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Tamborrino PP, Papi L, Michelotti L, Vitale C, Caravelli P, Petronio AS, Terlizzi E, Della Volpe L, Virlan M, Sardanelli A, Morganti R, De Caterina R. Do We Need Fasting Prior to Coronary Angiography? The CORO-NF Randomized Pragmatic Study. Am J Med 2024; 137:666-672. [PMID: 38336086 DOI: 10.1016/j.amjmed.2024.01.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 01/27/2024] [Accepted: 01/29/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND Similar to procedures requiring general anesthesia, current guidelines recommend fasting for 6 hours for solids and for 2 hours for liquids prior to coronary angiography, but without data supporting such recommendation. The CORO-NF study aimed at assessing whether a shorter fasting period prior to elective coronary angiography associates with improved patient satisfaction without more complications compared with the standard fasting approach. METHODS We conducted a single-center, randomized, prospective, pragmatic study in 2 sequential phases: a "conventional protocol phase," continuing the usual practice (F Group); and an "experimental phase" (NF Group), reducing minimum fasting duration to 2 hours. Patients received a questionnaire to express a satisfaction score ranging from 1 (maximum complain/no approval) to 5 (minimum or no complain/full approval). All patients admitted acutely were enrolled in a control A Group registry. Fasting time and every major complication and periprocedural complications were analyzed. RESULTS Fasting time was 821 ± 357 minutes in the F Group and 230 ± 146 minutes in the NF Group (P < .001). The satisfaction score was higher in the NF Group (4.2 ± 0.7 vs 2.9 ± 1.2, P < .001), even at multivariable analysis considering fasting time (P < .001). No intraprocedural food ingestion-related adverse events occurred in either of the 2 experimental groups, as well as in the parallel A Group, with no excess of peri- and postprocedural complications in the NF Group. CONCLUSIONS The significantly higher satisfaction scores among patients undergoing a shorter-than-recommended fasting period prior to coronary angiography, not counterbalanced by decreased safety, underscores the potential benefits of revising the traditional 6-hour fasting protocols.
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Affiliation(s)
- Pietro Paolo Tamborrino
- Chair and Postgraduate School of Cardiology, University of Pisa and Cardiovascular Division 1, Pisa University Hospital, Italy
| | - Laura Papi
- Chair and Postgraduate School of Cardiology, University of Pisa and Cardiovascular Division 1, Pisa University Hospital, Italy
| | - Laura Michelotti
- Chair and Postgraduate School of Cardiology, University of Pisa and Cardiovascular Division 1, Pisa University Hospital, Italy
| | - Carlo Vitale
- Chair and Postgraduate School of Cardiology, University of Pisa and Cardiovascular Division 1, Pisa University Hospital, Italy
| | - Paolo Caravelli
- Chair and Postgraduate School of Cardiology, University of Pisa and Cardiovascular Division 1, Pisa University Hospital, Italy
| | - Anna Sonia Petronio
- Cardiac Catheterization Laboratory, Cardiothoracic and Vascular Department, University of Pisa, Italy
| | - Emilia Terlizzi
- Chair and Postgraduate School of Cardiology, University of Pisa and Cardiovascular Division 1, Pisa University Hospital, Italy
| | - Ludovica Della Volpe
- Chair and Postgraduate School of Cardiology, University of Pisa and Cardiovascular Division 1, Pisa University Hospital, Italy
| | - Mihaela Virlan
- Chair and Postgraduate School of Cardiology, University of Pisa and Cardiovascular Division 1, Pisa University Hospital, Italy
| | - Annamaria Sardanelli
- Chair and Postgraduate School of Cardiology, University of Pisa and Cardiovascular Division 1, Pisa University Hospital, Italy
| | - Riccardo Morganti
- Section of Statistics, Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Raffaele De Caterina
- Chair and Postgraduate School of Cardiology, University of Pisa and Cardiovascular Division 1, Pisa University Hospital, Italy; Fondazione VillaSerena per la Ricerca, Città Sant'Angelo-Pescara, Italy.
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Tamborrino PP, De Caterina R. The Reply. Am J Med 2024; 137:e131-e132. [PMID: 38942489 DOI: 10.1016/j.amjmed.2024.03.009] [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: 03/12/2024] [Accepted: 03/14/2024] [Indexed: 06/30/2024]
Affiliation(s)
- Pietro Paolo Tamborrino
- Chair and Postgraduate School of Cardiology, University of Pisa and Cardiovascular Division 1, Pisa University Hospital, Pisa
| | - Raffaele De Caterina
- Chair and Postgraduate School of Cardiology, University of Pisa and Cardiovascular Division 1, Pisa University Hospital, Pisa; Fondazione VillaSerena per la Ricerca, Città Sant'Angelo-Pescara, Italy.
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3
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Anderson JC, Rex DK. Performing High-Quality, Safe, Cost-Effective, and Efficient Basic Colonoscopy in 2023: Advice From Two Experts. Am J Gastroenterol 2023; 118:1779-1786. [PMID: 37463252 DOI: 10.14309/ajg.0000000000002407] [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: 05/18/2023] [Accepted: 07/05/2023] [Indexed: 07/20/2023]
Abstract
Based on published evidence and our expert experience, we provide recommendations to maximize the efficacy, safety, efficiency, and cost-effectiveness of routine colonoscopy. High-quality colonoscopy begins with colon preparation using a split or same-day dose and preferably a low-volume regimen for optimal patient tolerance and compliance. Successful cecal intubation can be achieved by choosing the correct colonoscope and using techniques to facilitate navigation through challenges such as severe angulations and redundant colons. Safety is a primary goal, and complications such as perforation and splenic rupture can be prevented by avoiding pushing through fixed resistance and avoiding loops in proximal colon. Furthermore, barotrauma can be avoided by converting to water filling only (no gas insufflation) in every patient with a narrowed, angulated sigmoid. Optimal polyp detection relies primarily on compulsive attention to inspection as manifested by adequate inspection time, vigorous probing of the spaces between haustral folds, washing and removing residual debris, and achieving full distention. Achieving minimum recommended adenoma detection rate thresholds (30% in men and 20% in women) is mandatory, and colonoscopists should aspire to adenoma detection rate approaching 50% in screening patients. Distal attachments can improve mucosal exposure and increase detection while shortening withdrawal times. Complete resection of polyps complements polyp detection in preventing colorectal cancer. Cold resection is the preferred method for all polyps < 10 mm. For effective cold resection, an adequate rim of normal tissue should be captured in the snare. Finally, cost-effective high-quality colonoscopy requires the procedure not be overused, as demonstrated by following updated United States Multi Society Task Force on Colorectal Cancer postpolypectomy surveillance recommendations.
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Affiliation(s)
- Joseph C Anderson
- Division of Gastroenterology, Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
- Division of Gastroenterology, Department of Medicine, White River Junction VAMC, White River Junction, Vermont, USA
- Division of Gastroenterology, Department of Medicine, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Douglas K Rex
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Hommel E, Sissoho FB, Chang K, Suthar K. Reducing the use of nil per os past midnight for inpatient diagnostic and therapeutic procedures: A quality improvement initiative. J Hosp Med 2023; 18:375-381. [PMID: 36806907 PMCID: PMC10186274 DOI: 10.1002/jhm.13066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 01/07/2023] [Accepted: 02/02/2023] [Indexed: 02/22/2023]
Abstract
BACKGROUND Pre-procedural fasting (nil per os [NPO]) is a commonly implemented protocol to prevent aspiration during certain diagnostic and therapeutic procedures. However, evidence suggests aspiration risk is quite low. Current guidelines support a reduced fasting duration before procedures necessitating anesthesia or sedation, but many health systems persist in the use of NPO past midnight. OBJECTIVE We aimed to reduce the use of NPO p MN before inpatient diagnostic and therapeutic procedures necessitating anesthesia or sedation by 50% within 6 months. DESIGN, SETTING AND PARTICIPANTS We performed a quality improvement initiative at a single academic health system in Southeast Texas. We include the experience of patients of all ages across 4 affiliated hospitals (one main academic hospital and three community satellite hospitals). INTERVENTION An interprofessional team was convened to review best practices and oversee this quality improvement initiative. Diagnostic imaging protocols previously requiring NPO were amended to reflect evidence-based fasting requirements. A pre-procedure clear liquid diet was also implemented. MAIN OUTCOME AND MEASURES We describe the steps to implementation, feasibility of implementation as described through key process measures, and the safety of implementation (balancing measures). RESULTS NPO requirements were removed from 70% of existing diagnostic imaging and therapeutic orders. After these amended protocols and the implementation of a pre-procedure clear liquid diet, we displayed an immediate 50% reduction in NPO past midnight usage. Further stakeholder engagement/education and targeted interventions reduced NPO past midnight usage to only 33% of pre-procedural diet orders. Surgery remains the most common indication for continued use of NPO. Aspiration events and procedural delays were rare.
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Affiliation(s)
- Erin Hommel
- The University of Texas Medical Branch, Department of
Medicine, Division of Geriatrics and Palliative Care, Galveston, TX
| | - Fatoumatta B. Sissoho
- The University of Texas Medical Branch, Department of
Medicine, Division of Geriatrics and Palliative Care, Galveston, TX
| | - Karen Chang
- The University of Texas Medical Branch, School of
Medicine, Galveston, TX
| | - Krishna Suthar
- Baylor Scott & White, Department of Internal Medicine,
Division of Hematology & Medical Oncology, Temple, TX
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Green SM, Leroy PL, Roback MG, Irwin MG, Andolfatto G, Babl FE, Barbi E, Costa LR, Absalom A, Carlson DW, Krauss BS, Roelofse J, Yuen VM, Alcaino E, Costa PS, Mason KP. An international multidisciplinary consensus statement on fasting before procedural sedation in adults and children. Anaesthesia 2019; 75:374-385. [PMID: 31792941 PMCID: PMC7064977 DOI: 10.1111/anae.14892] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2019] [Indexed: 01/29/2023]
Abstract
The multidisciplinary International Committee for the Advancement of Procedural Sedation presents the first fasting and aspiration prevention recommendations specific to procedural sedation, based on an extensive review of the literature. These were developed using Delphi methodology and assessment of the robustness of the available evidence. The literature evidence is clear that fasting, as currently practiced, often substantially exceeds recommended time thresholds and has known adverse consequences, for example, irritability, dehydration and hypoglycaemia. Fasting does not guarantee an empty stomach, and there is no observed association between aspiration and compliance with common fasting guidelines. The probability of clinically important aspiration during procedural sedation is negligible. In the post-1984 literature there are no published reports of aspiration-associated mortality in children, no reports of death in healthy adults (ASA physical status 1 or 2) and just nine reported deaths in adults of ASA physical status 3 or above. Current concerns about aspiration are out of proportion to the actual risk. Given the lower observed frequency of aspiration and mortality than during general anaesthesia, and the theoretical basis for assuming a lesser risk, fasting strategies in procedural sedation can reasonably be less restrictive. We present a consensus-derived algorithm in which each patient is first risk-stratified during their pre-sedation assessment, using evidence-based factors relating to patient characteristics, comorbidities, the nature of the procedure and the nature of the anticipated sedation technique. Graded fasting precautions for liquids and solids are then recommended for elective procedures based upon this categorisation of negligible, mild or moderate aspiration risk. This consensus statement can serve as a resource to practitioners and policymakers who perform and oversee procedural sedation in patients of all ages, worldwide.
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Affiliation(s)
- S M Green
- Department of Emergency Medicine, Loma Linda University, Loma Linda, CA, USA
| | - P L Leroy
- Department of Pediatrics, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - M G Roback
- University of Colorado School of Medicine, Aurora, CO, USA
| | - M G Irwin
- Department of Anaesthesiology, University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - G Andolfatto
- University of British, Columbia Department of Emergency Medicine, Lions Gate Hospital, North Vancouver, BC, Canada
| | - F E Babl
- Department of Emergency Medicine, Royal Children's Hospital, Parkville, Vic., Australia
| | - E Barbi
- Department of Pediatrics, Institute for Maternal and Child Health-IRCCS 'Burlo Garofolo', Trieste, Italy
| | - L R Costa
- Department of Pediatric Dentistry, Federal University of Goias, Goiania-Goias, Brazil
| | - A Absalom
- Department of Anaesthesia, University of Groningen, University Medical Center Groningen, the Netherlands
| | - D W Carlson
- Department of Pediatrics, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - B S Krauss
- Department of Pediatrics, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | - J Roelofse
- Departments of Anaesthesia, University of the Western Cape, Stellenbosch University, Tygerberg, Republic of South Africa
| | - V M Yuen
- Department of Anaesthesiology, Hong Kong Children's Hospital and Queen Mary Hospital, University of Hong Kong, Hong Kong
| | - E Alcaino
- Department of Paediatric Dentistry, University of Sydney, Westmead Centre for Oral Health, Sydney, NSW, Australia
| | - P S Costa
- Department of Pediatrics, Federal University of Goias, Goiania-Goias, Brazil
| | - K P Mason
- Department of Anesthesia, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
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Kothari ST, Huang RJ, Shaukat A, Agrawal D, Buxbaum JL, Abbas Fehmi SM, Fishman DS, Gurudu SR, Khashab MA, Jamil LH, Jue TL, Law JK, Lee JK, Naveed M, Qumseya BJ, Sawhney MS, Thosani N, Yang J, DeWitt JM, Wani S. ASGE review of adverse events in colonoscopy. Gastrointest Endosc 2019; 90:863-876.e33. [PMID: 31563271 DOI: 10.1016/j.gie.2019.07.033] [Citation(s) in RCA: 86] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 07/29/2019] [Indexed: 02/07/2023]
Abstract
Colonoscopy is the most commonly performed endoscopic procedure and overall is considered a low-risk procedure. However, adverse events (AEs) related to this routinely performed procedure for screening, diagnostic, or therapeutic purposes are an important clinical consideration. The purpose of this document from the American Society for Gastrointestinal Endoscopy's Standards of Practice Committee is to provide an update on estimates of AEs related to colonoscopy in an evidence-based fashion. A systematic review and meta-analysis of population-based studies was conducted for the 3 most common and important serious AEs (bleeding, perforation, and mortality). In addition, this document includes an updated systematic review and meta-analysis of serious AEs (bleeding and perforation) related to EMR and endoscopic submucosal dissection for large colon polyps. Finally, a narrative review of other colonoscopy-related serious AEs and those related to specific colonic interventions is included.
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Affiliation(s)
| | - Robert J Huang
- Stanford University Medical Center, Stanford, California, USA
| | - Aasma Shaukat
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - Deepak Agrawal
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - James L Buxbaum
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | | | - Douglas S Fishman
- Baylor College of Medicine/Texas Children's Hospital, Houston, Texas, USA
| | | | | | - Laith H Jamil
- Pancreatic and Biliary Diseases Program, Cedars-Sinai Medical Center, West Hollywood, California, USA
| | - Terry L Jue
- The Permanente Medical Group, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA
| | - Joanna K Law
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Jeffrey K Lee
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA
| | - Mariam Naveed
- Division of Gastroenterology and Hepatology, University of Iowa Hospitals & Clinics, Coralville, Iowa, USA
| | | | - Mandeep S Sawhney
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Nirav Thosani
- University of Texas at Houston, Bellaire, Texas, USA
| | - Julie Yang
- Einstein Hospital, New York, New York, USA
| | - John M DeWitt
- Division of Gastroenterology, Indiana University Health Medical Center, Indianapolis, Indiana, USA
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
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