were no significant differences in the adverse effects observed in either group and all adverse events were treated conservatively. The patients in group B (midazolam plus propofol) entered the desired sedated state more quickly with no variation in the overall time of the exploration. The quality of the endoscopic evaluation was similar in both groups and the patients were equally satisfied regardless of the sedatives they received. CONCLUSIONS the use of midazolam plus propofol as a sedative does not affect the overall exploration time, a lower dose of propofol can be used and it is as safe as administering propofol as a monotherapy while providing the same level of both exploration quality and patient approval.
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Ebru TK, Resul K. Comparison of ketamine-propofol mixture (ketofol) and midazolam-meperidine in endoscopic retrograde cholangiopancretography (ERCP) for oldest old patients. Ther Clin Risk Manag 2019; 15:755-763. [PMID: 31417263 PMCID: PMC6592063 DOI: 10.2147/tcrm.s201441] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Accepted: 05/06/2019] [Indexed: 01/28/2023] Open
Abstract
Background and aim: Endoscopic retrograde cholangiopancreatography (ERCP) requires moderate-to-deep conscious sedation. Combinations of ketamine and propofol (ketofol) and of midazolam and meperidine were analyzed using the bispectral index (BIS). There is no research on the use of ketofol on very elderly patients. The aim of this study is to use BIS and offer insight into the use and safety of ketofol sedation for oldest old patients undergoing ERCP. Materials and methods: For the ERCP procedure, 168 patients aged 85+ years were enrolled in a 2-year retrospective single center study. Seventy-five patients received midazolam-meperidine (MM) sedation in 2016, while 75 patients received ketofol (KP) sedation in 2018. The two groups were compared for patient data, procedure duration, Ramsay Sedation Score (RSS), heart rate (HR), blood pressure (BP), and pulse oximetry (SpO2), BIS, facial pain score (FPS), time to achieve BIS, recovery time, and complications. The total amount of rescue medication was recorded. Results: The two groups did not differ by patient data or procedure duration (p>0.05). Group KP had significantly higher systolic and diastolic BP, HR, and SpO2 values and lower BIS scores than Group MM (p=0.0001). The two groups did not differ by time to achieve BIS scores (p>0.05). Group KP had significantly fewer complications and a shorter recovery time than Group MM (p<0.001). Conclusion: Ketofol induced sedation results in more stable vital signs and fewer complications than the midazolam-meperidine sedation regimen during ERCP in oldest old patients, indicating that ketofol can be an alternative to midazolam-meperidine.
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Affiliation(s)
- Tarıkçı Kılıç Ebru
- Department of Anesthesiology, Ümraniye Training and Research Hospital, İstanbul, Turkey
| | - Kahraman Resul
- Department of Gastroenterology, Ümraniye Training and Research Hospital, İstanbul, Turkey
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Feng LL, Ding WX, Sun YY, Zhang YY, Yuan NP, Zhang LJ, Han WJ, Xi HJ. Risk factors for hypoxemia during routine anesthesia for gastrointestinal endoscopy. Shijie Huaren Xiaohua Zazhi 2019; 27:427-434. [DOI: 10.11569/wcjd.v27.i7.427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Gastrointestinal endoscopy under anesthesia has been carried out as a routine procedure in China. Hypoxemia is still an adverse event with a high incidence in routine anesthesia for gastrointestinal endoscopy, but the incidence of hypoxemia varies greatly across countries (< 1% to 85%), and there is a lack of relevant high-quality reports in China. Propofol, as a sedative for anesthetic gastroscopy in outpatients, has been recognized for its safety and effectiveness and is recommended by the expert consensus on Sedation/Anesthesia for Digestive Endoscopic Diagnosis and Treatment in China (2014). However, there are still some debate over its safety in foreign countries. In this study, we used propofol as a sedative for gastroscopy in outpatients to observe its effect on the incidence of hypoxemia.
AIM To observe and analyze the incidence of and risk factors for hypoxemia in anesthesia for gastrointestinal endoscopy.
METHODS A total of 580 outpatients who were sedated with propofol from September 1, 2018 to November 30, 2018 in Digestive Endoscopy Center of Shanghai Changhai Hospital were included in the study. These patients were divided into either a hypoxemia (n = 110) group or a non-hypoxemia group (n = 470). The basic information, anesthesia procedure, and endoscopic operation related information of the two groups were recorded.
RESULTS The information of patients in the two groups was compared and analyzed. It was found that there were significantly differences between the two groups in snoring history, biopsy, age, body mass index, abdominal circumference, endoscopic operation time, propofol dosage, ASA classification, and endoscopic physician classification (P < 0.05). Multivariate Logistic regression analysis showed that age (>5 years, OR = 8.955, 95 %CI: 2.070-38.746) and propofol dosage (>197 mg, OR = 2.360, 95 %CI: 1.320-4.219) were independent risk factors for hypoxemia.
CONCLUSION Intervention is needed for elderly patients (especially patients over 75 years old) and patients requiring large amounts of propofol (especially > 197 mg) to prevent the occurrence of hypoxemia.
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Affiliation(s)
- Li-Li Feng
- Department of Anesthesiology, Changhai Hospital, Shanghai 200433, China
| | - Wen-Xia Ding
- Digestive Endoscopy Center, Changhai Hospital, Shanghai 200433, China
| | - Yuan-Yuan Sun
- Department of Anesthesiology, Changhai Hospital, Shanghai 200433, China
| | - Ying-Ying Zhang
- Department of Anesthesiology, Changhai Hospital, Shanghai 200433, China
| | - Ning-Ping Yuan
- Department of Anesthesiology, Changhai Hospital, Shanghai 200433, China
| | - Li-Jun Zhang
- Department of Anesthesiology, Changhai Hospital, Shanghai 200433, China
| | - Wen-Jun Han
- Department of Anesthesiology, Changhai Hospital, Shanghai 200433, China
| | - Hui-Jun Xi
- Digestive Endoscopy Center, Changhai Hospital, Shanghai 200433, China
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Bashiri M, Akçalı D, Coşkun D, Cindoruk M, Dikmen A, Çifdalöz BU. Evaluation of pain and patient satisfaction by music therapy in patients with endoscopy/colonoscopy. TURKISH JOURNAL OF GASTROENTEROLOGY 2019; 29:574-579. [PMID: 30260780 DOI: 10.5152/tjg.2018.18200] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND/AIMS Endoscopy and colonoscopy are frequently performed procedures to evaluate the gastrointestinal system. These procedures are sometimes disturbing and painful for the patient. In gastrointestinal suits, endoscopy and colonoscopy may be performed on awake or sedated patients. Music therapy is a common and non-pharmacological treatment for various medical conditions, pain, and anxiety. The aim of the present study was to add music therapy to sedation administered during endoscopy and colonoscopy. The effect of music treatment on drug consumption, anxiety, and pain was investigated. MATERIALS AND METHODS American Anesthesiologist Association I-III adult patients scheduled for endo/colonoscopy were randomized to music treatment and no music treatment groups. Patients with endoscopic ultrasound and endoscopic retrograde colangiopancreaticography were excluded from the study. Anxiety score and pain severity were evaluated before and after the procedure. Heart rate, mean arterial pressure, and oxygen saturation were recorded before, during, and after the procedure. Total drug consumption was recorded. Patient satisfaction and desire for the same protocol for recurrent procedures were investigated. RESULTS Music therapy added to deep sedation administered by anesthesiologists provided decreased anxiety score and propofol consumption. Patient satisfaction was increased, and patients reported a desire for the same protocol for recurrent procedures. CONCLUSION The present study may serve as the beginning of using music therapy for pain treatment in gastroenterology procedures in our hospital with/without sedation. Music and other non-pharmacological treatment methods must be remembered to increase patient comfort during enco/colonoscopies and other painful procedures.
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Affiliation(s)
- Mehrnoosh Bashiri
- Department of Anesthesiology and Reanimation, Gazi University School of Medicine, Ankara, Turkey
| | - Didem Akçalı
- Department of Anesthesiology and Reanimation, Gazi University School of Medicine, Ankara, Turkey
| | - Demet Coşkun
- Department of Anesthesiology and Reanimation, Gazi University School of Medicine, Ankara, Turkey
| | - Mehmet Cindoruk
- Department of Gastroenterology, Gazi University School of Medicine, Ankara, Turkey
| | - Asiye Dikmen
- Department of Public Health, Gazi University School of Medicine, Ankara, Turkey
| | - Burçin Uçaner Çifdalöz
- Department of Musicology, Gazi University Turkish Music National Conservatory, Ankara, Turkey
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Khalila A, Shavit I, Shaoul R. Propofol Sedation by Pediatric Gastroenterologists for Endoscopic Procedures: A Retrospective Analysis. Front Pediatr 2019; 7:98. [PMID: 30972312 PMCID: PMC6445344 DOI: 10.3389/fped.2019.00098] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Accepted: 03/04/2019] [Indexed: 12/27/2022] Open
Abstract
Background: There is a substantial literature on the favorable outcome of propofol administration by non-anesthesiologists for endoscopy in adults; however, very few data are currently available on propofol sedation by pediatric gastroenterologists. Aims: to evaluate the safety of propofol sedation by pediatric gastroenterologists. Methods: A retrospective chart review of all children who were sedated by pediatric gastroenterologists in three Northern Israeli hospitals over a 4 years period Demographic and medical characteristics and any data regarding the procedure were extracted from patient's records. The main outcome measurements were procedure completion and reported adverse events. Results: Overall, 1,214 endoscopic procedures for were performed during this period. Complete data was available for 1,190 procedures. All children sedated by pediatric gastroenterologists were classified as ASA I or II. Propofol dosage (in mg/kg) inversely correlated with patient age. The younger the child the higher the dose needed to reach a satisfactory level of sedation (r = -0.397, p < 0.001). The addition of fentanyl significantly decreased propofol dosage needed to provide optimal sedation, p < 0.001. Nine (0.7%) reversible adverse events were reported. All the procedures were successfully completed and all patients were discharged home. Conclusions: We conclude that our approach is safe in children as it is in adults and can be implemented for children with ASA I, II.
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Affiliation(s)
- Aya Khalila
- Pediatric Gastroenterology and Nutrition Institute, Ruth Children's Hospital, Rambam Health Care Campus, Haifa, Israel.,Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Itai Shavit
- Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel.,Pediatric Emergency Department, Ruth Children's Hospital, Rambam Health Care Campus, Haifa, Israel
| | - Ron Shaoul
- Pediatric Gastroenterology and Nutrition Institute, Ruth Children's Hospital, Rambam Health Care Campus, Haifa, Israel.,Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
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Zhang W, Zhu Z, Zheng Y. Effect and safety of propofol for sedation during colonoscopy: A meta-analysis. J Clin Anesth 2018; 51:10-18. [DOI: 10.1016/j.jclinane.2018.07.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 07/23/2018] [Accepted: 07/23/2018] [Indexed: 02/08/2023]
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Jopling MW, Qiu J. Capnography sensor use is associated with reduction of adverse outcomes during gastrointestinal endoscopic procedures with sedation administration. BMC Anesthesiol 2017; 17:157. [PMID: 29183278 PMCID: PMC5704394 DOI: 10.1186/s12871-017-0453-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 11/21/2017] [Indexed: 01/12/2023] Open
Abstract
Background Evidence to date suggests that capnography monitoring during gastrointestinal endoscopic procedures (GEP) reduces the incidence of hypoxemia, but the association of capnography monitoring with the incidence of other adverse outcomes surrounding these procedures has not been well studied. Our aims were to estimate the incidence of pharmacological rescue events and death at discharge from an inpatient or outpatient hospitalization where GEP was performed with sedation, and to determine if capnography monitoring was associated with reduced incidence of these adverse outcomes. Methods This retrospective Premier Database analysis included medical inpatients and all outpatients undergoing GEP with sedation. Patients were grouped as follows: (1) pulse oximetry (SpO2) only, (2) capnography only, (3) SpO2 with capnography, and (4) neither SpO2 nor capnography. Multivariable logistic regression and propensity-score matching were used to compare patients with capnography sensor use to patients with only SpO2 sensor use. Outcome measures included the incidence of pharmacological rescue events, as defined by administration of naloxone and/or flumazenil, and death. Results Two hundred fifty eight thousand and two hundred sixty two inpatients and 3,807,151 outpatients were analyzed. For inpatients, capnography monitoring was associated with a 47% estimated reduction in the odds of death at discharge (OR: 0.53 [95% CI: 0.40–0.70]; P < 0.0001) and a non-significant 10% estimated reduction in the odds of pharmacological rescue event at discharge (0.91 [0.65–1.3]; P = 0.5661). For outpatients, capnography monitoring was associated with a 61% estimated reduction in the odds of pharmacological rescue event at discharge (0.39 [0.29, 0.52]; P < 0.0001) and a non-significant 82% estimated reduction in the odds of death at discharge (0.18 [0.02, 1.99]; P = 0.16). Conclusions In hospital medical inpatients and all outpatients undergoing GEP performed with sedation, capnography monitoring was associated with a reduced likelihood of pharmacological rescue events in outpatients and death in inpatients when assessed at discharge. Despite the limitations of the retrospective data analysis methodology, the use of capnography during these procedures is recommended. Electronic supplementary material The online version of this article (10.1186/s12871-017-0453-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Michael W Jopling
- NorthStar Anesthesia, Springfield Regional Medical Center, Springfield, OH, USA.
| | - Jiejing Qiu
- Health Economics and Outcomes Research, Medtronic, Mansfield, MA, USA
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Schulman AR, Abougergi MS, Thompson CC. Assessment of the July effect in post-endoscopic retrograde cholangiopancreatography pancreatitis: Nationwide Inpatient Sample. World J Gastrointest Endosc 2017; 9:296-303. [PMID: 28744341 PMCID: PMC5507820 DOI: 10.4253/wjge.v9.i7.296] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 03/22/2017] [Accepted: 06/13/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To assess incidence of post-endoscopic retrograde cholangiopancreatography (post-ERCP) pancreatitis in the early (July/August/September) vs the late (April/May/June) academic year and evaluate in-hospital mortality, length of stay (LOS), and total hospitalization charge between these time periods.
METHODS This was a retrospective cohort study using the 2012 Nationwide Inpatient Sample (NIS). Patients with International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9 CM) procedure codes for ERCP were included. Patients were excluded from the study if they had an ICD-9 CM code for a principal diagnosis of acute pancreatitis, if the ERCP was performed before or on the day of admission or if they were admitted to non-teaching hospitals. Post-ERCP pancreatitis was defined as an ICD-9 CM code for a secondary diagnosis of acute pancreatitis in patients who received an ERCP as delineated above. ERCPs performed during the months of July, August and September was compared to those performed in April, May and June in academic hospitals. ERCPs performed at academic hospitals during the early vs late year were compared. Primary outcome was incidence of post-ERCP pancreatitis. Secondary outcomes included in-hospital mortality, length LOS, and total hospitalization charge. Proportions were compared using fisher’s exact test and continuous variables using student t-test. Multivariable regression was performed.
RESULTS From the 36480032 hospitalizations in 2012 in the United States, 6248 were included in the study (3065 in July/August/September and 3183 in April/May/June) in the 2012 academic year. Compared with patients admitted in July/August/September, patients admitted in April/May/June had no statistical difference in all variables including mean age, percent female, Charleston comorbidity index, race, median income, and hospital characteristics including region, bed size, and location. Incidence of post-ERCP pancreatitis in early vs late academic year were not statistically significant (OR = 1.03, 95%CI: 0.71-1.51, P = 0.415). Similarly, the adjusted odds ratio of mortality, LOS, and total hospitalization charge in early compared to late academic year were not statistically significant.
CONCLUSION Incidence of post-ERCP pancreatitis does not differ at academic institutions depending on the time of year. Similarly, mortality, LOS, and total hospital charge do not demonstrate the existence of a temporal effect, suggesting that trainee level of experience does not impact clinical outcomes in patients undergoing ERCP.
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Affiliation(s)
- Andrea Riphaus
- Department of Medicine and Gastroenterology, KRH Klinikum Agnes Karll, Laatzen, Germany
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18
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Achalasia case detected during endoscopy application accompanied by anaesthesia. GASTROENTEROLOGY REVIEW 2017; 11:302-303. [PMID: 28053688 PMCID: PMC5209467 DOI: 10.5114/pg.2016.61476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Accepted: 01/11/2016] [Indexed: 11/17/2022]
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Isik IA, Iyilikçi L, Ozturk Y, Adiyaman E. Sedation Practice Outside the Operating Room for Pediatric Gastrointestinal Endoscopy. Indian Pediatr 2016; 52:989-90. [PMID: 26615354 DOI: 10.1007/s13312-015-0761-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Medical records of the 575 children who underwent gastrointestinal endoscopy outside the operating room were investigated retrospectively. The most frequently used combinations were propofol-midazolam-fentanyl in 83.2% of the procedures and propofol-midazolam in 13.8% of the procedures. 24 (3.4%) of 703 procedures had complications due to sedation anesthesia; 11 had hypoxia and 8 had pain in the injection area. Sedation anesthesia practice provided by an anesthesiologist outside the operating room enables gastrointestional endoscopic procedures to be carried out more safely.
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Affiliation(s)
- Ishak A Isik
- Departments of Pediatric Gastroenterology, and #Anesthesiology and Reanimation, Dokuz Eylul University School of Medicine, Hepatology and Nutrition, yzmir, Turkey.
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Kochhar GS, Gill A, Vargo JJ. On the Horizon: The Future of Procedural Sedation. Gastrointest Endosc Clin N Am 2016; 26:577-92. [PMID: 27372779 DOI: 10.1016/j.giec.2016.03.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Sedation plays an integral part in endoscopy. By achieving patient comfort, it allows for a better examination and enhances patient satisfaction. Various medications have been used, propofol being the current favorite. With emphasis on patient safety and quality of endoscopy, various new medications in different combinations are being used to achieve adequate sedation and not escalate the cost of the procedure. With the advent of newer medications and newer modalities to administer these medications, there is need for more specialized training for the endoscopist to feel comfortable while using these medications.
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Affiliation(s)
- Gursimran S Kochhar
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Anant Gill
- Saraswathi Institute of Medical Sciences, Anwarpur, Uttar Pradesh, India
| | - John J Vargo
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic, Cleveland Clinic Foundation, A-30, 9500 Euclid Avenue, Cleveland, OH, USA.
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Li Q, Zhou Q, Xiao W, Zhou H. Determination of the appropriate propofol infusion rate for outpatient upper gastrointestinal endoscopy-a randomized prospective study. BMC Gastroenterol 2016; 16:49. [PMID: 27117223 PMCID: PMC4845313 DOI: 10.1186/s12876-016-0463-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 04/09/2016] [Indexed: 02/08/2023] Open
Abstract
Background Pain and discomfort related to endoscopy sessions can be alleviated by sedation, which minimizes anxiety and allows safe examination. For outpatient endoscopy, reliable short-term sedation without secondary effects is required. This study aimed to assess the effects of intravenous propofol rates on sedation in outpatients undergoing upper gastrointestinal endoscopy. Methods This randomized prospective study evaluated 300 outpatients submitted to upper gastrointestinal endoscopy. Patients received propofol at 500, 1000 or 2000 ml/h. The primary outcome assessed was hypoxemia incidence. In addition, time to sedation and incidence of hypotension, deep sedation, extremity motor activity, cough, nausea, hiccough, and awareness were evaluated. Results Recovery time and incidence of hypoxemia, hypotension, and deep sedation were significantly increased in individuals treated at 2000 ml/h in comparison with values obtained for 500 and 1000 ml/h groups (P < 0.01). Compared with the 500 ml/h group, motor activity of the extremities, cough, nausea, hiccough, and awareness were significantly decreased and the mean scores for endoscopist’s and patients’ satisfaction were significantly increased in the 1000 and 2000 ml/h groups (P < 0.01). Conclusion Propofol infused at 1000 ml/h appeared to be the most suitable infusion rate for outpatient upper gastrointestinal endoscopy. Trial registration Registration number: ChiCTR-TRC-14004786; Registration date: 2014-06-04
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Affiliation(s)
- Qiongzhen Li
- Department of Anesthesia, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Qinghe Zhou
- Department of Anesthesia, Second Hospital, Jiaxing Medical College, No. 1518, North Huancheng Road, Jianshe Street, Nanhu District, Jiaxing, 314000, Zhejiang, China
| | - Wangpin Xiao
- Department of Anesthesia, Second Hospital, Jiaxing Medical College, No. 1518, North Huancheng Road, Jianshe Street, Nanhu District, Jiaxing, 314000, Zhejiang, China
| | - Hongmei Zhou
- Department of Anesthesia, Second Hospital, Jiaxing Medical College, No. 1518, North Huancheng Road, Jianshe Street, Nanhu District, Jiaxing, 314000, Zhejiang, China.
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Vaessen HHB, Knape JTA. Considerable Variability of Procedural Sedation and Analgesia Practices for Gastrointestinal Endoscopic Procedures in Europe. Clin Endosc 2016; 49:47-55. [PMID: 26855924 PMCID: PMC4743717 DOI: 10.5946/ce.2016.49.1.47] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Revised: 07/24/2015] [Accepted: 08/16/2015] [Indexed: 12/19/2022] Open
Abstract
Background/Aims: The use of moderate to deep sedation for gastrointestinal endoscopic procedures has increased in Europe considerably. Because this level of sedation is a risky medical procedure, a number of international guidelines have been developed. This survey aims to review if, and if so which, quality aspects have been included in new sedation practices when compared to traditional uncontrolled sedation practices.
Methods: A questionnaire was sent to the National Associations of Nurse Anesthetists in Europe and the National Delegates of the European Section and Board of Anaesthesiology from January 2012 to August 2012.
Results: Huge variation in practices for moderate to deep sedation were identified between and within European countries in terms of safety, type of practitioners, responsibilities, monitoring, informed consent, patient satisfaction, complication registration, and training requirements. Seventy-five percent of respondents were not familiar with international sedation guidelines. Safe sedation practices (mainly propofol-based moderate to deep sedation) are rapidly gaining popularity.
Conclusions: The risky medical procedure of moderate to deep sedation has become common practice for gastrointestinal endoscopy. Safe sedation practices requiring adequate selection of patients, adequate monitoring, training of sedation practitioners, and adequate after-care, are gaining attention in a field that is in transition from uncontrolled sedation care to controlled sedation care.
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Affiliation(s)
- Hermanus H B Vaessen
- Division of Anaesthesiology, Intensive Care and Emergency Medicine, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Johannes T A Knape
- Division of Anaesthesiology, Intensive Care and Emergency Medicine, University Medical Centre Utrecht, Utrecht, Netherlands
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Orel R, Brecelj J, Dias JA, Romano C, Barros F, Thomson M, Vandenplas Y. Review on sedation for gastrointestinal tract endoscopy in children by non-anesthesiologists. World J Gastrointest Endosc 2015; 7:895-911. [PMID: 26240691 PMCID: PMC4515424 DOI: 10.4253/wjge.v7.i9.895] [Citation(s) in RCA: 14] [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] [Received: 04/03/2015] [Revised: 06/05/2015] [Accepted: 06/18/2015] [Indexed: 02/05/2023] Open
Abstract
AIM To present evidence and formulate recommendations for sedation in pediatric gastrointestinal (GI) endoscopy by non-anesthesiologists. METHODS The databases MEDLINE, Cochrane and EMBASE were searched for the following keywords "endoscopy, GI", "endoscopy, digestive system" AND "sedation", "conscious sedation", "moderate sedation", "deep sedation" and "hypnotics and sedatives" for publications in English restricted to the pediatric age. We searched additional information published between January 2011 and January 2014. Searches for (upper) GI endoscopy sedation in pediatrics and sedation guidelines by non-anesthesiologists for the adult population were performed. RESULTS From the available studies three sedation protocols are highlighted. Propofol, which seems to offer the best balance between efficacy and safety is rarely used by non-anesthesiologists mainly because of legal restrictions. Ketamine and a combination of a benzodiazepine and an opioid are more frequently used. Data regarding other sedatives, anesthetics and adjuvant medications used for pediatric GI endoscopy are also presented. CONCLUSION General anesthesia by a multidisciplinary team led by an anesthesiologist is preferred. The creation of sedation teams led by non-anesthesiologists and a careful selection of anesthetic drugs may offer an alternative, but should be in line with national legislation and institutional regulations.
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Amornyotin S. Registered nurse-administered sedation for gastrointestinal endoscopic procedure. World J Gastrointest Endosc 2015; 7:769-76. [PMID: 26191341 PMCID: PMC4501967 DOI: 10.4253/wjge.v7.i8.769] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Revised: 12/24/2014] [Accepted: 05/05/2015] [Indexed: 02/05/2023] Open
Abstract
The rising use of nonanesthesiologist-administered sedation for gastrointestinal endoscopy has clinical significances. Most endoscopic patients require some forms of sedation and/or anesthesia. The goals of this sedation are to guard the patient's safety, minimize physical discomfort, to control behavior and to diminish psychological responses. Generally, moderate sedation for these procedures has been offered by the non-anesthesiologist by using benzodiazepines and/or opioids. Anesthesiologists and non-anesthesiologist personnel will need to work together for these challenges and for safety of the patients. The sedation training courses including clinical skills and knowledge are necessary for the registered nurses to facilitate the patient safety and the successful procedure. However, appropriate patient selection and preparation, adequate monitoring and regular training will ensure that the use of nurse-administered sedation is a feasible and safe technique for gastrointestinal endoscopic procedures.
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Fanti L, Gemma M, Agostoni M, Rossi G, Ruggeri L, Azzolini ML, Dabizzi E, Beretta L, Testoni PA. Target Controlled Infusion for non-anaesthesiologist propofol sedation during gastrointestinal endoscopy: The first double blind randomized controlled trial. Dig Liver Dis 2015; 47:566-71. [PMID: 25840875 DOI: 10.1016/j.dld.2015.03.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 03/02/2015] [Accepted: 03/06/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Target Controlled Infusion is a sophisticated tool for providing optimal sedation regimen avoiding under or oversedation in gastrointestinal endoscopy. AIMS To compare standard moderate sedation vs. non-anaesthesiologist-administered propofol sedation during gastrointestinal endoscopy. METHODS Randomized controlled trial of 70 consecutive colonoscopies and 70 consecutive esophagogastroduodenoscopies (EGD). Standard group (n=70), received fentanyl (1 μg/kg)+midazolam (0.03-0.04 mg/kg) or midazolam only; propofol group (n=70), received fentanyl (1 μg/kg)+propofol Target Controlled Infusion (1.2-1.6 μg/ml) or propofol Target Controlled Infusion only. Discharge time, endoscopist satisfaction and patient satisfaction were recorded in all endoscopies. RESULTS Colonoscopy: discharge time was significantly shorter in the propofol than the standard group (1.1 ± 0.3 vs. 5 ± 10.2 min, respectively; P=0.03). Endoscopist satisfaction was significantly higher (98.3 ± 11.4/100 vs. 87.2±12/100; P=0.001); patient satisfaction was significantly higher (95 ± 9.3/100 vs. 85.5 ± 14.4/100; P=0.002) in the propofol compared to the standard group. EGD: discharge time was not significantly different in the propofol and standard groups (1.1 ± 0.7 vs. 3.9 ± 9.2 min, respectively; P=0.146). Endoscopist satisfaction was significantly higher (92.7 ± 14.3/100 vs. 82.8 ± 21.2/100; P=0.03); patient satisfaction was significantly higher (93.8 ± 18.2/100 vs. 76.5 ± 25.2/100; P=0.003). In the propofol group 94.3% of patients vs. 71.4% of patients in standard group asked to receive the same sedation in the future (P=0.021). CONCLUSION Target Controlled Infusion is a promising method for non-anaesthesiologist-administered propofol sedation.
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Affiliation(s)
- Lorella Fanti
- Division of Gastroenterology and Gastrointestinal Endoscopy, Vita-Salute San Raffaele University - Scientific Institute San Raffaele, Milan, Italy.
| | - Marco Gemma
- Department of Anesthesiology, Vita-Salute San Raffaele University - Scientific Institute San Raffaele, Milan, Italy
| | - Massimo Agostoni
- Department of Anesthesiology, Vita-Salute San Raffaele University - Scientific Institute San Raffaele, Milan, Italy
| | - Gemma Rossi
- Division of Gastroenterology and Gastrointestinal Endoscopy, Vita-Salute San Raffaele University - Scientific Institute San Raffaele, Milan, Italy
| | - Laura Ruggeri
- Department of Anesthesiology, Vita-Salute San Raffaele University - Scientific Institute San Raffaele, Milan, Italy
| | - Maria Luisa Azzolini
- Department of Anesthesiology, Vita-Salute San Raffaele University - Scientific Institute San Raffaele, Milan, Italy
| | - Emanuele Dabizzi
- Division of Gastroenterology and Gastrointestinal Endoscopy, Vita-Salute San Raffaele University - Scientific Institute San Raffaele, Milan, Italy
| | - Luigi Beretta
- Department of Anesthesiology, Vita-Salute San Raffaele University - Scientific Institute San Raffaele, Milan, Italy
| | - Pier Alberto Testoni
- Division of Gastroenterology and Gastrointestinal Endoscopy, Vita-Salute San Raffaele University - Scientific Institute San Raffaele, Milan, Italy
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Astoul P, Maldonado F. Anesthetic drugs managed by pulmonologists during medical thoracoscopy: one size does not fit all! Respiration 2014; 88:265-7. [PMID: 25196379 DOI: 10.1159/000365663] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Philippe Astoul
- Department of Thoracic Oncology, Pleural Diseases and Interventional Pulmonology, Hôpital Nord, and Aix-Marseille University, Marseille, France
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Sieg A, Beck S, Scholl SG, Heil FJ, Gotthardt DN, Stremmel W, Rex DK, Friedrich K. Safety analysis of endoscopist-directed propofol sedation: a prospective, national multicenter study of 24 441 patients in German outpatient practices. J Gastroenterol Hepatol 2014; 29:517-23. [PMID: 24716213 DOI: 10.1111/jgh.12458] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND AIM Since 2008, there exists a German S3-guideline allowing non-anesthesiological administration of propofol for gastrointestinal endoscopy. In this prospective, national, multicenter study, we evaluated the safety of endoscopist-administered propofol sedation (EDP) in German outpatient practices of Gastroenterology. METHODS In this multicenter survey of 53 ambulatory practices of Gastroenterology, we prospectively evaluated 24 441 patients that had received EDP. We recorded adverse events during the endoscopic procedure and additionally retrieved questionnaires investigating subjective parameters 24 h after the endoscopic procedure. RESULTS In 24 441 patients 13 793 colonoscopies, 6467 esophagogastroduodenoscopies, and 4181 double examinations were performed. In this study, 52.1% of the patients received propofol mono-sedation, and 47.9% received a combination of midazolam and propofol. Major adverse events occurred in four patients (0.016%) enrolled to this study (three mask ventilations and one laryngospasm). Minor adverse events were observed in 112 patients (0.46%) with hypoxemia being the most common minor event. All patients with adverse events recovered without persistent impairment. Minor adverse events occurred more frequently in patients sedated with propofol mono compared to propofol and midazolam (P < 0.0001) and correlated with increasing propofol dosages (P < 0.001; Pearson correlation coefficient r = 0.044). Twenty-four hours after the endoscopy, patients sedated with propofol plus midazolam stated a significantly reduced sensation of pain (P < 0.01) and improved symptoms of dizziness, nausea and vomiting (P < 0.001) compared to patients having received propofol mono-sedation. CONCLUSION Four years after the implementation of a German S3-Guideline for endoscopic sedation, we demonstrated that EDP is a safe procedure.
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Anaesthetist support during sedation for patients undergoing minimally invasive procedures outside the operating room. Eur J Anaesthesiol 2013; 30:655-7. [DOI: 10.1097/eja.0b013e3283613ff9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Dietrich CG, Kottmann T, Diedrich A, Drouven FM. Sedation-associated complications in endoscopy are not reduced significantly by implementation of the German S-3-guideline and occur in a severe manner only in patients with ASA class III and higher. Scand J Gastroenterol 2013; 48:1082-7. [PMID: 23834761 DOI: 10.3109/00365521.2013.812237] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION The German guideline for sedation in gastrointestinal endoscopy was published in 2008. Several recommendations in this guideline, especially concerning staffing and structural requirements for sedation, have low evidence and therefore are subject to discussion in the field. AIM Comparison of endoscopic complications in a department specialized for gastrointestinal and pulmological diseases before and after implementation of the German guideline grouped in sedation-associated and non-sedation-associated complications. METHODS Prospective documentation of complications with retrospective analysis of two patient groups (before guideline: 1.5.2008-30.4.2010; after guideline: 1.5.2010-30.4.2012) at which the sedation technique remained the same (balanced propofol sedation, BPS). RESULTS Both investigation periods covered almost 7000 procedures. Interventional and general complications were nonsignificantly elevated in the latter group (1.27% before vs. 1.55% after guideline, p = 0.08). Saturation decline (in both groups 0.26%) was unchanged, and circulation-associated complications (0.27% vs. 0.13%, p = 0.07) were reduced nonsignificantly. Necessity for the administration of flumazenil and for intensive care monitoring was reduced in a nonsignificant manner after the implementation of the guideline. Severe complications (reanimation, apnea, and death) were unchanged, and no patient with ASA I-II suffered from a severe complication. Propofol consumption was higher after guideline implementation. CONCLUSIONS The recommendations of the new German sedation guideline do not significantly reduce complications in endoscopic procedures. Especially, procedures involving patients with ASA classes I and II do not require an additional staff member solely for sedation. Prospective randomized studies might be necessary to optimize the utilization of resources.
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Affiliation(s)
- Christoph G Dietrich
- Medical Clinic, Bethlehem-Hospital, Academic Affiliated Hospital of the Technical University Aachen, Stolberg/Rhld, Germany.
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Parkinson I. Non-anaesthetist administration of propofol for sedation: caught 'NAAP'ing? Br J Hosp Med (Lond) 2013; 73:666-7. [PMID: 23502192 DOI: 10.12968/hmed.2012.73.12.666] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Murugesan SV, Davies MW, Nicholson J, Hughes M, Haslam N, Smart HL, Sarkar S. Evaluation of a new anaesthetist-led propofol sedation service for endoscopy within a UK day-case setting. Frontline Gastroenterol 2013; 4:73-81. [PMID: 28839703 PMCID: PMC5369790 DOI: 10.1136/flgastro-2012-100255] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2012] [Revised: 10/01/2012] [Accepted: 10/02/2012] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION The use of propofol in endoscopy is becoming more prevalent both in Europe and North America. Potential advantages over conscious sedation include controlled deep sedation for therapeutic endoscopy and improved patient satisfaction. A new anaesthetist-led propofol-based day-case sedation service was introduced within the endoscopy unit at the Royal Liverpool University Hospital in April 2011. AIMS To evaluate this new service of anaesthetist-led propofol-based sedation for safety, compliance with current guidelines and satisfaction (patient, anaesthetist and endoscopist). DESIGN A prospective, service evaluation audit of a new, weekly, anaesthetist-led propofol-based sedation service. Administrative records, anaesthetic notes and satisfaction scores (1=very dissatisfied; 5=very satisfied; patients, anaesthetists, endoscopists) and the 'patient journey' were evaluated for 40 consecutive patients treated over 18 weeks. Outcomes were measured against current British Society of Gastroenterology/Royal College of Anaesthetists guidelines. RESULTS All procedures were completed (100% intention-to-treat rate), all patients were discharged on the day of the procedure and none were readmitted within 7 days. Adverse events were minor (10%) and there were no deaths within 30 days. The median satisfaction score was 5 for patients, anaesthetists and endoscopists. The additional cost for provision of such a service included the services of the anaesthetist (one programmed activity) and operating department personnel and for drugs (propofol). The demand for the service rapidly increased. CONCLUSIONS Anaesthetist-led propofol-assisted endoscopy is safe in a day-case endoscopy unit and is associated with high satisfaction scores for patients, anaesthetists and endoscopists. There is a high demand for this service in this UK endoscopy day-case unit.
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Affiliation(s)
- Senthil V Murugesan
- Department of Gastroenterology & Hepatology, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Mark W Davies
- Department of Anaesthetics, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Jill Nicholson
- Department of Anaesthetics, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Mark Hughes
- Department of Radiology, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Neil Haslam
- Department of Gastroenterology & Hepatology, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Howard L Smart
- Department of Gastroenterology & Hepatology, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Sanchoy Sarkar
- Department of Gastroenterology & Hepatology, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK,University of Liverpool, Liverpool, UK
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A much sought-after drug--propofol sedation for GI endoscopy: always better but who cares? Dig Dis Sci 2012; 57:1980-2. [PMID: 22744431 DOI: 10.1007/s10620-012-2282-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Accepted: 06/07/2012] [Indexed: 12/09/2022]
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The sedation dispute: what is next? Eur J Anaesthesiol 2012; 30:39-40. [PMID: 22825565 DOI: 10.1097/eja.0b013e328356ba6b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Retraction of endorsement: 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 gastrointestinal endoscopy. Eur J Anaesthesiol 2012; 29:208; author reply 208-9. [PMID: 22273832 DOI: 10.1097/eja.0b013e32834f5e5a] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Riphaus A, Macias-Gomez C, Devière J, Dumonceau JM. Propofol, the preferred sedation for screening colonoscopy, is underused. Results of an international survey. Dig Liver Dis 2012; 44:389-92. [PMID: 22119619 DOI: 10.1016/j.dld.2011.10.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2011] [Revised: 10/06/2011] [Accepted: 10/20/2011] [Indexed: 12/11/2022]
Abstract
BACKGROUND The use of propofol during colonoscopy has become more widespread. To increase availability while maintaining quality and decreasing costs, European Guidelines have been issued for non-anesthesiologist administration of propofol (NAAP). We aimed to assess the current use of propofol during screening colonoscopy. METHODS International survey. RESULTS Eighty-four questionnaires were collected from endoscopists practicing in 29 countries. Practices were most often located in high-volume community hospitals (Italy, Belgium, Spain, Netherlands in half cases). An anesthesiologist was regularly present in the Endoscopy Unit of 69.0% survey respondents. In low-risk (ASA classification, 1-2) patients, propofol, benzodiazepine+opioids and benzodiazepine alone were used in 45%, 31% and 14% of screening colonoscopies, respectively. Propofol was associated with the highest endoscopist satisfaction (score on a 10-point visual analogue scale, 9.2±1.2 vs. 5.5±1.9 and 4.7±2.0 for benzodiazepine+opioids and benzodiazepine alone, respectively; P<0.0001). NAAP was used by 29.9% of respondents in 9 countries and approximately two-thirds of other endoscopists would consider implementing NAAP. Main reasons for not considering NAAP implementation were medico-legal issues and cost. CONCLUSION Propofol provides the highest endoscopist satisfaction but it is used in less than half of screening colonoscopies. Propofol is administered by non-anesthesiologists in one-third of settings; its implementation is foreseen by a majority of endoscopists who do not currently use it.
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Affiliation(s)
- Andrea Riphaus
- Department of Medicine, Ruhr University Bochum, Bochum, Germany.
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Schneemilch C, Schiltz K, Meinshausen E, Hachenberg T. [Sexual hallucinations and dreams under anesthesia and sedation : medicolegal aspects]. Anaesthesist 2012; 61:234-41. [PMID: 22430554 DOI: 10.1007/s00101-012-1999-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Dreams and hallucinations under sedation or anesthesia have been well known phenomena since the introduction of anesthesia. Sexual hallucinations may lead to allegations of sexual molestation or assault by medical doctors or professional nursing staff. Hallucinations under the influence of sedative or hypnotic drugs may be very vivid and as misinterpreted as being real and it is therefore often difficult to disprove the resulting false allegations. In this report the terms drug-induced dreams and hallucinations are defined and the probable mechanism described. By a historical review and case reports the medicolegal consequences are demonstrated and procedures recommended to avoid allegations of sexual assault.
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Affiliation(s)
- C Schneemilch
- Universitätsklinik für Anästhesiologie und Intensivtherapie, Otto-von-Guericke-Universität Magdeburg, Deutschland.
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Ibarra P. Analysis of a poor outcome during deep sedation: potential impact of the 2011 SCARE recommendations for sedation by non-anesthesiologists. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2012. [DOI: 10.1016/s2256-2087(12)40007-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Ibarra P. Análisis de un desenlace trágico con sedación profunda: potencial impacto de las recomendaciones SCARE 2011 de sedación por no anestesiólogos. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2012. [DOI: 10.1016/s0120-3347(12)70007-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Analysis of a poor outcome during deep sedation: potential impact of the 2011 SCARE recommendations for sedation by non-anesthesiologists. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2012. [DOI: 10.1097/01819236-201240010-00008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Slagelse C, Vilmann P, Hornslet P, Hammering A, Mantoni T. Nurse-administered propofol sedation for gastrointestinal endoscopic procedures: first Nordic results from implementation of a structured training program. Scand J Gastroenterol 2011; 46:1503-9. [PMID: 22050137 DOI: 10.3109/00365521.2011.619274] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Proper training to improve safety of NAPS (nurse-administered propofol sedation) is essential. OBJECTIVE To communicate our experience with a training program of NAPS. MATERIALS AND METHODS In 2007, a training program was introduced for endoscopists and endoscopy nurses in collaboration with the Department of Anaesthesiology. During a 2.5-year period, eight nurses were trained. Propofol was given as monotherapy. The training program for nurses consisted of a 6-week course including theoretical and practical training whereas the training program for endoscopists consisted of 2.5 h of theory. Patients were selected based on strict criteria including patients in ASA (American Society of Anesthesiologists) group I-III. RESULTS 2527 patients undergoing 2.656 gastrointestinal endoscopic procedures were included. The patients were ASA group I, II and III in 34.7%, 56% and 9,3%, respectively. Median dose of propofol was 300 mg. No mortality was noted. 119 of 2527 patients developed short lasting hypoxia (4.7%); 61 (2.4%) needed suction; 22 (0.9%) required bag-mask ventilation and 8 (0.3%) procedures had to be discontinued. In 11 patients (0.4%), anesthetic assistance was called due to short lasting desaturation. 34 patients (1.3%) experienced a change in blood pressure greater than 30%. CONCLUSION NAPS provided by properly trained nurses according to the present protocol is safe and only associated with a minor risk (short lasting hypoxia 4.7%). National or international structured training programs are at present few or non-existing. The present training program has documented its value and is suggested as the basis for the current development of guidelines.
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Affiliation(s)
- Charlotte Slagelse
- Department of Endoscopy, Copenhagen University Hospital Gentofte, Hellerup, Denmark
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Delaunay L, Gentilli M, Sfez M, Cittanova ML, Lévy M, Delbos A, Le Hétêt H, Arnaud CM, Dumeix JM, Chariot MP, Yavordios PG, Plantet F. [About anaesthesia without anaesthetist...]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2011; 30:851-852. [PMID: 22018791 DOI: 10.1016/j.annfar.2011.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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Non-anaesthesiologists should not be allowed to administer propofol for procedural sedation: a Consensus Statement of 21 European National Societies of Anaesthesia. Eur J Anaesthesiol 2011; 28:580-4. [PMID: 21705907 DOI: 10.1097/eja.0b013e328348a977] [Citation(s) in RCA: 114] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Propofol, which is the most commonly used drug for induction of general anaesthesia, has also become a popular drug for procedural sedation. Because its use may be associated with serious and potentially fatal side-effects, the manufacturers of propofol restrict its use solely to personnel trained in general anaesthesia. In spite of this warning, the use of propofol for procedural sedation by non-anaesthesiologists is rapidly expanding in many countries. Recently, the US Food and Drugs Administration (FDA) denied a petition from gastroenterologists seeking the removal of this particular restriction. This unequivocal ruling of the FDA received strong support from the American Society of Anesthesiologists (ASA). At about the same time, the European Society of Anaesthesiology (ESA), together with various European gastroenterology societies, published new guidelines entitled 'Non-anaesthesiologist Administration of Propofol for Gastrointestinal Endoscopy' (NAAP). Following publication of the NAAP guidelines, many reservations have been expressed by ESA member societies and individuals, dealing with professional, political, procedural and safety-oriented concerns. Out of concern for patient safety, and in order to officially and publicly dissociate themselves from the NAAP guidelines, 21 national societies of anaesthesiology in Europe, all of whom are ESA members, have signed a Consensus Statement confirming that due to its significant well known risks, propofol should be administered only by those trained in the administration of general anaesthesia.
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Guidelines on non-anaesthesiologist administration of propofol for gastrointestinal endoscopy. Eur J Anaesthesiol 2011; 28:553-5. [DOI: 10.1097/eja.0b013e328348a9db] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ræder J. Siste vers for Michael Jackson. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2011; 131:2450. [DOI: 10.4045/tidsskr.11.1417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Tramèr MR. EJA 2011: Finding the balance between science and politics. Eur J Anaesthesiol 2011; 28:1-2. [PMID: 21124096 DOI: 10.1097/eja.0b013e3283423bf0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Affiliation(s)
- Martin R Tramèr
- From the Editor-in-Chief, European Journal of Anaesthesiology, Division of Anaesthesiology, Geneva University Hospitals and Medical Faculty, University of Geneva, CH-1211 Geneva, Switzerland
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