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Williams MR, Ward DS, Carlson D, Cravero J, Dexter F, Lightdale JR, Mason KP, Miner J, Vargo JJ, Berkenbosch JW, Clark RM, Constant I, Dionne R, Dworkin RH, Gozal D, Grayzel D, Irwin MG, Lerman J, O'Connor RE, Pandharipande P, Rappaport BA, Riker RR, Tobin JR, Turk DC, Twersky RS, Sessler DI. Evaluating Patient-Centered Outcomes in Clinical Trials of Procedural Sedation, Part 1 Efficacy: Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research Recommendations. Anesth Analg 2017; 124:821-830. [PMID: 27622720 DOI: 10.1213/ane.0000000000001566] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research, established by the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks public-private partnership with the US Food and Drug Administration, convened a meeting of sedation experts from a variety of clinical specialties and research backgrounds with the objective of developing recommendations for procedural sedation research. Four core outcome domains were recommended for consideration in sedation clinical trials: (1) safety, (2) efficacy, (3) patient-centered and/or family-centered outcomes, and (4) efficiency. This meeting identified core outcome measures within the efficacy and patient-centered and/or family-centered domains. Safety will be addressed in a subsequent meeting, and efficiency will not be addressed at this time. These measures encompass depth and levels of sedation, proceduralist and patient satisfaction, patient recall, and degree of pain experienced. Consistent use of the recommended outcome measures will facilitate the comprehensive reporting across sedation trials, along with meaningful comparisons among studies and interventions in systematic reviews and meta-analyses.
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Affiliation(s)
- Mark R Williams
- From the *Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, New York; †Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, New York; ‡Department of Anesthesiology, Tufts School of Medicine, Boston, Massachusetts; §Department of Pediatrics, Southern Illinois University School of Medicine, Springfield, Illinois; ‖Department of Pediatrics, St John's Children's Hospital, Springfield, Illinois; ¶Department of Anesthesia, Harvard Medical School, Boston, Massachusetts; #Department of Anesthesiology, Boston Children's Hospital, Boston, Massachusetts; **Department of Anesthesia, University of Iowa, Iowa City; ††Pediatric Gastroenterology, University of Massachusetts Medical Center, University of Massachusetts Medical School, Worcester, Massachusetts; ‡‡Department of Anesthesiology, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts; §§Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, Minnesota; ‖‖Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota; ¶¶Department of Gastroenterology and Hepatology, Cleveland Clinic Lerner College of Medicine of Case Western University, Cleveland, Ohio; ##Pediatric Critical Care, Kosair Children's Hospital, University of Louisville School of Medicine, Louisville, Kentucky; ***Section for Professional Standards, American Society of Anesthesiologists Children's Hospital Colorado, University of Colorado School of Medicine, Denver, Colorado; †††Department of Anesthesiology, Hôpital Armand Trousseau, Paris, France; ‡‡‡Department of Pharmacology and Foundational Sciences, East Carolina University, Greenville, North Carolina; §§§Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, New York; ‖‖‖Division of Anesthesiology and CCM, Hadassah University Hospital, The Hebrew University of Jerusalem School of Medicine, Jerusalem, Israel; ¶¶¶Annovation BioPharma, Cambridge, Massachusetts; ###Department of Anesthesiology, University of Hong Kong, Hong Kong, China; ****Department of Anesthesiology, Women and Children's Hospital of Buffalo, SUNY at Buffalo, Buffalo, New York; ††††Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, Virginia; ‡‡‡‡Department of Anesthesiology, Vanderbilt University, Nashville, Tennessee; §§§§Analgesic Concepts LLC, Arlington, Virginia; ‖‖‖‖Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts; ¶¶¶¶Department of Critical Care Medicine and Neuroscience Institute, Maine Medical Center, Portland, Maine; ####Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina; *****Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington; †††††Department of Anesthesiology & Critical Care Medicine, Josie Robertson Surgery Center, Memorial Sloan Kettering Cancer Center, New York, New York; and ‡‡‡‡‡Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
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Chandran V, Jagadisan B, Ganth B. Validation of Adapted Dartmouth Operative Conditions Scale for sedation during pediatric esophagogastroduodenoscopy. Paediatr Anaesth 2017; 27:621-628. [PMID: 28370856 DOI: 10.1111/pan.13127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/13/2017] [Indexed: 11/26/2022]
Abstract
AIMS Pediatric esophagogastroduodenoscopy requires deep sedation as it involves stimulation of the airway. Frequency of adverse events is higher with esophagogastroduodenoscopy. Hence, monitoring needs sedation scales like the Dartmouth Operative Condition Scale that identifies safe states of sedation. This study aims at validating the Adapted Dartmouth Operative Condition Scale for sedation rating by pediatricians during pediatric esophagogastroduodenoscopy. METHODS Items in the Dartmouth Operating Conditions Scale were adapted for pediatric esophagogastroduodenoscopy. Videos of 35 procedures were recorded. The recording started 10 min before sedation and continued till recovery. The videos were split into preprocedure videos, intraprocedure videos, and recovery videos, and further split into 30-s clips. Twenty representative intraprocedure videos clips were selected. Ten raters scored the videos with the Adapted Dartmouth Operating Conditions Scale and modified-COMFORT score. The Adapted Dartmouth Operating Conditions Scale scoring was repeated after a month. The preprocedure videos, intraprocedure videos, and recovery videos of ten patients (six clips each) were scored by one rater to assess responsiveness. RESULTS The Adapted Dartmouth Operating Conditions Scale detected nonoptimal sedation states including laryngospasm due to undersedated states. It showed fair interrater reliability at timeline-1 (intraclass correlation coefficient = 0.45) and timeline-2 (intraclass correlation coefficient = 0.65) but poor intrarater reliability (intraclass correlation coefficient = 0.32). There was significant positive correlation with modified-COMFORT (Spearman's rank order correlation, r = 0.150). Responsiveness was demonstrated by the difference in the preprocedure videos, intraprocedure videos, and recovery videos scores (F = 126.50). CONCLUSION The Adapted Dartmouth Operating Conditions Scale detects nonoptimal sedation states during pediatric-esophagogastroduodenoscopy. It shows good criterion validity, interrater reliability, and responsiveness. Poor intrarater reliability seen in our study could be due to item ambiguity arising from the mode of training of the raters in the Dartmouth Operating Conditions Scale.
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Affiliation(s)
- Vanmathi Chandran
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| | - Barath Jagadisan
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| | - Barani Ganth
- Department of Applied Psychology, Pondicherry University, Pondicherry, India
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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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Chung HJ, Bang BW, Kim HG, Kwon KS, Shin YW, Jeong S, Lee DH, Park SG. Delayed flumazenil injection after endoscopic sedation increases patient satisfaction compared with immediate flumazenil injection. Gut Liver 2013; 8:7-12. [PMID: 24516695 PMCID: PMC3916690 DOI: 10.5009/gnl.2014.8.1.7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2013] [Revised: 03/10/2013] [Accepted: 03/13/2013] [Indexed: 12/20/2022] Open
Abstract
Background/Aims Flumazenil was administered after the completion of endoscopy under sedation to reduce recovery time and increase patient safety. We evaluated patient satisfaction after endoscopy under sedation according to the timing of a postprocedural flumazenil injection. Methods In total, 200 subjects undergoing concurrent colonoscopy and upper endoscopy while sedated with midazolam and meperidine were enrolled in our investigation. We randomly administered 0.3 mg of flumazenil either immediately or 15 minutes after the endoscopic procedure. A postprocedural questionnaire and next day telephone interview were conducted to assess patient satisfaction. Results Flumazenil injection timing did not affect the time spent in the recovery room when comparing the two groups of patients. However, the subjects in the 15 minutes injection group were more satisfied with undergoing endoscopy under sedation than the patients in the immediate injection group according to the postprocedural survey (p=0.019). However, no difference in overall satisfaction, memory, or willingness to undergo a future endoscopy was observed between the two groups when the telephone survey was conducted on the following day. Conclusions This study demonstrated that a delayed flumazenil injection after endoscopic sedation increased patient satisfaction without prolonging recovery time, even though the benefit of the delayed flumazenil injection did not persist into the following day.
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Affiliation(s)
- Hyun Jung Chung
- Division of Gastroenterology, Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | - Byoung Wook Bang
- Division of Gastroenterology, Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | - Hyung Gil Kim
- Division of Gastroenterology, Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | - Kye Sook Kwon
- Division of Gastroenterology, Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | - Yong Woon Shin
- Division of Gastroenterology, Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | - Seok Jeong
- Division of Gastroenterology, Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | - Don Haeng Lee
- Division of Gastroenterology, Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | - Shin Goo Park
- Department of Occupational and Environmental Medicine, Inha University School of Medicine, Incheon, Korea
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Jenssen C, Alvarez-Sánchez MV, Napoléon B, Faiss S. Diagnostic endoscopic ultrasonography: Assessment of safety and prevention of complications. World J Gastroenterol 2012; 18:4659-76. [PMID: 23002335 PMCID: PMC3442204 DOI: 10.3748/wjg.v18.i34.4659] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2012] [Revised: 07/06/2012] [Accepted: 07/18/2012] [Indexed: 02/06/2023] Open
Abstract
Endoscopic ultrasonography (EUS) has gained wide acceptance as an important, minimally invasive diagnostic tool in gastroenterology, pulmonology, visceral surgery and oncology. This review focuses on data regarding risks and complications of non-interventional diagnostic EUS and EUS-guided fine-needle biopsy (EUS-FNB). Measures to improve the safety of EUS und EUS-FNB will be discussed. Due to the specific mechanical properties of echoendoscopes in EUS, there is a low but noteworthy risk of perforation. To minimize this risk, endoscopists should be familiar with the specific features of their equipment and their patients’ specific anatomical situations (e.g., tumor stenosis, diverticula). Most diagnostic EUS complications occur during EUS-FNB. Pain, acute pancreatitis, infection and bleeding are the primary adverse effects, occurring in 1% to 2% of patients. Only a few cases of needle tract seeding and peritoneal dissemination have been reported. The mortality associated with EUS and EUS-FNB is 0.02%. The risks associated with EUS-FNB are affected by endoscopist experience and target lesion. EUS-FNB of cystic lesions is associated with an increased risk of infection and hemorrhage. Peri-interventional antibiotics are recommended to prevent cyst infection. Adequate education and training, as well consideration of contraindications, are essential to minimize the risks of EUS and EUS-FNB. Restricting EUS-FNB only to patients in whom the cytopathological results may be expected to change the course of management is the best way of reducing the number of complications.
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Sedation, analgesia, and cardiorespiratory function in colonoscopy using midazolam combined with fentanyl or propofol. Int J Colorectal Dis 2011; 26:703-8. [PMID: 21409424 DOI: 10.1007/s00384-011-1162-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/18/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS The use of sedatives during colonoscopy remains controversial because of its safety concerns. We compared cardiorespiratory function and sedative and analgesic effects in sedative colonoscopy, using combinations of midazolam with either fentanyl or propofol. METHODS Eligible patients (n = 480) received 1.0-2.0 mg midazolam alone (n = 160), midazolam combined with either 50-100 mg fentanyl intramuscularly (n = 160), or 0.5-2.5 mg/kg propofol intravenously, as premedication for sedative colonoscopy. Pulse rate, blood pressure, and saturation of peripheral oxygen (SpO(2)) were monitored. Levels of sedation and analgesia were semi-quantitatively scored using visual analog scales, and amnesia profiles were qualitatively evaluated. RESULTS Combining midazolam with either fentanyl or propofol resulted in acceptable sedative and analgesic effects compared to treatment with midazolam alone (P < 0.001), with the combination with propofol giving more favorable results. More patients receiving the propofol combination became amnestic to the procedure than patients receiving the fentanyl combination. However, midazolam combined with propofol disturbed the pulse rate (P < 0.05) and blood pressure (P < 0.001) more significantly than a combination with fentanyl, or midazolam alone. CONCLUSION The combination of midazolam with either fentanyl or propofol allowed patients to undergo colonoscopy under comparable sedative and analgesic conditions. The combination with fentanyl had a significantly lower effect on pulse rate and blood pressure. The combination with propofol produced superior amnestic effects.
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Yamagata T, Hirasawa D, Fujita N, Suzuki T, Obana T, Sugawara T, Ohira T, Harada Y, Maeda Y, Koike Y, Suzuki K, Noda Y. Efficacy of propofol sedation for endoscopic submucosal dissection (ESD): assessment with prospective data collection. Intern Med 2011; 50:1455-60. [PMID: 21757829 DOI: 10.2169/internalmedicine.50.4627] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE The indications for endoscopic treatment in early stage cancer of the digestive tract are expanding with the emergence and technical development of endoscopic submucosal dissection (ESD). ESD requires longer term stable sedation than conventional endoscopic procedures due to the necessity of meticulous control of the devices during the procedure. Propofol has a very short half-life and can be administered continuously, which is advantageous for long-term sedation. Propofol, thus, is likely to be useful for sedation during ESD. METHODS Fifty consecutive patients who underwent ESD for early gastric cancer with propofol sedation (Group P) and those with midazolam sedation (Group M) were included in this study. Cardiorespiratory suppression rate and the condition of arousal were compared between the groups. A questionnaire survey on the satisfaction of endoscopists, anesthesiologists, endoscopy nurses, and ward nurses with the use of propofol was also carried out. RESULTS Respiratory suppression was observed in 50% in Group M and in 20% in Group P (p<0.05). Hypotension was seen in 14% and 36% in Groups M and P, respectively (p<0.05). No sedation-related complications were encountered in either of the groups. Arousal rates 1 hour and 3 hours after the procedure were 23% and 60% in group M and 86% and 100% in Group P (p<0.05). As for the questionnaire survey, most respondents, in particular the ward nurses, supported the use of propofol. CONCLUSION Our data suggest that propofol is safe and useful during ESD as compared with midazolam.
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Affiliation(s)
- Taku Yamagata
- Department of Gastroenterology, Sendai City Medical Center, Japan.
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Tan G, Irwin MG. Recent advances in using propofol by non-anesthesiologists. F1000 MEDICINE REPORTS 2010; 2:79. [PMID: 21170368 PMCID: PMC2998802 DOI: 10.3410/m2-79] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Evidence is accumulating that non-anesthesiologist-administered propofol (NAAP) sedation has a safety and efficacy profile comparable or superior to that provided by benzodiazepines with or without opioids. The guidelines currently available emphasize the importance of appropriate patient selection, staff training, monitoring, and low-dose sedation protocols for NAAP safety. In addition, capnograph monitoring and computer-assisted sedation systems may further improve patient safety during NAAP.
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Affiliation(s)
- Gang Tan
- Department of Anaesthesiology, University of Hong KongRoom 424, Block K, Queen Mary Hospital, 102 Pokfulam RoadHong Kong
- Department of Anaesthesiology, Peking Union Medical College Hospital100730, 1 Shuaifuyuan, BeijingChina
| | - Michael G Irwin
- Department of Anaesthesiology, University of Hong KongRoom 424, Block K, Queen Mary Hospital, 102 Pokfulam RoadHong Kong
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