1
|
Maruki Y, Hijioka S, Yagi S, Takasaki T, Chatto M, Fukuda S, Yamashige D, Okamoto K, Agarie D, Hara H, Hagiwara Y, Nagashio Y, Morizane C, Sone M, Okusaka T, Saito Y. Sedative effects of propofol and risk factors for excessive sedation in the endoscopic treatment of biliary and pancreatic diseases. DEN OPEN 2025; 5:e417. [PMID: 39228861 PMCID: PMC11369203 DOI: 10.1002/deo2.417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 06/24/2024] [Accepted: 07/14/2024] [Indexed: 09/05/2024]
Abstract
Objectives The safety and effectiveness of propofol in more complex endoscopic procedures, such as endoscopic retrograde cholangiopancreatography, remain unknown. Thus, we aimed to evaluate propofol sedation during endoscopic cholangiopancreatography, ultrasound-guided intervention, and gastroduodenal stenting and examine risk factors for excessive sedation. Methods We retrospectively analyzed data from 870 patients who underwent endoscopic treatment with propofol sedation for biliary and pancreatic disease between October 2020 and September 2021. Sedation included propofol and fentanyl, with continuous monitoring of vital signs and the bispectral index. The assessed risk factors included age, complications, body mass index, treatment duration, and specialty. Results Distal bile duct treatment (n = 367), hilar bile duct treatment (n = 197), post-small-intestinal reconstruction treatment (n = 75), endoscopic ultrasound-guided intervention (n = 140), and gastrointestinal obstruction treatment (n = 91) were performed. The rates of excessive sedation, hypoxemia, and hypotension were 7.8%, 6.0%, and 1.8%, respectively. Post-small-intestinal reconstruction treatment had the highest incidence rate of excessive sedation (16%), whereas endoscopic ultrasound-guided intervention had the lowest incidence rate (4.3%). Multivariate analysis revealed significant associations between excessive sedation and comorbid sleep apnea, obesity, and prolonged procedural time. Conclusions Obesity, sleep apnea syndrome, and prolonged procedure time are risk factors for excessive sedation related to propofol use. Thus, sedation techniques should be tailored for these patients.
Collapse
Affiliation(s)
- Yuta Maruki
- Department of Hepatobiliary and Pancreatic OncologyNational Cancer Center HospitalTokyoJapan
- Molecular OncologyThe Jikei University School of MedicineTokyoJapan
| | - Susumu Hijioka
- Department of Hepatobiliary and Pancreatic OncologyNational Cancer Center HospitalTokyoJapan
| | - Shin Yagi
- Department of Hepatobiliary and Pancreatic OncologyNational Cancer Center HospitalTokyoJapan
| | - Tetsuro Takasaki
- Department of Hepatobiliary and Pancreatic OncologyNational Cancer Center HospitalTokyoJapan
| | - Mark Chatto
- Department of Hepatobiliary and Pancreatic OncologyNational Cancer Center HospitalTokyoJapan
- Department of GastroenterologyMakati Medical CenterMakati CityPhilippines
| | - Soma Fukuda
- Department of Hepatobiliary and Pancreatic OncologyNational Cancer Center HospitalTokyoJapan
| | - Daiki Yamashige
- Department of Hepatobiliary and Pancreatic OncologyNational Cancer Center HospitalTokyoJapan
| | - Kouhei Okamoto
- Department of Hepatobiliary and Pancreatic OncologyNational Cancer Center HospitalTokyoJapan
| | - Daiki Agarie
- Department of Hepatobiliary and Pancreatic OncologyNational Cancer Center HospitalTokyoJapan
| | - Hidenobu Hara
- Department of Hepatobiliary and Pancreatic OncologyNational Cancer Center HospitalTokyoJapan
| | - Yuya Hagiwara
- Department of Hepatobiliary and Pancreatic OncologyNational Cancer Center HospitalTokyoJapan
| | - Yoshikuni Nagashio
- Department of Hepatobiliary and Pancreatic OncologyNational Cancer Center HospitalTokyoJapan
| | - Chigusa Morizane
- Department of Hepatobiliary and Pancreatic OncologyNational Cancer Center HospitalTokyoJapan
| | - Miyuki Sone
- Department of Diagnostic RadiologyNational Cancer Center HospitalTokyoJapan
| | - Takuji Okusaka
- Department of Hepatobiliary and Pancreatic OncologyNational Cancer Center HospitalTokyoJapan
| | - Yutaka Saito
- Endoscopy DivisionNational Cancer Center HospitalTokyoJapan
| |
Collapse
|
2
|
Choe JW, Chung MJ, Park SW, Oh D, Han SY, Yang MJ, Kim EJ, Cho JH, Lee KJ, Jang SI. Safety and efficacy of remimazolam versus propofol during EUS: a multicenter randomized controlled study. Gastrointest Endosc 2024; 100:183-191.e1. [PMID: 38580132 DOI: 10.1016/j.gie.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 02/25/2024] [Accepted: 04/01/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND AND AIMS Propofol, a widely used sedative in GI endoscopic procedures, is associated with cardiorespiratory suppression. Remimazolam is a novel ultrashort-acting benzodiazepine sedative with rapid onset and minimal cardiorespiratory depression. This study compared the safety and efficacy of remimazolam and propofol during EUS procedures. METHODS A multicenter randomized controlled study was conducted between October 2022 and March 2023 in patients who underwent EUS procedures. Patients were randomly assigned to receive either remimazolam or propofol as a sedative agent. The primary endpoint was cardiorespiratory adverse events (AEs) during the procedure, including desaturation, respiratory depression, hypotension, and tachycardia. Secondary endpoints were the time to achieve sedation, recovery time, quality of sedation, pain at the injection site, and satisfaction of both endoscopists and patients. RESULTS Four hundred patients enrolled in the study: 200 received remimazolam (10.8 ± 7.7 mg) and 200 received propofol (88.0 ± 49.1 mg). For cardiorespiratory AEs, the remimazolam group experienced fewer occurrences than the propofol group (8.5% vs 16%, P = .022). A nonsignificant trend was found toward less oxygen desaturation (1.0% vs 3.5%, P = .09), respiratory depression (.5% vs 1.5%, P = .62), hypotension (2.5% vs 5.5%, P = .12), and tachycardia (4.5% vs 5.5%, P = .68) with remimazolam than with propofol. Remimazolam showed a shorter induction time than propofol while maintaining comparable awakening and recovery times. Injection site pain was significantly lower in the remimazolam group than in the propofol group. The remimazolam group demonstrated a significantly higher quality of sedation and satisfaction scores than the propofol group, as evaluated by both endoscopists and patients. CONCLUSIONS Remimazolam was superior to propofol in terms of safety and efficacy during EUS examinations. (Clinical trial registration number: KCT 0007643.).
Collapse
Affiliation(s)
- Jung Wan Choe
- Department of Internal Medicine, Korea University College of Medicine, Seoul, South Korea
| | - Moon Jae Chung
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Se Woo Park
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, South Korea
| | - Dongwook Oh
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sung Yong Han
- Department of Internal Medicine, Biomedical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, South Korea
| | - Min Jae Yang
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, South Korea
| | - Eui Joo Kim
- Division of Gastroenterology, Department of Internal Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, South Korea
| | - Jae Hee Cho
- Departments of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Kyong Joo Lee
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, South Korea
| | - Sung Ill Jang
- Departments of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| |
Collapse
|
3
|
Zhang Q, Zhao R, Wu Y, Zhang L, Feng Y. Etomidate Combined with Propofol versus Remimazolam for Sedation in Elderly Patients During Gastrointestinal Endoscopy: A Randomized Prospective Clinical Trial. Drug Des Devel Ther 2024; 18:2681-2692. [PMID: 38974124 PMCID: PMC11227308 DOI: 10.2147/dddt.s454314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 06/25/2024] [Indexed: 07/09/2024] Open
Abstract
Purpose Remimazolam is a novel short-acting benzodiazepine used for sedation and general anesthesia. This study aimed to evaluate the efficacy and safety of remimazolam besylate in elderly patients who underwent diagnostic gastrointestinal endoscopy. Patients and Methods A total of 120 patients aged 60-75 years were randomly allocated to one of two groups. Remifentanil 0.3μg/kg was used for analgesia. Patients were administered remimazolam besylate 7 mg (R group) or etomidate 0.1 mg/kg combined with 1% propofol 0.5 mg/kg (EP group) for induction, supplemental repeated doses were given as needed. Some time metrics, vital signs, adverse events were evaluated. Patients' Mini-cog score and recovery questionnaires were compared. Results Compared to the EP group, the induction time was slightly longer in the R group (1.50 VS 1.15 minutes) (P<0.05), the time spent in the post-anesthesia care unit (PACU) was shorter (15.17 VS 17.40 minutes) (P<0.05). Compare with EP group, SBP was lower in R group at T15 and T25 time point, but heart rate was higher in T2, T3, T5 (P< 0.05). The Mini-Cog score was higher after the procedure (2.83 VS 2.58) (P<0.05). The incidence of respiratory adverse events was higher in the EP group than R group (18.3% VS 5.0%, P < 0.05). The most common adverse event in R group was hiccups. The sedation satisfaction rate and degree of amnesia were higher in the R group (66.7% VS 11.7%) (P < 0.05), and the effect on patient's life within 24 hours was lower (12.0% VS 30.5%) (P < 0.05). Conclusion The safety and efficacy of remimazolam besylate are not inferior to those of etomidate combined with propofol, rendering it a safe option for sedation during gastrointestinal endoscopy in ASA I-II elderly patients, but care should be taken to monitor the occurrence of hiccups.
Collapse
Affiliation(s)
- Qin Zhang
- Endoscopy Center, Peking University People’s Hospital, Beijing, People’s Republic of China
| | - Rui Zhao
- Endoscopy Center, Peking University People’s Hospital, Beijing, People’s Republic of China
| | - Yaqing Wu
- Department of Anesthesiology, Peking University People’s Hospital, Beijing, People’s Republic of China
| | - Liming Zhang
- Endoscopy Center, Peking University People’s Hospital, Beijing, People’s Republic of China
| | - Yi Feng
- Department of Anesthesiology, Peking University People’s Hospital, Beijing, People’s Republic of China
| |
Collapse
|
4
|
Kim HI, Jung DH, Lee SJ, Lee YC, Lee SK, Kim GH, Nam HJ, Lee S, Byon HJ, Shin SK. Associations between Clinicopathological Characteristics and Intraoperative Opioid Requirements during Endoscopic Submucosal Dissection with Monitored Anesthesia Care: A Retrospective Study. J Clin Med 2024; 13:3119. [PMID: 38892830 PMCID: PMC11172858 DOI: 10.3390/jcm13113119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Revised: 05/24/2024] [Accepted: 05/24/2024] [Indexed: 06/21/2024] Open
Abstract
Background and study aims: Endoscopic submucosal dissection is used to treat early gastric neoplasms. Compared with other endoscopic procedures, it requires higher doses of opioids, leading to adverse events during monitored anesthesia care. We investigated the correlations between clinicopathological characteristics and intraprocedural opioid requirements in patients who underwent endoscopic submucosal dissection under monitored anesthesia care. Patients and methods: The medical records of patients who underwent endoscopic submucosal dissection under monitored anesthesia care were retrospectively reviewed. The dependent variable was the total dose of fentanyl administered during the dissection, while independent variables were patient demographics, the American Society of Anesthesiologists physical status classification, preoperative vital sign data, and the pathological characteristics of the neoplasm. Correlations between variables were examined using multiple regression analysis. Results: The study included 743 patients. The median total fentanyl dose was 100 mcg. Younger age (coefficient -1.37; 95% confidence interval [CI] -1.78 to -0.95), male sex (16.12; 95% CI 6.99-25.24), baseline diastolic blood pressure (0.44; 95% CI 0.04-0.85), neoplasm length (1.63; 95% CI 0.90-2.36), and fibrosis (28.59; 95% CI 17.77-39.42) were positively correlated with the total fentanyl dose. Total fentanyl dose was higher in the differentiated (16.37; 95% CI 6.40-26.35) and undifferentiated cancers group (32.53; 95% CI 16.95-48.11) than in the dysplasia group; no significant differences were observed among the others. The mid-anterior wall (22.69; 95% CI 1.25-44.13), mid-posterior wall (29.65; 95% CI 14.39-44.91), mid-greater curvature (28.77; 95% CI 8.56-48.98), and upper groups (30.06; 95% CI 5.01-55.12) had higher total fentanyl doses than the lower group, whereas doses did not significantly differ for the mid-lesser curvature group. Conclusions: We identified variables that influenced opioid requirements during monitored anesthesia care for endoscopic submucosal dissection. These may help predict the needed opioid doses and identify factors affecting intraprocedural opioid requirements.
Collapse
Affiliation(s)
- Hyun Il Kim
- Department of Anesthesiology and Pain Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; (H.I.K.); (S.J.L.); (H.J.N.)
| | - Da Hyun Jung
- Division of Gastroenterology, Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; (D.H.J.); (Y.C.L.); (S.K.L.); (G.H.K.)
| | - Sung Jin Lee
- Department of Anesthesiology and Pain Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; (H.I.K.); (S.J.L.); (H.J.N.)
| | - Yong Chan Lee
- Division of Gastroenterology, Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; (D.H.J.); (Y.C.L.); (S.K.L.); (G.H.K.)
| | - Sang Kil Lee
- Division of Gastroenterology, Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; (D.H.J.); (Y.C.L.); (S.K.L.); (G.H.K.)
| | - Ga Hee Kim
- Division of Gastroenterology, Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; (D.H.J.); (Y.C.L.); (S.K.L.); (G.H.K.)
| | - Ho Jae Nam
- Department of Anesthesiology and Pain Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; (H.I.K.); (S.J.L.); (H.J.N.)
| | - Sihak Lee
- Stanley Center for Psychiatric Research, Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA 02142, USA;
| | - Hyo-Jin Byon
- Department of Anesthesiology and Pain Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; (H.I.K.); (S.J.L.); (H.J.N.)
| | - Sung Kwan Shin
- Division of Gastroenterology, Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; (D.H.J.); (Y.C.L.); (S.K.L.); (G.H.K.)
| |
Collapse
|
5
|
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
| |
Collapse
|
6
|
Takahashi K, Ohyama H, Takiguchi Y, Sekine Y, Toyama S, Yamada N, Sugihara C, Kan M, Ouchi M, Nagashima H, Iino Y, Kusakabe Y, Okitsu K, Ohno I, Kato N. Safety of endoscopic ultrasound-guided fine-needle aspiration for pancreatic solid mass in the elderly: A single-center retrospective study. Geriatr Gerontol Int 2023; 23:836-841. [PMID: 37752034 DOI: 10.1111/ggi.14693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 08/14/2023] [Accepted: 09/14/2023] [Indexed: 09/28/2023]
Abstract
AIM There are few reports on the safety of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in the elderly. In this study, we investigated the safety of EUS-FNA for pancreatic solid masses in patients aged ≥80 years. METHODS This is a single-center retrospective study. A total of 600 patients with pancreatic solid masses who underwent EUS-FNA under midazolam-based sedation at our institution between September 2016 and December 2022 were enrolled in this study. Eligible patients were divided into two groups: an elderly group aged ≥80 (n = 84), as well as a nonelderly group aged ≤79 (n = 516). These two groups were compared. RESULTS The elderly group required significantly fewer midazolam doses for sedation (P < 0.001). Adverse events occurred in eight patients (1.3%), including one (1.2%) and seven (1.4%) in the elderly and nonelderly groups, respectively (P = 0.90). There were no cases of early adverse events in the elderly group and six cases (1.2%) in the nonelderly group (P = 0.32). There was one case of late adverse events in both the elderly and nonelderly groups (P = 0.14), and both were needle tract seeding. There was no significant difference between the two groups in the proportion of cases in which percutaneous oxygen saturation decreased to ≤90% during the EUS-FNA. CONCLUSIONS Our analysis suggests that EUS-FNA for pancreatic solid masses can be safely performed in patients aged >80 years without increasing the adverse event rate compared to nonelderly patients aged <80 years. Geriatr Gerontol Int 2023; 23: 836-841.
Collapse
Affiliation(s)
- Koji Takahashi
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
- Department of Medical Oncology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Hiroshi Ohyama
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yuichi Takiguchi
- Department of Medical Oncology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yu Sekine
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Shodai Toyama
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Nana Yamada
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Chihei Sugihara
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Motoyasu Kan
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Mayu Ouchi
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Hiroki Nagashima
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yotaro Iino
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yuko Kusakabe
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Kohichiroh Okitsu
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Izumi Ohno
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
- Department of Medical Oncology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Naoya Kato
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| |
Collapse
|
7
|
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
| |
Collapse
|
8
|
Tumino E, Visaggi P, Bolognesi V, Ceccarelli L, Lambiase C, Coda S, Premchand P, Bellini M, de Bortoli N, Marciano E. Robotic Colonoscopy and Beyond: Insights into Modern Lower Gastrointestinal Endoscopy. Diagnostics (Basel) 2023; 13:2452. [PMID: 37510196 PMCID: PMC10378494 DOI: 10.3390/diagnostics13142452] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 07/17/2023] [Accepted: 07/21/2023] [Indexed: 07/30/2023] Open
Abstract
Lower gastrointestinal endoscopy is considered the gold standard for the diagnosis and removal of colonic polyps. Delays in colonoscopy following a positive fecal immunochemical test increase the likelihood of advanced adenomas and colorectal cancer (CRC) occurrence. However, patients may refuse to undergo conventional colonoscopy (CC) due to fear of possible risks and pain or discomfort. In this regard, patients undergoing CC frequently require sedation to better tolerate the procedure, increasing the risk of deep sedation or other complications related to sedation. Accordingly, the use of CC as a first-line screening strategy for CRC is hampered by patients' reluctance due to its invasiveness and anxiety about possible discomfort. To overcome the limitations of CC and improve patients' compliance, several studies have investigated the use of robotic colonoscopy (RC) both in experimental models and in vivo. Self-propelling robotic colonoscopes have proven to be promising thanks to their peculiar dexterity and adaptability to the shape of the lower gastrointestinal tract, allowing a virtually painless examination of the colon. In some instances, when alternatives to CC and RC are required, barium enema (BE), computed tomographic colonography (CTC), and colon capsule endoscopy (CCE) may be options. However, BE and CTC are limited by the need for subsequent investigations whenever suspicious lesions are found. In this narrative review, we discussed the current clinical applications of RC, CTC, and CCE, as well as the advantages and disadvantages of different endoscopic procedures, with a particular focus on RC.
Collapse
Affiliation(s)
- Emanuele Tumino
- Endoscopy Unit, Azienda Ospedaliero Universitaria Pisana, 56125 Pisa, Italy
| | - Pierfrancesco Visaggi
- Endoscopy Unit, Azienda Ospedaliero Universitaria Pisana, 56125 Pisa, Italy
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56100 Pisa, Italy
| | - Valeria Bolognesi
- Endoscopy Unit, Azienda Ospedaliero Universitaria Pisana, 56125 Pisa, Italy
| | - Linda Ceccarelli
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56100 Pisa, Italy
| | - Christian Lambiase
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56100 Pisa, Italy
| | - Sergio Coda
- Digestive Disease Centre, Division of Surgery, Barking, Havering and Redbridge University Hospitals NHS Trust, Romford RM70AG, UK
| | - Purushothaman Premchand
- Digestive Disease Centre, Division of Surgery, Barking, Havering and Redbridge University Hospitals NHS Trust, Romford RM70AG, UK
| | - Massimo Bellini
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56100 Pisa, Italy
| | - Nicola de Bortoli
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56100 Pisa, Italy
| | - Emanuele Marciano
- Endoscopy Unit, Azienda Ospedaliero Universitaria Pisana, 56125 Pisa, Italy
| |
Collapse
|
9
|
Ayuse T, Kurata S, Mori T, Kuroda S, Ichinomiya T, Yano R, Mishima G, Ozawa E, Tatkov S, Sato S, Kazuhiko N, Hara T. Examination of stabilization of sedation by Nasal High Flow in patients with endoscopic retrograde cholangiopancreatography during sedation using Dexmedetomidine. Medicine (Baltimore) 2023; 102:e34004. [PMID: 37335651 DOI: 10.1097/md.0000000000034004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2023] Open
Abstract
INTRODUCTION Dexmedetomidine is used for the sedation method in the case of endoscopic retrograde cholangiopancreatography (ERCP) for the purpose of relieving patient anxiety. It has been reported that CO2 accumulated during sedation causes an arousal reaction, so how to normalize CO2 during sedation can be improved by administration of the minimum necessary sedative.Nasal High Flow oxygen therapy (NHF) uses a mild positive pressure load that improves carbon dioxide washout and reduces rebreathing to improve respiratory function and therefore is widely used to prevent hypoxemia and hypercapnia. In this study, we will investigate whether the upper airway patency would be maintained and the hypercapnia and hypoxemia during sedation would be prevented, by applying NHF as a respiratory management method to patients undergoing ERCP under sedation. METHODS/DESIGN In a randomized comparative study of 2 groups, the NHF device use group and the nasal cannula use group, for adult patients who visited the Nagasaki University Hospital and underwent ERCP examination under sedation. For sedation, Dexmedetomidine will be used in combination with and Midazolam and evaluation by anesthesiologist. In addition, as an analgesic, pethidine hydrochloride was administered intravenously. The total dose of the analgesic pethidine hydrochloride used in combination is used as the primary endpoint. As a secondary evaluation item, the percutaneous CO2 concentration is evaluated with a TCO2 monitor to examine whether it is effective in preventing hypercapnia. Furthermore, we will evaluate the incidence of hypoxemia with a percutaneous oxygen saturation value of 90% or less, and examine whether the use of equipment is effective in preventing the occurrence of hypercapnia and hypoxemia. DISCUSSION The purpose of this study was to obtain evidence for the utility of NHF as a potential therapeutic device for patients undergoing an ERCP under sedation, assessed by determining if the incidence rates of hypercapnia and hypoxemia decreased in the NHF device group, compared to the control group that did not use of this device.
Collapse
Affiliation(s)
- Takao Ayuse
- Division of Clinical Physiology, Department of Translational Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Shinji Kurata
- Division of Clinical Physiology, Department of Translational Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Tomotaka Mori
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Shohei Kuroda
- Nagasaki University Hospital, Clinical Research Center, Nagasaki, Japan
| | - Taiga Ichinomiya
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Rintaro Yano
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Gaku Mishima
- Department of Dental Anesthesiology, Nagasaki University Hospital, Nagasaki, Japan
| | - Eisuke Ozawa
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | | | - Shuntaro Sato
- Nagasaki University Hospital, Clinical Research Center, Nagasaki, Japan
| | - Nakao Kazuhiko
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Tetsuya Hara
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| |
Collapse
|
10
|
Sawase H, Ozawa E, Yano H, Ichinomiya T, Yano R, Miyaaki H, Komatsu N, Ayuse T, Kurata S, Sato S, Pinkham MI, Tatkov S, Ashizawa K, Nagata K, Nakao K. Respiratory support with nasal high flow without supplemental oxygen in patients undergoing endoscopic retrograde cholangiopancreatography under moderate sedation: a prospective, randomized, single-center clinical trial. BMC Anesthesiol 2023; 23:156. [PMID: 37158818 PMCID: PMC10165286 DOI: 10.1186/s12871-023-02125-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 05/04/2023] [Indexed: 05/10/2023] Open
Abstract
BACKGROUND Nasal high flow (NHF) may reduce hypoxia and hypercapnia during an endoscopic retrograde cholangiopancreatography (ERCP) procedure under sedation. The authors tested a hypothesis that NHF with room air during ERCP may prevent intraoperative hypercapnia and hypoxemia. METHODS In the prospective, open-label, single-center, clinical trial, 75 patients undergoing ERCP performed with moderate sedation were randomized to receive NHF with room air (40 to 60 L/min, n = 37) or low-flow O2 via a nasal cannula (1 to 2 L/min, n = 38) during the procedure. Transcutaneous CO2, peripheral arterial O2 saturation, a dose of administered sedative and analgesics were measured. RESULTS The primary outcome was the incidence of marked hypercapnia during an ERCP procedure under sedation observed in 1 patient (2.7%) in the NHF group and in 7 patients (18.4%) in the LFO group; statistical significance was found in the risk difference (-15.7%, 95% CI -29.1 - -2.4, p = 0.021) but not in the risk ratio (0.15, 95% CI 0.02 - 1.13, p = 0.066). In secondary outcome analysis, the mean time-weighted total PtcCO2 was 47.2 mmHg in the NHF group and 48.2 mmHg in the LFO group, with no significant difference (-0.97, 95% CI -3.35 - 1.41, p = 0.421). The duration of hypercapnia did not differ markedly between the two groups either [median (range) in the NHF group: 7 (0 - 99); median (range) in the LFO group: 14.5 (0 - 206); p = 0.313] and the occurrence of hypoxemia during an ERCP procedure under sedation was observed in 3 patients (8.1%) in the NHF group and 2 patients (5.3%) in the LFO group, with no significant difference (p = 0.674). CONCLUSIONS Respiratory support by NHF with room air did not reduce marked hypercapnia during ERCP under sedation relative to LFO. There was no significant difference in the occurrence of hypoxemia between the groups that may indicate an improvement of gas exchanges by NHF. TRIAL REGISTRATION jRCTs072190021 . The full date of first registration on jRCT: August 26, 2019.
Collapse
Affiliation(s)
- Hironori Sawase
- Department of Clinical Oncology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki-Shi, Nagasaki, 852-8501, Japan
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki-Shi, Nagasaki, 852-8501, Japan
- Department of Internal Medicine, National Hospital Organization Saga Hospital, 1-20-1 Hinode, Saga-Shi, Saga, 849-8577, Japan
| | - Eisuke Ozawa
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki-Shi, Nagasaki, 852-8501, Japan
| | - Hiroshi Yano
- Clinical Research Center, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki-Shi, Nagasaki, 852-8501, Japan
| | - Taiga Ichinomiya
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki-Shi, Nagasaki, 852-8501, Japan
| | - Rintaro Yano
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki-Shi, Nagasaki, 852-8501, Japan
| | - Hisamitsu Miyaaki
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki-Shi, Nagasaki, 852-8501, Japan
| | - Naohiro Komatsu
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki-Shi, Nagasaki, 852-8501, Japan
- Department of Gastroenterology, Japan Community Healthcare Organization Isahaya General Hospital, 24-1 Eishohigashi-Machi, Isahaya-Shi, Nagasaki, 854-8501, Japan
| | - Takao Ayuse
- Department of Translational Medical Sciences, Division of Clinical Physiology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki-Shi, Nagasaki, 852-8501, Japan.
| | - Shinji Kurata
- Department of Translational Medical Sciences, Division of Clinical Physiology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki-Shi, Nagasaki, 852-8501, Japan
| | - Shuntaro Sato
- Clinical Research Center, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki-Shi, Nagasaki, 852-8501, Japan
| | | | - Stanislav Tatkov
- Fisher & Paykel Healthcare Ltd, 15 Maurice Paykel Place, East Tamaki, Auckland, 2013, New Zealand
| | - Kazuto Ashizawa
- Department of Clinical Oncology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki-Shi, Nagasaki, 852-8501, Japan
| | - Kazuyoshi Nagata
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki-Shi, Nagasaki, 852-8501, Japan
| | - Kazuhiko Nakao
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki-Shi, Nagasaki, 852-8501, Japan
| |
Collapse
|
11
|
Murate K, Nakamura M, Yamamura T, Maeda K, Sawada T, Ishikawa E, Kida Y, Esaki M, Hamazaki M, Iida T, Mizutani Y, Yamao K, Ishikawa T, Furukawa K, Ohno E, Honda T, Ishigami M, Kinoshita F, Ando M, Kawashima H. CO 2 enterography in endoscopic retrograde cholangiography using double-balloon endoscopy: A randomized clinical trial. J Gastroenterol Hepatol 2023; 38:761-767. [PMID: 36648892 DOI: 10.1111/jgh.16112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 12/22/2022] [Accepted: 01/14/2023] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND AIM Double-balloon endoscopic retrograde cholangiography (DBERC) is a valuable procedure for patients with altered gastrointestinal anatomy. Nonetheless, it is time-consuming and burdensome for both patients and endoscopists, partly because route selection in the reconstructed bowel with complicating loop is challenging. Carbon dioxide insufflation enterography is reportedly useful for route selection in the blind loop. This prospective randomized clinical trial investigated the usefulness of carbon dioxide insufflation enterography for route selection by comparing it with conventional observation. METHODS Patients scheduled to undergo DBERC were consecutively registered. They were divided into carbon dioxide insufflation enterography and conventional groups via randomization according to stratification factors, type of reconstruction methods, and experience with DBERC. The primary endpoint was the correct rate of initial route selection. The secondary endpoints were the insertion time, examination time, amount of anesthesia drugs, and complications. RESULTS The correct rate of route selection was significantly higher in the carbon dioxide insufflation enterography group (23/25, 92%) than in the visual method (15/25, 60%) (P = 0.018). The insertion time was significantly shorter in the carbon dioxide insufflation enterography group than in the visual group (10.8 ± 11.1 min vs 29.8 ± 15.7 min; P < 0.001). No significant differences in complications were noted between the two groups. The amounts of sedatives and analgesics used were significantly lower in the carbon dioxide insufflation enterography group (P < 0.001 and P < 0.001, respectively). CONCLUSIONS Carbon dioxide insufflation enterography can reduce the burden of DBERC on patients and endoscopists by shortening the examination time and reducing the amount of medication.
Collapse
Affiliation(s)
- Kentaro Murate
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masanao Nakamura
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takeshi Yamamura
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Keiko Maeda
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tsunaki Sawada
- Department of Endoscopy, Nagoya University Hospital, Nagoya, Japan
| | - Eri Ishikawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yuichi Kida
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masaya Esaki
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Motonobu Hamazaki
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tadashi Iida
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yasuyuki Mizutani
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kentaro Yamao
- Department of Endoscopy, Nagoya University Hospital, Nagoya, Japan
| | - Takuya Ishikawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuhiro Furukawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Eizaburo Ohno
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan.,Department of Gastroenterology and Hepatology, Fujita Health University, Toyoake, Japan
| | - Takashi Honda
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masatoshi Ishigami
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Fumie Kinoshita
- Center for Advanced Medical Care, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masahiko Ando
- Center for Advanced Medical Care, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroki Kawashima
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| |
Collapse
|
12
|
Randomized trial comparing general anesthesia with anesthesiologist-administered deep sedation for ERCP in average-risk patients. Gastrointest Endosc 2022; 96:983-990.e2. [PMID: 35690151 DOI: 10.1016/j.gie.2022.06.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 05/09/2022] [Accepted: 06/01/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS General anesthesia (GA) or monitored anesthesia care (MAC) is increasingly used to perform ERCP. The definitive choice between the 2 sedative types remains to be established. This study compared outcomes of GA with MAC in ERCP performed in patients at average risk for sedation-related adverse events (SRAEs). METHODS At a tertiary referral center, patients with American Society of Anesthesiologists (ASA) class ≤III were randomly assigned to undergo ERCP with MAC or GA. The main outcome was a composite of hypotension, arrhythmia, hypoxia, hypercapnia, apnea, and procedural interruption or termination defined as SRAEs. In addition, ERCP procedural time, success, adverse events, and endoscopist and patient satisfaction were compared. RESULTS Of 204 randomized, 203 patients were evaluated for SRAEs (MAC, n = 96; GA, n = 107). SRAEs developed in 35% of the MAC cohort (34/96) versus 9% in the GA cohort (10/107), which was statistically significant (P < .001). Mean induction time for GA was significantly longer than that for MAC (10.3 ± 10 minutes vs 6.5 ± 10.8 minutes, respectively; P < .001). ERCP procedure time, recovery time, cannulation time and success, and procedure-related adverse events were not statistically different between the 2 sedative groups. The use of GA improved endoscopist and patient satisfaction (P < .001). CONCLUSION GA is safe with fewer SRAEs than MAC in patients with ASA scores ≤III undergoing ERCP. Apart from prolonging induction time, use of GA does not change the procedural success or ERCP-related adverse events and offers greater endoscopist and patient satisfaction. Hence, GA is a consideration in patients undergoing ERCP in this population group. (Clinical trial registration number: NCT04099693.).
Collapse
|
13
|
Hamada Y, Horiki N, Nakagawa H. Carbon dioxide narcosis after an endoscopic procedure in a patient with obstructive sleep apnoea syndrome. QJM 2022; 115:765-766. [PMID: 35788406 DOI: 10.1093/qjmed/hcac163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Indexed: 11/14/2022] Open
Affiliation(s)
- Y Hamada
- From the Department of Gastroenterology and Hepatology, Mie University Hospital, 2-174 Edobashi, Tsu, Mie 514-8507, Japan
| | - N Horiki
- From the Department of Gastroenterology and Hepatology, Mie University Hospital, 2-174 Edobashi, Tsu, Mie 514-8507, Japan
| | - H Nakagawa
- From the Department of Gastroenterology and Hepatology, Mie University Hospital, 2-174 Edobashi, Tsu, Mie 514-8507, Japan
| |
Collapse
|
14
|
Tang L, Ye C, Wang N, Chen C, Chen S, Gao S, Liu X. The median effective doses of propofol combined with two different doses of nalbuphine for adult patients during painless gastroscopy. Front Pharmacol 2022; 13:1014486. [PMID: 36204238 PMCID: PMC9531776 DOI: 10.3389/fphar.2022.1014486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 09/06/2022] [Indexed: 12/02/2022] Open
Abstract
Objective: Propofol is the most widely administered intravenous anesthetic to induce deep sedation for gastroscopy procedures. Coadministration of nalbuphine can provide analgesia and sedation to patients experiencing visceral pain, thereby decreasing the amount of propofol needed and reducing the risk of propofol-induced adverse events. We carried out this study to determine the median effective dose (ED50) of propofol in combination with different dosages of nalbuphine and the optimal dosage of nalbuphine during painless gastroscopy. Methods: We recruited sixty-five patients aged 18–60 years who underwent elective painless gastroscopy. A total of sixty-one patients were allocated randomly to the N1 group (nalbuphine 0.1 mg/kg) or N2 group (nalbuphine 0.15 mg/kg). Three minutes after administration of nalbuphine, patients received a preset dose of propofol at 2.0 mg/kg with a dose gradient of 0.2 mg/kg according to Dixon’s “up-and-down” method. The primary outcome was the ED50 of propofol in combination with nalbuphine. Hemodynamic parameters, recovery time, pain score, and adverse events were recorded as secondary outcomes. Results: The ED50 of propofol in the N2 group was significantly lower than that observed in the N1 group (p < 0.01). Using probit analysis, the ED50 and ED95 of propofol were 1.632 mg/kg and 2.759 mg/kg in the N1 group and 1.111 mg/kg and 2.243 mg/kg in the N2 group, respectively. The incidence of hypotension in the N2 group was lower than that in the N1 group (p < 0.05), and the recovery time was shorter than that of the N1 group (p < 0.05). Conclusion: In adult patients, 0.15 mg/kg nalbuphine led to a significant reduction in the ED50 and ED95 of propofol during gastroscopy. This dose of nalbuphine also reduced the incidence of hypotension and shortened the recovery time. Therefore, nalbuphine (0.15 mg/kg) combined with propofol is a safe option for enhancing recovery after painless gastroscopy in adult patients. Clinical Trial Registration: [https://www.chictr.org.cn/edit.aspx?pid=126699&htm=4], identifier [ChiCTR2100053204].
Collapse
Affiliation(s)
- Lili Tang
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Chenxuan Ye
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Nan Wang
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Chen Chen
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Sirui Chen
- Department of Biomedical Engineering, City University of Hong Kong, Kowloon Tong, Hong Kong SAR, China
| | - Shan Gao
- Department of Pharmacology, Basic Medical College, Anhui Medical University, Hefei, China
| | - Xuesheng Liu
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
- *Correspondence: Xuesheng Liu,
| |
Collapse
|
15
|
Nakano M, Torisu Y, Nakagawa C, Ueda K, Kanai T, Saeki C, Oikawa T, Saruta M. Safety and efficacy of pentazocine–midazolam combination for pain and anxiety relief in radiofrequency ablation therapy for hepatocellular carcinoma. JGH Open 2022; 6:569-576. [PMID: 35928702 PMCID: PMC9344584 DOI: 10.1002/jgh3.12788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 06/20/2022] [Accepted: 06/23/2022] [Indexed: 12/24/2022]
Abstract
Background and Aim Radiofrequency ablation (RFA) therapy is frequently used as first‐line treatment for small hepatocellular carcinoma (HCC). RFA is often associated with pain; however, no definitive solution has been established for its relief. We retrospectively analyzed the safety and efficacy of the combination of pentazocine and midazolam to relieve pain experienced by HCC patients undergoing RFA. Methods We studied 77 patients with 98 HCCs treated with RFA between January 2015 and August 2019. Patients were divided into two groups: the sedative‐free group, which included those who received pentazocine alone, and the pentazocine–midazolam group, which included those who received a combination of pentazocine and midazolam. The degrees of analgesia and sedation were evaluated using the numerical rating scale (NRS) and the Richmond Agitation‐Sedation Scale (RASS), respectively. Other parameters such as treatment time, awakening time, midazolam dosage, vital signs, local recurrence rate, and time to recurrence were also examined. Results The median NRS score and RASS score were significantly lower in the pentazocine–midazolam group. Ninety‐five percent of patients in the pentazocine–midazolam group had no memory of the RFA session. The treatment time and awakening time were prolonged for the pentazocine–midazolam group. No significant differences in oxygen saturation, recurrence rates, and time to local recurrence were observed between groups. Conclusion A combination of pentazocine and midazolam is safe and effective for pain and anxiety relief experienced by patients undergoing RFA for local treatment of HCC.
Collapse
Affiliation(s)
- Masanori Nakano
- Division of Gastroenterology and Hepatology, Department of Internal Medicine The Jikei University School of Medicine Tokyo Japan
| | - Yuichi Torisu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine The Jikei University School of Medicine Tokyo Japan
| | - Chika Nakagawa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine The Jikei University School of Medicine Tokyo Japan
| | - Kaoru Ueda
- Division of Gastroenterology and Hepatology, Department of Internal Medicine The Jikei University School of Medicine Tokyo Japan
| | - Tomoya Kanai
- Division of Gastroenterology, Department of Internal Medicine Fuji City General Hospital Shizuoka Japan
| | - Chisato Saeki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine The Jikei University School of Medicine Tokyo Japan
| | - Tsunekazu Oikawa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine The Jikei University School of Medicine Tokyo Japan
| | - Masayuki Saruta
- Division of Gastroenterology and Hepatology, Department of Internal Medicine The Jikei University School of Medicine Tokyo Japan
| |
Collapse
|
16
|
Comparison of high flow nasal oxygen and conventional nasal cannula during gastrointestinal endoscopic sedation in the prone position: a randomized trial. Can J Anaesth 2021; 68:460-466. [DOI: 10.1007/s12630-020-01883-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 06/03/2020] [Accepted: 06/28/2020] [Indexed: 12/15/2022] Open
|
17
|
Gotoda T, Akamatsu T, Abe S, Shimatani M, Nakai Y, Hatta W, Hosoe N, Miura Y, Miyahara R, Yamaguchi D, Yoshida N, Kawaguchi Y, Fukuda S, Isomoto H, Irisawa A, Iwao Y, Uraoka T, Yokota M, Nakayama T, Fujimoto K, Inoue H. Guidelines for sedation in gastroenterological endoscopy (second edition). Dig Endosc 2021; 33:21-53. [PMID: 33124106 DOI: 10.1111/den.13882] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 10/12/2020] [Accepted: 10/21/2020] [Indexed: 12/14/2022]
Abstract
Sedation in gastroenterological endoscopy has become an important medical option in routine clinical care. Here, the Japan Gastroenterological Endoscopy Society and the Japanese Society of Anesthesiologists together provide the revised "Guidelines for sedation in gastroenterological endoscopy" as a second edition to address on-site clinical questions and issues raised for safe examination and treatment using sedated endoscopy. Twenty clinical questions were determined and the strength of recommendation and evidence quality (strength) were expressed according to the "MINDS Manual for Guideline Development 2017." We were able to release up-to-date statements related to clinical questions and current issues relevant to sedation in gastroenterological endoscopy (henceforth, "endoscopy"). There are few reports from Japan in this field (e.g., meta-analyses), and many aspects have been based only on a specialist consensus. In the current scenario, benzodiazepine drugs primarily used for sedation during gastroenterological endoscopy are not approved by national health insurance in Japan, and investigations regarding expense-related disadvantages have not been conducted. Furthermore, including the perspective of beneficiaries (i.e., patients and citizens) during the creation of clinical guidelines should be considered. These guidelines are standardized based on up-to-date evidence quality (strength) and supports on-site clinical decision-making by patients and medical staff. Therefore, these guidelines need to be flexible with regard to the wishes, age, complications, and social conditions of the patient, as well as the conditions of the facility and discretion of the physician.
Collapse
Affiliation(s)
- Takuji Gotoda
- Japanese Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Takuji Akamatsu
- Japanese Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Seiichiro Abe
- Japanese Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Yousuke Nakai
- Japanese Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Waku Hatta
- Japanese Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Naoki Hosoe
- Japanese Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Yoshimasa Miura
- Japanese Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Ryoji Miyahara
- Japanese Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Naohisa Yoshida
- Japanese Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Shinsaku Fukuda
- Japanese Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Hajime Isomoto
- Japanese Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Atsushi Irisawa
- Japanese Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Yasushi Iwao
- Japanese Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Toshio Uraoka
- Japanese Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Takeo Nakayama
- Department of Health Informatics, Kyoto University School of Public Health, Kyoto, Japan
| | - Kazuma Fujimoto
- Japanese Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Haruhiro Inoue
- Japanese Gastroenterological Endoscopy Society, Tokyo, Japan
| |
Collapse
|
18
|
Ayuse T, Sawase H, Ozawa E, Nagata K, Komatsu N, Sanuki T, Kurata S, Mishima G, Hosogaya N, Nakashima S, Pinkham M, Tatkov S, Kazuhiko N. Study on prevention of hypercapnia by nasal high flow in patients undergoing endoscopic retrograde cholangiopancreatography during intravenous anesthesia. Medicine (Baltimore) 2020; 99:e20036. [PMID: 32384464 PMCID: PMC7220513 DOI: 10.1097/md.0000000000020036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND For relatively invasive upper gastrointestinal endoscopy procedures, such as an endoscopic retrograde cholangiopancreatography (ERCP), and also lower gastrointestinal endoscopy procedures, intravenous anesthesia is routinely used to reduce patient anxiety. However, with the use of intravenous anesthesia, even at mild to moderate depth of anesthesia, there is always a risk of upper airway obstruction due to a relaxation of the upper airway muscles.With the advent of nasal high flow (NHF) devices that allow humidified high flow air through the nasal cavity, can be used as a respiratory management method in the context of anesthesia. AIRVO is commonly used for patients with obstructive sleep apnea and other respiratory disorders. This device uses a mild positive pressure load (several cmH2O) that improves carbon dioxide (CO2) washout and reduces rebreathing to improve respiratory function and therefore is widely used to prevent hypoxemia and hypercapnia.This study aims to maintain upper airway patency by applying NHF with air (AIRVO) as a respiratory management method during intravenous anesthesia for patients undergoing an ERCP. In addition, this study investigates whether the use of an NHF device in this context can prevent intraoperative hypercapnia and hypoxemia. METHODS/DESIGN This study design employed 2 groups of subjects. Both received intravenous anesthesia while undergoing an ERCP, and 1 group also used a concurrent nasal cannula NHF device. Here we examine if the use of an NHF device during intravenous anesthesia can prevent hypoxemia and hypercapnia, which could translate to improved anesthesia management.Efficacy endpoints were assessed using a transcutaneous CO2 monitor (TCM). This device measured the changes in CO2 concentration during treatment. Transcutaneous CO2 (PtcCO2) concentrations of 60 mm Hg or more (PaCO2 > 55 mm Hg) were considered marked hypercapnia. PtcCO2 concentrations of 50 to 60 mm Hg or more (equivalent to PaCO2 > 45 mm Hg) were considered moderate hypercapnia.Furthermore, the incidence of hypoxemia with a transcutaneous oxygen saturation value of 90% or less, and whether the use of NHF was effective in preventing this adverse clinical event were evaluated. DISCUSSION The purpose of this study was to obtain evidence for the utility of NHF as a potential therapeutic device for patients undergoing an ERCP under sedation, assessed by determining if the incidence rates of hypercapnia and hypoxemia decreased in the NHF device group, compared to the control group that did not use this device. TRIAL REGISTRATION The study was registered in the jRCTs 072190021.URL https://jrct.niph.go.jp/en-latest-detail/jRCTs072190021.
Collapse
Affiliation(s)
- Takao Ayuse
- Division of Clinical Physiology, Department of Translational Medical Sciences
| | - Hironori Sawase
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences
| | - Eisuke Ozawa
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences
| | - Kazuyoshi Nagata
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences
| | - Naohiro Komatsu
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences
| | - Takuro Sanuki
- Division of Clinical Physiology, Department of Translational Medical Sciences
| | - Shinji Kurata
- Department of Dental Anesthesiology, Nagasaki University Hospital
| | - Gaku Mishima
- Department of Dental Anesthesiology, Nagasaki University Hospital
| | - Naoki Hosogaya
- Nagasaki University Hospital, Clinical Research Center, Nagasaki, Japan
| | - Sawako Nakashima
- Nagasaki University Hospital, Clinical Research Center, Nagasaki, Japan
| | - Max Pinkham
- Fisher & Paykel Healthcare Ltd, Auckland, New Zealand
| | | | - Nakao Kazuhiko
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences
| |
Collapse
|
19
|
Ayuse T, Yamguchi N, Hashiguchi K, Sanuki T, Mishima G, Kurata S, Hosogaya N, Nakashima S, Pinkham M, Tatkov S, Nakao K. Study on prevention of hypercapnia by Nasal High Flow in patients with endoscopic submucosal dissection during intravenous anesthesia. Medicine (Baltimore) 2020; 99:e20038. [PMID: 32384465 PMCID: PMC7220533 DOI: 10.1097/md.0000000000020038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND For relatively invasive upper gastrointestinal endoscopy procedures, such as an endoscopic submucosal dissection (ESD), intravenous anesthesia is routinely used to reduce patient anxiety. However, with the use of intravenous sedation, even at mild to moderate depth of anesthesia, there is always a risk of upper airway obstruction due to a relaxation of the upper airway muscles.With the advent of Nasal High Flow (NHF) devices that allow humidified high flow air through the nasal cavity, can be used as a respiratory management method in the context of anesthesia. AIRVO is commonly used for patients with obstructive sleep apnea and other respiratory disorders. This device uses a mild positive pressure load (several cmH2O) that improves carbon dioxide (CO2) washout and reduces rebreathing to improve respiratory function and therefore is widely used to prevent hypoxemia and hypercapnia.This study aims to maintain upper airway patency by applying NHF with air (AIRVO) as a respiratory management method during intravenous anesthesia for patients undergoing an ESD. In addition, this study investigates whether the use of an NHF device in this context can prevent intraoperative hypercapnia and hypoxemia. METHODS/DESIGN This study design employed 2 groups of subjects. Both received intravenous anesthesia while undergoing an ESD, and 1 group also used a concurrent nasal cannula NHF device. Here we examine if the use of an NHF device during intravenous anesthesia can prevent hypoxemia and hypercapnia, which could translate to improved anesthesia management.Efficacy endpoints were assessed using a transcutaneous CO2 monitor. This device measured the changes in CO2 concentration during treatment. Transcutaneous CO2 (PtcCO2) concentrations of 60 mmHg or more (PaCO2 > 55 mmHg) were considered marked hypercapnia. PtcCO2 concentrations of 50 to 60 mmHg or more (equivalent to PaCO2 > 45 mmHg) were considered moderate hypercapnia.Furthermore, the incidence of hypoxemia with a transcutaneous oxygen saturation value of 90% or less, and whether the use of NHF was effective in preventing this adverse clinical event were evaluated. DISCUSSION The purpose of this study was to obtain evidence for the utility of NHF as a potential therapeutic device for patients undergoing an ESD under anesthesia, assessed by determining if the incidence rates of hypercapnia and hypoxemia decreased in the NHF device group, compared to the control group that did not use of this device. TRIAL REGISTRATION The study was registered the jRCTs 072190022.URL https://jrct.niph.go.jp/en-latest-detail/jRCTs072190022.
Collapse
Affiliation(s)
- Takao Ayuse
- Division of Clinical Physiology, Department of Translational Medical Sciences
| | - Naoyuki Yamguchi
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences
| | - Keiichi Hashiguchi
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences
| | - Takuro Sanuki
- Division of Clinical Physiology, Department of Translational Medical Sciences
| | - Gaku Mishima
- Department of Dental Anesthesiology, Nagasaki University Hospital
| | - Shinji Kurata
- Department of Dental Anesthesiology, Nagasaki University Hospital
| | - Naoki Hosogaya
- Nagasaki University Hospital, Clinical Research Center, Nagasaki, Japan
| | - Sawako Nakashima
- Nagasaki University Hospital, Clinical Research Center, Nagasaki, Japan
| | - Max Pinkham
- Fisher & Paykel Healthcare Ltd, Auckland, New Zealand
| | | | - Kazuhiko Nakao
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences
| |
Collapse
|
20
|
Ikeda Y, Yoshida M, Ishikawa K, Kubo T, Murase K, Takada K, Miyanishi K, Kobune M, Kato J. Efficacy of combination therapy with dexmedetomidine for benzodiazepines-induced disinhibition during endoscopic retrograde cholangiopancreatography. Therap Adv Gastroenterol 2020; 13:1756284820911822. [PMID: 32523618 PMCID: PMC7236568 DOI: 10.1177/1756284820911822] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 02/13/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Benzodiazepines (BZDs) and analgesics are widely used for conscious sedation during endoscopic ultrasound (EUS) or endoscopic retrograde cholangiopancreatography (ERCP). However, endoscopic procedures are sometimes discontinued because of BZD-induced disinhibitory reactions such as excessive movement. We evaluated the usefulness of dexmedetomidine (DEX) for BZD-induced disinhibition in ERCP. METHODS Between February 2018 and August 2019, 22 patients who underwent EUS or ERCP were enrolled. All patients showed BZD-induced excessive movement at the first examination (BZD group) and received DEX at the second examination (DEX group). The initial DEX dose was 6 μg/kg/h for a 10-min loading, followed by 0.4 μg/kg/h during the procedure. BZDs and analgesics were administered before scope insertion. An additional sedative was administered to achieve a Ramsay sedation scale (RSS) of 4-5. Sedative effect, procedure completion rate, and changes in circulatory and respiratory dynamics were evaluated. RESULTS Mean RSS scores were significantly higher (p < 0.001) in the DEX (5.1 ± 0.5) compared with the BZD (4.0 ± 0.5) group. The movement score (p < 0.001) and number of additional sedatives required (p < 0.01) were lower in the DEX group. The procedure completion rate was significantly higher in the DEX (95.5%) compared with the BZD group (63.6%; p < 0.05). Significant differences in the frequency of hypotension (p = 1.00), bradycardia (p = 0.22), and respiratory depression (p = 0.68) were not noted between groups. CONCLUSIONS The addition of DEX to BZD therapy yielded better sedative efficacy, lower excessive movement, a reduction in BZDs used, and a higher procedure complete rate. DEX may be used as an alternative method for BZD-induced inhibition during ERCP.
Collapse
Affiliation(s)
- Yuki Ikeda
- Department of Medical Oncology, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Makoto Yoshida
- Department of Medical Oncology, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Kazuma Ishikawa
- Department of Medical Oncology, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Tomohiro Kubo
- Department of Medical Oncology, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Kazuyuki Murase
- Department of Medical Oncology, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Kohichi Takada
- Department of Medical Oncology, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Koji Miyanishi
- Department of Medical Oncology, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Masayoshi Kobune
- Department of Hematology, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | | |
Collapse
|
21
|
Ichijima R, Esaki M, Suzuki S, Kusano C, Ikehara H, Gotoda T. Effectiveness and safety of sedation in gastrointestinal endoscopy: An opinion review. World J Meta-Anal 2020; 8:48-53. [DOI: 10.13105/wjma.v8.i2.48] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Revised: 03/04/2020] [Accepted: 03/19/2020] [Indexed: 02/06/2023] Open
Abstract
Although endoscopy is a less invasive procedure than surgery, patients can experience pain without sedation. Patients expect reduced pain during endoscopies from effective and safe sedatives. Midazolam and propofol are used for endoscopic sedation in many countries and regions. Midazolam is a widely available benzodiazepine, and many clinical trials have shown it to be an effective sedative. However, patients who are sedated with midazolam require rest in the recovery room due to its relatively long half-life, and an antagonist such as flumazenil may need to be administered in cases of deep or prolonged sedation. Propofol is a short-acting sedative with a short half-life and a quick recovery time. Therefore, the use of propofol has been increasing. However, propofol has a narrow margin of safety and often induces adverse effects such as respiratory depression. Also, propofol has no specific antagonist, and should be administered by an anesthesiologist or an endoscopist familiar with anesthesia. Remimazolam, which is a novel ultra-short-acting benzodiazepine, has recently gained attention. Remimazolam has a short half-life and an antagonist. Both effective and safe sedation is desired in accordance with the increasing need for sedative endoscopies. Therefore, in this review each sedative is summarized.
Collapse
Affiliation(s)
- Ryoji Ichijima
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Chiyoda-ku, Tokyo 101-8309, Japan
| | - Mitsuru Esaki
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Chiyoda-ku, Tokyo 101-8309, Japan
| | - Sho Suzuki
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Chiyoda-ku, Tokyo 101-8309, Japan
| | - Chika Kusano
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Chiyoda-ku, Tokyo 101-8309, Japan
| | - Hisatomo Ikehara
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Chiyoda-ku, Tokyo 101-8309, Japan
| | - Takuji Gotoda
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Chiyoda-ku, Tokyo 101-8309, Japan
| |
Collapse
|
22
|
Schmutz A, Loeffler T, Schmidt A, Goebel U. LMA Gastro™ airway is feasible during upper gastrointestinal interventional endoscopic procedures in high risk patients: a single-center observational study. BMC Anesthesiol 2020; 20:40. [PMID: 32035477 PMCID: PMC7007643 DOI: 10.1186/s12871-020-0938-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 01/13/2020] [Indexed: 01/16/2023] Open
Abstract
Background Nonoperating room anesthesia during gastroenterological procedures is a growing field in anesthetic practice. While the numbers of patients with severe comorbidities are rising constantly, gastrointestinal endoscopic interventions are moving closer to minimally invasive endoscopic surgery. The LMA Gastro™ is a new supraglottic airway device, developed specifically for upper gastrointestinal endoscopy and interventions. The aim of this study was to evaluate the feasibility of LMA Gastro™ in patients with ASA physical status ≥3 undergoing advanced endoscopic procedures. Methods We analyzed data from 214 patients retrospectively who received anesthesia for gastroenterological interventions. Inclusion criteria were upper gastrointestinal endoscopic interventions, airway management with LMA Gastro™ and ASA status ≥3. The primary outcome measure was successful use of LMA Gastro™ for airway management and endoscopic intervention. Results Thirtyone patients with ASA physical status ≥3, undergoing complex and prolonged upper gastrointestinal endoscopic procedures were included. There were 7 endoscopic retrograde cholangiopancreatographies, 7 peroral endoscopic myotomies, 5 percutaneous endoscopic gastrostomies and 12 other complex procedures (e.g. endoscopic submucosal dissection, esophageal stent placement etc.). Of these, 27 patients were managed successfully using the LMA Gastro™. Placement of the LMA Gastro™ was reported as easy. Positive pressure ventilation was performed without difficulty. The feasibility of the LMA Gastro™ for endoscopic intervention was rated excellent by the endoscopists. In four patients, placement or ventilation with LMA Gastro™ was not possible. Conclusions We demonstrated the feasibility of the LMA Gastro™ during general anesthesia for advanced endoscopic procedures in high-risk patients. Trial registration German Clinical Trials Register (DRKS00017396) Date of registration: 23rd May 2019, retrospectively registered.
Collapse
Affiliation(s)
- Axel Schmutz
- Department of Anesthesiology and Critical Care, Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg im Breisgau, Germany.
| | - Thomas Loeffler
- Department of Anesthesiology and Critical Care, Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg im Breisgau, Germany
| | - Arthur Schmidt
- Department of Medicine II, Faculty of Medicine, Medical Center - University of Freiburg University of Freiburg, Hugstetter Strasse 55, Freiburg im Breisgau, 79106, Germany
| | - Ulrich Goebel
- Department of Anesthesiology and Critical Care, Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg im Breisgau, Germany
| |
Collapse
|
23
|
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.
Collapse
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
| |
Collapse
|
24
|
Cabadas Avión R, Baluja A, Ojea Cendón M, Leal Ruiloba MS, Vázquez López S, Rey Martínez M, Magdalena López P, Álvarez-Escudero J. Effectiveness and safety of gastrointestinal endoscopy during a specific sedation training program for non-anesthesiologists. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2018; 111:199-208. [PMID: 30507244 DOI: 10.17235/reed.2018.5713/2018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION sedation is a key component for the improvement of sedation quality. A correct administration requires appropriate training. We performed a study to compare sedation effectiveness, safety and patient satisfaction when administered by gastroenterologists, with and without specific training. METHODS a training program enrolled a group of gastroenterologists (trained group, n = 4) and their results were compared to those from a non-trained group (n = 3). ASA 1-3 patients who had undergone sedation by a gastroenterologist using midazolam and fentanyl were included over a period of 30 months. Safety was assessed in terms of the complication rate, effectiveness was assessed via the rate of completed endoscopic procedures and patient satisfaction was evaluated via a phone interview the day after the procedure. RESULTS a total of 3,475 patients were sedated by gastroenterologists during the study period. Significant differences were found that favored the trained group for completed procedures (5.6% vs 8.9%). A lower rate of excessive sedation (1.3% vs 8.61%), hypoxemia (0.72% vs 2.49%) and post-procedural pain (1.8% vs 4.3%) were also achieved. Patient satisfaction surpassed 99.5% and there were no significant differences between groups. CONCLUSIONS our sedation training program improved the effectiveness and safety outcomes when compared to sedation administered by gastroenterologists without this specific training.
Collapse
Affiliation(s)
| | - Aurora Baluja
- Anestesiología, Hospital universitario Santiago Compostela, España
| | | | | | | | | | | | - Julián Álvarez-Escudero
- Anestesiología y Reanimación, Complejo Hospitalario Universitario de Santiago de Compostela. Universidad de Santiago de Compostela, España
| |
Collapse
|
25
|
Inatomi O, Imai T, Fujimoto T, Takahashi K, Yokota Y, Yamashita N, Hasegawa H, Nishida A, Bamba S, Sugimoto M, Andoh A. Dexmedetomidine is safe and reduces the additional dose of midazolam for sedation during endoscopic retrograde cholangiopancreatography in very elderly patients. BMC Gastroenterol 2018; 18:166. [PMID: 30400828 PMCID: PMC6219039 DOI: 10.1186/s12876-018-0897-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 10/24/2018] [Indexed: 12/21/2022] Open
Abstract
Background Endoscopic retrograde cholangiopancreatography (ERCP) often requires deep sedation. Dexmedetomidine, a highly selective α2-adrenoceptor agonist with sedative activity and minimal effects on respiration, has recently been widely used among patients in the intensive care unit. However, its use in endoscopic procedures in very elderly patients is unclear. In this study, we retrospectively investigated the safety and efficacy of dexmedetomidine sedation during ERCP. Methods The study included 62 very elderly patients (aged over 80 years) who underwent ERCP from January 2014, with sedation involving dexmedetomidine (i.v. infusion at 3.0 μg/kg/h over 10 min followed by continuous infusion at 0.4 μg/kg/h) along with midazolam. For comparison, the study included 78 patients who underwent ERCP before January 2014, with midazolam alone. We considered additional administration of midazolam as needed to maintain a sedation level of 3–4, according to the Ramsay sedation scale. The outcome measures were amount of midazolam, adverse events associated with sedation, and hemodynamics. Results The incidence of decreased SpO2 and median dose of additional midazolam were significantly lower in the dexmedetomidine group than in the conventional group. The minimum systolic blood pressure and minimum heart rate during and after examination was significantly lower in the dexmedetomidine group than in the conventional group. However, serious acute heart failure or arrhythmia was not noted. Conclusions Dexmedetomidine can decrease the incidence of respiratory complications and the total dose of other sedative agents. It can be used as an alternative to conventional methods with midazolam for adequate sedation during ERCP in very elderly patients.
Collapse
Affiliation(s)
- Osamu Inatomi
- Division of Gastroenterology, Department of Medicine, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu, Shiga, 520-2192, Japan.
| | - Takayuki Imai
- Division of Gastroenterology, Department of Medicine, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu, Shiga, 520-2192, Japan
| | - Takehide Fujimoto
- Division of Gastroenterology, Department of Medicine, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu, Shiga, 520-2192, Japan
| | - Kenichiro Takahashi
- Division of Gastroenterology, Department of Medicine, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu, Shiga, 520-2192, Japan
| | - Yoshihiro Yokota
- Division of Gastroenterology, Department of Medicine, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu, Shiga, 520-2192, Japan
| | - Noriaki Yamashita
- Division of Gastroenterology, Department of Medicine, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu, Shiga, 520-2192, Japan
| | - Hiroshi Hasegawa
- Division of Gastroenterology, Department of Medicine, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu, Shiga, 520-2192, Japan
| | - Atsushi Nishida
- Division of Gastroenterology, Department of Medicine, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu, Shiga, 520-2192, Japan
| | - Shigeki Bamba
- Division of Clinical Nutrition, Department of Medicine, Shiga University of Medical Science, Otsu, Japan
| | - Mitsushige Sugimoto
- Division of Digestive Endoscopy, Shiga University of Medical Science Hospital, Otsu, Japan
| | - Akira Andoh
- Division of Gastroenterology, Department of Medicine, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu, Shiga, 520-2192, Japan
| |
Collapse
|
26
|
Dobson G, Chong MA, Chow L, Flexman A, Hurdle H, Kurrek M, Laflamme C, Perrault MA, Sparrow K, Stacey S, Swart PA, Wong M. Procedural sedation: a position paper of the Canadian Anesthesiologists’ Society. Can J Anaesth 2018; 65:1372-1384. [DOI: 10.1007/s12630-018-1230-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 07/30/2018] [Indexed: 11/24/2022] Open
|
27
|
Stone AB, Brovman EY, Greenberg P, Urman RD. A medicolegal analysis of malpractice claims involving anesthesiologists in the gastrointestinal endoscopy suite (2007–2016). J Clin Anesth 2018; 48:15-20. [DOI: 10.1016/j.jclinane.2018.04.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 04/13/2018] [Accepted: 04/15/2018] [Indexed: 11/26/2022]
|
28
|
Trummel JM, Chandrasekhara V, Kochman ML. Anesthesia for Colonoscopy and Lower Endoscopic Procedures. Anesthesiol Clin 2018; 35:679-686. [PMID: 29101957 DOI: 10.1016/j.anclin.2017.08.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Demand for anesthesiologist-assisted sedation is expanding for gastrointestinal lower endoscopic procedures and may add to the cost of these procedures. Most lower endoscopy can be accomplished with either no, moderate, or deep sedation; general anesthesia and active airway management are rarely needed. Propofol-based sedation has advantages in terms of satisfaction and recovery over other modalities, but moderate sedation using benzodiazepines and opiates work well for low-risk patients and procedures. No sedation for routine colonoscopy works well for selected patients and eliminates sedation-related risks. There is no difference in outcome measures based on sedation received.
Collapse
Affiliation(s)
- John Michael Trummel
- Anesthesiology, Dartmouth Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756, USA.
| | - Vinay Chandrasekhara
- Gastroenterology Division, Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Michael L Kochman
- Gastroenterology Division, Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
| |
Collapse
|
29
|
Kim EH, Park JC, Shin SK, Lee YC, Lee SK. Effect of the midazolam added with propofol-based sedation in esophagogastroduodenoscopy: A randomized trial. J Gastroenterol Hepatol 2018; 33:894-899. [PMID: 29048708 DOI: 10.1111/jgh.14026] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Revised: 10/11/2017] [Accepted: 10/12/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM Although propofol has been widely used for sedation during esophagogastroduodenoscopy (EGD), adverse events including hypoxia and hypotension may be a concern in the propofol-based sedation. We aimed to analyze whether administration of midazolam would improve safety and efficacy of propofol-based sedation in EGD. METHODS One hundred twenty patients who were scheduled to undergo diagnostic EGD were randomly assigned to either midazolam plus propofol (MP) or propofol alone groups. In the MP group, 2 mg of midazolam and 10 mg of propofol were given initially. In the propofol alone group, 40-60 mg of propofol was given initially. In both groups, 20 mg of propofol was given repeatedly to maintain moderate sedation as needed. Vital signs including oxygen saturation were monitored every 2 min. After the patients fully recovered, satisfaction score was investigated from endoscopists, nurses, and patients, respectively. RESULTS The baseline characteristics did not differ between the MP and propofol alone groups. The mean required doses of propofol was (mean ± standard deviation) 0.3 ± 0.3 and 0.8 ± 0.2 mg/kg in the MP and propofol alone groups, respectively (P < 0.001). In addition, sedation-related adverse events and recovery time did not differ between the two groups. The proportion of satisfactory did not differ between the two groups (MP vs propofol alone; proportion; patient, 95.0% vs 93.3%, P > 0.999; endoscopist, 73.3% vs 80.0%, P = 0.064; nurse, 73.3% vs 76.7%, P = 0.551). CONCLUSION Adding midazolam to propofol did not reduced the safety and efficacy, and sedation using propofol alone could be suitable for sedation during diagnostic EGD.
Collapse
Affiliation(s)
- Eun Hye Kim
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jun Chul Park
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Kwan Shin
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Chan Lee
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Kil Lee
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| |
Collapse
|
30
|
Li S, Sheng G, Teng Y, Sun M. Systematic review of anaesthetic medication for ERCP based on a network meta-analysis. Int J Surg 2018; 51:56-62. [PMID: 29367034 DOI: 10.1016/j.ijsu.2018.01.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 11/30/2017] [Accepted: 01/02/2018] [Indexed: 12/21/2022]
Abstract
AIMS We performed a systematic review of various anaesthetic medications for endoscopic retrograde cholangiopancreatography (ERCP) and aimed to make a comprehensive comparison based on a network meta-analysis. METHODS We searched globally recognized electronic databases, including PubMed, Cochrane Central and EMBASE, to retrieve relevant randomized controlled trials (RCTs) of anaesthetic medications for ERCP. Network meta-analysis was conducted by evaluating the procedure time, adverse effects and drug requirements. The cumulative probability P value was utilized to rank the medications under examination. RESULTS Seventeen RCTs that examined 1877 patients were included in this research. Under good convergence and efficiency, data analysis was performed using a consistency model. For the comparison of procedure times, we found that a combination of dexmedetomidine and ketamine (P = 0.19) or propofol plus pethidine (P = 0.18) seemed to be the two best medications for reducing procedure time. Additionally, midazolam combined with dexmedetomidine plus pethidine seemed to be the safest application for ERCP (P = 0.36). Propofol plus alfentanil also exhibited a good safety value (P = 0.28). For evaluation of drug requirements, the whole network connection could not be established; thus, comparisons in two subgroups were conducted. The results showed that midazolam combined with dexmedetomidine plus pethidine (P = 0.41) and propofol plus refentanil (P = 0.94) were superior to others in decreasing drug requirements. CONCLUSIONS Based on the objective results and our conclusions, we deemed that a combination of midazolam and dexmedetomidine was recommended, and propofol plus opioids also revealed great clinical value. However, we are still expecting more clinical research in the future.
Collapse
Affiliation(s)
- Shuangxi Li
- Hepatobiliary and Pancreatic Surgery Three Wards, The Second Affiliated Hospital of Kunming Medical University, Kunming, 650101, Yunnan Province, PR China
| | - Guotao Sheng
- Department of General Surgery, Second People's Hospital of Bengbu City, Bengbu, 233000, Anhui Province, PR China
| | - Yishan Teng
- Hepatobiliary and Pancreatic Surgery Three Wards, The Second Affiliated Hospital of Kunming Medical University, Kunming, 650101, Yunnan Province, PR China
| | - Min Sun
- Hepatobiliary and Pancreatic Surgery Three Wards, The Second Affiliated Hospital of Kunming Medical University, Kunming, 650101, Yunnan Province, PR China.
| |
Collapse
|
31
|
Spatio-temporal dynamics of multimodal EEG-fNIRS signals in the loss and recovery of consciousness under sedation using midazolam and propofol. PLoS One 2017; 12:e0187743. [PMID: 29121108 PMCID: PMC5679575 DOI: 10.1371/journal.pone.0187743] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 10/25/2017] [Indexed: 12/29/2022] Open
Abstract
On sedation motivated by the clinical needs for safety and reliability, recent studies have attempted to identify brain-specific signatures for tracking patient transition into and out of consciousness, but the differences in neurophysiological effects between 1) the sedative types and 2) the presence/absence of surgical stimulations still remain unclear. Here we used multimodal electroencephalography–functional near-infrared spectroscopy (EEG–fNIRS) measurements to observe electrical and hemodynamic responses during sedation simultaneously. Forty healthy volunteers were instructed to push the button to administer sedatives in response to auditory stimuli every 9–11 s. To generally illustrate brain activity at repetitive transition points at the loss of consciousness (LOC) and the recovery of consciousness (ROC), patient-controlled sedation was performed using two different sedatives (midazolam (MDZ) and propofol (PPF)) under two surgical conditions. Once consciousness was lost via sedatives, we observed gradually increasing EEG power at lower frequencies (<15 Hz) and decreasing power at higher frequencies (>15 Hz), as well as spatially increased EEG powers in the delta and lower alpha bands, and particularly also in the upper alpha rhythm, at the frontal and parieto-occipital areas over time. During ROC from unconsciousness, these spatio-temporal changes were reversed. Interestingly, the level of consciousness was switched on/off at significantly higher effect-site concentrations of sedatives in the brain according to the use of surgical stimuli, but the spatio-temporal EEG patterns were similar, regardless of the sedative used. We also observed sudden phase shifts in fronto-parietal connectivity at the LOC and the ROC as critical points. fNIRS measurement also revealed mild hemodynamic fluctuations. Compared with general anesthesia, our results provide insights into critical hallmarks of sedative-induced (un)consciousness, which have similar spatio-temporal EEG-fNIRS patterns regardless of the stage and the sedative used.
Collapse
|
32
|
Wadhwa V, Issa D, Garg S, Lopez R, Sanaka MR, Vargo JJ. Similar Risk of Cardiopulmonary Adverse Events Between Propofol and Traditional Anesthesia for Gastrointestinal Endoscopy: A Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2017; 15:194-206. [PMID: 27451091 DOI: 10.1016/j.cgh.2016.07.013] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Revised: 07/02/2016] [Accepted: 07/06/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Even though propofol use for gastrointestinal endoscopic procedures has increased over the past decade, there is a perception that it causes a higher rate of cardiopulmonary adverse events. The aim of this study was to compare the sedation-related adverse events associated with use of propofol vs nonpropofol agents for endoscopic procedures. We also wanted to determine the influence of duration or complexity of the procedures and endoscopist-directed (gastroenterologist) vs non-gastroenterologist-directed sedation on the outcomes. METHODS A search was conducted using Medline, EMBASE, and the Cochrane controlled trials registry. The following cardiopulmonary adverse events were assessed: hypoxia, hypotension, and arrhythmias. The procedures were divided into 2 groups based on the procedure length: a nonadvanced endoscopic procedure group consisting of esophagogastroduodenoscopy, colonoscopy, and sigmoidoscopy, and an advanced endoscopic procedures group including endoscopic retrograde cholangiopancreatography, endoscopic ultrasonography, balloon enteroscopy, and endoscopic submucosal dissection. Pooled odds ratios for complications were calculated for all the procedures combined and then separately for the 2 groups. Random-effects models were used for 2-proportion comparisons. RESULTS Of the 2117 citations identified, 27 original studies qualified for this meta-analysis and included 2518 patients. Of these, 1324 received propofol, and 1194 received midazolam, meperidine, pethidine, remifentanil, and/or fentanyl. Most of the included studies were randomized trials of moderate quality and nonsignificant heterogeneity (Cochran Q, 26.07; P = .13). Compared with traditional sedative agents, the pooled odds ratio with the use of propofol for developing hypoxia for all the procedures combined was 0.82 (95% confidence interval [CI], 0.63-1.07), and for developing hypotension was 0.92 (95% CI, 0.64-1.32). In the nonadvanced endoscopic procedure group, those who received propofol were 39% less likely to develop complications than those receiving traditional sedative agents (odds ratio, 0.61; 95% CI, 0.38-0.99). There was no difference in the complication rate for the advanced endoscopic procedure group (odds ratio, 0.86; 95% CI, 0.56-1.34). A subgroup analysis did not show any difference in adverse events when propofol was administered by gastroenterologists or nongastroenterologists. CONCLUSIONS Propofol sedation has a similar risk of cardiopulmonary adverse events compared with traditional agents for gastrointestinal endoscopic procedures. Propofol use in simple endoscopic procedures was associated with a decreased number of complications. When used for gastrointestinal endoscopic procedures of a complex nature and longer duration, propofol was not associated with increased rates of hypoxemia, hypotension, or arrhythmias. Administration of propofol by gastroenterologists does not appear to increase the complication rates.
Collapse
Affiliation(s)
- Vaibhav Wadhwa
- Department of Internal Medicine, Fairview Hospital, Cleveland Clinic, Cleveland, Ohio
| | - Danny Issa
- Department of Gastroenterology and Hepatology, Virginia Commonwealth University, Richmond, Virginia
| | - Sushil Garg
- Department of Internal Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Rocio Lopez
- Department of Biostatistics, Cleveland Clinic, Cleveland, Ohio
| | - Madhusudhan R Sanaka
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio
| | - John J Vargo
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio.
| |
Collapse
|
33
|
Wejner-Mik P, Sobczak M, Miskowiec D, Wdowiak-Okrojek K, Kasprzak JD, Lipiec P. Feasibility and clinical benefit of cognitive-behavioral intervention for preparing patients for transesophageal echocardiography. Anatol J Cardiol 2016; 16:684-8. [PMID: 27488750 PMCID: PMC5331353 DOI: 10.5152/anatoljcardiol.2015.6514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Objective: Despite premedication, anxiety in patients undergoing transesophageal echocardiography (TEE) is prevalent, often causing adverse physiological and psychological effects and contributing to decreased patient compliance. We aimed to evaluate the feasibility of cognitive–behavioral intervention (CBI) in patients undergoing TEE and to assess its impact on the severity of anxiety, patient’s and physician’s comfort, and administered dose of sedatives. Methods: Our study was designed as a prospective, single-center, single-blinded, case-controlled pilot study. The study group comprised 49 patients (26 men, 66±8 years old) referred for TEE. Before the examination, 26 randomly selected patients underwent CBI. Sedatives were administered, if necessary. After the examination, patient anxiety and patient’s and physician’s comfort were evaluated using dedicated questionnaires and scores. Intergroup comparison was performed using Student’s t-test for independent variables and Mann–Whitney U test and Pearson’s chi-square test or Fisher’s exact test for categorical variables. Results: The mean level of pre-TEE distress and anxiety were significantly lower in patients receiving CBI than in those without intervention (p=0.022). Furthermore, the application of CBI significantly reduced patient’s discomfort (p<0.001) and resulted in increased comfort of physician (p<0.001) during TEE. The need of sedative administration (31% vs. 91%, p<0.001) and its mean dose was significantly lower in patients receiving CBI (1.6±0.5 mg vs. 2.7±1.6 mg midazolam, p=0.009). Conclusions: CBI is feasible in patients undergoing TEE. It decreases patient’s anxiety and discomfort and increases physician’s comfort. It also results in reduced use of sedatives during the examination.
Collapse
Affiliation(s)
| | - Maria Sobczak
- Department of Cardiology, Medical University of Lodz, Lodz-Poland
| | - Dawid Miskowiec
- Department of Cardiology, Medical University of Lodz, Lodz-Poland.
| | | | | | - Piotr Lipiec
- Department of Cardiology, Medical University of Lodz, Lodz-Poland
| |
Collapse
|
34
|
Applegate RL, Lenart J, Malkin M, Meineke MN, Qoshlli S, Neumann M, Jacobson JP, Kruger A, Ching J, Hassanian M, Um M. Advanced Monitoring Is Associated with Fewer Alarm Events During Planned Moderate Procedure-Related Sedation: A 2-Part Pilot Trial. Anesth Analg 2016; 122:1070-8. [PMID: 26836134 PMCID: PMC4791313 DOI: 10.1213/ane.0000000000001160] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Supplemental Digital Content is available in the text. Published ahead of print February 1, 2016 Diagnostic and interventional procedures are often facilitated by moderate procedure-related sedation. Many studies support the overall safety of this sedation; however, adverse cardiovascular and respiratory events are reported in up to 70% of these procedures, more frequently in very young, very old, or sicker patients. Monitoring with pulse oximetry may underreport hypoventilation during sedation, particularly if supplemental oxygen is provided. Capnometry may result in false alarms during sedation when patients mouth breathe or displace sampling devices. Advanced monitor use during sedation may allow event detection before complications develop. This 2-part pilot study used advanced monitors during planned moderate sedation to (1) determine incidences of desaturation, low respiratory rate, and deeper than intended sedation alarm events; and (2) determine whether advanced monitor use is associated with fewer alarm events.
Collapse
Affiliation(s)
- Richard L Applegate
- From the *Department of Anesthesiology, Loma Linda University School of Medicine, Loma Linda, California; †Department of Anesthesiology, Loma Linda University School of Medicine, Loma Linda, California; and ‡Department of Radiology, Loma Linda University School of Medicine, Loma Linda, California
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
35
|
Yamashita K, Shiwaku H, Ohmiya T, Shimaoka H, Okada H, Nakashima R, Beppu R, Kato D, Sasaki T, Hoshino S, Nimura S, Yamaura K, Yamashita Y. Efficacy and safety of endoscopic submucosal dissection under general anesthesia. World J Gastrointest Endosc 2016; 8:466-471. [PMID: 27433293 PMCID: PMC4937162 DOI: 10.4253/wjge.v8.i13.466] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Revised: 04/21/2016] [Accepted: 05/27/2016] [Indexed: 02/05/2023] Open
Abstract
AIM: To evaluate the efficacy and safety of endoscopic submucosal dissection (ESD) under general anesthesia.
METHODS: From January 2011 to July 2014, 206 consecutive patients had undergone ESD under general anesthesia for neoplasms of the stomach, esophagus, and colorectum were enrolled in this retrospective study. The efficacy and safety of ESD under general anesthesia were assessed.
RESULTS: The en bloc resection rate of esophageal, gastric, and colorectal lesions was 100.0%, 98.3%, and 96.1%, respectively. The complication rate of perforation and bleeding were 0.0% and 0.0% in esophageal ESD, 1.7% and 1.7% in gastric ESD, and 3.9% and 2.0% in colorectal ESD, respectively. No cases of aspiration pneumonia were observed. All complications were managed by conservative treatment, with no surgical intervention required.
CONCLUSION: With the cooperation of an anesthesiologist, ESD under general anesthesia appears to be a useful method, decreasing the risk of complications.
Collapse
|
36
|
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.
Collapse
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.
| |
Collapse
|
37
|
Bronchoscopist-directed Continuous Propofol Infusion for Targeting Moderate Sedation During Endobronchial Ultrasound Bronchoscopy: A Practical and Effective Protocol. J Bronchology Interv Pulmonol 2016; 22:226-36. [PMID: 26165893 DOI: 10.1097/lbr.0000000000000187] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Propofol use for sedation during routine flexible bronchoscopy is expanding. However, there are concerns over propofol's reliability in targeting moderate sedation during more complex and lengthy procedures, such as endobronchial ultrasound (EBUS) bronchoscopy. Its delivery by continuous infusion, which provides a steady sedation effect, may be a practical model for achieving reliable outcomes in this setting. METHODS We tested a continuous propofol infusion protocol targeting moderate sedation for EBUS bronchoscopy. A fixed loading rate of 125 mcg/kg/min and initial maintenance rate of 75 mcg/kg/min were used. Sedation assessments were performed every 2.5 minutes. The infusion was adjusted by a nurse under the direction of the bronchoscopist to maintain moderate sedation, normal vital signs, and patient comfort. Prospectively collected data from the first 31 patients using the protocol were analyzed. RESULTS A mix of EBUS types was performed in a fellowship training environment. Median procedure duration was 51 minutes (interquartile range, 41 to 75 min). Ninety-four percent of total bronchoscopy time was spent in moderate sedation, whereas only 1.9% was occupied by agitation-related delays. Average propofol dose per case was 0.07 mg/kg/min (±0.020), and infusion adjustments were required once every 8 minutes. Sampling goals were met in all patients, and diagnostic and nodal staging accuracies were 90% and 91%, respectively. All tumor specimens sent for genetics were sufficient for analysis. There were no major procedure-related complications. CONCLUSION Bronchoscopist-directed continuous propofol infusion is effective and practical for reliably and safely targeting moderate sedation during EBUS bronchoscopy, without sacrificing the breadth and accuracy of the procedure.
Collapse
|
38
|
Narayanan S, Shannon A, Nandalan S, Jaitly V, Greer S. Alternative sedation for the higher risk endoscopy: a randomized controlled trial of ketamine use in endoscopic retrograde cholangiopancreatography. Scand J Gastroenterol 2016; 50:1293-303. [PMID: 26061267 DOI: 10.3109/00365521.2015.1036113] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Sedation for endoscopy carries an element of cardiorespiratory risk, more significant for certain procedures and in certain patient groups. Ketamine has features which make it an attractive agent for sedation during the higher risk endoscopy; the objectives of this pilot trial were to assess the effectiveness and tolerability of ketamine as a primary agent for sedation during endoscopy. METHODS The study was a prospective randomized controlled trial, in which American Society of Anesthesiologists' (ASA) class 1-3 patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) received either conventional sedation with midazolam and pethidine or a combination of midazolam and ketamine. Patients were monitored physiologically and in respect to depth of sedation (Modified Observer's Assessment of Alertness/Sedation score) and were observed post procedure for evidence of emergence reactions or other complications. After full recovery, patients completed a questionnaire on their experiences, with particular emphasis on vivid dreaming or other complications attributable to ketamine. RESULTS Demographically, control (n = 18) and study (n = 19) groups were similar in makeup. Median midazolam dose was 2 mg (interquartile range [IQR] = 1-3) and 2 mg (IQR = 2-3), respectively (p = 0.98); median procedure duration was 25.5 min (IQR = 17-30) and 21.0 min (IQR = 15-34) (p = 0.92). Median satisfaction with sedation (scored from 0 to 4) was 3.5 (range 1-4) and 4 (range 2-4) respectively (p = 0.88). No patient in either group experienced emergence reactions, dysphoria, or vivid dreaming. CONCLUSION In this pilot study, sedation for endoscopy with ketamine and midazolam was as effective as conventional sedation, as acceptable to patients, and was not associated with dysphoric events. Ketamine may have potential as an agent for sedation in higher risk patients.
Collapse
|
39
|
Vaessen H, Bruens E, Knape J. Clinical analysis of moderate-to-deep-sedation by nonmedical sedation practitioners in 597 patients undergoing gastrointestinal endoscopy: a retrospective study. Endosc Int Open 2016; 4:E564-71. [PMID: 27227116 PMCID: PMC4874805 DOI: 10.1055/s-0042-103238] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 02/08/2016] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND AND STUDY AIM The purpose of this study was to evaluate whether moderate-to-deep sedation with propofol and alfentanil can be administered safely by nonmedical sedation practitioners, and the outcomes of this practice in the Netherlands. We retrospectively analyzed the occurrence of sedation-related complications in patients undergoing gastrointestinal endoscopic procedures. PATIENTS AND METHODS In this study, 597 adult patients consecutively underwent upper gastrointestinal endoscopic procedures. The health status of the patients was screened according to a standardized protocol, and the patients were sedated by trained nonmedical sedation practitioners. Their vital signs were continuously monitored and recorded. All patients received oxygen, and the depth of sedation was continuously assessed and recorded. Mild and severe complications were recorded and analyzed. RESULTS All patients recovered uneventfully, and no mortality occurred. Overall, of the 597 sedated patients, 85 had mild and 4 had severe complications. Hypoxemia and upper airway obstruction, which were easily managed by trained nonmedical sedation practitioners, were the most common events. Hypotension was rare. No signs or symptoms suggestive of aspiration were reported. CONCLUSION Moderate-to-deep sedation has been and continues to be a risky medical procedure. Serious complications of propofol/opioid-based sedation, especially respiratory and cardiovascular adverse events, may occur. These complications need to be recognized rapidly and appropriately managed. Our study shows that well-trained nonmedical sedation practitioners can be entrusted to take responsibility for the safe administration of moderate-to-deep sedation.
Collapse
Affiliation(s)
- Hermanus Vaessen
- Department of Anesthesiology, Intensive Care and Emergency Medicine, University Medical Centre Utrecht, the Netherlands,Corresponding author H. H. B. (Paul) Vaessen, RNA, PSA Specialist University Medical Centre UtrechtDepartment of Anesthesiology, Intensive Care and Emergency MedicineHeidelberglaan 100Huispostnr.: F02.8113584 CX UtrechtThe Netherlands+ 31-30-7555442
| | - Elisabeth Bruens
- Department of Anesthesiology, Intensive Care and Emergency Medicine, University Medical Centre Utrecht, the Netherlands
| | - Johannes Knape
- Department of Anesthesiology, Intensive Care and Emergency Medicine, University Medical Centre Utrecht, the Netherlands
| |
Collapse
|
40
|
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.
Collapse
|
41
|
Durmuş Kocaaslan N, Tuncer FB, Ayanoglu HO, Celebiler O. Nasopharyngeal Placement of a Nelaton Suction Catheter in Respiratory Monitoring of Sedated Patients. Aesthet Surg J 2016; 36:NP135-6. [PMID: 26530479 DOI: 10.1093/asj/sjv216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2015] [Indexed: 11/13/2022] Open
Affiliation(s)
- Nihal Durmuş Kocaaslan
- Dr Kocaaslan is an Associate Professor, Dr Tuncer is a Resident, and Dr Celebiler is a Professor, Department of Plastic, Reconstructive, and Aesthetic Surgery, Marmara University Hospital, Istanbul, Turkey. Dr Ayanoglu is a Professor, Department of Anaesthesiology and Reanimation, Marmara University Hospital, Istanbul, Turkey
| | - Fatma Betul Tuncer
- Dr Kocaaslan is an Associate Professor, Dr Tuncer is a Resident, and Dr Celebiler is a Professor, Department of Plastic, Reconstructive, and Aesthetic Surgery, Marmara University Hospital, Istanbul, Turkey. Dr Ayanoglu is a Professor, Department of Anaesthesiology and Reanimation, Marmara University Hospital, Istanbul, Turkey
| | - Hilmi Omer Ayanoglu
- Dr Kocaaslan is an Associate Professor, Dr Tuncer is a Resident, and Dr Celebiler is a Professor, Department of Plastic, Reconstructive, and Aesthetic Surgery, Marmara University Hospital, Istanbul, Turkey. Dr Ayanoglu is a Professor, Department of Anaesthesiology and Reanimation, Marmara University Hospital, Istanbul, Turkey
| | - Ozhan Celebiler
- Dr Kocaaslan is an Associate Professor, Dr Tuncer is a Resident, and Dr Celebiler is a Professor, Department of Plastic, Reconstructive, and Aesthetic Surgery, Marmara University Hospital, Istanbul, Turkey. Dr Ayanoglu is a Professor, Department of Anaesthesiology and Reanimation, Marmara University Hospital, Istanbul, Turkey
| |
Collapse
|
42
|
Nassar BS, Schmidt GA. Capnography During Critical Illness. Chest 2016; 149:576-585. [DOI: 10.1378/chest.15-1369] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 09/15/2015] [Accepted: 09/16/2015] [Indexed: 11/01/2022] Open
|
43
|
Yoon SB, Cho YS. Sedation for Gastrointestinal Endoscopy: Practical Issues in Patient Safety and Quality Management. Clin Endosc 2016; 49:1-3. [PMID: 26855914 PMCID: PMC4743727 DOI: 10.5946/ce.2016.49.1.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Accepted: 12/31/2015] [Indexed: 02/07/2023] Open
Affiliation(s)
- Seung Bae Yoon
- Division of Gastroenterology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Young-Seok Cho
- Division of Gastroenterology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| |
Collapse
|
44
|
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.
Collapse
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
| |
Collapse
|
45
|
Optimization of Deep Sedation with Spontaneous Respiration for Therapeutic Endoscopy Combining Propofol and Bispectral Index Monitoring. Gastroenterol Res Pract 2015; 2015:282149. [PMID: 26351450 PMCID: PMC4550768 DOI: 10.1155/2015/282149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 07/30/2015] [Accepted: 08/04/2015] [Indexed: 02/06/2023] Open
Abstract
Background/Aims. This study aimed to establish optimal propofol anesthesia for therapeutic endoscopy, which has not been established. Methodology. We retrospectively investigated data on 89 patients who underwent upper-GI endoscopic submucosal dissection or endoscopic mucosal resection under anesthesia with propofol. Examined doses of propofol were changed according to efficacy and/or adverse events and classified into 5 periods. A bispectral index (BIS) monitor was used at Period 5 to decrease the incidence of adverse events caused by oversedation. The initial dose of propofol was administered after bolus injection of pethidine hydrochloride (0.5 mg/kg), and 1.0 mL of propofol was added every minute until the patients fell asleep. Continuous and bolus infusion were performed to maintain sedation. When the patient moved or an adverse event occurred, the maintenance dose examined was increased or decreased by 5 mL/h regardless of body weight. Results. Dose combinations (introduction : maintenance) and patient numbers for each period were as follows: Period 1 (n = 27), 0.5 mg/kg : 5 mg/kg/h; Period 2 (n = 11), 0.33 mg/kg : 3.3 mg/kg/h; Period 3 (n = 7), 0.5 mg/kg : 3.3 mg/kg/h; Period 4 (n = 14), 0.5 mg/kg : 2.5 mg/kg/h; Period 5 (n = 30), 0.5 mg/kg : 2.5 mg/kg/h, using BIS monitor. During Period 5, an adverse event occurred in 10.0% of patients, which was lower than that for Periods 1–4. Conclusions. Period 5 propofol anesthesia with BIS protocol could be safe and useful for therapeutic endoscopy under deep sedation with spontaneous respiration.
Collapse
|
46
|
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.
Collapse
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
| |
Collapse
|
47
|
Wu Y, Zhang Y, Hu X, Qian C, Zhou Y, Xie J. A comparison of propofol vs. dexmedetomidine for sedation, haemodynamic control and satisfaction, during esophagogastroduodenoscopy under conscious sedation. J Clin Pharm Ther 2015; 40:419-25. [PMID: 25970229 DOI: 10.1111/jcpt.12282] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2014] [Accepted: 04/15/2015] [Indexed: 12/27/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Esophagogastroduodenoscopy (EGD) is a common diagnostic procedure which requires sedation for most patients. We undertook a prospective, randomized, double-blinded study to compare the effect of propofol vs. dexmedetomidine on the sedation of outpatients during EGD. METHODS Prior to the procedure, outpatients received either propofol at 0·6 mg/kg, with additional doses of 10-20 mg until the Observer's Assessment of Alertness/Sedation Scale (OAA/S) score reached 2-4, or dexmedetomidine at a loading dose of 1 μg/kg over a 10-min period followed by a 0·5 μg/kg/h infusion until the OAA/S score reached 2-4. Vital signs, sedation level, adverse events, patients' and endoscopist's satisfaction score, and an evaluation of the recovery time were assessed. RESULTS AND DISCUSSION Negligible haemoglobin oxygen saturation (SpO2 ) and respiratory rate variations were observed in both groups, although respiratory depression occurred in two cases (5·9%) in the propofol group. Mean arterial pressure (MAP) in the propofol group decreased during the procedure compared with baseline (P < 0·05) and was also lower in comparison with the dexmedetomidine group (P < 0·05). Heart rate (HR) decreased after the loading dose in the dexmedetomidine group (P < 0·05). More patients in the propofol group underwent deeper sedation at the beginning of the procedure (P < 0·05), although the recovery time was comparable between the two groups (P > 0·05). Three cases (9·1%) in the dexmedetomidine group were delayed because of dizziness, bradycardia and nausea. There was a higher satisfaction score among patients in the propofol group (P < 0·05), although the endoscopist's satisfaction score was comparable between the two groups (P > 0·05). WHAT IS NEW AND CONCLUSION Propofol and dexmedetomidine provide a relatively satisfactory level of sedation without clinically notable adverse effects during EGD. In addition, patients preferred propofol administration for the deeper sedation and rapid recovery, and dexmedetomidine exhibited minimal adverse effects on respiratory function.
Collapse
Affiliation(s)
- Y Wu
- Department of Anaesthesiology, the Second Hospital of Anhui Medical University, Hefei, China
| | - Y Zhang
- Department of Anaesthesiology, the Second Hospital of Anhui Medical University, Hefei, China
| | - X Hu
- Department of Anaesthesiology, the Second Hospital of Anhui Medical University, Hefei, China
| | - C Qian
- Department of Endoscopy, the Second Hospital of Anhui Medical University, Hefei, China
| | - Y Zhou
- Department of Endoscopy, the Second Hospital of Anhui Medical University, Hefei, China
| | - J Xie
- Department of Endoscopy, the Second Hospital of Anhui Medical University, Hefei, China
| |
Collapse
|
48
|
Obara K, Haruma K, Irisawa A, Kaise M, Gotoda T, Sugiyama M, Tanabe S, Horiuchi A, Fujita N, Ozaki M, Yoshida M, Matsui T, Ichinose M, Kaminishi M. Guidelines for sedation in gastroenterological endoscopy. Dig Endosc 2015; 27:435-449. [PMID: 25677012 DOI: 10.1111/den.12464] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 02/06/2015] [Indexed: 12/12/2022]
Abstract
Recently, the need for sedation in gastrointestinal endoscopy has been increasing. However, the National Health Insurance Drug Price list in Japan does not include any drug specifically used for the sedation. Although benzodiazepines are the main medication, their use in cases of gastrointestinal endoscopy has not been approved. This has led the Japan Gastrointestinal Endoscopy Society to develop the first set of guidelines for sedation in gastrointestinal endoscopy on the basis of evidence-based medicine in collaboration with the Japanese Society for Anesthesiologists. The present guidelines comprise 14 statements, five of which were judged to be valid on the highest evidence level and three on the second highest level. The guidelines are not intended to strongly recommend the use of sedation for gastrointestinal endoscopy, but rather to indicate the policy as to the choice of appropriate procedures when such sedation is deemed necessary. In clinical practice, the final decision as to the use of sedation should be made by physicians considering patient willingness and physical condition.
Collapse
Affiliation(s)
| | - Ken Haruma
- The Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Atsushi Irisawa
- The Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Mitsuru Kaise
- The Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Takuji Gotoda
- The Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Satoshi Tanabe
- The Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Akira Horiuchi
- The Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Naotaka Fujita
- The Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Makoto Ozaki
- The Japanese Society of Anesthesiologists, Tokyo, Japan
| | | | | | - Masao Ichinose
- The Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | |
Collapse
|
49
|
Park CH, Shin S, Lee SK, Lee H, Lee YC, Park JC, Yoo YC. Assessing the stability and safety of procedure during endoscopic submucosal dissection according to sedation methods: a randomized trial. PLoS One 2015; 10:e0120529. [PMID: 25803441 PMCID: PMC4372558 DOI: 10.1371/journal.pone.0120529] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 01/21/2015] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Although endoscopic submucosal dissection (ESD) is routinely performed under sedation, the difference in ESD performance according to sedation method is not well known. This study attempted to prospectively assess and compare the satisfaction of the endoscopists and patient stability during ESD between two sedation methods. METHODS One hundred and fifty-four adult patients scheduled for ESD were sedated by either the IMIE (intermittent midazolam/propofol injection by endoscopist) or CPIA (continuous propofol infusion by anesthesiologist) method. The primary endpoint of this study was to compare the level of satisfaction of the endoscopists between the two groups. The secondary endpoints included level of satisfaction of the patients, patient's pain scores, events interfering with the procedure, incidence of unintended deep sedation, hemodynamic and respiratory events, and ESD outcomes and complications. RESULTS Level of satisfaction of the endoscopists was significantly higher in the CPIA Group compared to the IMIE group (IMIE vs. CPIA; high satisfaction score; 63.2% vs. 87.2%, P=0.001). The incidence of unintended deep sedation was significantly higher in the IMIE Group compared to the CPIA Group (IMIE vs. CPIA; 17.1% vs. 5.1%, P=0.018) as well as the number of patients showing spontaneous movement or those requiring physical restraint (IMIE vs. CPIA; spontaneous movement; 60.5% vs. 42.3%, P=0.024, physical restraint; 27.6% vs. 10.3%, P=0.006, respectively). In contrast, level of satisfaction of the patients were found to be significantly higher in the IMIE Group (IMIE vs. CPIA; high satisfaction score; 85.5% vs. 67.9%, P=0.027). Pain scores of the patients, hemodynamic and respiratory events, and ESD outcomes and complications were not different between the two groups. CONCLUSION Continuous propofol and remifentanil infusion by an anesthesiologist during ESD can increase the satisfaction levels of the endoscopists by providing a more stable state of sedation. TRIAL REGISTRATION ClinicalTrials.gov NCT01806753.
Collapse
Affiliation(s)
- Chan Hyuk Park
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Seokyung Shin
- Department of Anesthesiology and Pain Medicine, Severance Hospital, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Kil Lee
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Hyuk Lee
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong Chan Lee
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Jun Chul Park
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
- * E-mail:
| | - Young Chul Yoo
- Department of Anesthesiology and Pain Medicine, Severance Hospital, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| |
Collapse
|
50
|
Adams L, Butas S, Spurlock D. Capnography (ETCO2), Respiratory Depression, and Nursing Interventions in Moderately Sedated Adults Undergoing Transesophageal Echocardiography (TEE). J Perianesth Nurs 2015; 30:14-22. [DOI: 10.1016/j.jopan.2013.07.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Revised: 05/06/2013] [Accepted: 07/15/2013] [Indexed: 10/24/2022]
|