An effective and safe sedation technique combining target-controlled infusion pump with propofol, intravenous pentazocine, and bispectral index monitoring for peroral double-balloon endoscopy

Safety and efficacy of capsule endoscopy for patients with newly diagnosed Crohn's disease: A multicenter retrospective study

Crohn's disease (CD) is a chronic inflammatory disease that develops at a young age and frequently leads to intestinal resection. Capsule endoscopy (CE) can directly and non-invasively inspect the entire small bowel mucosa. We suspected that CE could be a good diagnostic tool for detecting CD in young patients. The aim of this study was to investigate the safety and efficacy of CE in patients with newly diagnosed CD and to evaluate the CE findings, especially in the upper small bowel of young patients. We retrospectively investigated 32 patients with newly diagnosed CD from 5 institutions. Patient characteristics, clinical course, and characteristics of CE findings were analyzed. The total small intestine observation rate was 93%, and the retention rate was 3% (1/32). No abnormality was identified by ileocolonoscopy in 46% (15/32), and transition of small bowel lesions (TSL) was found in 35% (12/34) of the patients. The frequency of longitudinal ulcers and cobblestones in the upper small intestine was significantly higher in younger patients (≤20 years). Moreover, positive findings in the upper small intestine were predominantly observed in younger patients (≤20 years). CE for patients with newly diagnosed CD was safe and useful, especially for the detection of upper small bowel lesions in young patients.

Paradigm shift: should the elderly undergo propofol sedation for DBE? A prospective cohort study

OBJECTIVE

Evaluate the safety of propofol-assisted double balloon enteroscopy (DBE) in elderly patients against a younger cohort.

DESIGN

Prospective cohort study.

SETTING

All patients undergoing DBE over a 30-month period were recruited at our tertiary centre.

PATIENTS

215 procedures in 161 patients were performed. An age cut-off of 65 years and above was used to define those who were elderly.

INTERVENTIONS

Patients were subcategorised into four groups: elderly or young undergoing DBE with propofol or conventional sedation (with midazolam±fentanyl).

MAIN OUTCOME MEASURES

Patient demographics, comorbidities, procedural data, complications, diagnostic and therapeutic yield were compared.

RESULTS

Cardiovascular disease and a higher American Society of Anaethesiologists (ASA) status were more prevalent in elderly patients undergoing DBE with propofol (p<0.05). Common indications for DBE were occult and overt obscure gastrointestinal bleeding and suspected Crohn's disease (elderly vs young: 50.7% vs 42.3%, 17.8% vs 12% and 19.2% vs 26.1%, respectively). Diagnostic yield was higher in elderly compared with young patients (75.3% vs 58.5%, p=0.016). The most common findings in elderly and young patients were angioectasia (30.1% and. 18.3%, respectively) and ulcers (17.8% and 9.2%, respectively), while therapeutic intervention rates were comparable (42.5% vs 32.4%, p=0.18). ASA status did not affect propofol dose (p=0.55) or procedure duration (p=0.31). Tolerance scores were favourable in those receiving propofol compared with conventional sedation (p<0.05). There was no difference in complications between the four groups (p=0.17).

CONCLUSION

Compared with young patients, propofol-assisted DBE in the elderly is safe and has a high diagnostic yield.

Use of computer-assisted drug therapy outside the operating room

PURPOSE OF REVIEW

The number of procedures performed in the out-of-operating room setting under sedation has increased many fold in recent years. Sedation techniques aim to achieve rapid patient turnover through the use of short-acting drugs with minimal residual side-effects (mainly propofol and opioids). Even for common procedures, the practice of sedation delivery varies widely among providers. Computer-based sedation models have the potential to assist sedation providers and offer a more consistent and safer sedation experience for patients.

RECENT FINDINGS

Target-controlled infusions using propofol and other short-acting opioids for sedation have shown promising results in terms of increasing patient safety and allowing for more rapid wake-up times. Target-controlled infusion systems with real-time patient monitoring can titrate drug doses automatically to maintain optimal depth of sedation. The best recent example of this is the propofol-based Sedasys sedation system. Sedasys redefined individualized sedation by the addition of an automated clinical parameter that monitors depth of sedation. However, because of poor adoption and cost issues, it has been recently withdrawn by the manufacturer.

SUMMARY

Present automated drug delivery systems can assist in the provision of sedation for out-of-operating room procedures but cannot substitute for anesthesia providers. Use of the available technology has the potential to improve patient outcomes, decrease provider workload, and have a long-term economic impact on anesthesia care delivery outside of the operating room.

Dexmedetomidine provides less body motion and respiratory depression during sedation in double-balloon enteroscopy than midazolam

Objectives:

Patients undergoing double-balloon enteroscopy require sedatives such as midazolam; however, patient’s body motion often hampers the outcome of double-balloon enteroscopy. Recently, dexmedetomidine has been used for endoscopic sedation and was reported to effectively reduce body motion. This study aimed to evaluate the efficacy and safety of sedation with dexmedetomidine in double-balloon enteroscopy (UMIN ID000015785).

Methods:

A prospective, observational study was conducted in 81 patients who underwent 111 double-balloon enteroscopy from July to December 2015 (dexmedetomidine group). The medical records of 112 patients who underwent 166 double-balloon enteroscopy with midazolam and pentazocine sedation from January 1 to October 31, 2014, were used for comparison (midazolam group). After propensity score matching, 182 double-balloon enteroscopy (91 double-balloon enteroscopy for each group) were analyzed.

Results:

There were 13 cases (11.7%) with body movements in the dexmedetomidine group. Comparison of the two groups matched by propensity score showed that the dexmedetomidine group had less body movement (12.1% vs 34.1%, p = 0.001) and less respiratory depression (50.5% vs 68.1%, p = 0.023). Hypotension (8.8% vs 4.4%, p = 0.232) and bradycardia (2.2% vs 0%, p = 0.497) were not significantly different in the two groups.

Conclusion:

Using dexmedetomidine for conscious sedation can reduce body motion and respiratory depression compared to our previous records.

Comparison of patients' tolerance between computed tomography enterography and double-balloon enteroscopy

BACKGROUND

Computed tomography enterography (CTE) and double-balloon enteroscopy (DBE) are widely used in diagnosis of small bowel diseases. Both of these examinations bring discomfort to patients. The aim of this study was to compare patients' tolerance and preference between CTE and DBE.

METHODS

From August 1, 2014 to December 31, 2016, patients with suspected or known small bowel diseases who underwent both CTE and DBE were prospectively enrolled in our study. They were asked to fill out a questionnaire evaluating discomfort of the procedure after each examination.

RESULTS

One hundred and seven patients completed our study. Abdominal distension, painfulness, tenesmus, general discomfort, prolonged duration, difficulty in completing the test, and discomfort after the examination were significantly lower with CTE than with DBE (P<0.001, respectively). Mannitol intake (47.7%), bowel preparation (31.9%), and radiation exposure (15.0%) were regarded as the three most intolerable burdens in CTE. Painfulness (38.3%), bowel preparation (26.2%), and invasiveness (16.8%) were considered as the three most unacceptable parts of DBE. More patients (61.7%) preferred to repeat CTE rather than DBE (P<0.001).

CONCLUSION

Compared to DBE, CTE was a more tolerable and less burdensome examination and enjoyed higher preference by most patients.

Adult and pediatric anesthesia/sedation for gastrointestinal procedures outside of the operating room

PURPOSE OF REVIEW

This review presents current trends of safe and efficient anesthesia and sedation for adults and children for gastrointestinal procedures outside of the operating room with a special focus on total intravenous anesthesia (TIVA), target-controlled infusion (TCI), intravenous or topical lidocaine, and the use of the video laryngoscope.

RECENT FINDINGS

The concepts of a well tolerated and adequate anesthesia or sedation for gastrointestinal procedures outside of the operating room have to meet the needs of the adult and pediatric patients and the special requests of the gastroenterologists. Anesthesia and sedation of adults for gastrointestinal procedures with TIVA or TCI and spontaneous breathing is well established. Many institutions perform anesthesia for pediatric patients undergoing gastrointestinal procedures with an inhalational agent, especially in young children and for short procedures. Unlike adults, in young children the airways frequently must be secured with a tracheal tube or laryngeal mask. Respiration may be spontaneous, assisted, or controlled. TIVA and TCI are increasingly chosen for older children and longer procedures. A local anesthetic administered intravenously or topically to the upper airways and the use of the video laryngoscope can facilitate the insertion of the endoscope.

SUMMARY

Both anesthesiologists and nonanesthesiologists have to achieve a consensus and develop quality-improvement strategies to provide safe and efficient anesthesia and sedation for gastrointestinal procedures outside of the operating room for pediatric and adult patients. Techniques using TIVA, TCI, intravenous or topical application of lidocaine, and the video laryngoscope may improve and facilitate gastrointestinal procedures for the patients, the anesthesiologists, and the gastroenterologists.