Prevalence of Anesthetic and Gastrointestinal Complications of Endoscopic Retrograde Cholangiopancreatography

Randomized, Single-Blind, Comparative Study of Remimazolam Besylate vs Propofol for Facial Plastic Surgery

BACKGROUND

Use of local anesthesia and conscious sedation with a combination of a sedative and anesthetic drug during a surgical procedure is an approach designed to avoid intubation, which produces fewer adverse events compared to general anesthesia. In the present study, a comparison was made between the efficacy and safety of remimazolam besylate and propofol for facial plastic surgery.

OBJECTIVES

The objective was to evaluate the clinical efficacy, comfort, and incidence of adverse events of remimazolam compared with propofol combined with alfentanil in outpatient facial plastic surgery.

METHODS

In this randomized, single-blind, single-center, comparative study, facial plastic surgery patients were randomly divided into remimazolam-alfentanil (n = 50) and propofol-alfentanil (n = 50) groups for sedation and analgesia. The primary endpoint was the incidence of hypoxemia, while secondary endpoints included efficacy and safety evaluations.

RESULTS

There were no significant differences regarding the surgical procedure, sedation and induction times, pain and comfort scores, muscle strength recovery, heart rate, respiratory rate, and blood pressure, but the dosage of alfentanil administered to the remimazolam group (387.5 μg) was lower than that for the propofol group (600 μg). The incidence of hypoxemia (P = .046) and towing of the mandibular (P = .028), as well as wake-up (P = .027) and injection pain (P = .008), were significantly higher in the propofol group than the remimazolam group.

CONCLUSIONS

Remimazolam and propofol had similar efficacies for sedation and analgesia during facial plastic surgery, but especially the incidence of respiratory depression was significantly lower in patients given remimazolam.

LEVEL OF EVIDENCE: 2

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).

Consensus guidelines for the perioperative management of patients undergoing endoscopic retrograde cholangiopancreatography

Deep sedation without tracheal intubation (monitored anaesthesia care) and general anaesthesia with tracheal intubation are commonly used anaesthesia techniques for endoscopic retrograde cholangiopancreatography (ERCP). There are distinct pathophysiological differences between monitored anaesthesia care and general anaesthesia that need to be considered depending on the nature and severity of the patient's underlying disease, comorbidities, and procedural risks. An international group of expert anaesthesiologists and gastroenterologists created clinically relevant questions regarding the merits and risks of monitored anaesthesia care vs general anaesthesia in specific clinical scenarios for planning optimal anaesthetic approaches for ERCP. Using a modified Delphi approach, the group created practical recommendations for anaesthesiologists, with the aim of reducing the incidence of perioperative adverse outcomes while maximising healthcare resource utilisation. In the majority of clinical scenarios analysed, our expert recommendations favour monitored anaesthesia care over general anaesthesia. Patients with increased risk of pulmonary aspiration and those undergoing prolonged procedures of high complexity were thought to benefit from general anaesthesia with tracheal intubation. Patient age and ASA physical status were not considered to be factors for choosing between monitored anaesthesia care and general anaesthesia. Monitored anaesthesia care is the favoured anaesthesia plan for ERCP. An individual risk-benefit analysis that takes into account provider and institutional experience, patient comorbidities, and procedural risks is also needed.

A randomized, controlled clinical trial comparing remimazolam to propofol when combined with alfentanil for sedation during ERCP procedures

STUDY OBJECTIVE

In many countries, the combination of propofol and opioid is used as the preferred sedative regime during ERCP. However, the most serious risks of propofol sedation are oxygen deficiency and hypotension. Compared to midazolam, remimazolam has a faster onset and offset of hypnotic effect, as well as cardiorespiratory stability, and to achieve widespread acceptance for procedural sedation, remimazolam must replace propofol which is the most commonly used for procedural sedation. The objective of this study was to compare the safety and efficacy profiles of the remimazolam and propofol when combined with alfentanil for sedation during ERCP procedures.

DESIGN

A randomized, controlled, single-center trial.

SETTING

The Endoscopic Centre of Tianjin Nankai Hospital, China.

PATIENTS

518 patients undergoing elective ERCP under deep sedation.

INTERVENTIONS

Patients scheduled for ERCP were randomly assigned to be sedated with either a combination of remimazolam-alfentanil or propofol-alfentanil.

MEASUREMENTS

The primary outcome was the prevalence of hypoxia, which was defined as SpO₂ < 90% for >10 s. Other outcomes were the need for airway maneuver, procedure, and sedation-related outcomes and side effects (e.g., nausea, vomiting, and cardiovascular adverse events).

MAIN RESULTS

A total of 518 patients underwent randomization. Of these, 250 were assigned to the remimazolam group and 255 to the propofol group. During ERCP, 9.6% of patients in the remimazolam group showed hypoxia, while in the propofol group, 15.7% showed hypoxia (p = 0.04). The need for airway maneuvering due to hypoxia was significantly greater in the propofol group (p = 0.04). Furthermore, patients sedated with remimazolam had a lower percentage of hypotension than patients sedated with propofol (p < 0.001). Patients receiving remimazolam sedation expressed higher satisfaction scores and were recommended the same sedation for the next ERCP. The procedure time in the remimazolam group was much longer than in the propofol group due to the complexity of the patient's disease, which resulted in a longer sedation time.

CONCLUSION

During elective ERCP, patients administered with remimazolam showed fewer respiratory depression events under deep sedation with hemodynamic advantages over propofol when administered in combination with alfentanil.

Machine-Learning Model for the Prediction of Hypoxaemia during Endoscopic Retrograde Cholangiopancreatography under Monitored Anaesthesia Care

PURPOSE

Hypoxaemia is a significant adverse event during endoscopic retrograde cholangiopancreatography (ERCP) under monitored anaesthesia care (MAC); however, no model has been developed to predict hypoxaemia. We aimed to develop and compare logistic regression (LR) and machine learning (ML) models to predict hypoxaemia during ERCP under MAC.

MATERIALS AND METHODS

We collected patient data from our institutional ERCP database. The study population was randomly divided into training and test sets (7:3). Models were fit to training data and evaluated on unseen test data. The training set was further split into k-fold (k=5) for tuning hyperparameters, such as feature selection and early stopping. Models were trained over k loops; the i-th fold was set aside as a validation set in the i-th loop. Model performance was measured using area under the curve (AUC).

RESULTS

We identified 6114 cases of ERCP under MAC, with a total hypoxaemia rate of 5.9%. The LR model was established by combining eight variables and had a test AUC of 0.693. The ML and LR models were evaluated on 30 independent data splits. The average test AUC for LR was 0.7230, which improved to 0.7336 by adding eight more variables with an l₁ regularisation-based selection technique and ensembling the LRs and gradient boosting algorithm (GBM). The high-risk group was discriminated using the GBM ensemble model, with a sensitivity and specificity of 63.6% and 72.2%, respectively.

CONCLUSION

We established GBM ensemble model and LR model for risk prediction, which demonstrated good potential for preventing hypoxaemia during ERCP under MAC.

Is endoscopist-directed sedation for endoscopic retrograde cholangiopancreatography with balanced propofol solution (BPS) practical and safe? A prospective study from a tertiary care centre in India

Introduction

Endoscopist-directed, nurse-administered sedation using propofol, midazolam, and fentanyl for endoscopic retrograde cholangiopancreatography (ERCP) is being utilized worldwide. However, this is not usually employed in India by endoscopists.

Aim

To assess the efficacy, acceptability, and safety of this sedation in low to moderate risk patients undergoing ERCP.

Material and methods

This was a prospective study involving 500 patients with any indication for ERCP. The sedation was given by trained nurses.

Results

The sedative dosages per patient were as follows: propofol = 90 ±20 mg, fentanyl 0.75 ±0.25 mg (range: 0.25-1.00 mg), and midazolam 2 ±0.5 mg (range: 1-3 mg). Ninety-seven percent of patients achieved Richmond agitation sedation score of ≥ -3, and 96.8% achieved Gloucester comfort score of ≤ 2. 4.22% of the patients had mild adverse events (AE), and 2.11% had moderate AE. Two (0.4%) patients required intubation and intensive care unit admission. Mean recovery time was 15.3 min. 98.3% of the endoscopists were satisfied with the sedation achieved. 31.2% of the patients remembered the procedure. 93% of the patients were satisfied with the type of sedation. 92.75% of ERCPs were successful. 7.59% had procedure-related complications: in the form PEP - 5.290%, significant bleeding - 1.08%, and perforation - 0.43%.

Conclusions

Endoscopist-directed, nurse-administered sedation for ERCP with balanced propofol solution is practical, efficient, time saving, safe, and acceptable to patients.

Comparison of etomidate and propofol-mediated anesthesia induction followed by intubation and sevoflurane maintenance during ERCP in obese patients

OBJECTIVE

In this study, we focused on obese patients (Body Mass Index (BMI) ≥30 kg/m²) and compared the efficacy and safety of etomidate or propofol-mediated anesthesia induction followed by intubation and sevoflurane maintenance during endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

A total of 180 patients were computer-randomized into a propofol group or an etomidate group, with 90 cases in each group. Patients received anesthesia induction by etomidate or propofol followed by intubation and sevoflurane maintenance during ERCP. Baseline characteristics, information about procedure-related time and satisfaction, and adverse events were collected and compared between the etomidate group and propofol group.

RESULTS

Baseline characteristics of both groups were similar. The propofol group had a longer time of intraoperative SpO₂ <95% (etomidate group vs propofol group, 0.07±0.47 min vs 0.24±0.87 min, P-value = 0.019), higher frequency of SpO₂ <95% for any period of time (etomidate group vs propofol group, 2.22% vs 11.11%, P-value = 0.032), and higher frequency of transient hypotension (etomidate group vs propofol group, 1.11% vs 8.89%, P-value = 0.034). The etomidate group had longer induction time and recovery time than the propofol group with P-values of 0.019 and 0.004, respectively.

CONCLUSION

In obese patients who underwent ERCP and needed intubation, etomidate appears better than propofol for anesthesia induction followed by anesthesia maintenance of sevoflurane.

Pre- and post-procedure risk prediction models for post-endoscopic retrograde cholangiopancreatography pancreatitis

BACKGROUND

Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is the most common serious adverse event. Given recent endoscopic advances, we aimed to develop and validate a risk prediction model for PEP using the latest clinical database.

METHODS

We analyzed the data of patients with naïve papilla who underwent endoscopic retrograde cholangiopancreatography (ERCP). Pre-ERCP and post-ERCP risk prediction models for PEP were developed using logistic regression analysis. Patients were classified into low- (0 points), intermediate- (1-2 points), and high-risk (≥ 3 points) groups according to point scores.

RESULTS

We included 760 and 735 patients in the derivation and validation cohorts, respectively. The incidence of PEP was 5.5% in the derivation cohort and 3.9% in the validation cohort. Age ≤ 65 (1 point), female sex (1 point), acute pancreatitis history (2 points), malignant biliary obstruction (2 points [pre-ERCP model] or 1 point [post-ERCP model]), and pancreatic sphincterotomy (2 points, post-ERCP model only) were independent risk factors. In the validation cohort, the high-risk group (≥ 3 points) had a significantly higher risk of PEP compared to the low- or intermediate-risk groups under the post-ERCP risk prediction model (low: 2.0%; intermediate: 3.4%; high: 18.4%), while there was no significant between-group difference under the pre-ERCP risk prediction model (low: 2.2%; intermediate: 3.8%; high: 6.9%).

CONCLUSIONS

We developed and validated pre-ERCP and post-ERCP risk prediction models. In the latter, the high-risk group had a higher risk of PEP development than the low- or intermediate-risk groups. Our study findings will help clinicians stratify patient risk for the development of PEP.

Safety and sedation-associated adverse event reporting among patients undergoing endoscopic cholangiopancreatography: a comparative systematic review and meta-analysis

BACKGROUND AND AIM

There is wide variation in choice of sedation and airway management for endoscopic retrograde cholangiopancreatography (ERCP). The aim of this study was to perform a systematic review and meta-analysis to investigate safety outcomes of deep sedation with monitored anesthesia care (MAC) versus general endotracheal anesthesia (GETA).

METHODS

Individualized search strategies were performed in accordance with PRISMA and MOOSE guidelines. This meta-analysis was performed by calculating pooled proportions using random effects models. Measured outcomes included procedure success, all-cause and anesthesia-associated adverse events, and post-procedure recovery time. Heterogeneity was assessed with I² statistics and publication bias by funnel plot and Egger regression testing.

RESULTS

Five studies (MAC: n = 1284 vs GETA: n = 615) were included. Patients in the GETA group were younger, had higher body mass index (BMI), and higher mean ASA scores (all P < 0.001) with no difference in Mallampati scores (P = 0.923). Procedure success, all-cause adverse events, and anesthesia-associated events were similar between groups [OR 1.16 (95% CI 0.51-2.64); OR 1.16 (95% CI 0.29-4.70); OR 1.33 (95% CI 0.27-6.49), respectively]. MAC resulted in fewer hypotensive episodes [OR 0.32 (95% CI 0.12-0.87], increased hypoxemic events [OR 5.61 (95% CI 1.54-20.37)], and no difference in cardiac arrhythmias [OR 0.48 (95% CI 0.13-1.78)]. Procedure time was decreased for MAC [standard difference - 0.39 (95% CI - 0.78-0.00)] with no difference in recovery time [standard difference - 0.48 (95% CI - 1.04-0.07)].

CONCLUSIONS

This study suggests MAC may be a safe alternative to GETA for ERCP; however, MAC may not be appropriate in all patients given an increased risk of hypoxemia.