1
|
Gravina AG, Pellegrino R, De Micco R, Dellavalle M, Grasso A, Palladino G, Satolli S, Ciaravola M, Federico A, Tessitore A, Romano M, Ferraro F. Effectiveness and safety of an atropine/midazolam and target controlled infusion propofol-based moderate sedation protocol during percutaneous endoscopic transgastric jejunostomy procedures in Parkinson's disease: a real-life retrospective observational study. Front Med (Lausanne) 2023; 10:1233575. [PMID: 37771983 PMCID: PMC10523572 DOI: 10.3389/fmed.2023.1233575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 08/28/2023] [Indexed: 09/30/2023] Open
Abstract
Patients with Parkinson's disease (PD), often elderly with various comorbidities, may require a continuous intestinal infusion of carbidopa/levodopa gel by the placement of a percutaneous endoscopic gastrostomy (PEG) with a jejunal tube (PEG-J) to improve their motor outcome and quality of life. However, it is unclear what is the best procedural sedation protocol for PEG-J procedures. Fifty patients with PD and indication for PEG-J procedure (implantation, replacement, removal) underwent, from 2017 to 2022, a sedation protocol characterized by premedication with atropine (0.01 mg/Kg i.v.), midazolam (0.015-0.03 mg/Kg i.v.) and induction with bolus propofol (0.5-1 mg/Kg i.v.) as well as, finally, sedation with continuous infusion propofol (2-5 mg/Kg/h i.v.) by Target Controlled Infusion (TCI) technique. Ninety-eight per cent of patients experienced no intraprocedural or peri-procedural adverse events. All the procedures were technically successful. A good discharge time was recorded. The vital parameters recorded during the procedure did not vary significantly. A PEG-J procedure conducted within 30 min showed a significant advantage over end-tidal carbon dioxide (EtCO2). Indeed, the latter showed some predictive behavior (OR: 1.318, 95% CI 1.075-1.615, p = 0.008). In the real world, this sedation protocol showed a good safety and effectiveness profile, even with reduced doses of midazolam and a TCI propofol technique in moderate sedation.
Collapse
Affiliation(s)
- Antonietta Gerarda Gravina
- Department of Precision Medicine, Hepatogastroenterology and Digestive Endoscopy Unit, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Raffaele Pellegrino
- Department of Precision Medicine, Hepatogastroenterology and Digestive Endoscopy Unit, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Rosa De Micco
- Department of Advanced Medical and Surgical Sciences, Neurology Unit, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Mirco Dellavalle
- Department of Woman, Child, General and Specialized Surgery, Anaesthesia and Intensive Care Unit, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Anna Grasso
- Department of Woman, Child, General and Specialized Surgery, Anaesthesia and Intensive Care Unit, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Giovanna Palladino
- Department of Precision Medicine, Hepatogastroenterology and Digestive Endoscopy Unit, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Sara Satolli
- Department of Advanced Medical and Surgical Sciences, Neurology Unit, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Massimo Ciaravola
- Department of Woman, Child, General and Specialized Surgery, Anaesthesia and Intensive Care Unit, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Alessandro Federico
- Department of Precision Medicine, Hepatogastroenterology and Digestive Endoscopy Unit, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Alessandro Tessitore
- Department of Advanced Medical and Surgical Sciences, Neurology Unit, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Marco Romano
- Department of Precision Medicine, Hepatogastroenterology and Digestive Endoscopy Unit, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Fausto Ferraro
- Department of Woman, Child, General and Specialized Surgery, Anaesthesia and Intensive Care Unit, University of Campania “Luigi Vanvitelli”, Naples, Italy
| |
Collapse
|
2
|
Miyamoto K, Matsumoto K, Obata T, Sato R, Matsumi A, Morimoto K, Ogawa T, Terasawa H, Fujii Y, Yamazaki T, Uchida D, Horiguchi S, Tsutsumi K, Kato H, Otsuka M. The efficacy of non-anesthesiologist-administered propofol sedation with a target-controlled infusion system during double-balloon endoscopic retrograde cholangiopancreatography. BMC Gastroenterol 2023; 23:296. [PMID: 37667224 PMCID: PMC10478296 DOI: 10.1186/s12876-023-02936-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 08/28/2023] [Indexed: 09/06/2023] Open
Abstract
BACKGROUND The sedation method used during double-balloon endoscopic retrograde cholangiopancreatography (DB-ERCP) differs among countries and/or facilities, and there is no established method. This study aimed to evaluate the efficacy of non-anesthesiologist-administered propofol (NAAP) sedation using a target-controlled infusion (TCI) system during DB-ERCP. METHODS This retrospective study was conducted between May 2017 and December 2020 at an academic center. One hundred and fifty-six consecutive patients who underwent DB-ERCP were sedated by gastroenterologists using diazepam (n = 77) or propofol with a TCI system (n = 79), depending on the period. The primary endpoint was a comparison of poor sedation rates between the two groups. Poor sedation was defined as a condition requiring the use of other sedative agents or discontinuation of the procedure. Secondary endpoints were sedation-related adverse events and risk factors for poor sedation. RESULTS Poor sedation occurred significantly more often in the diazepam sedation group (diazepam sedation, n = 12 [16%] vs. propofol sedation, n = 1 [1%]; P = 0.001). Vigorous body movements (3 or 4) (diazepam sedation, n = 40 [52%] vs. propofol sedation, n = 28 [35%]; P = 0.038) and hypoxemia (< 85%) (diazepam sedation, n = 7 [9%] vs. propofol sedation, n = 1 [1%]; P = 0.027) occurred significantly more often in the diazepam sedation group. In the multivariate analysis, age < 70 years old (OR, 10.26; 95% CI, 1.57-66.98; P = 0.015), BMI ≥ 25 kg/m2 (OR, 11.96; 95% CI, 1.67-85.69; P = 0.014), and propofol sedation (OR, 0.06; 95% CI, 0.01-0.58; P = 0.015) were associated factors for poor sedation. CONCLUSIONS NAAP sedation with the TCI system during DB-ERCP was safer and more effective than diazepam sedation.
Collapse
Affiliation(s)
- Kazuya Miyamoto
- Department of Gastroenterology and Hepatology, Okayama University Hospital, 2-5-1 Shikata-Cho, Okayama, 700-8558 Japan
| | - Kazuyuki Matsumoto
- Department of Gastroenterology and Hepatology, Okayama University Hospital, 2-5-1 Shikata-Cho, Okayama, 700-8558 Japan
| | - Taisuke Obata
- Department of Gastroenterology and Hepatology, Okayama University Hospital, 2-5-1 Shikata-Cho, Okayama, 700-8558 Japan
| | - Ryosuke Sato
- Department of Gastroenterology and Hepatology, Okayama University Hospital, 2-5-1 Shikata-Cho, Okayama, 700-8558 Japan
| | - Akihiro Matsumi
- Department of Gastroenterology and Hepatology, Okayama University Hospital, 2-5-1 Shikata-Cho, Okayama, 700-8558 Japan
| | - Kosaku Morimoto
- Department of Gastroenterology and Hepatology, Okayama University Hospital, 2-5-1 Shikata-Cho, Okayama, 700-8558 Japan
| | - Taiji Ogawa
- Department of Gastroenterology and Hepatology, Okayama University Hospital, 2-5-1 Shikata-Cho, Okayama, 700-8558 Japan
| | - Hiroyuki Terasawa
- Department of Gastroenterology and Hepatology, Okayama University Hospital, 2-5-1 Shikata-Cho, Okayama, 700-8558 Japan
| | - Yuki Fujii
- Department of Gastroenterology and Hepatology, Okayama University Hospital, 2-5-1 Shikata-Cho, Okayama, 700-8558 Japan
| | - Tatsuhiro Yamazaki
- Department of Gastroenterology and Hepatology, Okayama University Hospital, 2-5-1 Shikata-Cho, Okayama, 700-8558 Japan
| | - Daisuke Uchida
- Department of Gastroenterology and Hepatology, Okayama University Hospital, 2-5-1 Shikata-Cho, Okayama, 700-8558 Japan
| | - Shigeru Horiguchi
- Department of Gastroenterology and Hepatology, Okayama University Hospital, 2-5-1 Shikata-Cho, Okayama, 700-8558 Japan
| | - Koichiro Tsutsumi
- Department of Gastroenterology and Hepatology, Okayama University Hospital, 2-5-1 Shikata-Cho, Okayama, 700-8558 Japan
| | - Hironari Kato
- Department of Gastroenterology and Hepatology, Okayama University Hospital, 2-5-1 Shikata-Cho, Okayama, 700-8558 Japan
| | - Motoyuki Otsuka
- Department of Gastroenterology and Hepatology, Okayama University Hospital, 2-5-1 Shikata-Cho, Okayama, 700-8558 Japan
| |
Collapse
|
3
|
Yang Y, Ji H, Lu Y, Hong J, Yang G, Kong X, Liu J, Ma X. Sedative-sparing effect of acupuncture in gastrointestinal endoscopy: systematic review and meta-analysis. Front Med (Lausanne) 2023; 10:1189429. [PMID: 37396891 PMCID: PMC10311963 DOI: 10.3389/fmed.2023.1189429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 06/01/2023] [Indexed: 07/04/2023] Open
Abstract
Objective This study aimed to perform a systematic review and meta-analysis to identify the efficacy of acupuncture therapy (including manual acupuncture and electroacupuncture) performed before or during gastrointestinal endoscopy with propofol as the main sedative, compared with placebo, sham acupuncture, or no additional treatment other than the same sedation. Methods A systematic search was performed through PubMed, Embase, Web of Science, Cochrane Library, Chinese Biomedical Databases (CBM), Wanfang database, China National Knowledge Infrastructure (CNKI), SinoMed, and Chinese Scientific Journal Database (VIP) to collect randomized controlled trials published before 5 November 2022. Bias assessment of the included RCTs was performed according to Version 2 of the Cochrane risk-of-bias tool for randomized trials (RoB 2). Stata16.0 software was used to perform statistical analysis, sensitivity analysis, and publication bias analysis. The primary outcome was sedative consumption, and the secondary outcomes included the incidence of adverse events and wake-up time. Results A total of 10 studies with 1331 participants were included. The results showed that sedative consumption [mean difference (MD) = -29.32, 95% CI (-36.13, -22.50), P < 0.001], wake-up time [MD = -3.87, 95% CI (-5.43, -2.31), P < 0.001] and the incidence of adverse events including hypotension, nausea and vomiting, and coughing (P < 0.05) were significantly lower in the intervention group than in the control group. Conclusion Acupuncture combined with sedation reduces sedative consumption and wake-up time compared with sedation alone in gastrointestinal endoscopy; this combined approach allows patients to regain consciousness more quickly after examination and lower the risk of adverse effects. However, with the limited quantity and quality of relevant clinical studies, caution must be applied until more high-quality clinical studies verify and refine the conclusions. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?, identifier: CRD42022370422.
Collapse
Affiliation(s)
- Yun Yang
- Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Haiyang Ji
- Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yunqiong Lu
- Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Jue Hong
- Shanghai Research Institute of Acupuncture and Meridian, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Guang Yang
- Shanghai Research Institute of Acupuncture and Meridian, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Xiehe Kong
- Shanghai Research Institute of Acupuncture and Meridian, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Jie Liu
- Shanghai Research Institute of Acupuncture and Meridian, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Xiaopeng Ma
- Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Shanghai Research Institute of Acupuncture and Meridian, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| |
Collapse
|
4
|
Lee MJ, Cha B, Park JS, Kim JS, Cho SY, Han JH, Park MH, Yang C, Jeong S. Impact of High-Flow Nasal Cannula Oxygenation on the Prevention of Hypoxia During Endoscopic Retrograde Cholangiopancreatography in Elderly Patients: A Randomized Clinical Trial. Dig Dis Sci 2022; 67:4154-4160. [PMID: 34727281 DOI: 10.1007/s10620-021-07272-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 09/29/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hypoxia is the most frequently occurring adverse effect during endoscopic retrograde cholangiopancreatography (ERCP) under sedation; thus, oxygen must be properly supplied to prevent a reduction of oxygen saturation. In this study, we intend to verify the preventive effect for hypoxia during ERCP, using a high-flow nasal cannula (HFNC), in elderly patients. METHODS As a multicenter prospective randomized trial, patients who underwent ERCP with propofol-based sedation were randomly assigned into two groups: Patients in the HFNC group were supplied with oxygen via an HFNC, and those in the standard nasal cannula group were supplied with oxygen via a low-flow nasal cannula. The co-primary end points were the lowest oxygen saturation rate and hypoxia during the overall procedure. RESULTS A total of 187 patients (HFNC group: 95; standard nasal cannula group: 92) were included in the analysis. Unexpected hypoxia events were more frequently observed among patients in the standard nasal cannula group than among patients in the HFNC group (13% vs. 4%, odds ratio 3.41, 95% confidence interval 1.06-11.00, p = 0.031). The mean of the lowest oxygen saturation rate during ERCP was significantly lower in the standard nasal cannula group than in the HFNC group (95% vs. 97%, p = 0.002). CONCLUSION Oxygen supplementation with an HFNC can prevent oxygen desaturation and hypoxia events in patients undergoing ERCP under sedation. Trial registration Clinical Research Information Service (CRIS; KCT0004960).
Collapse
Affiliation(s)
- Man-Jong Lee
- Division of Critical Care Medicine, Department of Hospital Medicine, Inha University College of Medicine, Incheon, Republic of Korea
| | - Boram Cha
- Division of Gastroenterology, Department of Internal Medicine, Inha University College of Medicine, 27 Inhang-ro, Jung-gu, Incheon, 22332, Republic of Korea
| | - Jin-Seok Park
- Division of Gastroenterology, Department of Internal Medicine, Inha University College of Medicine, 27 Inhang-ro, Jung-gu, Incheon, 22332, Republic of Korea.
| | - Jung Soo Kim
- Division of Critical Care Medicine, Department of Hospital Medicine, Inha University College of Medicine, Incheon, Republic of Korea
| | - Sang Yong Cho
- Division of Gastroenterology, Department of Internal Medicine, Inha University College of Medicine, 27 Inhang-ro, Jung-gu, Incheon, 22332, Republic of Korea
| | - Joung-Ho Han
- Division of Gastroenterology, Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Republic of Korea
| | - Mi Hwa Park
- Division of Critical Care Medicine, Department of Hospital Medicine, Inha University College of Medicine, Incheon, Republic of Korea
| | - Chunwoo Yang
- Department of Anesthesiology and Pain Medicine, Inha University College of Medicine, Incheon, Republic of Korea
| | - Seok Jeong
- Division of Gastroenterology, Department of Internal Medicine, Inha University College of Medicine, 27 Inhang-ro, Jung-gu, Incheon, 22332, Republic of Korea
| |
Collapse
|
5
|
Efficacy and Safety of Non-Anesthesiologist Administration of Propofol Sedation in Endoscopic Ultrasound: A Propensity Score Analysis. Diagnostics (Basel) 2020; 10:diagnostics10100791. [PMID: 33036219 PMCID: PMC7601714 DOI: 10.3390/diagnostics10100791] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 10/02/2020] [Accepted: 10/05/2020] [Indexed: 11/21/2022] Open
Abstract
In spite of promising preliminary results, evidence supporting the use of non-anesthesiologist-administered propofol sedation (NAAP) in endoscopic ultrasound (EUS) procedures is still limited. The aim of this manuscript was to examine the safety and efficacy of NAAP as compared to anesthesiologist-administered propofol sedation in EUS procedures performed in a referral center. Out of 832 patients referred to our center between 2016 and 2019, after propensity score matching two groups were compared: 305 treated with NAAP and 305 controls who underwent anesthesiologist-administered propofol sedation. The primary outcome was the rate of major complications. The median age was 67 years and the proportion of patients with comorbidities was 31.8% in both groups. One patient in each group (0.3%) experienced a major complication, whereas minor complications were observed in 13 patients in the NAAP group (4.2%) and 10 patients in the control group (3.2%; p = 0.52). Overall pain during the procedure was 2.3 ± 1 in group 1 and 1.8 ± 1 in group 2 (p = 0.67), whereas pain/discomfort upon awakening was rated as 1 ± 0.5 in both groups (p = 0.72). NAAP is safe and effective even in advanced EUS procedures. Further randomized-controlled trials (RCTs) are warranted to confirm these findings.
Collapse
|
6
|
Abstract
PURPOSE OF REVIEW Advances in early diagnosis and treatment of diseases using minimally invasive procedures has led to an increase in the number of cases in locations outside the operating room. This surge created the need for anesthesia services to expand to these areas to provide well tolerated and favorable procedural conditions. The present review describes nonoperating room anesthesia patterns in different parts of the world. RECENT FINDINGS Nonoperating room anesthesia has grown exponentially over the last years. Patients scheduled in these areas are sicker and older compared to the operating room patients. Anesthesiologist-directed care has proven to be well tolerated, with less serious complications and improvement in patients and proceduralist satisfaction. SUMMARY There are marked variations in how anesthesia services are delivered in out of operating room locations in different parts of the world. Although there are some data available from the United States, expansion of minimally invasive procedures across continents will likely lead to the emergence of various models of delivering anesthetic care.
Collapse
|
7
|
Weinberg L, Grover H, Cowie D, Langley E, Heland M, Story DA. Attitudes of anesthetists towards an anesthesia-led nurse practitioner model for low-risk colonoscopy procedures: a cross-sectional survey. HUMAN RESOURCES FOR HEALTH 2020; 18:20. [PMID: 32183813 PMCID: PMC7076960 DOI: 10.1186/s12960-020-0458-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 02/17/2020] [Indexed: 06/10/2023]
Abstract
BACKGROUND The mounting pressure on the Australian healthcare system is driving a continual exploration of areas to improve patient care and access and to maximize utilization of our workforce. We hypothesized that there would be support by anesthetists employed at our hospital for the design, development, and potential implementation of an anesthesia-led nurse practitioner (NP) model for low-risk colonoscopy patients. METHODS We conducted a cross-sectional, mixed methods study to ascertain the attitudes and acceptability of anesthetists towards a proposed anesthesia-led NP model for low-risk colonoscopy patients. An online survey using commercial software and theoretical questions pertaining to participants' attitudes towards an anesthesia-led NP model was e-mailed to consultant anesthetists. Participants were also invited to participate in a voluntary 20-min face-to-face interview. RESULTS A total of 60 survey responses were received from a pool of 100 anesthetists (response rate = 60%, accounting for 8.04% margin of error). Despite the theoretical benefits of improved patient access to colonoscopy services, most anesthetists were not willing to participate in the supervision and training of NPs. The predominant themes underlying their lack of support for the program were a perception that patient safety would be compromised compared to the current model of anesthesia-led care, the model does not meet the Australian and New Zealand College of Anesthetists guidelines for procedural sedation and analgesia, and the program may be a public liability prone to litigation in the event of an adverse outcome. Concerns about consumer acceptance and cost-effectiveness were also raised. Finally, participants thought the model should be pilot tested to better understand consumer attitudes, logistical feasibility, patient and proceduralist attitudes, clinical governance, and, importantly, patient safety. CONCLUSIONS Most anesthetists working in a single-center university hospital did not support an anesthesia-led NP model for low-risk colonoscopy patients. Patient safety, violations of the current Australian and New Zealand College of Anesthetists guidelines on procedural sedation, and logistical feasibility were significant barriers to the acceptance of the model. TRIAL REGISTRATION Australian and New Zealand Clinical Trials Registry, 12619001036101.
Collapse
Affiliation(s)
- L. Weinberg
- Department of Anesthesia, Austin Hospital, 145 Studley Road, Heidelberg, Victoria 3084 Australia
- Department of Surgery, The University of Melbourne, Melbourne, Victoria Australia
| | - H. Grover
- Department of Anesthesia, Austin Hospital, 145 Studley Road, Heidelberg, Victoria 3084 Australia
| | - D. Cowie
- Department of Anesthesia, Austin Hospital, 145 Studley Road, Heidelberg, Victoria 3084 Australia
| | - E. Langley
- Department of Anesthesia Perioperative and Pain Medicine Unit, The University of Melbourne, Melbourne, Victoria Australia
| | - M. Heland
- Department of Anesthesia Perioperative and Pain Medicine Unit, The University of Melbourne, Melbourne, Victoria Australia
| | - D. A. Story
- Centre for Integrated Critical Care, The University of Melbourne, Melbourne, Victoria Australia
| |
Collapse
|
8
|
Krigel A, Chen L, Wright JD, Lebwohl B. Substantial Increase in Anesthesia Assistance for Outpatient Colonoscopy and Associated Cost Nationwide. Clin Gastroenterol Hepatol 2019; 17:2489-2496. [PMID: 30625407 DOI: 10.1016/j.cgh.2018.12.037] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 12/20/2018] [Accepted: 12/23/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS The use of anesthesia assistance (AA) for outpatient colonoscopy has been increasing over the past decade, raising concern over its effects on procedure safety, quality, and cost. We performed a nationwide claims-based study to determine regional, patient-related, and facility-related patterns of anesthesia use as well as cost implications of AA for payers. METHODS We analyzed the Premier Perspective database to identify patients undergoing outpatient colonoscopy at over 600 acute-care hospitals throughout the United States from 2006 through 2015, with or without AA. We used multivariable analysis to identify factors associated with AA and cost. RESULTS We identified 4,623,218 patients who underwent outpatient colonoscopy. Of these, 1,671,755 (36.2%) had AA; the proportion increased from 16.7% in 2006 to 58.1% in 2015 (P < .001). Factors associated with AA included younger age (odds ratios [ORs], compared to patients 18-39 years old: 0.94, 0.82, 0.77, 0.72, and 0.77 for age groups 40-49 years, 50-59 years, 60-69 years, 70-79 years, and ≥80 years, respectively); and female sex (OR, 0.96 for male patients compared to female patients; 95% CI, 0.95-0.96). Black patients were less likely to receive AA than white patients (OR, 0.81; 95% CI, 0.81-0.82), although this difference decreased with time. The median cost of outpatient colonoscopy with AA was higher among all payers, ranging from $182.43 (95% CI, $180.80-$184.06) higher for patients with commercial insurance to $232.62 (95% CI, $222.58-$242.67) higher for uninsured patients. CONCLUSIONS In an analysis of a database of patients undergoing outpatient colonoscopy throughout the United States, we found that the use of AA during outpatient colonoscopy increased significantly from 2006 through 2015, associated with increased cost for all payers. The increase in anesthesia use mandates evaluation of its safety and effectiveness in colorectal cancer screening programs.
Collapse
Affiliation(s)
- Anna Krigel
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Ling Chen
- Department of Obstetrics and Gynecology, Columbia University, New York, New York
| | - Jason D Wright
- Department of Obstetrics and Gynecology, Columbia University, New York, New York; Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Benjamin Lebwohl
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, New York; Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York.
| |
Collapse
|
9
|
Lapidus A, Gralnek IM, Suissa A, Yassin K, Khamaysi I. Safety and efficacy of endoscopist-directed balanced propofol sedation during endoscopic retrograde cholangiopancreatography. Ann Gastroenterol 2019; 32:303-311. [PMID: 31040629 PMCID: PMC6479659 DOI: 10.20524/aog.2019.0360] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Accepted: 01/17/2019] [Indexed: 12/17/2022] Open
Abstract
Background Endoscopist-directed balanced propofol sedation (BPS) appears to be safe and effective for routine endoscopy. However, there are limited data on its use in endoscopic retrograde cholangiopancreatography (ERCP). We evaluated the safety and efficacy of endoscopist-directed BPS for ERCP, and compared patient outcomes with anesthesiologist-administered moderate sedation. Methods This was a retrospective cohort study, using prospectively collected endoscopy data from a tertiary care medical center where endoscopist-directed BPS during ERCP is routine practice. Adverse outcomes included need for bag-mask ventilation or intubation, aborted ERCP due to sedation, hospital admission post-ERCP (outpatients)/change in the level of care (inpatients), and death within 24 h. Results A total of 501 patients underwent ERCP with the use of endoscopist-directed BPS: Cohort 1 - 380 (76%) inpatients, mean age 64.1, 46% male, 24% American Society of Anesthesiologists physical status (ASA) score I, 65% ASA II, 11% ASA III. Concurrently, 24 patients received anesthesiologist-administered moderate sedation: Cohort 2 - 19 (79%) inpatients, mean age 65.0, 67% male, 12% ASA I, 25% ASA II, 38% ASA III, 25% ASA IV. In Cohort 1, none of the adverse outcomes were observed. Propofol dose was inversely correlated with age (r=-0.42, P<0.001), ASA score (r=-0.19, P<0.001), and Mallampati score (r=-0.24, P<0.001). One patient in Cohort 2 who received anesthesiologist-administered BPS required bag-mask ventilation and the ERCP was prematurely aborted because of the sedation. There were no deaths from any cause within 24 h of ERCP. Conclusion Endoscopist-directed BPS appears safe, efficacious, and feasible for ASA I-III patients undergoing inpatient or ambulatory ERCP.
Collapse
Affiliation(s)
- Alon Lapidus
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa (Alon Lapidus, Ian M. Gralnek, Iyad Khamaysi), Israel
| | - Ian M Gralnek
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa (Alon Lapidus, Ian M. Gralnek, Iyad Khamaysi), Israel.,Ellen and Pinchas Mamber Institute of Gastroenterology, Hepatology, and Nutrition, Emek Medical Center, Afula (Ian M. Gralnek), Israel
| | - Alain Suissa
- Department of Gastroenterology, Rambam Health Care Campus, Haifa (Alain Suissa, Kamel Yassin, Iyad Khamaysi), Israel
| | - Kamel Yassin
- Department of Gastroenterology, Rambam Health Care Campus, Haifa (Alain Suissa, Kamel Yassin, Iyad Khamaysi), Israel
| | - Iyad Khamaysi
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa (Alon Lapidus, Ian M. Gralnek, Iyad Khamaysi), Israel.,Department of Gastroenterology, Rambam Health Care Campus, Haifa (Alain Suissa, Kamel Yassin, Iyad Khamaysi), Israel
| |
Collapse
|
10
|
Assessment of the Quality of Outpatient Endoscopic Procedures by Using a Patient Satisfaction Questionnaire. CURRENT HEALTH SCIENCES JOURNAL 2019; 45:52-58. [PMID: 31297263 PMCID: PMC6592669 DOI: 10.12865/chsj.45.01.07] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 02/15/2019] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Endoscopic procedures represent an important part of daily practice, both for gastroenterologists and nurses, enabling diagnosis and treatment of digestive diseases. An optimal level of quality needs to be obtained for endoscopic procedures to be efficient, which is reflected directly by patient satisfaction. The Gastrointestinal Endoscopy Satisfaction Questionnaire (GESQ) has already been validated in a multicenter trial as an efficient method for measuring patient satisfaction. Aim The aim of our study was to evaluate the quality of endoscopic procedures and patient satisfaction by applying a modified version of the GESQ in an outpatient facility, with or without deep sedation performed under the supervision of an anesthesiologist. MATERIAL AND METHODS Our study included 552 patients undergoing diagnostic and therapeutic upper and lower GI endoscopies, including endoscopic ultrasound procedures (EUS) performed under propofol sedation, from September 2015 to February 2016. Consecutive patients examined during these 6 months received the questionnaire which was handed by the endoscopy nurse two hours after procedure. The GESQ was modified to include different sections for: 1) communication skills with questions regarding the quantity and clarity of the information delivered to the patient before and after the procedures; 2) pain and discomfort related to the examination with an added question about the specific procedure the patient had undergone; 3) staff manners; 4) physician's technical skills; 5) facility organization (waiting time, comfort in the recovery room, good facilities and equipment) and 6) overall satisfaction. The questionnaire did not include personal data, while answers were analyzed in a confidential manner. RESULTS A total number of 552 patients agreed to answer our questionnaire, 192 (34,7%) underwent gastroscopies, 288 (52,1%) colonoscopies and 72 (13,2%) EUS examinations. Regarding the overall level of satisfaction (assessed on a five-point scale), 476 (86,2%) were very satisfied or satisfied, 69 (12,5%) dissatisfied and the remainder 7 (1,3%) were indifferently. For the communication section 16 (3%) patients were not satisfied with the explanations received before the procedure or with the answers to their questions. Pain and discomfort were mentioned by 29 (5,2%) of the patients, usually related to colonoscopies or EUS examinations. 13 (2,3%) of the patients considered the comfort or intimacy of the recovery room to be poor, and 11 (2%) patients were not satisfied with the waiting time before the procedure. CONCLUSION Our modified questionnaire showed good overall patient satisfaction with our endoscopy unit, while also suggesting some areas in need of improvement, such as staff communication skills, better time management and reorganization of the recovery area. Our study demonstrates the importance of such questionnaires in providing feedback information meant to improve standards in endoscopy, including staff skills and organization.
Collapse
|
11
|
Periprocedural Role of Nurses During Interventional Endoscopic Procedures Under Deep Sedation. CURRENT HEALTH SCIENCES JOURNAL 2019; 44:14-18. [PMID: 30622749 PMCID: PMC6295179 DOI: 10.12865/chsj.44.01.02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 03/22/2018] [Indexed: 11/18/2022]
Abstract
Background. Most of endoscopic procedures, either diagnostic or therapeutic, are nowadays performed under sedation, used as a standard practice in most of the centers. Consequently, the number and complexity of endoscopic procedures has increased as sedation diminishes anxiety and discomfort for patients, also improving the quality of endoscopic examinations, and outcomes in therapeutic endoscopy. Compared to standard diagnostic upper or lower GI endoscopy, endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) are often longer and more complicated procedures, thus requiring higher doses of sedatives. Sedation levels and medication types depend on a variety of factors, related both to patient characteristics (age, comorbidities, preference, etc.), and procedure types (simple diagnostic endoscopy or more complex therapeutic procedures). Propofol has become undoubtedly the induction agent of choice as it is easy to administer, enables prompt awakening, and has fewer side effects. Aim. The aim of this paper is to outline the role and efficacy of the endoscopy nurse in the peri-procedural care of patients undergoing complex therapeutic interventions
(EUS-guided and/or ERCP) under propofol sedation. Methods. At our institution, the Research Centre of Gastroenterology and Hepatology Craiova, 192 patients underwent interventional endoscopic procedures between January 2014-December 2014 (130 EUS and 62 ERCP) under sedation with propofol. We included 110 patients in our study that were followed-up between 4 to 6 hours after the procedures. The GI nurse was responsible that the patients and/or their accompanying persons receive proper information in both written and spoken form regarding their procedure and potential adverse events after sedation. After the procedures the side effects related to anesthesia were marked down by the GI nurse based on a standard questionnaire. Results. The patients mean age was 53.5 years old, with 46 (41.8%) women and 64 (58.2%) men. Most of the patients, that is 90 (81.8%), presented no adverse events. The other 20 patients (18.2%) had the following side effects from sedation: drowsiness in 5 (4.5%) of the cases, nausea in 3 cases (2.8%), vomiting in one case (0.9%), 2 (1.8%) of the patients presented dizziness, 2 (1.8%) headache, 3 (2.8%) coughing, only one patient (0.9%) had an injection site reaction, one (0.9%) had shivers, and 2 patients (1.8%) presented bradycardia. Patients that had side effects were mainly of advanced age and with associated diseases which included chronic kidney disease, cardio-vascular diseases. The nurse responsible with the follow-up of patients was able to rapidly assess their complaints and intervene to the benefit of the patient, before serious adverse events could occur. Conclusions. Although propofol sedations is generally considered safe, potential side effects should be held in mind. The GI nurse has a valuable role in monitoring patients and assessing their response to sedation after the procedure, as well as in timely stepping in where necessary to prevent further complications.
Collapse
|
12
|
Han SJ, Lee TH, Yang JK, Cho YS, Jung Y, Chung IK, Park SH, Park S, Kim SJ. Etomidate Sedation for Advanced Endoscopic Procedures. Dig Dis Sci 2019; 64:144-151. [PMID: 30054843 DOI: 10.1007/s10620-018-5220-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 07/18/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND STUDY AIM Although propofol is widely used for sedation for endoscopic procedures, concerns remain regarding cardiopulmonary adverse events. Etomidate has little effect on the cardiovascular and respiratory systems, but patient satisfaction analysis is lacking. We compared the efficacy and safety of balanced propofol and etomidate sedation during advanced endoscopic procedures. METHODS As a randomized noninferiority trial, balanced endoscopic sedation was achieved using midazolam and fentanyl, and patients were randomly assigned to receive propofol (BPS) or etomidate (BES) as add-on drug. The main outcomes were sedation efficacy measured on a 10-point visual analog scale (VAS) and safety. RESULTS In total, 186 patients (94 in the BPS group and 92 in the BES group) were evaluated. BES did not show noninferiority in terms of overall patient satisfaction, with a difference in VAS score of -0.35 (97.5 % confidence interval -1.03 to ∞, p = 0.03). Among endoscopists and nurses, BES showed noninferiority to BPS, with differences in VAS scores of 0.06 and 0.08, respectively. Incidence of cardiopulmonary adverse events was lower in the BES group (27.7 versus 14.1 %, p = 0.023). Hypoxia occurred in 5.3 and 1.1 % of patients in the BPS and BES group (p = 0.211). Myoclonus occurred in 12.1 % (11/92) in the BES group. BES had lower risk of overall cardiopulmonary adverse events (odds ratio 0.401, p = 0.018). CONCLUSIONS BES was not noninferior to BPS in terms of patient satisfaction. However, BES showed better safety outcomes in terms of cardiopulmonary adverse events.
Collapse
Affiliation(s)
- Su Jung Han
- Division of Gastroenterology, Department of Internal Medicine, Digestive Disease Center, Cheonan Hospital, Soonchunhyang University School of Medicine, 31, Sooncheonhyang 6-gil, Dongnam-gu, Cheonan-si, Chungcheongnam-do, 31151, Republic of Korea
| | - Tae Hoon Lee
- Division of Gastroenterology, Department of Internal Medicine, Digestive Disease Center, Cheonan Hospital, Soonchunhyang University School of Medicine, 31, Sooncheonhyang 6-gil, Dongnam-gu, Cheonan-si, Chungcheongnam-do, 31151, Republic of Korea.
| | - Jae Kook Yang
- Division of Gastroenterology, Department of Internal Medicine, Digestive Disease Center, Cheonan Hospital, Soonchunhyang University School of Medicine, 31, Sooncheonhyang 6-gil, Dongnam-gu, Cheonan-si, Chungcheongnam-do, 31151, Republic of Korea
| | - Young Sin Cho
- Division of Gastroenterology, Department of Internal Medicine, Digestive Disease Center, Cheonan Hospital, Soonchunhyang University School of Medicine, 31, Sooncheonhyang 6-gil, Dongnam-gu, Cheonan-si, Chungcheongnam-do, 31151, Republic of Korea
| | - Yunho Jung
- Division of Gastroenterology, Department of Internal Medicine, Digestive Disease Center, Cheonan Hospital, Soonchunhyang University School of Medicine, 31, Sooncheonhyang 6-gil, Dongnam-gu, Cheonan-si, Chungcheongnam-do, 31151, Republic of Korea
| | - Il-Kwun Chung
- Division of Gastroenterology, Department of Internal Medicine, Digestive Disease Center, Cheonan Hospital, Soonchunhyang University School of Medicine, 31, Sooncheonhyang 6-gil, Dongnam-gu, Cheonan-si, Chungcheongnam-do, 31151, Republic of Korea
| | - Sang-Heum Park
- Division of Gastroenterology, Department of Internal Medicine, Digestive Disease Center, Cheonan Hospital, Soonchunhyang University School of Medicine, 31, Sooncheonhyang 6-gil, Dongnam-gu, Cheonan-si, Chungcheongnam-do, 31151, Republic of Korea
| | - Suyeon Park
- Department of Statistics, Soonchunhyang University School of Medicine, Seoul, Republic of Korea
| | - Sun-Joo Kim
- Division of Gastroenterology, Department of Internal Medicine, Digestive Disease Center, Cheonan Hospital, Soonchunhyang University School of Medicine, 31, Sooncheonhyang 6-gil, Dongnam-gu, Cheonan-si, Chungcheongnam-do, 31151, Republic of Korea
| |
Collapse
|
13
|
Pérez-Cuadrado-Robles E, Ferreira A, García-Cano J. Enhancing the current evidence on endoscopist-directed propofol-based sedation. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2018; 110:215-216. [PMID: 29620407 DOI: 10.17235/reed.2018.5502/2017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
During the last years, there is more and more scientific evidence about the safety and feasibility of non-anesthesiologist administration of propofol (NAAP) in gastrointestinal endoscopy, reducing sedation induction and recovery time as well as increasing patient and endoscopist satisfaction. Furthermore, a similar risk of adverse events compared with traditional agents or anesthesiologist administration of propofol (AAP) has been described. The present special issue of the Spanish Journal of Gastroenterology (Revista Española de Enfermedades Digestivas) focusses on NAAP in different settings, including complex endoscopic procedures.
Collapse
|
14
|
Luzón Solanas L, Ollero Domenche L, Sierra Moros EM, Val Pérez J, Soria San Teodoro MT, Giménez Júlvez T, Uribarrena Amezaga R. The safety of deep sedation with propofol controlled by the endoscopist in endoscopic retrograde cholangiopancreatography (ERCP): a prospective study in a tertiary hospital. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2018; 110:217-222. [DOI: 10.17235/reed.2018.5262/2017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
15
|
Safety of Propofol Used as a Rescue Agent During Colonoscopy. J Clin Gastroenterol 2016; 50:e77-80. [PMID: 26565970 DOI: 10.1097/mcg.0000000000000445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
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.
Collapse
|
16
|
Anesthesia on the run. Curr Opin Anaesthesiol 2016; 29:482-4. [DOI: 10.1097/aco.0000000000000354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
17
|
Da B, Buxbaum J. Training and Competency in Sedation Practice in Gastrointestinal Endoscopy. Gastrointest Endosc Clin N Am 2016; 26:443-62. [PMID: 27372769 DOI: 10.1016/j.giec.2016.02.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The practice of endoscopic sedation requires a thorough understanding of preprocedural assessment, sedation pharmacology, intraprocedure monitoring, adverse event management, and postprocedural care. The training process has become increasingly standardized and entails knowledge and practice-based components. The use of propofol in particular requires a higher level of structured training owing to its narrow therapeutic window. Simulation has increased opportunities for practice-based training in a controlled environment. After completion of training, the endoscopist must demonstrate competence in theoretical understanding and technical ability to administer sedation. Although individual institutions have certification processes, there is a lack of validated, standardized methods to confirm competence.
Collapse
Affiliation(s)
- Ben Da
- Division of Gastroenterology and Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - James Buxbaum
- Division of Gastroenterology and Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
| |
Collapse
|