Sedation and monitoring for gastrointestinal endoscopy

Unsedated colonoscopy utilizing virtual reality distraction: a pilot-controlled study

BACKGROUND

Sedation increases colonoscopy risks and prolongs recovery time. We examined whether virtual reality (VR) can substitute for sedation. The primary outcome was the overall satisfaction of patients who underwent colonoscopy with VR headset compared with patients who underwent standard sedation. Pain during the procedure, polyp detection rate (PDR), colonoscopy duration, post-colonoscopy adverse events, post-colonoscopy recovery, time-to-return to daily functions, and turnaround time at the endoscopy unit were secondary outcomes.

METHODS

The study was approved by Sheba Medical Center's ethics committee IRB number 21-8177-SMC. Sixty patients were sequentially enrolled in a 1:1 ratio to either standard sedated colonoscopy or VR-unsedated procedure, and all patients signed a written informed consent. 28/30 patients successfully completed the colonoscopy using VR headset. Overall satisfaction score was comparable between the groups.

RESULTS

There was no difference between VR and controls in colonoscopy duration, or PDR. VR patients had numerically lower rate of post-colonoscopy adverse events than controls. The proportion of VR patients who reported resuming daily activities on the day of the procedure was significantly higher than in the control group. The VR group patients spent significantly less time in the hospital compared to the control group.

CONCLUSIONS

VR technology can provide adequate substitution for sedation for most patients undergoing colonoscopy and offers comparable patient satisfaction and faster return to daily activities.

Intraoperative transcutaneous electroacupoint stimulation on early postoperative fatigue in patients with Parkinson's disease undergoing deep brain stimulation surgery

Background

In this clinical trial, we evaluated the effects of transcutaneous electroacupoint stimulation (TEAS) on postoperative fatigue (POF) in Parkinson disease (PD) patients undergoing deep brain stimulation (DBS) surgery.

Methods

A total 60 PD patients undergoing DBS surgery were enrolled. They were randomized to receive either electrical stimulation [alternative frequency 2/10 Hz, dense and disperse, intensity adjusted to the maximum tolerated by the participants (6-15 mAmp)] via surface electrodes (TEAS group) or surface electrodes only without electrical stimulation (Con group) at bilateral Zusanli and Sanyinjiao acupuncture points. All participants received their assigned intervention (TEAS or Con) during the 1st stage of surgery [(except during microelectrode recording (MER)] and the entire 2nd stage of surgery. Intraoperative anesthetic requirements were adjusted based on bispectral index (BIS) monitor. POF was assessed by Christensen fatigue scales (ChrFS), along with Quality of Recovery-15 (QoR-15) and mini-mental state examination (MMSE) postoperatively over a 7-day-period. We recorded the usage of rescue analgesics and anti-emetics.

Results

Fifty-nine patients' datasets were included for final analyses. Fewer patients in TEAS experienced severe POF (defined as ChrFS ≥6) at T3 than those in the Con group (TEAS vs. Con: 7 vs. 22, p < 0.001). During the 1st stage of surgery, more patients in Con group required dexmedetomidine infusion (TEAS vs. Con: 2 vs. 6; P < 0.01). Total dosages of propofol and remifanil during the 2nd stage of surgery were TEAS vs. Con: 374.7 ± 61.2 vs 421.5 ± 81.9; p < 0.001 and 572.3 ± 82.0 vs. 662 ± 148.2; P < 0.001, respectively. Postoperative rescue analgesics (TEAS vs. Con: 2 vs. 6; P < 0.001) were used less in the TEAS group. TEAS patients reported better POF, MMSE and QoR15 scores than those in the Con group during most of the assessment period.

Conclusions

Intraoperative TEAS decreased the severity of POF, reduced intraoperative anesthetic requirements and facilitated post-DBS recovery in this group of PD patients.

Up-to-date literature review and issues of sedation during digestive endoscopy

Sedation is common during digestive endoscopy to provide comfort and pain relief for patients. However, the use of sedation in endoscopy also poses potential risks, and recent issues have been raised regarding its safety and administration. This literature review paper will discuss the most recent developments in the field of sedation in digestive endoscopy, including the adverse events that might be associated with sedation and how to manage it, the legal issues associated with administration, the impact of COVID-19 on sedation practices, and sedation in special situations. It will also touch upon the current guidelines and recommendations for sedation, including the importance of patient selection and monitoring and the need for training and certification for endoscopists administering sedation. The review will also analyse studies evaluating the safety and efficacy of various sedation techniques, including propofol, midazolam, and others. It will examine the benefits and drawbacks of these agents.

A Comparison of the Sedative Effect of Dexmedetomidine and Midazolam on Patients Undergoing Gastrointestinal Endosonography Outside the Operating Room

Background

Patients may experience anxiety, discomfort, and pain during endoscopy, which cannot be tolerated without sedative drugs.

Objectives

This study aimed to compare the sedative effects of dexmedetomidine and midazolam on patients undergoing endosonography outside the operating room.

Methods

This randomized, double-blind clinical trial was conducted on 126 patients aged 18 - 65 years old with American Society of Anesthesiologists (ASA) physical status I - II undergoing elective endosonography. Patients were randomly divided into 2 groups. The dexmedetomidine group received dexmedetomidine (1 μg/kg) for 25 minutes with propofol (0.5 mg/kg) and fentanyl (1 μg/kg) at the start of the procedure. The midazolam group received midazolam (0.03 mg/kg) with propofol (0.5 mg/kg) and fentanyl (1 μg/kg). Heart rate, mean arterial pressure (MAP), and oxygen saturation (SpO2) were recorded before and 5, 10, and 15 minutes after starting the procedure. The Ramsay Sedation Scale (RSS) and the need for an additional dose of propofol were recorded during the procedure. The Numeric Pain Rating scale (Ambesh score) scores were recorded at the beginning, immediately after, and 1 hour after the procedure. Nausea and vomiting were assessed using the Visual Analogue Scale in cooperation with the patient.

Results

The dexmedetomidine group had significantly higher SpO2 and RSS scores during sedation than the midazolam group (P = 0.02). Overall, specialist satisfaction was higher in the dexmedetomidine group than in the midazolam group. There was no clinically significant difference in pain score and nausea and vomiting frequencies between the 2 groups.

Conclusions

Dexmedetomidine is more effective than midazolam for sedation during gastrointestinal endosonography.

The Effect of Preoperative Combined with Intravenous Lidocaine and Ketamine vs. Intravenous Ketamine on Pediatric Patients Undergoing Upper Gastrointestinal Endoscopy

Background

Ketamine is widely used in pediatric sedation. New studies have recommended combination therapy to reduce the side effects of ketamine.

Objectives

This study investigated the effect of adding intravenous (IV) lidocaine to ketamine on hemodynamic parameters, endoscopist satisfaction, and recovery time of children undergoing gastrointestinal endoscopy.

Methods

This triple-blind, randomized, controlled clinical trial was conducted in Isfahan, Iran (2021). One hundred twenty children between the ages of 1 and 6 were enrolled. Patients were divided into 2 groups. The intervention group received 1.0 mg/kg of IV lidocaine and 1.0 mg/kg of IV ketamine, and the placebo group received 1.0 mg/kg of IV ketamine and placebo 2 minutes before entering the endoscopic room. Patients in both groups were sedated with 1.0 mg/kg of propofol, 0.1 mg/kg of midazolam, and 2.0 ug/kg of fentanyl for the procedure. The pulse rate, mean arterial pressure (MAP), respiratory rate, and oxygen saturation were recorded 1 minute before injection and every 5 minutes afterward.

Results

The mean (SD) ages of the intervention and control groups were 3.4 (1.5) and 3.4 (1.7), respectively. The mean difference in hemodynamic parameters between the 2 groups was insignificant during the investigation (P > 0.05). Furthermore, no significant differences were found regarding endoscopist satisfaction scores and length of recovery room stay (P > 0.05).

Conclusions

Adding low-dose IV lidocaine to ketamine for pediatric sedation does not significantly affect the hemodynamic status, endoscopist satisfaction, and recovery time.

Advances in Analgosedation and Periprocedural Care for Gastrointestinal Endoscopy

The number and complexity of endoscopic gastrointestinal diagnostic and therapeutic procedures is globally increasing. Procedural analgosedation during gastrointestinal endoscopic procedures has become the gold standard of gastrointestinal endoscopies. Patient satisfaction and safety are important for the quality of the technique. Currently there are no uniform sedation guidelines and protocols for specific gastrointestinal endoscopic procedures, and there are several challenges surrounding the choice of an appropriate analgosedation technique. These include categories of patients, choice of drug, appropriate monitoring, and medical staff providing the service. The ideal analgosedation technique should enable the satisfaction of the patient, their maximum safety and, at the same time, cost-effectiveness. Although propofol is the gold standard and the most used general anesthetic for endoscopies, its use is not without risks such as pain at the injection site, respiratory depression, and hypotension. New studies are looking for alternatives to propofol, and drugs like remimazolam and ciprofol are in the focus of researchers' interest. New monitoring techniques are also associated with them. The optimal technique of analgosedation should provide good analgesia and sedation, fast recovery, comfort for the endoscopist, patients' safety, and will have financial benefits. The future will show whether these new drugs have succeeded in these goals.

Comparison of ciprofol (HSK3486) versus propofol for the induction of deep sedation during gastroscopy and colonoscopy procedures: A multi-centre, non-inferiority, randomized, controlled phase 3 clinical trial

Ciprofol is a propofol analogue with improved pharmacokinetic properties. A multi‐centre, non‐inferiority trial was conducted to compare the deep sedation properties of ciprofol and propofol with a non‐inferiority margin of 8% in patients undergoing gastroscopy and colonoscopy. In total, 289 patients were randomly allocated for surgery (259 colonoscopy and 30 gastroscopy) at a 1:1 ratio to be given intravenous injections of ciprofol (0.4 mg/kg) or propofol (1.5 mg/kg). The primary outcome was the success rate of colonoscopy defined as colonoscopy completion with no need for an alternative sedative or >5 ciprofol or propofol top up doses within any 15‐min time period. The success rate of colonoscopy was 100% in the ciprofol group vs. 99.2% in the propofol group (mean difference 0.8%, 95% CI: −2.2% to 4.2%). Except for the gastrointestinal lesions found during the gastroscopy and colonoscopy procedures, the occurrence rates of adverse drug reactions in the ciprofol and propofol groups were 31.3% and 62.8%, respectively (P < 0.001). Pain on injection was less common in the ciprofol group (4.9% vs. 52.4%, P < 0.001). The outcomes demonstrated that ciprofol was non‐inferior to propofol with regard to successful sedation for gastroscopy or colonoscopy procedures and no obvious important adverse events occurred.

Identifying Recall Under Sedation by a Novel EEG Based Index of Attention—A Pilot Study

Overview

Recall is an accepted consequence of sedation. But due to the very low prevalence of the more devastating awareness under anesthesia (AUA), it might be of value to assess first the efficacy of new markers for AUA by their efficacy in discovering the more prevalent recall under sedation (RUS). In this pilot study we assessed whether a novel index for attentional effort, the cognitive effort index (CEI), derived in real-time from one forehead EEG channel, could differentiate between patients with or without RUS.

Methods

EEG was sampled from 2 groups: (1) Patients who underwent deep sedation (n = 25) (using drugs according to the anesthesiologist preference, but generally combining either Midazolam or Propofol together with either Fentanyl or Remifentanil). (2) Patients who underwent general anesthesia (GA, n = 13, a negative control for recall). In recovery, recall was assessed using the BRICE questionnaire.

Results

Of the 25 sedated patients, 11 experienced recall. The CEI marker was high during significantly longer periods in patients with recall, compared to sedated patients, or patients under GA, without recall. Moreover, the increase in CEI was evident mainly toward the end of the procedure.

Conclusion

RUS seems to associate with higher level of attention, which is identified in real-time by the easy-to-extract CEI marker.

Colonoscopy: an evidence-based approach

Colonoscopy is an invasive, endoscopic procedure undertaken to visualise the inner lumen of the colon and is used for a variety of diagnostic purposes. The procedure is increasingly performed by nurse endoscopists. This article provides an overview of the indications and contraindications for colonoscopy and describes various elements of the procedure, including consent, sedation and bowel preparation within the context of the evidence base. The article also discusses patient care before, during and after the procedure.

Do difficulties in emotional processing predict procedure pain and shape the patient's colonoscopy experience?

OBJECTIVES

Pain and fear of colonoscopy are inter-related; they make the colonoscopy experience unpleasant and impede adherence to colorectal cancer screening and prevention campaigns. According to previous research, fear and pain have been found to depend on patients' maladaptive cognitions and exaggerated emotional responses. The present study investigated whether emotional processing difficulties predicted colonoscopy pain and the associated catastrophising thoughts.

DESIGN

Prospective, observational, blinded.

METHOD

A sample of 123 patients was assessed for specific emotional processing difficulties (ie, suppression of emotions, unprocessed emotions, failure to control emotions, avoidance of emotional triggers and impoverished emotional experience) and anxiety-related variables (ie, worry, anxiety and depression) before colonoscopy. A trained medical doctor rated patients' behavioural manifestations of pain during colonoscopy. After complete recovery from sedation, the patients rated the endoscopy experience using perceived pain and situation-specific pain catastrophising scales.

RESULTS

About half of the patients were above the cut-off for anxiety before the procedure. Notwithstanding sedation, behavioural manifestations of pain during colonoscopy indicated probable or moderate pain for about one-third of the patients. Failure to control emotions, poor emotional experience and avoiding emotional triggers were positively correlated with behavioural manifestations of pain, self-reported pain and pain catastrophising. Regression analyses, controlling for gender, age, colonoscopy experience and sedation, revealed that avoidance of emotional triggers uniquely contributed to predicting pain outcomes.

CONCLUSIONS

Early identification of emotional processing difficulties associated with pain catastrophising can help define personalised psychological preparation paths to manage negative emotions in patients who fear colonoscopy pain.

Ventilatory Effect of Midazolam in Propofol Deep Sedation for Hepatic Tumor Patients Undergoing Percutaneous Radiofrequency Ablation Procedure

Objective: The aim of the study was to compare the ventilatory effect between propofol deep sedation technique with and without midazolam in hepatic tumor patients undergoing radiofrequency ablation procedure. Methods: Three hundred and seventy-four patients who underwent radiofrequency ablation procedure in a single year were randomly assigned to the deep sedation without midazolam group (A, n = 187) and deep sedation with midazolam group (B, n = 187). Patients in group A received normal saline, and those in group B received 0.02 mg/kg of midazolam intravenously in equivalent volume. All patients were oxygenated with 100% O2 via nasal cannula and sedated with intravenous fentanyl and the titration of intravenous propofol. Ventilatory parameters, including oxygen saturation, end tidal carbon dioxide, and respiratory rate every five minutes, during and after the procedure, as well as the duration of sleep and sedation score in the recovery room, were recorded. Results: There were no significant differences in the patients’ characteristics, duration of procedure, total dose of propofol, ventilatory parameters including oxygen saturation, end tidal carbon dioxide, and respiratory rate, as well as sedation score at 20, 25, 30, 35, and 40 min after the procedure, between the two groups. However, mean sedation score at 5, 10, and 15 min after the procedure, in group B, was significantly lower than in group A. In addition, the duration of sleep after the procedure, in group B, was significantly greater than in group A. No serious ventilatory adverse effects were observed either group. Conclusion: Propofol deep sedation with and without midazolam for hepatic tumor patients who underwent radiofrequency ablation procedure was safe and effective. A low dose of midazolam in propofol deep-sedation technique did not create serious ventilatory effects.

Complication rates in emergent endoscopy for foreign bodies under different sedation modalities: A large single-center retrospective review

BACKGROUND

Foreign object ingestion (FOI) and food bolus impaction (FBI) are common causes of emergent endoscopic intervention. The choice of sedation used is often dictated by physician experience. Many endoscopists frequently prefer to use monitored anesthesia care (MAC) and general anesthesia (GA) as opposed to conscious sedation (CS) due to the concern for inadequate airway protection. However, there is insufficient data examining the safety of different sedation modalities in emergent endoscopic management of FOI and FBI.

AIM

To investigate the complication rates of emergent endoscopic extraction performed under different sedation modalities.

METHODS

We conducted a retrospective chart review of patients presenting with acute FBI and FOI between 2010 and 2018 in two hospitals. A standardized questionnaire was utilized to collect data on demographics, endoscopic details, sedation practices, hospital stay and adverse events. Complications recognized during and within 24 h of the procedure were considered early, whereas patients presenting with a procedure-related adverse event within two weeks of the index event were considered delayed complications. Complication rates of patients who underwent emergent endoscopic retrieval were compared based on sedation types, namely CS, MAC and GA. Chi-square analysis and multiple logistic regression were used to compare complication rate based on sedation type.

RESULTS

Among the 929 procedures analyzed, 353 procedures (38.0%) were performed under CS, 278 procedures (29.9%) under MAC and the rest (32.1%) under GA. The median age of the subjects was 52 years old, with 57.4% being male. The majority of the procedures (64.3%) were FBI with the rest being FOI (35.7%). A total of 132 subjects (14.2%) had chronic comorbidities while 29.0% had psychiatric disorders. The most commonly observed early complications were mucosal laceration (3.8%) and bleeding (2.6%). The most common delayed complication was aspiration pneumonia (1.8%). A total of 20 patients (5.6%) could not adequately be sedated with CS and had to be converted to MAC or GA. Patient sedated with MAC and GA were more likely to require hospitalization, P < 0.0001. Analysis revealed no statistically significant difference in the complication rate between patients sedated under CS (14.7%), MAC (14.7%) and GA (19.5%), P = 0.19.

CONCLUSION

For patients who present with FOI or FBI and undergo emergent endoscopic treatment, there is no significant difference in adverse event rates between CS, MAC and GA.

Clinical decision support system, using expert consensus-derived logic and natural language processing, decreased sedation-type order errors for patients undergoing endoscopy

OBJECTIVE

Determination of appropriate endoscopy sedation strategy is an important preprocedural consideration. To address manual workflow gaps that lead to sedation-type order errors at our institution, we designed and implemented a clinical decision support system (CDSS) to review orders for patients undergoing outpatient endoscopy.

MATERIALS AND METHODS

The CDSS was developed and implemented by an expert panel using an agile approach. The CDSS queried patient-specific historical endoscopy records and applied expert consensus-derived logic and natural language processing to identify possible sedation order errors for human review. A retrospective analysis was conducted to evaluate impact, comparing 4-month pre-pilot and 12-month pilot periods.

RESULTS

22 755 endoscopy cases were included (pre-pilot 6434 cases, pilot 16 321 cases). The CDSS decreased the sedation-type order error rate on day of endoscopy (pre-pilot 0.39%, pilot 0.037%, Odds Ratio = 0.094, P-value < 1e-8). There was no difference in background prevalence of erroneous orders (pre-pilot 0.39%, pilot 0.34%, P = .54).

DISCUSSION

At our institution, low prevalence and high volume of cases prevented routine manual review to verify sedation order appropriateness. Using a cohort-enrichment strategy, a CDSS was able to reduce number of chart reviews needed per sedation-order error from 296.7 to 3.5, allowing for integration into the existing workflow to intercept rare but important ordering errors.

CONCLUSION

A workflow-integrated CDSS with expert consensus-derived logic rules and natural language processing significantly reduced endoscopy sedation-type order errors on day of endoscopy at our institution.

High Incidence of Burst Suppression during Propofol Sedation for Outpatient Colonoscopy: Lessons Learned from Neuromonitoring

Background

Although anesthesia providers may plan for moderate sedation, the depth of sedation is rarely quantified. Using processed electroencephalography (EEG) to assess the depth of sedation, this study investigates the incidence of general anesthesia with variable burst suppression in patients receiving propofol for outpatient colonoscopy. The lessons learned from neuromonitoring can then be used to guide institutional best sedation practice.

Methods

This was a prospective observational study of 119 outpatients undergoing colonoscopy at Thomas Jefferson University Hospital (TJUH). Propofol was administered by CRNAs under anesthesiologists' supervision. The Patient State Index (PSi™) generated by the Masimo SedLine® Brain Root Function monitor (Masimo Corp., Irvine, CA) was used to assess the depth of sedation. PSi data correlating to general anesthesia with variable burst suppression were confirmed by neuroelectrophysiologists' interpretation of unprocessed EEG.

Results

PSi values of <50 consistent with general anesthesia were attained in 118/119 (99.1%) patients. Of these patients, 33 (27.7%) attained PSi values <25 consistent with variable burst suppression. The 118 patients that reached PSi <50 spent a significantly greater percentage (53.1% vs. 42%) of their case at PSi levels <50 compared to PSi levels >50 (p=0.001). Mean total propofol dose was significantly correlated to patient PSi during periods of PSi <25 (R=0.406, p=0.021).

Conclusion

Although providers planned for moderate to deep sedation, processed EEG showed patients were under general anesthesia, often with burst suppression. Anesthesiologists and endoscopists may utilize processed EEG to recognize their institutional practice patterns of procedural sedation with propofol and improve upon it.

Comparison of the effects and side-effects of sedation with propofol versus midazolam plus pethidine in patients undergoing endoscopy in Imam Khomeini Hospital, Ahvaz

INTRODUCTION

Gastrointestinal endoscopy is an invasive and diagnostic procedure that causes the patients considerable pain, discomfort, and anxiety. Therefore, various types of sedation and analgesia techniques have been used during the procedure.

AIM

To compare the effects and side-effects of sedation with propofol versus midazolam plus pethidine in patients undergoing endoscopy.

MATERIAL AND METHODS

This is a randomised controlled double-blind clinical trial study conducted on 272 patients undergoing diagnostic and treatment endoscopy and colonoscopy in Imam Khomeini Hospital in Ahvaz between 2017 and 2018. The patients were randomly assigned to two groups. Patients in the first group (n = 136) received propofol with midazolam and ketamine, and the second group (n = 136) received pethidine and midazolam. Study outcome measures included the recovery time, patient satisfaction, quality of sedation, and adverse events.

RESULTS

The occurrence of complications was higher in the propofol group (25% vs. 0%; p = 0.0001). No serious adverse events were observed in the study groups. Overall patient satisfaction and quality of sedation assessment scores in the propofol group were significantly better than those seen in the pethidine-midazolam group (p = 0.012 and p = 0.001, respectively). Recovery time was statistically shorter in the propofol-midazolam group (6.05 ±1.62 min) compared to the pethidine-midazolam group (6.72 ±2.21 min) (p = 0.006).

CONCLUSIONS

Propofol-midazolam can provide better sedation, patient satisfaction, and recovery than pethidine-midazolam during endoscopy. Therefore, it can be recommended in patients scheduled for diagnostic and treatment endoscopy.

Capnography compared to pulse oximetry for early detection of respiratory compromise in non-intubated patients undergoing gastrointestinal endoscopy procedures: a systematic review protocol

Does the use of capnography versus pulse oximetry increase the early detection of respiratory compromise and improve safety in non-intubated patients undergoing moderate sedation for gastrointestinal endoscopy procedures?Respiratory compromise will be detected by alveolar hypoventilation/hyperventilation (EtCO2 < 35 mmHg/EtCO2 > 50 mmHg), arterial oxygen desaturation (defined as a pulse oximetry reading of <95% for >5 s), visual assessments of abnormal ventilation including apnea detection and adverse respiratory events that involve the need for bag-mask ventilation.

Safety of Propofol Used as a Rescue Agent During Colonoscopy

GOAL

The goal of this study was to evaluate the safety of propofol when used by gastroenterologists in patients who have an inadequate response to standard sedation (narcotics and benzodiazepines).

BACKGROUND

Many patients fail to achieve adequate sedation from narcotics and benzodiazepines during colonoscopy. The administration of propofol for colonoscopy is increasing, although its use by gastroenterologists is controversial.

STUDY

We performed a retrospective review of our hospital's colonoscopy records from January 2006 to December 2009 to identify 403 subjects undergoing screening colonoscopies who required propofol (20 to 30 mg every 3 min as needed) because of inadequate response to standard sedation. We also randomly selected 403 controls undergoing screening colonoscopies from the same time period that only required standard sedation. The incidence of adverse effects was then compared.

RESULTS

There were no major adverse events in either group. The rates of minor adverse events in the propofol and control group were 0.02 and 0.01, respectively (P=0.56). Adverse effects in the propofol group included: transient hypotension (n=1), nausea/vomiting (n=3), agitation (n=2), and rash (n=1). Adverse effects seen with standard sedation included: transient hypotension (n=2), nausea/vomiting (n=1), and oversedation (n=2). Patients who received propofol were more likely to be younger, had a history of illicit drug use, and a longer procedure time (P<0.05).

CONCLUSIONS

Adjunctive propofol administered by gastroenterologist for conscious sedation was not associated with increased incidence of adverse events. It may be of value in patients who do not respond to conventional sedation.

Dexmedetomidine in gastrointestinal endoscopic procedures

Gastrointestinal endoscopy is the gold standard in the examination and the treatment of the diseases of gastrointestinal system, but the disadvantage of being painful process. At this point the sedative and analgesic agents may be important. Dexmedetomidine is a new sedoanalgesic agent which is alternative to benzodiazepines and opioids. It has analgesia, amnesia, sedative and anxiolytic properties. The use of dexmedetomidine as the sole anesthetic agent and as the adjuvant analgesic agent has been published but has not been approved because of the inconsistency of efficacy and safety. The author has been collected the published papers in the literature. This article is aimed to describe the use of dexmedetomidine in various gastrointestinal endoscopic procedures.

Registered nurse-administered sedation for gastrointestinal endoscopic procedure

The rising use of nonanesthesiologist-administered sedation for gastrointestinal endoscopy has clinical significances. Most endoscopic patients require some forms of sedation and/or anesthesia. The goals of this sedation are to guard the patient's safety, minimize physical discomfort, to control behavior and to diminish psychological responses. Generally, moderate sedation for these procedures has been offered by the non-anesthesiologist by using benzodiazepines and/or opioids. Anesthesiologists and non-anesthesiologist personnel will need to work together for these challenges and for safety of the patients. The sedation training courses including clinical skills and knowledge are necessary for the registered nurses to facilitate the patient safety and the successful procedure. However, appropriate patient selection and preparation, adequate monitoring and regular training will ensure that the use of nurse-administered sedation is a feasible and safe technique for gastrointestinal endoscopic procedures.

Prerequisites of colonoscopy

Colonoscopy is a widely accepted method for the evaluation of the colon and terminal ileum. Its diagnostic accuracy and therapeutic safety are influenced by prerequisites, including modulation of medication and bowel cleansing. Appropriate choices of sedative medication and bowel-cleansing regimen, together with diet modification, should be made based on the patient's underlying disease, age, and medication intake. Moreover, effective methods for patient education regarding bowel preparation should be considered.

Effects of nasal cleansing and topical decongestants on patient tolerance during upper gastrointestinal endoscopy: a prospective randomized study

Adequate patient tolerance is essential for successful completion of safe endoscopic examination. Although there are many reported methods to increase patient tolerance, none of these fully resolve this problem. The aim of this study was to investigate whether relaxing the nasal airways increase patient tolerance to upper gastrointestinal endoscopy (UGE). A total of 300 patients scheduled for diagnostic UGE were randomized into three separate groups. Prior to the UGE procedure the first group was administered intranasal cortisone spray following nasal cleansing (INC). Patients in the second group were administered intranasal saline after nasal cleansing (INSP). The patients in the third group were treated with the standard endoscopic procedure alone (SEP). After the UGE procedure, both endoscopists and patients were asked to evaluate the ease of performing the procedure. Furthermore, patients who had undergone endoscopy before were asked to compare their current experience to their most recent endoscopy. Results shown that INC and INSP groups had significantly better tolerance than the SEP group. When comparing their current experience with the previous one, INC and INSP groups reported that the current experience was better.

CONCLUSIONS

Taking measures to relax the nasal airways makes breathing more comfortable and increase patient tolerance during UGE.

Guidelines for safety in the gastrointestinal endoscopy unit

Historically, safety in the gastrointestinal (GI) endoscopy unit has focused on infection control, particularly around the reprocessing of endoscopes. Two highly publicized outbreaks where the transmission of infectious agents were related to GI endoscopy have highlighted the need to address potential gaps along the endoscopy care continuum that could impact patient safety.