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Patel HK, Desai R, Doshi S, Haider M, Lakhani N, Abu Hassan F, Doshi R, Thoguluva Chandrasekar V. Endoscopic Retrograde Cholangiopancreatography in Patients With Versus Without Prior Myocardial Infarction or Coronary Revascularization: A Nationwide Cohort Study. Cureus 2021; 13:e13921. [PMID: 33880272 PMCID: PMC8051429 DOI: 10.7759/cureus.13921] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background Endoscopic retrograde cholangiopancreatography (ERCP) can be associated with complications, including precipitation of peri-procedural myocardial ischemia. However, data regarding the trends and impact of previous myocardial infarction (MI) and/or percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) on ERCP outcomes remains unknown. Methods Using the National Inpatient Sample (2007-2014) and relevant ICD-9-CM codes, we identified adults who underwent ERCP with (Group 1) and without (Group 2) prior history of MI/PCI/CABG, and compared their demographics, comorbidities, and inpatient outcomes. Primary endpoints were inpatient mortality and post-ERCP complications. The secondary endpoints were discharge disposition, the mean length of stay, and total hospital charges. Results Of 1,374,773 ERCP procedures performed, 120,418 (8.8%) were performed in adult patients with a prior history of MI/PCI/CABG with an increasing trend from 2007-2014 (7.5% to 9.5%, ptrend=0.022). Group 1 consisted of older, white, males compared to Group 2. Group 1 demonstrated a higher prevalence of all-cause mortality (1.7% vs. 1.5%, p<0.001), other cardiovascular comorbidities, post-ERCP cardiopulmonary complications (5.6% vs. 3.8%, p<0.001), sepsis (10.2% vs. 8.2%, p<0.001) and hemorrhage (1.5% vs.1.2%, p<0.001) as compared to Group 2. However, post-ERCP pancreatitis (14.1% vs. 15.4%, p<0.001) was lower in Group 1 without any difference in frequency of cholecystitis (0.4% vs. 0.4%, p=0.180). The mean length of stay was marginally higher in Group 1, without any difference in the hospitalization charges between the groups. Conclusions This nationwide study revealed higher inpatient mortality, sepsis, and hemorrhage in adult patients who underwent ERCP with a prior history of MI/PCI/CABG.
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Affiliation(s)
- Harsh K Patel
- Internal Medicine, Ochsner Clinic Foundation, New Orleans, USA
| | - Rupak Desai
- Cardiology, Atlanta Veterans Affairs Medical Center, Decatur, USA
| | - Shreyans Doshi
- Gastroenterology, Medical College of Georgia, Augusta University, Augusta, USA
| | - Mohammad Haider
- Internal Medicine, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, USA
| | - Neet Lakhani
- Internal Medicine, Baroda Medical College, The Maharaja Sayajirao University of Baroda, Vadodara, IND
| | | | - Rajkumar Doshi
- Internal Medicine, University of Nevada, Reno School of Medicine, Reno, USA
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Kim SH, Choi YS, Lee SK, Oh H, Choi SH. Comparison of general anesthesia and conscious sedation in procedure-related complications during esophageal endoscopic submucosal dissection. Surg Endosc 2020; 34:3560-3566. [PMID: 32468261 DOI: 10.1007/s00464-020-07663-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 05/20/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) has a favorable outcome, compared to esophagectomy, for early esophageal neoplasia. Recent studies used general anesthesia for esophageal ESD to minimize complications due to insufficient sedation and patient movement. We aimed to evaluate the safety of general anesthesia in comparison with conscious sedation provided by anesthesiologists for esophageal ESD. METHODS We retrospectively reviewed the electronic medical records of 158 patients who underwent esophageal ESD under general anesthesia or conscious sedation provided by anesthesiologists. We evaluated the incidence of procedure-related complications, including perforation, post-ESD bleeding, cardiopulmonary adverse events (arrhythmia, hypotension, and hypoxemia), procedure failure, stricture, and new lung consolidation after ESD. Cases of frank perforation, post-ESD bleeding requiring a vigorous diagnostic approach, and cardiopulmonary adverse events were regarded as acute complications of ESD. RESULTS Acute complications occurred only in the conscious sedation group (8/83 [9.6%] vs. 0/75 [0.0%]; p value = 0.007). The numbers of patients with frank perforation, post-ESD bleeding, and cardiopulmonary adverse events were four, one, and three, respectively. Moreover, new lung consolidation after ESD developed only in the conscious sedation group (7/83 [8.4%] vs. 0/75 [0.0%]; p value = 0.014). ESD failed in four patients in the conscious sedation group. The incidences of stricture that required stent insertion and hospital stay after ESD were comparable between the two groups. CONCLUSION General anesthesia is associated with a lower incidence of acute procedure-related complications in esophageal ESD compared to conscious sedation provided by anesthesiologists. Therefore, we recommend general anesthesia as a safer option for esophageal ESD.
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Affiliation(s)
- Seung Hyun Kim
- Department of Anesthesiology and Pain Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Seon Choi
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Kil Lee
- Division of Gastroenterology, Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Hanseul Oh
- Department of Anesthesiology and Pain Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Ho Choi
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
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Chawla S, Willingham FF. Cardiopulmonary complications of endoscopic retrograde cholangiopancreatography. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2014. [DOI: 10.1016/j.tgie.2014.07.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Nojkov B, Cappell MS. Safety and efficacy of ERCP after recent myocardial infarction or unstable angina. Gastrointest Endosc 2010; 72:870-80. [PMID: 20883868 DOI: 10.1016/j.gie.2010.06.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2010] [Accepted: 06/14/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND ERCP after myocardial infarction (MI) or unstable angina (UnA) can potentially entail significant cardiovascular risks. OBJECTIVE To analyze the safety of ERCP after MI or UnA. DESIGN Retrospective study. PATIENTS Adult patients less than 30 days after MI or UnA. SETTING Three hospitals from 1985 to 2010, encompassing 7600 ERCPs. INTERVENTIONS ERCP. MAIN OUTCOME MEASUREMENTS ERCP diagnosis, therapy, efficacy, and complications. RESULTS Thirteen patients (mean age 77.9 ± 11.4 years) underwent ERCP on average 6.9 ± 7.7 days after MI. ERCP indications were suspected choledocholithiasis/gallstone pancreatitis (n = 10); cholangitis (n = 7); obstructive jaundice with suspected pancreatic mass (n = 1); and biliary stent removal/replacement (n = 2). ERCP revealed choledocholithiasis (n = 8); previous stent (n = 2); and nonpathologic findings (n = 3). Therapies included balloon sweep (n = 11), sphincterotomy (n = 8), visible stones extracted by balloon sweep (n = 8), and biliary stent placement/replacement/removal (n = 3). Two mild complications occurred: hypotension during ERCP successfully treated with ephedrine and obstructing periampullary clot successfully removed at repeat ERCP. Eleven patients subsequently did well (mean hospital discharge 6.5 days after ERCP); 1 patient with metastatic ovarian cancer remained ventilator dependent, and another patient with multiple comorbidities had a fatal pulmonary embolus 10 days after ERCP. Six patients underwent ERCP 7.5 ± 5.2 days after UnA for suspected choledocholithiasis (n = 5) and bile duct injury (n = 1). ERCP findings included choledocholithiasis (n = 3), cystic duct leak (n = 1), ampullary stenosis (n = 1), and nonpathologic findings (n = 1). Sphincterotomy was performed in 5 patients, visible stones were extracted by balloon sweep in 3, and a biliary stent was inserted in 1. One mild complication occurred: hypotension during ERCP which was successfully treated with ephedrine. All 6 patients were discharged (mean 8.0 days after ERCP). LIMITATIONS Small study size; retrospective study. CONCLUSIONS This study suggests that therapeutic ERCP involves acceptable risks when performed soon after MI or UnA for suspected choledocholithiasis or other therapeutic indications and may be performed in such situations when strongly indicated.
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Affiliation(s)
- Borko Nojkov
- Division of Gastroenterology, Department of Medicine, William Beaumont Hospital, Royal Oak, Michigan 48073, USA
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Ristikankare M, Julkunen R, Heikkinen M, Laitinen T, Wang SX, Hartikainen J. Cardiac autonomic regulation during gastroscopy. Dig Liver Dis 2009; 41:648-52. [PMID: 19231302 DOI: 10.1016/j.dld.2009.01.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2008] [Revised: 12/20/2008] [Accepted: 01/13/2009] [Indexed: 12/11/2022]
Abstract
BACKGROUND Gastroscopy is sometimes associated with adverse cardiovascular events. AIMS We evaluated the effects of sedation and pharyngeal anaesthesia on cardiac autonomic regulation during gastroscopy. PATIENTS Two hundred thirteen outpatients undergoing gastroscopy. METHODS The patients were assigned to 4 groups: (1) sedation with intravenous midazolam and placebo throat spray (midazolam group), (2) placebo sedation and pharyngeal anaesthesia with lidocaine (lidocaine group), (3) placebo sedation and placebo throat spray (placebo group), and (4) no intravenous cannula nor throat spray (control group). Continuous electrocardiogram was recorded. Heart rate variability was assessed; the powers of low frequency (0.04-0.15 Hz) and high frequency (0.15-0.40 Hz) components as well as total power (0.0-0.4 Hz) were calculated. RESULTS Gastroscopy was associated with a decrease in high frequency normalized units, increases in low frequency normalized units and low frequency/high frequency ratio indicating activation of sympathetic and withdrawal of vagal modulation. Sympathetic activation resulted in a decrease in total power and all components of heart rate variability. The decrease was most prominent in the midazolam treated patients (p<0.001 vs the lidocaine group and p<0.01 vs placebo and control groups during the postendoscopy phase). CONCLUSION Gastroscopy induces a shift towards dominance of the sympathetic modulation of the heart. Premedication with midazolam potentiates this shift.
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Affiliation(s)
- M Ristikankare
- Laakso Hospital, City of Helsinki Health Centre, 00099 Helsinki, Finland.
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Lin S, Konstance R, Jollis J, Fisher DA. The utility of upper endoscopy in patients with concomitant upper gastrointestinal bleeding and acute myocardial infarction. Dig Dis Sci 2006; 51:2377-83. [PMID: 17151907 DOI: 10.1007/s10620-006-9326-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2005] [Accepted: 03/22/2006] [Indexed: 02/06/2023]
Abstract
Patients who present with upper gastrointestinal bleeding (UGIB) in the setting of acute myocardial infarction (AMI) may have suffered an UGIB that subsequently led to an AMI or endured an AMI and subsequently suffered a UGIB as a consequence of anticoagulation. We hypothesized that patients in the former group bled from more severe upper tract lesions. The aim of this study was to evaluate predictors for endoscopic therapy in patients who suffer a concomitant UGIB and AMI. Retrospective, single center medical record abstraction of hospital admissions from January 1, 1996-December 31, 2002. During the study period, 183 patients underwent an esophagogastroduodenoscopy (EGD) within 7 days of suffering an AMI and UGIB (AMI group N=105, UGIB group N=78). A higher proportion of patients in the UGIB group (41%) was found to have high-risk UGI lesions requiring endoscopic treatment compared to patients in the AMI group (17%; P < 0.004). UGIB as the inciting event and patients suffering from hematemesis and hemodynamic instability were significantly associated with requiring endoscopic therapy. Although predominantly diagnostic, endoscopic findings in the AMI group did alter the decision to perform cardiac catheterization in 43% of patients. Severe complications occurred in 1% (95% confidence interval, 0%-4%) of patients. We conclude that in patients suffering from concomitant UGIB and AMI, urgent endoscopy was most beneficial in patients with UGIB as the initial event and those presenting with hematemesis and hemodynamic instability. In patients without these clinical features, urgent endoscopy may be delayed, unless cardiac management decisions are dependent on endoscopic findings.
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Affiliation(s)
- Sauyu Lin
- Division of Gastroenterology, Department of Medicine, Durham, North Carolina, USA.
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Ristikankare M, Julkunen R, Heikkinen M, Mattila M, Laitinen T, Wang SX, Hartikainen J. Sedation, topical pharyngeal anesthesia and cardiorespiratory safety during gastroscopy. J Clin Gastroenterol 2006; 40:899-905. [PMID: 17063108 DOI: 10.1097/01.mcg.0000225579.65761.b1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
GOALS In a prospective, double-blind study, we examined the effects of routine sedation and pharyngeal anesthesia on cardiorespiratory parameters during gastroscopy. BACKGROUND Intravenous sedation and topical pharyngeal anesthesia are used to alleviate the discomfort during upper gastrointestinal endoscopy. Cardiorespiratory changes during gastroscopy are common. STUDY Two hundred fifty two consecutive outpatients undergoing gastroscopy were assigned into 4 groups: (1) sedation with intravenous midazolam and placebo throat spray (midazolam group), (2) placebo sedation and pharyngeal anesthesia with lidocaine throat spray (lidocaine group), (3) placebo sedation and placebo throat spray (placebo group), and (4) no intravenous cannula nor throat spray (control group). Arterial oxygen saturation (SaO2), systolic and diastolic blood pressure and continuous electrocardiogram were recorded before, during, and after the endoscopic procedure. RESULTS Gastroscopy increased heart rate in all study groups. Premedication with intravenous midazolam or lidocaine spray alleviated this rise (P<0.001, repeated measures analysis of variance) and decreased the incidence of tachycardia. Similarly, sedation with midazolam or topical pharyngeal anesthesia decreased the rise in systolic blood pressure (P<0.001). Midazolam produced lower SaO2 values during gastroscopy compared with lidocaine, placebo or control groups (P<0.001). However, episodes of desaturation (SaO2 </=92) were no more common in the midazolam group than in other groups. CONCLUSIONS Premedication with midazolam alleviated the rise in heart rate and systolic blood pressure but induced a statistically significant decrease in arterial oxygen saturation. However, gastroscopy proved to be a safe procedure both with and without sedation.
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Ochi Y, Nomura M, Okamura S, Yano M, Saito K, Nakaya Y, Ito S. Changes in autonomic nervous activity during endoscopic retrograde cholangiopancreatography: a possible factor in cardiac complications. J Gastroenterol Hepatol 2002; 17:1021-9. [PMID: 12167125 DOI: 10.1046/j.1440-1746.2002.02796.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIMS The changes of autonomic nervous activity during endoscopic retrograde cholangiopancreatography (ERCP) are closely related to the development of cardiovascular complications, such as arrhythmias and acute coronary syndrome. In the present study, the correlation between changes in hemodynamics and autonomic nervous activity during ERCP procedures was evaluated by analyzing heart rate variability and blood catecholamine levels. METHODS Twenty-three patients who underwent ERCP (ERCP group) and 15 control subjects who were only premedicated (C group) were studied. Ambulant ECG, blood pressure, arterial oxygen saturation, and blood level of catecholamine were measured. Autonomic nervous function was assessed by analyzing the spectral analysis and 1/f fluctuation. The low frequency power (LF power; 0.04-0.15 Hz), high frequency power (HF power; 0.15-0.40 Hz, indicator of parasymapathetic tone), the ratio of LF power to HF power (LF/HF ratio, indicator of sympathetic tone), and 1/f fluctuation (indicator of pleasant mood) were calculated. RESULTS Blood pressure and heart rate were increased and arterial oxygen saturation was decreased in the ERCP group during the endoscopic procedure. Changes in the parameters of autonomic nervous function (LF power, HF power, LF/HF ratio, and 1/f fluctuation) were significantly greater in the ERCP group than in the C group, especially during cholangiography. Moreover, blood levels of catecholamines were significantly increased during the ERCP procedure. In the C group, however, blood levels of catecholamines did not significantly change except directly after premedication. CONCLUSIONS Autonomic nervous activity varied greatly during cholangiography, demonstrating that ERCP has more than a little influence on the cardiovascular system. The results of the present study indicated that attention should be focused on changes in hemodynamics in patients with cardiovascular complications by monitoring the aforementioned hemodynamic parameters during ERCP.
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Affiliation(s)
- Yoshie Ochi
- Second Department of Internal Medicine, University of Tokushima, Japan
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Christensen M, Rasmussen V, Schulze S, Rosenberg J. Vagal withdrawal during endoscopic retrograde cholangiopancreatography. Scand J Gastroenterol 2000; 35:96-101. [PMID: 10672842 DOI: 10.1080/003655200750024605] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) are at risk of developing cardiorespiratory complications, but the mechanism is still unknown. Treatment with metoprolol 2 h before the endoscopy has been shown to decrease the incidence of myocardial ischaemia during ERCP. The present study evaluated whether the endoscopic stress would decrease vagal tone and whether metoprolol given before the procedure could prevent this defence-like reaction. METHODS Thirty-eight patients were randomized to receive either placebo or 100 mg metoprolol 2 h before ERCP. During ERCP the patients were monitored with a Holter tape recorder. Holter tapes from 31 patients (16 receiving metoprolol) were available to analyse the ratio of the standard deviations of the RR intervals (SDRR) to the mean RR intervals (measure of vagal tone) during ERCP. RESULTS A decreased vagal tone during the ERCP was found, but we observed no difference between the metoprolol and the placebo group. For both groups the lowest vagal tone occurred at maximum heart rate during endoscopy. The SDRR/meanRR ratio returned towards base line for the subsequent 60 min after endoscopy. CONCLUSIONS The existence of a defence-like reaction ('vagal withdrawal') during ERCP has been shown. Metoprolol given 2 h before the procedure did not affect the occurrence of this phenomenon. The interaction of other periendoscopic factors is still unclear and should be studied further.
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Affiliation(s)
- M Christensen
- Dept. of Surgical Gastroenterology, Hvidovre University Hospital, Denmark
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10
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Holm C, Christensen M, Rasmussen V, Schulze S, Rosenberg J. Hypoxaemia and myocardial ischaemia during colonoscopy. Scand J Gastroenterol 1998; 33:769-72. [PMID: 9712244 DOI: 10.1080/00365529850171747] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Myocardial ischaemia (defined as ST-segment deviation on electrocardiogram (ECG)) may occur during colonoscopy, but the pathogenic mechanisms are unknown. We have evaluated the occurrence of arterial hypoxaemia, tachycardia, and myocardial ischaemia during routine colonoscopy. METHODS Eighteen patients underwent colonoscopy under conscious sedation and without supplementary oxygen. Arterial oxygen saturation was measured by continuous pulse oximetry, and ECG was monitored continuously with a Holter tape recorder during the procedure. RESULTS Arterial oxygen desaturation and tachycardia were common during colonoscopy and occurred in 45% and 35% of patients, respectively. Two patients developed signs of myocardial ischaemia during the colonoscopy: one case of ST depression (1.7 mV) and one case of ST elevation (4.3 mV). In both patients the ST deviation disappeared when the colonoscope was retracted. Myocardial ischaemia occurred in both patients simultaneously with tachycardia, and in one of these arterial hypoxaemia was also present. CONCLUSIONS Myocardial ischaemia occurs during routine colonoscopy, but with a lower incidence than previously reported during upper endoscopy. Myocardial ischaemia during colonoscopy may be associated with tachycardia and/or hypoxaemia. Further studies should clarify the relative role of tachycardia, hypoxaemia, and viscerocardiac reflexes in the pathogenesis of myocardial ischaemia during colonoscopy.
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Affiliation(s)
- C Holm
- Dept. of Surgery, Sundby Hospital, Copenhagen, Denmark
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Etzkorn KP, Diab F, Brown RD, Dodda G, Edelstein B, Bedford R, Venu RP. Endoscopic retrograde cholangiopancreatography under general anesthesia: indications and results. Gastrointest Endosc 1998; 47:363-7. [PMID: 9609427 DOI: 10.1016/s0016-5107(98)70219-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Conscious sedation is usually used during endoscopic retrograde cholangiopancreatography (ERCP). Little is known about the indications and outcomes for ERCP in patients who cannot undergo conscious sedation and therefore require general anesthesia. We retrospectively evaluated the indications and outcome for patients undergoing ERCP who required general anesthesia at four teaching hospitals over a 2-year period. METHODS Of 1200 ERCPs performed over a 2-year period, 65 patients required general anesthesia. Retrospective chart analysis was undertaken to determine indications and outcomes of ERCP performed under general anesthesia. Eleven patients underwent sphincter of Oddi manometry. RESULTS The major indication for general anesthesia was substance abuse. Therapeutic intervention was successful in 45 of 48 patients; 6 of the 63 patients had complications, all mild and not related to the anesthesia. Sphincter of Oddi manometry was normal in 7 patients; 4 patients had elevated basal pressures. CONCLUSIONS ERCP under general anesthesia may be considered when conscious sedation fails to achieve a satisfactory level of sedation for a successful and safe ERCP. Procedure-related complication rates appear to be comparable if not lower with general anesthesia.
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Affiliation(s)
- K P Etzkorn
- Therapeutic Endoscopy Services, University of Illinois at Chicago, 60612-7323, USA
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Principles & guidelines for respiratory monitoring on the general care floor. The Consortium on Respiratory Monitoring on the General Care Floor. J Clin Monit Comput 1996; 12:411-6. [PMID: 8934349 DOI: 10.1007/bf02077640] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Rosenberg J, Overgaard H, Andersen M, Rasmussen V, Schulze S. Double blind randomised controlled trial of effect of metoprolol on myocardial ischaemia during endoscopic cholangiopancreatography. BMJ (CLINICAL RESEARCH ED.) 1996; 313:258-61. [PMID: 8704533 PMCID: PMC2351707 DOI: 10.1136/bmj.313.7052.258] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To evaluate the effect of metoprolol, a beta adrenergic blocking drug, on the occurrence of myocardial ischaemia during endoscopic cholangiopancreatography. DESIGN Double blind, randomised, controlled trial. SETTING University Hospital. SUBJECTS 38 (two groups of 19) patients scheduled for endoscopic cholangiopancreatography. INTERVENTIONS Metoprolol 100 mg or placebo as premedication two hours before endoscopy. MAIN OUTCOME MEASURES Heart rate, arterial oxygen saturation by continuous pulse oximetry, ST segment changes during endoscopic cholangiopancreatography (an ST segment deviation > 1 mV was defined as myocardial ischaemia), electrocardiogram monitored continuously with a Holter tape recorder. RESULTS All patients had increased heart rate during endoscopy compared with rate before endoscopy, but heart rate during endoscopy was significantly lower in the metoprolol group compared with the placebo group (P = 0.0002). Twenty one patients (16 placebo, 5 metoprolol; P = 0.0008) developed tachycardia (heart rate > 100/min) during the procedure, and 11 patients (10 placebo, 1 metoprolol; P = 0.003) developed myocardial ischaemia. One patient in the placebo group had an acute inferolateral myocardial infarction. In the 10 other patients with signs of myocardial ischaemia during endoscopy the ST deviation disappeared when the endoscope was retracted. In all patients myocardial ischaemia was related to increases in heart rate, and 10 of the 11 patients had tachycardia coherent with myocardial ischaemia. CONCLUSIONS Metoprolol prevented myocardial ischaemia during endoscopic cholangiopancreatography, probably through lowering the heart rate. Thus, tachycardia seems to be a key pathogenic factor in the development of myocardial ischaemia during endoscopy.
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Affiliation(s)
- J Rosenberg
- Department of Surgery, Sundby Hospital, Copenhagen, Denmark
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Rosenberg J, Stausholm K, Andersen IB, Pedersen MH, Brinch K, Rasmussen V, Matzen P. No effect of oxygen therapy on myocardial ischaemia during gastroscopy. Scand J Gastroenterol 1996; 31:200-5. [PMID: 8658044 DOI: 10.3109/00365529609031986] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Myocardial ischaemia (defined as an ST-segment depression on ECG) may occur during upper gastrointestinal endoscopy, but the mechanism is still unknown. The aim of our study was to evaluate the effect of oxygen therapy and tachycardia on the occurrence of ST-segment depression during routine diagnostic esophagogastroduodenoscopy. METHODS Eighty-nine consecutive patients were randomized to receive either oxygen (21/min by nasal prongs) or nothing during endoscopy, in which arterial oxygen saturation was measured by continuous pulse oximetry, and ECG was measured continuously with a Holter tape recorder. RESULTS A total of 28 patients (12 receiving oxygen) developed ST-segment depression ( > 0.1 mV) during endoscopy. In 22 patients (12 receiving oxygen) ST depression was related to tachycardia, and in 5 of these (none receiving oxygen) simultaneous episodic hypoxaemia was present during the event. Thus, in every case of ST depression related to episodic hypoxaemia there was simultaneous tachycardia. In six patients developing ST depression during endoscopy we did not find preendoscopy levels, and 63 patients (29 receiving oxygen) developed tachycardia during the procedure (rate > 100 min-1_. CONCLUSIONS Oxygen therapy had no significant effect on the occurrence of ST-segment depression during upper gastrointestinal endoscopy. The results suggest that tachycardia is more important than hypoxaemia in the pathogenesis of ST depression during gastroscopy.
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Affiliation(s)
- J Rosenberg
- Dept. of Surgical Gastroenterology, University Hospital, Hvidovre, Denmark
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Lee JG, Krucoff MW, Brazer SR. Periprocedural myocardial ischemia in patients with severe symptomatic coronary artery disease undergoing endoscopy: prevalence and risk factors. Am J Med 1995; 99:270-5. [PMID: 7653487 DOI: 10.1016/s0002-9343(99)80159-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
PURPOSE To determine the prevalence of and risk factors for periprocedural myocardial ischemia associated with gastrointestinal endoscopy in patients with severe symptomatic coronary artery disease. PATIENTS AND METHODS In this prospective observational study, myocardial ischemia (ST segment change > 100 microV in any 2 leads or > 200 microV in any 1 lead, lasting > 60 seconds) was assessed using a continuous 12-lead digital electrocardiographic monitor before, during, and after gastrointestinal endoscopy. RESULTS Between June 1992 and May 1993, 1,084 esophagogastroduodenoscopies and 588 colonoscopies were performed during 1,438 consecutive endoscopies on patients admitted to a university hospital. Seventy (18%) of 252 patients with prior angiography had significant coronary artery disease. Fifty-two (74%) were successfully enrolled, and satisfactory electrocardiographic recordings were obtained from 49 (median age 65 years, interquartile range 58 to 74). Thirty-six were men, 12 had myocardial infarctions within the 6 weeks (median 12.5 days, interquartile range 8 to 18), and 25 had unstable angina. The coronary artery disease involved 1 vessel in 14 subjects, 2 vessels in 21, and 3 vessels in 14. Nineteen episodes of ischemia (4 pre-, 6 intra-, 9 postprocedure) were detected in 8 patients (16%; 95% confidence interval, 6% to 26%) during the recording period (median duration 322 min, interquartile range 227 to 429). One patient became symptomatic with a myocardial infarction. Multivariable logistic regression showed that women experienced more periprocedural ischemia compared to men (31% versus 11%; P = 0.058). CONCLUSIONS Myocardial ischemia occurs during the periprocedural period in 16% of hospitalized patients with severe coronary artery disease undergoing gastrointestinal endoscopy. Endoscopy is safe in hemodynamically stable patients with recent myocardial infarction and/or unstable angina. Women appear to be at greater risk for periprocedural ischemia associated with endoscopy.
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Affiliation(s)
- J G Lee
- Division of Gastroenterology, Duke University Medical Center, Durham, North Carolina, USA
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Rosenberg J. Nasal oxygen during endoscopy. Gut 1993; 34:288. [PMID: 8432489 PMCID: PMC1373987 DOI: 10.1136/gut.34.2.288] [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] [Indexed: 01/30/2023]
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