Cardiac arrests in patients undergoing gastrointestinal endoscopy: A retrospective analysis of 73,029 procedures

Efficacy and safety of supraglottic jet oxygenation and ventilation to minimize sedation-related hypoxemia: a meta-analysis with GRADE approach

INTRODUCTION

Hypoxemia is a common complication of sedation. This meta-analysis aimed to evaluate the efficacy and safety of supraglottic jet oxygenation and ventilation (SJOV) in preventing hypoxemia during sedative procedures.

METHODS

Randomized controlled trials (RCTs) that compared SJOV with conventional oxygen therapy in sedated patients were searched in five databases (MEDLINE, EMBASE, Cochrane Library, China National Knowledge Infrastructure [CNKI], and Google Scholar) from their inception to March 2024. The primary outcome was the proportion of patients who developed hypoxia (SpO2 < 90%). The secondary outcomes included subclinical respiratory depression (90% ≤ SpO2 < 95%), severe hypoxemia (SpO2 < 75%), airway interventions, adverse events, hemodynamics, propofol dosage, and procedure time. The certainty of evidence was determined using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

RESULTS

Twelve trials (n = 3058) were included in the analysis. The evidence suggests that SJOV results in a large reduction in the risk of hypoxemia (risk ratio [RR], 0.26; 95% confidence interval, 0.19-0.36; low certainty) and subclinical respiratory depression (RR, 0.40; low certainty) compared with the control. SJOV likely resulted in a large reduction in the risk of severe hypoxemia (RR, 0.22; moderate certainty). In addition, it may result in a large reduction in the need for jaw lift (RR, 0.22; low certainty) and mask ventilation (RR, 0.13; low certainty). The risk of sore throat probably increases with SJOV (RR, 1.71; moderate certainty), whereas SJOV may result in little to no difference in nasal bleeding (RR, 1.75; low certainty). Evidence is very uncertain regarding the effect of SJOV on hemodynamics (very low certainty) and procedure time (very low certainty). SJOV probably resulted in little to no difference in sedative doses between the groups (moderate certainty).

CONCLUSION

According to the GRADE approach, SJOV likely results in a large reduction in the risk of severe hypoxemia but probably increases the risk of sore throat. Compared with the control, evidence suggests that SJOV results in a large reduction in the risk of hypoxemia, subclinical respiratory depression, and the need for airway manipulation, with little to no difference in nasal bleeding. The integration of SJOV into clinical practice may help minimize hypoxemic events in at-risk patients.

Bispectral Index Guidance Reduced Target Plasma Propofol Concentration During ERCP in Patients with Liver Cirrhosis

Objective

The primary aim of this study was to investigate the guidance effect of the bispectral index (BIS) on the target plasma concentration (TPC) of propofol required for deep sedation during endoscopic retrograde cholangiopancreatography (ERCP). Second, to identify propofol consumption, recovery time, and adverse events.

Methods

A total of 42 consecutive patients with liver cirrhosis and 43 consecutive patients with healthy livers were enrolled. Propofol was administered via a target control infusion (TCI) syringe pump (Marsh Model) at BIS 60-70. Patients were not intubated, were placed in the prone position, and underwent spontaneous breathing. Propofol TPCs (μg mL-1) and BIS values were recorded at T0 (baseline), T1 (5 min after induction), T2 (5 min into ERCP), T3 (15 min), T4 (30 min), and T5 (recovery).

Results

TPCs and propofol consumption were lower in patients with cirrhosis than in those without cirrhosis (T4: 2.7±0.5 vs. 3.3±0.4 μg mL-1), P=0.001, and 270.4±6.9 mg vs. 390.8±13.4 mg, P=0.001), respectively. Patients with cirrhosis required more time to recover (8.5±2 vs. 6.2±0.9 min, P=0.001), despite comparable ERCP durations (31.1±11.1 vs. 34±12.5 min, P=0.28). A significant decline in TPC values among patients with cirrhosis with time (T1: 3.3±0.3, T2: 3.1±0.3, T3: 2.9±0.4, T4: 2.7±0.5 μg mL-1, P=0.001), indicating a cumulative effect. One patient with cirrhosis required bag-mask ventilation, while three patients without cirrhosis were converted to general anaesthesia.

Conclusion

Combining the TCI Marsh pharmacokinetic model with BIS monitoring lowered the TPC levels required for deep sedation in patients with cirrhosis compared with healthy patients and allowed for individual variations. The prone position in deeply sedated and non-intubated spontaneous breathing patients is not without the risk of hypoxia.

Do all sedatives promote biological sleep electroencephalogram patterns? A machine learning framework to identify biological sleep promoting sedatives using electroencephalogram

BACKGROUND

Sedatives are commonly used to promote sleep in intensive care unit patients. However, it is not clear whether sedation-induced states are similar to the biological sleep. We explored if sedative-induced states resemble biological sleep using multichannel electroencephalogram (EEG) recordings.

METHODS

Multichannel EEG datasets from two different sources were used in this study: (1) sedation dataset consisting of 102 healthy volunteers receiving propofol (N = 36), sevoflurane (N = 36), or dexmedetomidine (N = 30), and (2) publicly available sleep EEG dataset (N = 994). Forty-four quantitative time, frequency and entropy features were extracted from EEG recordings and were used to train the machine learning algorithms on sleep dataset to predict sleep stages in the sedation dataset. The predicted sleep states were then compared with the Modified Observer's Assessment of Alertness/ Sedation (MOAA/S) scores.

RESULTS

The performance of the model was poor (AUC = 0.55-0.58) in differentiating sleep stages during propofol and sevoflurane sedation. In the case of dexmedetomidine, the AUC of the model increased in a sedation-dependent manner with NREM stages 2 and 3 highly correlating with deep sedation state reaching an AUC of 0.80.

CONCLUSIONS

We addressed an important clinical question to identify biological sleep promoting sedatives using EEG signals. We demonstrate that propofol and sevoflurane do not promote EEG patterns resembling natural sleep while dexmedetomidine promotes states resembling NREM stages 2 and 3 sleep, based on current sleep staging standards.

British Society of Gastroenterology guidelines on sedation in gastrointestinal endoscopy

Over 2.5 million gastrointestinal endoscopic procedures are carried out in the United Kingdom (UK) every year. Procedures are carried out with local anaesthetic r with sedation. Sedation is commonly used for gastrointestinal endoscopy, but the type and amount of sedation administered is influenced by the complexity and nature of the procedure and patient factors. The elective and emergency nature of endoscopy procedures and local resources also have a significant impact on the delivery of sedation. In the UK, the vast majority of sedated procedures are carried out using benzodiazepines, with or without opiates, whereas deeper sedation using propofol or general anaesthetic requires the involvement of an anaesthetic team. Patients undergoing gastrointestinal endoscopy need to have good understanding of the options for sedation, including the option for no sedation and alternatives, balancing the intended aims of the procedure and reducing the risk of complications. These guidelines were commissioned by the British Society of Gastroenterology (BSG) Endoscopy Committee with input from major stakeholders, to provide a detailed update, incorporating recent advances in sedation for gastrointestinal endoscopy.This guideline covers aspects from pre-assessment of the elective 'well' patient to patients with significant comorbidity requiring emergency procedures. Types of sedation are discussed, procedure and room requirements and the recovery period, providing guidance to enhance safety and minimise complications. These guidelines are intended to inform practising clinicians and all staff involved in the delivery of gastrointestinal endoscopy with an expectation that this guideline will be revised in 5-years' time.

Outcomes and evaluation of endoscopic retrograde cholangiopancreatography via Gastro-Laryngeal Tube in adult patients: a prospective randomised control study

OBJECTIVES

In conventional endoscopic retrograde cholangiopancreatography (ERCP), the patient lies prone or in a semi-prone position under deep sedation and maintains spontaneous ventilation. Sedative-induced respiratory depression and unprotected airway compromise patients' safety. The gastro-laryngeal tube (G-LT) is a novel reusable supraglottic airway device with two separate ports for endoscopy and ventilation. This study attempts to evaluate the performance characteristic of G-LT.

METHODS

One hundred and forty patients undergoing ERCP were enrolled and randomized. In Group G, patients underwent ERCP with G-LT, whereas Group S patients underwent ERCP conventionally. G-LT insertion attempts, esophageal visualization times, vital parameters, propofol consumption, endoscopists' and anesthesiologists' satisfaction scores, time to achieve Modified Aldrete Score of ≥ 9, and complications were recorded.

RESULTS

Both groups showed similar demographic parameters and 100% procedure completion rates. G-LT group showed shortened esophageal visualization times (4.71 ± 1.687 s vs 7.37 ± 1.515 s) and increased propofol consumption (423.14 ± 106.982 mg vs 178.00 ± 100.125 mg). Group G showed better endoscopic maneuvrability and lesser hemodynamic variability. Sore throat, dysphagia, and mucosal trauma were higher in the G-LT group.

CONCLUSION

G-LT provides less intra-procedural hemodynamic changes, quicker esophageal visualization, and better scope maneuvrability at the cost of higher propofol consumption, sore throat, dysphagia, and mucosal trauma.

TRIAL REGISTRATION

Clinical Trial Registry of India CTRI/2021/06/034212 (Registered on: 14/06/2021).

High-flow nasal oxygenation during gastrointestinal endoscopy. Systematic review and meta-analysis

Background

The use of high-flow nasal oxygen (HFNO) has the potential to improve patient safety by limiting hypoxaemia during gastrointestinal endoscopy. The degree of benefit is not adequately established.

Methods

English language literature searches of PubMed, Scopus, Web of Science, and Cochrane Library electronic databases were performed to identify randomised controlled trials comparing HFNO and conventional oxygen therapy (COT) for patients undergoing gastrointestinal endoscopy under deep sedation. The primary endpoint was the incidence of hypoxic events observed during endoscopic procedures. The secondary endpoints were the incidence of recourse to rescue manoeuvres, procedure interruption, and adverse events. A meta-analysis and a post hoc trial sequence analysis were performed.

Results

A total of 2867 patients from six randomised controlled trials were considered. Desaturation was observed in 5.2% and 27.2% of patients receiving HFNO and COT, respectively. Desaturation <90% was observed in 1.8% and 12.6% of the patients receiving HFNO and COT, respectively. In the subgroup analysis, desaturation occurrence was lower during HFNO than during COT in non-obese patients (2.2% vs 25.2%) and obese patients (22.9% vs 43.3%). Desaturation occurrence was lower during maximum (3.6% vs 26.9%) and minimum (15.9% vs 29.8%) HFNO therapy than during COT. HFNO showed a lower recurrence to rescue manoeuvres rate (4.7% vs 34.3%), a lower procedure interruption rate (0.4% vs 6.7%), and a lower adverse events rate (18.7% vs 21%) than COT. A high level of heterogeneity between the studies precluded confidence in drawing inference from the meta-analysis.

Conclusions

The evidence reviewed suggests that compared with COT, HFNO has fewer hypoxaemic events during gastrointestinal endoscopy, but this may not apply to all patients and clinical scenarios.

Efficacy of high flow nasal oxygenation against hypoxemia in sedated patients receiving gastrointestinal endoscopic procedures: A systematic review and meta-analysis

STUDY OBJECTIVE

To evaluate the impact of high flow nasal oxygenation (HFNO) on the risk of hypoxemia during gastrointestinal endoscopic procedures (GEPs) under sedation.

DESIGN

Meta-analysis of randomized controlled trials.

SETTING

Gastrointestinal endoscopy.

INTERVENTION

HFNO.

PATIENTS

Adults patients undergoing GEPs under sedation.

MEASUREMENTS

The primary outcome was risk of hypoxemia, while the secondary outcomes included risks of severe hypoxemia, hypercapnia, need for jaw thrust or other airway interventions, and procedural interruption as well as procedure time, minimum SpO₂, and level of carbon dioxide (CO₂). Analyses based on age, gender, flow rate, risk status of patients were performed to investigate subgroup effects.

RESULTS

Medline, Google scholar, Cochrane Library, and EMBASE databases were searched from inception to July 2021. Seven randomized controlled trials (RCTs) involving 2998 patients published from 2019 to 2021 were included. All GEPs were performed under propofol sedation. Pooled results revealed significantly lower risks of hypoxemia [relative risk (RR) = 0.31, 95% CI:0.13-0.75; 2998 patients], severe hypoxemia (RR = 0.38, 95% CI:0.2-0.74; 2766 patients), other airway interventions (RR = 0.34, 95% CI:0.22-0.52; 2736 patients), procedural interruption (RR = 0.12, 95% CI:0.02-0.64, 451 patients) and a lower CO₂ level [standard mean difference (MD) = -0.21, 95% CI: -0.4 to -0.03; 458 patients] in HFNO group compared to control group. Subgroup analysis focusing on risk of hypoxemia showed no significant subgroup effects, indicating consistent benefits of HFNO in different clinical settings. There were no difference in minimum SpO₂ (p = 0.06; 262 patients), risk of hypercapnia (p = 0.09; 393 patients), need for jaw thrust (p = 0.28; 2256 patients), and procedure time (p = 0.41, 1004 patients) between the two groups.

CONCLUSION

Our results demonstrated the efficacy of high flow nasal oxygenation for reducing the risk of hypoxemia in patients receiving elective gastrointestinal endoscopic procedures under sedation. Further studies are warranted to verify its cost-effectiveness in the gastrointestinal endoscopy setting.

Non-intubated general anesthesia in prone position for advanced biliopancreatic therapeutic endoscopy: A single tertiary referral center experience

Background and Study Aim:

Advance biliopancreatic endoscopies are nowadays performed in non-operating room anesthesia (NORA) under general anesthesia (GA). We evaluate the outcomes of non-intubated patients in prone position who received GA for endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) in a tertiary referral center for digestive endoscopy.

Patients and Methods:

Anesthesiological records, anamnestic, and intraoperative data of patients who underwent advanced therapeutic biliopancreatic endoscopies at our tertiary referral center from January 2019 until January 2020 were collected in the present observational study.

Results:

One hundred fifty-three patients (93 M; median age: 68-year-old; mean ASA status: 2) were considered eligible for a procedure in the prone position with GA in spontaneous breathing. Prone position was always the initial setting. Propofol administration through a target-controlled infusion (TCI) pump was the choice to achieve GA. In our experience, desaturation appears to be the most frequent adverse event, accounting for 35% of cases (55/153). Treatment foresaw additional oxygen through a nasopharyngeal catheter, which proved to be a sufficient measure in almost all patients (52/55). Other adverse events (i.e., inadequate sedative plan, pain, and bradycardia) accounted for 2.6% of cases (4/153).

Conclusions:

Non-intubated GA in the prone position may be regarded as a safe procedure, as long as the anesthesiological criteria of exclusion are respected and the anesthesiological team has become acquainted with the peculiar NORA setting and familiar with the management of possible adverse events.

Oliceridine- Opioid of the 21st Century

Oliceridine (Olinvyk® Trevena, PA, USA) was approved by the United States Food and Drug Administration for clinical use on Aug 8, 2020. Even though, the indication of its approval is very restrictive (to manage moderate-to-severe acute pain in adults when the pain is severe enough), for such an innovative opioid, off-label indications are bound to abound. What could be described as the "opioid of the century," it aims to overcome some of the stubbornest barriers to opioid prescribing, namely addiction liability, respiratory depression, and gastrointestinal (GI) side effects, just to name a few. The novel opioid accomplishes this by a unique mechanism of action. By selectively acting on the G-protein sub-pathway in preference to the beta-arrestin, it aims to mitigate these unwanted µ-opioid receptors-associated opioid side effects, while preserving its analgesic activity. What remains to be seen, however, is if these observations seen in phases 2 and 3 trials will be borne in actual large-scale clinical use, both inside and outside the USA. Unfortunately, the field of anesthesia is rife with innovations that have shown enormous promise at the research stage, only to end up as damp squibs when released to the clinicians for general use. Rapcuronium and althesin are some such examples. We aim to present some of the contentious and emerging issues associated with this drug and some of the potential pitfalls of this new opioid.

Effect of high-flow vs. low-flow nasal plus mouthguard oxygen therapy on hypoxaemia during sedation: a multicentre randomised controlled trial

Whether high-flow vs. low-flow nasal oxygen reduces hypoxaemia for sedation during endoscopic retrograde cholangiopancreatography is currently unknown. In this multicentre trial, 132 patients ASA physical status 3 or higher, BMI > 30 kg.m^-2 or with known or suspected obstructive sleep apnoea were randomly allocated to high-flow nasal oxygen up to 60 l.min^-1 at 100% F_I O₂ or low-flow nasal oxygen at 4 l.min^-1 . The low-flow nasal oxygen group also received oxygen at 4 l.min^-1 through an oxygenating mouthguard, totalling 8 l.min^-1 . Primary outcome was hypoxaemia, defined as S_p O₂ < 90% regardless of duration. Hypoxaemia occurred in 7.7% (5/65) of patients with high-flow and 9.1% (6/66) with low-flow nasal oxygen (percentage point difference -1.4%, 95%CI -10.9 to 8.0; p = 0.77). Between the groups, there were no significant differences in frequency of hypoxaemic episodes; lowest S_p O₂ ; peak transcutaneous carbon dioxide; hypercarbia (transcutaneous carbon dioxide > 2.66 kPa from baseline); requirement of chin lift/jaw thrust; nasopharyngeal airway insertion; bag-mask ventilation; or tracheal intubation. Following adjustment for duration of the procedure, the primary outcome remained non-significant. In high-risk patients undergoing endoscopic retrograde cholangiopancreatography, oxygen therapy with high-flow nasal oxygen did not reduce the rate of hypoxaemia, hypercarbia or the need for airway interventions, compared with combined oral and nasal low-flow oxygen.

Discharge following sedation for endoscopic procedures: a best practice implementation project

OBJECTIVES

The aim of this project was to promote best discharge practice in sedated patients following endoscopic procedures in an endoscopy tertiary center in Shanghai, China.

INTRODUCTION

Discharge of sedated patients is the final stage of the endoscopic procedure. Healthcare providers must ensure patient safety through timely and appropriate discharge from endoscopic procedures.

METHODS

A clinical audit was undertaken using the JBI Practical Application of Clinical Evidence System tool. Eight audit criteria that were representative of best-practice recommendations for the discharge of sedated patients following endoscopic procedures were used. A baseline audit was conducted, followed by the implementation of multiple strategies that were determined by the key stakeholders. The project was finalized with a follow-up audit to determine change in practice.

RESULTS

Improvements in practice were observed for all eight criteria. The most significant improvements were for the following criteria: an organizational policy exists for patient discharge after endoscopy, minimum discharge criteria are established, minimum discharge criteria are met before the patient is discharged (each from 0% to 100% compliance), patient received written and verbal discharge instructions (from 12% to 100% compliance), and discharge care plan is documented in the patient's medical file (from 0% to 88%). Criteria 4 (discharge is authorized by an appropriate staff member), 6 (staff member is appropriately trained and educated) and 7 (patient is accompanied by a responsible adult) achieved the least improvement in compliance rates, as baseline measures already showed a high degree of compliance. Overall, there was improvement in compliance for all best-practice recommendations.

CONCLUSIONS

The project demonstrated positive changes in the discharge care of sedated patients following endoscopic procedures in an endoscopy tertiary center in Shanghai, China. A formalized organizational discharge policy is currently in place and a continuous cycle of audit and re-audit will need to be carried out in the future to keep the quality at a high and steady level.

Recent Developments in Devices Used for Gastrointestinal Endoscopy Sedation

Hypoxemia is a frequent and potentially fatal complication occurring in patients during gastrointestinal endoscopy. The administration of propofol sedation increases the risk of most complications, especially hypoxemia. Nevertheless, propofol has been increasingly used in the United States, and the trend is likely to increase in the years to come. Patient satisfaction and endoscopist satisfaction along with rapid turnover are some of the touted reasons for this trend. However, propofol sedation generally implies deep sedation or general anesthesia. As a result, hypopnea and apnea frequently occur. Inadequate sedation and presence of irritable airway often cause coughing and laryngospasm, both leading to hypoxemia and potential cardiac arrest. Hence, prevention of hypoxemia is of paramount importance. Traditionally, standard nasal cannula is used to administer supplement oxygen. However, it cannot sufficiently provide continuous positive airway pressure (CPAP) or positive pressure ventilation. Device manufacturers have stepped in to fill this void and created many types of cannulas that provide apneic insufflation of oxygen and CPAP and eliminate dead space. Such measures decrease the incidence of hypoxemia. This review aimed to provide essential information of some of these devices.

High-Flow Nasal Cannula Oxygen in Patients Having Anesthesia for Advanced Esophagogastroduodenoscopy: HIFLOW-ENDO, a Randomized Clinical Trial

BACKGROUND

Over 6 million esophagogastroduodenoscopy (EGD) procedures are performed in the United States each year. Patients having anesthesia for advanced EGD procedures, such as interventional procedures, are at high risk for hypoxemia.

METHODS

Our primary study aim was to evaluate whether high-flow nasal cannula (HFNC) oxygen reduces the incidence of hypoxemia during anesthesia for advanced EGD. Secondarily, we studied whether HFNC oxygen reduces hypercarbia or hypotension. After obtaining written informed consent, adults having anesthesia for advanced EGD, expected to last longer than 15 minutes, were randomly assigned to receive HFNC oxygen or standard nasal cannula (SNC) oxygen. The primary outcome was occurrence of one or more hypoxemia events during anesthesia, defined by arterial oxygen saturation <92% for at least 15 consecutive seconds. Secondary outcomes were occurrence of one or more hypercarbia or hypotension events. A hypercarbia event was defined by a transcutaneous CO2 measurement 20 mm Hg or more above baseline, and a hypotension event was defined by a mean arterial blood pressure measurement 25% or more below baseline.

RESULTS

Two hundred seventy-one adult patients were enrolled and randomized, and 262 patients completed study procedures. Eight randomized patients did not complete study procedures due to changes in their anesthesia or endoscopy plan. One patient was excluded from analysis because their procedure was aborted after 1 minute. Patients who received HFNC oxygen (N = 132) had a significantly lower incidence of hypoxemia than those who received SNC oxygen (N = 130; 21.2% vs 33.1%; hazard ratio [HR] = 0.59 [95% confidence interval {CI}, 0.36-0.95]; P = .03). There was no difference in the incidence of hypercarbia or hypotension between the groups. The HR for hypercarbia with HFNC oxygen was 1.29 (95% CI, 0.89-1.88; P = .17), and the HR for hypotension was 1.25 (95% CI, 0.86-1.82; P = .25).

CONCLUSIONS

HFNC oxygen reduces the incidence of hypoxemia during anesthesia for advanced EGD and may offer an opportunity to enhance patient safety during these procedures.

Oliceridine and its potential to revolutionize GI endoscopy sedation

Providing sedation to patients undergoing gastrointestinal (GI) endoscopy is a controversial and emotive issue. The mainstay of sedation is propofol, whose administration is within the sole jurisdiction of anesthesia providers, at least in the USA. Attempts have been made to seize the authority by the GI community. One of the first attempts was the use of the prodrug of propofol -fospropofol. However, as the drug has a similar adverse effect profile as propofol in terms of respiratory depression, the FDA did not approve its use by providers other than those trained in airway management. Sedasys® was the next attempt, which was a computer-assisted personalized sedation system. As a result of insufficient sedation that could be provided with the device, although very successful in research settings, it was not a commercial success. It seems that remimazolam is the next effort in this direction. It is likely to fail in this regard unless its respiratory depressant properties and failure rates could be addressed. G protein-biased μ-receptor agonists are a new class of opioids exhibiting analgesic properties similar to morphine without equivalent respiratory depressant properties. Oliceridine is the prototype. As a result, the drug can be additive to midazolam or remimazolam and allow screening colonoscopy to be comfortably completed without the need for propofol. For an anesthesia provider, the administration of oliceridine can eliminate the need for drugs such as fentanyl that add to the respiratory depressant properties of propofol. As a result, oliceridine has the potential to render the sedation for GI endoscopy procedures both safe and cost-effective.

Nasopharyngeal Tube Effects on Breathing during Sedation for Dental Procedures: A Randomized Controlled Trial

WHAT WE ALREADY KNOW ABOUT THIS TOPIC

Dental procedures under sedation can cause hypoxic events and even death. However, the mechanism of such hypoxic events is not well understood.

WHAT THIS ARTICLE TELLS US THAT IS NEW

Apnea and hypopnea occur frequently during dental procedures under sedation. The majority of the events are not detectable with pulse oximetry. Insertion of a nasal tube with small diameter does not reduce the incidence of apnea/hypopnea.

BACKGROUND

Intravenous sedation is effective in patients undergoing dental procedures, but fatal hypoxemic events have been documented. It was hypothesized that abnormal breathing events occur frequently and are underdetected by pulse oximetry during sedation for dental procedures (primary hypothesis) and that insertion of a small-diameter nasopharyngeal tube reduces the frequency of the abnormal breathing events (secondary hypothesis).

METHODS

In this nonblinded randomized control study, frequency of abnormal breathing episodes per hour (abnormal breathing index) of the patients under sedation for dental procedures was determined and used as a primary outcome to test the hypotheses. Abnormal breathing indexes were measured by a portable sleep monitor. Of the 46 participants, 43 were randomly allocated to the control group (n = 23, no nasopharyngeal tube) and the nasopharyngeal tube group (n = 20).

RESULTS

In the control group, nondesaturated abnormal breathing index was higher than the desaturated abnormal breathing index (35.2 [20.6, 48.0] vs. 7.2 [4.1, 18.5] h, difference: 25.1 [95% CI, 13.8 to 36.4], P < 0.001). The obstructive abnormal breathing index was greater than central abnormal breathing index (P < 0.001), and half of abnormal breathing indexes were followed by irregular breathing. Despite the obstructive nature of abnormal breathing, the nasopharyngeal tube did not significantly reduce the abnormal breathing index (48.0 [33.8, 64.4] h vs. 50.5 [36.4, 63.9] h, difference: -2.0 [95% CI, -15.2 to 11.2], P = 0.846), not supporting the secondary hypothesis.

CONCLUSIONS

Patients under sedation for dental procedure frequently encounter obstructive apnea/hypopnea events. The majority of the obstructive apnea/hypopnea events were not detectable by pulse oximetry. The effectiveness of a small-diameter nasopharyngeal tube to mitigate the events is limited.

Medical, Political, and Economic Considerations for the Use of MAC for Endoscopic Sedation: Big Price, Little Justification?

The last few decades of gastrointestinal (GI) endoscopy have seen phenomenal growth. In many aspects, GI endoscopy has led the field of nonsurgical interventional medicine. In many aspects, this growth is facilitated by advancements in sedation-both drugs and techniques. Unfortunately, the topic of GI endoscopy sedation is also mired in many controversies, mainly emanating from the cost of anesthesia providers. While no one debates their role in the majority of advanced endoscopic procedures, the practice of universal propofol sedation in the USA, delivered by anesthesia providers, needs a closer look. In this review, medical, political, and economic considerations of this important topic are discussed in a very frank and honest way. While such ubiquitous propofol use has increased satisfaction of both patients and gastroenterologists, there is little justification. More importantly, going by the evidence, there is even less justification for the mandated anesthesia providers use for such delivery. Unfortunately, the FDA could not be convinced otherwise. The new drug fospropofol met the same fate. Approval of SEDASYS^®, the first computer-assisted personalized sedation system, was a step in the right direction, nevertheless an insufficient step that failed to takeoff. As a result, in spite of years of research and efforts of many august societies, the logjam of balancing cost and justification of propofol sedation has continued. We hope that recent approval of remimazolam, a novel benzodiazepine, and potential approval of oliceridine, a novel short-acting opioid, might be able to contain the cost without compromising the quality of sedation.

Occurrence of Cortical Arousal at Recovery from Respiratory Disturbances during Deep Propofol Sedation

Abstract: Recent evidences suggest that non-arousal mechanisms can restore and stabilize breathing in sleeping patients with obstructive sleep apnea. This possibility can be examined under deep sedation which increases the cortical arousal threshold. We examined incidences of cortical arousal at termination of apneas and hypopneas in elderly patients receiving propofol sedation which increases the cortical arousal threshold. Ten elderly patients undergoing advanced endoscopic procedures under propofol-sedation were recruited. Standard polysomnographic measurements were performed to assess nature of breathing, consciousness, and occurrence of arousal at recovery from apneas and hypopneas. A total of 245 periodic apneas and hypopneas were identified during propofol-induced sleep state. Cortical arousal only occurred in 55 apneas and hypopneas (22.5%), and apneas and hypopneas without arousal and desaturation were most commonly observed (65.7%) regardless of the types of disordered breathing. Chi-square test indicated that incidence of no cortical arousal was significantly associated with occurrence of no desaturation. Higher dose of propofol was associated with a higher apnea hypopnea index (r = 0.673, p = 0.033). In conclusion, even under deep propofol sedation, apneas and hypopneas can be terminated without cortical arousal. However, extensive suppression of the arousal threshold can lead to critical hypoxemia suggesting careful respiratory monitoring.

Airway rescue during sedation: a proposed airway rescue pathway for nonanesthesiologists

PURPOSE OF REVIEW

This review summarizes key features of adverse airway and respiratory events for which sedation providers must be prepared to diagnose and treat in a timely manner. Key features include elements of the presedation patient evaluation that predict adverse airway and respiratory events; patient profiles, target sedation levels, and procedure types that should prompt a consult with an anesthesiologist; necessary clinical skills, essential equipment, and reversal drugs necessary to manage adverse airway and respiratory events; and a proposed airway rescue pathway that describes a sequence of interventions and prompts to call for help when encountering an adverse airway or respiratory event.

RECENT FINDINGS

Several studies have reported adverse events from sedation. Although the overall rate can approach 4.5%, the incidence of events associated with severe harm is low (e.g., <0.5%). Some that are most harmful are prolonged ventilatory compromise leading to hypoxic brain injury or death. Inadequate clinical skills that contribute to these poor outcomes include undetected or delayed detection of hypopnea, apnea, and partial or complete airway obstruction, inadequate rescue skills to manage drug-induced ventilatory depression or airway obstruction, and/or a delay or no attempt to call for expert help followed by a timely response and intervention from that expert help.

SUMMARY

To improve outcomes in detecting and managing adverse airway and respiratory events, nonanesthesiologists sedation practitioners must be trained in patient selection, monitoring, pharmacology, physiology, and airway management. One gap in sedation training curriculum is a roadmap to use when managing an adverse airway or respiratory events. This review puts forth a suggested airway rescue pathway for nonanesthesiologist sedation practitioners to use as a decision aid during an adverse airway or respiratory event associated with procedural sedation.

A case of esophagogastroduodenoscopy induced Takotsubo cardiomyopathy with complete heart block

Takotsubo cardiomyopathy (TC) describes a reversible left ventricular dysfunction characterized by apical ballooning and basal hyperkinesis, commonly triggered by emotional or physical distress. TC associated with an esophagogastroduodenoscopy (EGD) has rarely been reported. We report a case of TC with complete heart block (CHB) in a patient receiving an EGD, who had no underlying cardiac disease, had previously tolerated both local and general anesthesia, and who had previously undergone similar endoscopic procedures without complications. The concurrence of both TC and CHB is unique in this case pertaining to a patient with no significant risk factors. The incidence, mechanism and prognosis of TC-associated arrhythmias are also reviewed.

Analysis of Anesthesia Administration in the Endoscopy Unit in Terms of Patient Profile and Complications: Retrospective Study

Objective:

This study aimed to analyze patients undergoing endoscopic interventions in terms of comorbid diseases, preoperative anesthesia management predictions, intraoperative-postoperative complications and requirements for intensive care.

Method:

Records of patients who underwent procedures under anesthesia in the endoscopy unit were retrospectively screened. The patients’ preoperative anesthesia evaluation, intraoperative anesthesia, and postoperative recovery data and intensive care monitoring requirements were recorded. The data obtained were analyzed statistically.

Results:

It was identified that the preoperative risk prediction of patients was statistically significant for intraoperative and postoperative monitoring. Comorbid disease and high age were determined to increase the requirements for intensive care after the procedure. Increased need for qualified admission was determined in patients with desaturation and hypotension.

Conclusion:

A prerequisite for reliable administration of anesthesia is having detailed information about the patient and being prepared for possible complications. When examined from this aspect, analysis of the patient profile undergoing procedures in the endoscopy unit is important. In our study, we revealed the presence of elderly patients and comorbid disease(s) in the patient group who underwent procedures in this unit. The need for detailed preliminary evaluation of the patients undergoing these types of procedure and requirements for intensive care after the procedure, if necessary, should definitely be considered.

Polysomnographic assessment of respiratory disturbance during deep propofol sedation for endoscopic submucosal dissection of gastric tumors

AIM

To investigate that polysomnographic monitoring can accurately evaluate respiratory disturbance incidence during sedation for gastrointestinal endoscopy compare to pulse oximetry alone.

METHODS

This prospective observational study included 10 elderly patients with early gastric cancer undergoing endoscopic submucosal dissection (ESD) under propofol sedation. Apart from routine cardiorespiratory monitoring, polysomnography measurements were acquired. The primary hypothesis was tested by comparing the apnea hypopnea index (AHI), defined as the number of apnea and hypopnea instances per hour during sedation, with and without hypoxemia; hypoxemia was defined as the reduction in oxygen saturation by ≥ 3% from baseline.

RESULTS

Polysomnography (PSG) detected 207 respiratory disturbances in the 10 patients. PSG yielded a significantly greater AHI (10.44 ± 5.68/h) compared with pulse oximetry (1.54 ± 1.81/h, P < 0.001), thus supporting our hypothesis. Obstructive AHI (9.26 ± 5.44/h) was significantly greater than central AHI (1.19 ± 0.90/h, P < 0.001). Compared with pulse oximetry, PSG detected the 25 instances of respiratory disturbances with hypoxemia 107.4 s earlier on average.

CONCLUSION

Compared with pulse oximetry, PSG can better detect respiratory irregularities and thus provide superior AHI values, leading to avoidance of fatal respiratory complications during ESD under propofol-induced sedation.

Prospective analysis of the complications, efficacy, and satisfaction level on the sedation performed by anaesthetists in gastrointestinal endoscopy

OBJECTIVE

To describe the anaesthesia/sedation complications during gastrointestinal endoscopy, as well as comparing scheduled procedures versus urgent procedures.

METHODS

A protocol was developed to define the anaesthesia/sedation in gastrointestinal endoscopy, where the anaesthetist should always be present. These include ASA 3 and 4 patients, complex tests such as polypectomies, endoscopic retrograde cholangiopancreatography (ERCP) or endoscopic ultrasound, deep sedation, or patients with probable difficult airway management. An analysis was made of the safety based on the complications recorded from the data directly collected automatically from the monitors, both during the sedation and in the recovery unit. An analysis was also performed on the risk factors associated with cardiorespiratory complications, the effectiveness based on the completed tests and the overall level of satisfaction through an interview using a satisfaction scale.

RESULTS

The study included a total of 3746 patients over a 7 year-period. The incidence of major complications was low, especially haemodynamic and respiratory complications. An incidence of hypoxaemia of 3% was found in scheduled endoscopy versus 5.7% in urgent endoscopy (P<.05). The rate of hypotension was also low, with significant differences between scheduled and urgent endoscopy (6.4% vs. 18.8%, P<.001). In present study, no test had to be suspended due to poor patient tolerance, and the satisfaction was high in more than 99% of cases.

CONCLUSION

The participation of the anaesthetist in sedation for gastrointestinal endoscopy has shown excellent results in this study, in terms of safety and efficacy, mainly in the most serious patients and complex tests, as well as a high level of satisfaction.

Do we really need an anesthesiologist for routine colonoscopy in American Society of Anesthesiologist 1 and 2 patients?

PURPOSE OF REVIEW

In an era where healthcare costs are being heavily scrutinized, every expenditure is reviewed for medical necessity. Multiple national gastroenterology societies have issued statements regarding whether an anesthesiologist is necessary for routine colonoscopies in American Society of Anesthesiologist (ASA) 1 and 2 patients.

RECENT FINDINGS

A large percentage of patients are undergoing screening colonoscopy without any sedation at all, which would not require an independent practitioner to administer medications. Advances in technique and technology are making colonoscopies less stimulating. Advantages to administering sedation, including propofol, have been seen even when not administered under the direction of an anesthesiologist and complications seem to be rare. The additional cost of having monitored anesthesia care appears to be a driving factor in whether a patient receives it or not.

SUMMARY

A large multiinstitutional randomized control trial would be necessary to rule out potential confounders and to determine whether there is a safety benefit or detriment to having anesthesiologist-directed care in the setting of routine colonoscopies in ASA 1 and 2 patients. Further discussion would be necessary regarding what the monetary value of that effect is if a small difference were to be detected.

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.

Practical considerations in the development of a nonoperating room anesthesia practice

PURPOSE OF REVIEW

More than 25% of the procedures necessitating an anesthesia provider's involvement are performed outside the operating room. As a result, it is imperative that the expansion of anesthesia services to any new nonoperating room anesthesia (NORA) location takes into account the challenges and safety considerations associated with such a transformation.

RECENT FINDINGS

Although the adverse events encountered in the NORA suite are similar to those met in the operating room, the frequency and implications are different. In addition, many adverse events are site specific. Hypoxemia events, including cardiac arrest continue to dominate all areas of NORA practice. Challenges posed by new minimally invasive procedures continue to grow. Electronic documentation is rapidly expanding into the NORA suite, which brings both advantages and challenges.

SUMMARY

Involvement of anesthesia providers at the development stage and an understanding of the administrative and clinical challenges are essential elements in the building of a NORA practice.

Safety of non-anesthesia provider administered propofol sedation in non-advanced gastrointestinal endoscopic procedures: A meta-analysis

BACKGROUND/AIMS

The aim of the study was to evaluate the safety of non-anesthesia provider (NAPP) administered propofol sedation in patients undergoing non-advanced gastrointestinal (GI) endoscopic procedures.

MATERIALS AND METHODS

Pubmed, Embase, Cochrane central register of controlled trials, Scopus, and Web of Science databases were searched for prospective observational trials involving non-advanced endoscopic procedures. From a total of 608 publications, 25 [colonoscopy (9), upper GI endoscopy (5), and combined procedures (11)] were identified to meet inclusion criteria and were analyzed. Data was analyzed for hypoxia rates, airway intervention rates, and airway complication rates.

RESULTS

A total of 137,087 patients were involved. A total of 2931 hypoxia episodes (defined as an oxygen saturation below 90%) were reported with a pooled hypoxia rate of 0.014 (95% CI being 0.008-0.023). Similarly, pooled airway intervention rates and pooled airway complication rates were 0.002 (95% CI being 0.006-0.001) and 0.001 (95% CI being 0.000-0.001), respectively.

CONCLUSIONS

The rates of adverse events in patients undergoing non-advanced GI endoscopic procedures with NAPP sedation are extremely small. Similar data for anesthesia providers is not available. It is prudent for anesthesia providers to demonstrate their superiority in prospective randomized controlled trials, if they like to retain exclusive ownership over propofol sedation in patients undergoing GI endoscopy.

Airway Management During Upper GI Endoscopic Procedures: State of the Art Review

With the growing popularity of propofol mediated deep sedation for upper gastrointestinal (GI) endoscopic procedures, challenges are being felt and appreciated. Research suggests that management of the airway is anything but routine in this setting. Although many studies and meta-analyses have demonstrated the safety of propofol sedation administered by registered nurses under the supervision of gastroenterologists (likely related to the lighter degrees of sedation than those provided by anesthesia providers and is under medicolegal controversy in the United States), there is no agreement on the optimum airway management for procedures such as endoscopic retrograde cholangiopancreatography. Failure to rescue an airway at an appropriate time has led to disastrous consequences. Inability to evaluate and appreciate the risk factors for aspiration can ruin the day for both the patient and the health care providers. This review apprises the reader of various aspects of airway management relevant to the practice of sedation during upper GI endoscopy. New devices and modification of existing devices are discussed in detail. Recognizing the fact that appropriate monitoring is important for timely recognition and management of potential airway disasters, these issues are explored thoroughly.

A comparison of propofol and midazolam/meperidine sedation in upper gastrointestinal endoscopy

INTRODUCTION

There is increasing interest in sedation for upper gastrointestinal endoscopy (UGE). Prospective randomized studies comparing sedation properties and complications of propofol and midazolam/meperidine in upper gastrointestinal endoscopy (UGE) are few.

AIM

To compare propofol and midazolam/meperidine sedation for UGE in terms of cardiopulmonary side effects, patient and endoscopist satisfaction and procedure-related times.

MATERIAL AND METHODS

This was a prospective, randomized, double-blind study of propofol versus midazolam and meperidine in 100 patients scheduled for diagnostic upper gastrointestinal endoscopy. The patients were divided into propofol and midazolam/meperidine groups. Randomization was generated by a computer. Cardiopulmonary side effects (hypotension, bradycardia, hypoxemia), procedure-related times (endoscopy time, awake time, time to hospital discharge), and patient and endoscopist satisfaction were compared between groups.

RESULTS

There was no significant difference between the groups with respect to the cost, endoscopy time, or demographic and clinical characteristics of the patients. Awake time and time to hospital discharge were significantly shorter in the propofol group (6.58 ±4.72 vs. 9.32 ±4.26 min, p = 0.030 and 27.60 ±7.88 vs. 32.00 ±10.54 min, p = 0.019). Hypotension incidence was significantly higher in the propofol group (12% vs. 0%, p = 0.027). The patient and endoscopist satisfaction was better with propofol.

CONCLUSIONS

Propofol may be preferred to midazolam/meperidine sedation, with a shorter awake and hospital discharge time and better patient and endoscopist satisfaction. However, hypotension risk should be considered with propofol, and careful evaluation is needed, particularly in cardiopulmonary disorders.

Association between Type of Sedation and the Adverse Events Associated with Gastrointestinal Endoscopy: An Analysis of 5 Years' Data from a Tertiary Center in the USA

Background/Aims

The landscape of sedation for gastrointestinal (GI) endoscopic procedures and the nature of the procedures themselves have changed over the last decade. In this study, an attempt is made to analyze the frequency and etiology of all major adverse events associated with GI endoscopy.

Methods

All adverse events extracted from the electronic database and local registry were analyzed. Although the data analysis was retrospective, the adverse events themselves were documented prospectively. These events were evaluated after subdivision into propofol-based anesthesia and intravenous conscious sedation groups.

Results

Cardiorespiratory events, including cardiac arrest, were the most common adverse events during esophagogastroduodenoscopy, while bleeding was more frequent in patients undergoing colonoscopy. Pancreatitis was the most frequent adverse event in patients undergoing endoscopic retrograde cholangiopancreatography. The frequencies of most adverse events were significantly higher in patients anesthetized with propofol. Automatic regression modeling showed that the type of sedation, the American Society of Anesthesiologists physical status classification, and the procedure type were some of the predictors of immediate life-threatening complications.

Conclusions

Clearly, our regression modeling suggests a strong association between the type of sedation as well as various patient factors and the frequency of adverse events. The possible reasons for our results are the changing demographics, the worsening comorbidities of the patient population, and the increasing technical complexity of these procedures. Although extensive use of propofol has increased patient satisfaction and procedure acceptability, its use is also associated with more frequent adverse events.