Neurologic Safety of Etomidate-Based Sedation during Upper Endoscopy in Patients with Liver Cirrhosis Compared with Propofol: A Double-Blind, Randomized Controlled Trial

Endo-anesthesia: a primer

Gastrointestinal (GI) endoscopy has witnessed a Cambrian explosion of techniques, indications, and expanding target populations. GI endoscopy encompasses traditional domains that include preventive measures, palliation, as alternative therapies in patients with prohibitive risks of more invasive procedures, and indicated primary treatments. But, it has expanded to include therapeutic and diagnostic interventional endosonography, luminal endoscopic resection, third space endotherapy, endohepatology, and endobariatrics. The lines between surgery and endoscopy are blurred on many occasions within this paradigm. Moreover, patients with high degrees of co-morbidity and complex physiology require more nuanced peri-endoscopic management. The rising demand for endoscopy services has resulted in the development of endoscopy referral centers that offer these invasive procedures as directly booked referrals for regional and rural patients. This further necessitates specialized programs to ensure appropriate evaluation, risk stratification, and optimization for safe sedation and general anesthesia if needed. This landscape is conducive to the organic evolution of endo-anesthesia to meet the needs of these focused and evolving practices. In this primer, we delineate important aspects of endo-anesthesia care and provide relevant clinical and logistical considerations pertaining to the breadth of procedures.

Etomidate affects spatial learning and memory and neuronal apoptosis of rats via MAPK/ERK pathway

OBJECTIVE

To observe the effect of etomidate on spatial learning and memory and neuronal apoptosis in rats of different ages.

METHODS

The rats of different ages were divided into 3 age groups: juvenile (21-day old), adult (~3-months old) and elderly (~19-months old). Then, rats with similar age within a group were randomly divided into three subgroups, with 10 rats in each group. The experimental subgroups were intraperitoneally injected with etomidate (emulsion formulated, i.p. injection) at a dose of 5 mg/kg; the solvent control subgroups were given intraperitoneal injection of vehicle emulsion; and blank control subgroups received laparoscopic injection of normal saline. The rats' learning and memory ability was tested by Morris water maze. The tissue sections of each group's hippocampus were analyzed by H&E staining. The apoptosis of hippocampal cells was detected by TUNEL staining. MAPK expression in hippocampus was tested by Western blot.

RESULTS

Etomidate significantly extended the escape latency and reduced the platform crossings and the swimming time at original platform of juvenile rats, indicating that the spatial learning and memory function of juvenile rats can be affected by etomidate. However, etomidate had no effect on spatial learning and memory in adult and elderly rats. There were no obvious abnormalities in number of neurons and morphology of vertebral cells in the hippocampus of all experimental subgroups when compared with those of corresponding blank control subgroups. There was no statistically significant difference in apoptosis index of the hippocampal tissue between the experimental subgroups and corresponding blank control subgroups (P>0.05). Within juvenile group, the expression of p-ERK in the hippocampus of experimental subgroup was remarkably lower than that of solvent control subgroup and blank control subgroup (P<0.05), while there were no significant differences in p-p38 and p-JNK expressions among the three subgroups of juvenile rats (P>0.05). The expressions of p-ERK, p-p38 and p-JNK in adult and elderly rats were not affected by etomidate.

CONCLUSION

Etomidate may have certain effects on spatial learning and memory in juvenile rats but not in adult and elderly rats. Etomidate affects neither the number of neurons in the CA1 area of the hippocampus nor the morphology of vertebral cells and did not cause the apoptosis of nerve cells. The mechanism of etomidate influence on the spatial learning and memory function of young rats may connect with the inhibition of MAPK/ERK pathway.

Pre-procedural Preparation and Sedation for Gastrointestinal Endoscopy in Patients with Advanced Liver Disease

Gastrointestinal endoscopy in patients with advanced liver disease poses various challenges, a major one being procedural sedation and its associated considerations. While sedation during endoscopy can improve patient comfort, decrease anxiety, and facilitate procedural completion, in patients with advanced liver disease, it is also associated with substantial and unique risks due to alterations in drug metabolism and other factors. As such, the choice of sedative agent(s) and related logistics may require careful inter-disciplinary planning and individualized considerations. Furthermore, a large proportion of agents require dose reductions and particular monitoring of the vital signs, level of consciousness, and other indices. In the present review, we provide a contemporary overview of procedural sedation considerations, commonly used intravenous sedatives, and second-line as well as novel sedatives for gastrointestinal endoscopy in patients with advanced liver disease.

Comparative Safety Profiles of Sedatives Commonly Used in Clinical Practice: A 10-Year Nationwide Pharmacovigilance Study in Korea

This study aims to compare the prevalence and seriousness of adverse events (AEs) among sedatives used in critically ill patients or patients undergoing invasive procedures and to identify factors associated with serious AEs. Retrospective cross-sectional analysis of sedative-related AEs voluntarily reported to the Korea Adverse Event Reporting System from 2008 to 2017 was performed. All AEs were grouped using preferred terms and System Organ Classes per the World Health Organization-Adverse Reaction Terminology. Logistic regression was performed to identify factors associated with serious events. Among 95,188 AEs, including 3132 (3.3%) serious events, the most common etiologic sedative was fentanyl (58.8%), followed by pethidine (25.9%). Gastrointestinal disorders (54.2%) were the most frequent AEs. The most common serious AE was heart rate/rhythm disorders (33.1%). Serious AEs were significantly associated with male sex; pediatrics; etiologic sedative with etomidate at the highest risk, followed by dexmedetomidine, ketamine, and propofol; polypharmacy; combined sedative use; and concurrent use of corticosteroids, aspirin, neuromuscular blockers, and antihistamines (reporting odds ratio > 1, p < 0.001 for all). Sedative-induced AEs are most frequently reported with fentanyl, primarily manifesting as gastrointestinal disorders. Etomidate is associated with the highest risk of serious AEs, with the most common serious events being heart rate/rhythm disorders.