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

Safe outpatient discharge after gastrointestinal endoscopy with sedation and analgesia: a systematic literature review

Sedation and analgesia during gastrointestinal (GI) endoscopy increase procedural quality, contributing at the same time to greater patient satisfaction and willingness to undergo the procedure. Although sedation use has been optimized by the advent of efficacious and safe medications, data regarding the minimal criteria for discharge after outpatient endoscopy remain scant. Moreover, the time of discharge after endoscopy can be highly variable, depending not only on the type of procedure and anesthesia administered, but also on postprocedural complications and the patient's comorbidities. To make things even more conflicting, there is neither consensus among various endoscopic societies, concerning the most appropriate discharge strategy, nor a universally established tool that could be incorporated into everyday clinical practice, allowing patients' safe discharge as well as ability to drive. In this context, we conducted a systematic review, aiming to summarize the evidence regarding the available discharge scoring systems after outpatient GI endoscopy with sedation and analgesia administration.

Sedation for GI Endoscopy in the Morbidly Obese: Challenges and Possible Solutions

With the increasing prevalence of obesity and morbid obesity, this subgroup's contribution to patients presenting for elective procedures requiring sedation is significant. Gastrointestinal (GI) procedures clearly form the largest group of such procedures. These procedures may be intended to treat obesity such as the insertion of an intragastric balloon or one or more unrelated procedures such as a screening colonoscopy and (or) diagnostic/therapeutic endoscopy. Regardless of the procedure, these patients pose significant challenges in terms of choice of sedatives, dosing, airway management, ventilation, and oxygenation. An understanding of dissimilarity in the handling of different groups of medications used by an anesthesia provider and alterations in airway anatomy is critical for providing safe sedation. Administration of sedative medications and conduct of anesthesia requires dose modifications and airway adjuncts. In this review, we discuss the above issues in detail, with a particular focus on GI endoscopy.

Upper gastrointestinal endoscopy procedure volume trends, perioperative mortality, and malpractice claims: Population-based analysis

Background and study aims Upper gastrointestinal endoscopy (EGD) is one of the most common diagnostic procedures done to examine the foregut, but it can also be used for therapeutic interventions. The main objectives of this study were to investigate trends in EGD utilization and mortality related to it in a national low-threshold healthcare system, assess perioperative safety, and identify and describe patient-reported malpractice claims from the national database. Patients and methods We retrospectively identified patients from the Finnish Patient Care Registry who underwent diagnostic or procedural EGD between 2010 and 2018. In addition, patient-reported claims for malpractice were analyzed from the National Patient Insurance Center (PIC) database. Patient survival data were gathered collectively from the National Death Registry from Statistics Finland. Results During the study period, 409,153 EGDs were performed in Finland for 298,082 patients, with an annual rate of 9.30 procedures per 1,000 inhabitants, with an annual increase of 2.6%. Thirty-day all-cause mortality was 1.70% and 90-day mortality was 3.84%. For every 1,000 patients treated, 0.23 malpractice claims were filed. Conclusions The annual rate of EGD increased by 2.6% during the study, while the rate of interventional procedures remained constant. Also, while the 30-day mortality rate declined over the study period, it is an unsuitable quality metric for EGDs in comprehensive centers because a patient's underlying disease plays a larger role than the procedure in perioperative mortality. Finally, there were few malpractice claims, with self-evident causes prevailing.

Predictors and impact of aspiration pneumonia in patients undergoing esophagogastroduodenoscopy: national inpatient sample 2016-2020

OBJECTIVES

Aspiration pneumonia is a rare but feared complication among patients undergoing esophagogastroduodenoscopy (EGD). Our study aims to assess the incidence as well as risk factors for aspiration pneumonia in patients undergoing EGD.

METHODS

National Inpatient Sample 2016-2020 was used to identify adult patients undergoing EGD. Patients were stratified into two groups based on the presence of aspiration pneumonia. Multivariate logistic regression analysis was performed to identify the risk factors associated with aspiration pneumonia. We adjusted for patient demographics, Elixhauser comorbidities and hospital characteristics.

RESULTS

Of the 1.8 million patients undergoing EGD, 1.9% of the patients developed aspiration pneumonia. Patients with aspiration pneumonia were mostly males (59.54%), aged >65 years old (66.19%), White (72.2%), had Medicare insurance (70.5%) and were in the lowest income quartile (28.7%). On multivariate analysis, the age >65 group, White race, congestive heart failure (CHF), neurological disorders and chronic obstructive pulmonary disease were associated with higher odds of aspiration pneumonia. This complication was associated with higher in-hospital mortality (9% vs. 0.8%; P  < 0.001) and longer length of stay (10.54 days vs. 4.85 days; P  < 0.001).

CONCLUSION

Our study found that rates of post-EGD aspiration pneumonia are increasing. We found a significant association between various comorbidities and aspiration pneumonia. Our data suggests that we need to optimize these patients before EGD, as the development of aspiration is associated with worsened outcomes. Further prospective studies are needed to clarify these associations.

Nasal continuous positive pressure versus simple face mask oxygenation for adult obese and obstructive sleep apnea patients undergoing colonoscopy under propofol-based general anesthesia without tracheal intubation: A randomized controlled trial

STUDY OBJECTIVE

To determine if a nasal positive airway pressure (nasal CPAP) mask would decrease the number of hypoxemic events in obese and obstructive sleep apnea patients undergoing colonoscopy.

DESIGN

Single-center prospective randomized controlled trial.

SETTING

Tertiary academic center.

PATIENTS

We enrolled 109 patients with diagnosis of obesity and/or obstructive sleep apnea scheduled to undergo colonoscopy under propofol general anesthesia without planned tracheal intubation.

INTERVENTION

Patients were randomly allocated (1:1 ratio) to receive supplementary oxygen at a flow of 10 L/min, either through a nasal CPAP or a simple facemask.

MEASUREMENTS

The primary endpoint was the difference in the mean percentage of time spent with oxygen saturation below 90% between the two groups. Secondary outcomes included the need for airway maneuvers/interventions, average SpO2 during the case, duration and severity of oxygen desaturation, incidence and duration of procedural interruptions, and satisfaction and tolerance scores.

MAIN RESULTS

54 were allocated to the simple face mask and 55 to the nasal CPAP mask arms, respectively. A total of 6 patients experienced a hypoxemic event. Among these patients, the difference in the percentage of time spent with oxygen saturation below 90% was not clinically relevant (p = 1.0). However, patients in the nasal CPAP group required less chin lift (20% vs. 42.6%; p = 0.01) and oral cannula insertion (12.7% vs.29.6%; p = 0.03). The percentage of patients with at least one airway maneuver was higher in the simple face mask arm (68.5% vs. 41.8%; p = 0.005). Patient tolerance to device score was lower in the nasal CPAP group (8.85 vs. 9.56; p = 0.003).

CONCLUSIONS

A nasal CPAP did not prevent hypoxemia and should not be used routinely for colonoscopy in obese or OSA patients if a simple face mask is an alternative therapy. However, potential advantages of its use include fewer airway maneuvers or interventions, which may be desirable in certain clinical settings.

TRIAL REGISTRATION

Clinicaltrials.gov, identifier: NCT05175573.

Procedural sedation analgesia in the elderly patient

Elderly patients are perceived as a high-risk group for procedural sedation. Procedural sedation analgesia (PSA) is generally safe in older adults. What is not acceptable is undertreating pain or inadequately sedating a stable patient. All the usual precautions should be taken. One should consider any comorbidities that could make the patient more at risk of adverse reactions or complications. Older patients may be at higher risk for oxygen desaturation, but they usually respond quickly to supplemental oxygen. Geriatric patients usually require lower doses of medications. They tend to be more sensitive to medications, with slower metabolism, less physiologic reserve to handle side effects, and a smaller volume of distribution. The use of drugs for sedation in elderly patients requires careful consideration of their age-related changes in physiology and pharmacokinetics. The choice of drug should be based on the patient's medical condition, comorbidities, and potential adverse effects. Moreover, the administration should be done by trained personnel with close monitoring of vital signs and level of consciousness to prevent complications such as respiratory depression.

Comparison of the Jcerity endoscoper airway and the endotracheal tube in endoscopic esophageal variceal ligation: a prospective randomized controlled trial

Various airway techniques have been used in endoscopic esophageal variceal ligation (EVL). In this respect, Jcerity endoscoper airway (JEA) is a novel laryngeal mask airway that is designed for use in gastrointestinal endoscopy. In the present study, 164 patients who underwent EVL were randomly divided into JEA group or endotracheal tube (ETT) group (ratio: 1:1). Success rate of endoscopic procedure, endoscope insertion time, procedure duration, recovery time, airway technique extubation time, anesthesia costs, hospital stay duration, complications, and hemodynamic parameters were recorded. The success rate of EVL in the JEA group was noninferior to that in the ETT group (98.8% vs. 100.0%). The airway insertion time, anesthesia duration, and recovery time were significantly shorter in the JEA group than in the ETT group (p < 0.001). Furthermore, the blood pressure during extubation was more stable in the JEA group (p < 0.001). Moreover, there were less heart rate variations during intubation (p < 0.005) and extubation (p < 0.05) in the JEA group. Nonetheless, the endoscopists' satisfaction scores were comparable between the two groups. Overall, our findings suggest that JEA is efficient and safe for clinical use in EVL.Trial registration: Chinese Clinical Trial Registry, ChiCTR2000031892, Registered April 13, 2020, https://www.chictr.org.cn/searchproj.html .

Effect of Premedication with Glycopyrrolate on Patient Tolerance and Procedure Outcomes in Patients Undergoing Unsedated Upper Gastrointestinal Endoscopy: A Randomized Placebo-controlled Trial

Background and aim

An optimal topical pharyngeal anesthesia (TPA) is required for better patient tolerance and procedural outcomes of an unsedated upper gastrointestinal endoscopy (UGIE). Several additional strategies have been tried to improve patient tolerance with limited success. We hypothesized that premedication with glycopyrrolate would enhance TPA and improve patient tolerance and procedural outcomes of an unsedated UGIE.

Materials and methods

We conducted a randomized, double-blind, placebo-controlled trial between July 2020 and May 2022. Consecutive patients undergoing unsedated UGIE were randomly assigned to receive either intravenous glycopyrrolate or a placebo 30 minutes before TPA. Patient tolerance, comfort level for the endoscopist, cardiorespiratory fluctuations, percentage of failed esophageal intubation, and incomplete examination were studied.

Results

380 patients were randomized to 190 in each arm. The median (IQR) VAS scores for the overall patient satisfaction in the glycopyrrolate and placebo groups were 8 (1) and 7 (2), respectively (p = 0.04). The median (IQR) VAS scores for endoscopist assessment of patient cooperation in the glycopyrrolate and placebo groups were 8 (1.3) and 8 (1), respectively (p = 0.04). There was no difference in the percentage of failed esophageal intubation and incomplete examination, fluctuations in heart rate, and oxygen saturation of the participants. However, the mean arterial pressure (MAP) on-table before the start of the procedure at 1 minute and 3 minutes was significantly higher in the glycopyrrolate group (p = 0.01, 0.01, and 0.04, respectively).

Conclusion

In unsedated UGIE, glycopyrrolate premedication significantly improves the patient tolerance and endoscopist's comfort, with minimal cardiorespiratory effects. Hence, it could be incorporated into day-care unsedated endoscopy practice.Trial registration - CTRI/2020/07/026786.

How to cite this article

Ramalingam R, Senthamizhselvan K, Harichandrakumar KT, et al. Effect of Premedication with Glycopyrrolate on Patient Tolerance and Procedure Outcomes in Patients Undergoing Unsedated Upper Gastrointestinal Endoscopy: A Randomized Placebo-controlled Trial. Euroasian J Hepato-Gastroenterol 2023;13(2):55-60.

Gastrointestinal endoscopy procedures under intravenous sedation in the prone position: keep LMA gastro handy!

Gastrointestinal endoscopies are often done in the prone position and anesthesiologists are needed to provide sedation. Airway access is limited in the prone position and may make timely airway management difficult in case of airway obstruction during sedation. Specialized laryngeal mask airway devices customized for endoscopy procedures like LMA® Gastro™ can be inserted in the prone position and may help anesthesiologists tide over such crisis situations while simultaneously allowing the endoscopy procedures through the dedicated conduit available for inserting the endoscopes. We have described one such case managed successfully by inserting LMA® Gastro™ in the prone position.

Cost-Effectiveness of Earlier or More Intensive Colorectal Cancer Screening in Overweight and Obese Patients

BACKGROUND & AIMS

Overweight and obese persons have not only elevated rates of colorectal cancer (CRC), but also higher competing mortality and healthcare spending. We examined the cost-effectiveness of intensified CRC screening in overweight and obese persons.

METHODS

We adapted our validated decision analytic model of CRC screening to compare screening starting at 45 or 40 years of age instead of at 50 years of age, or shortening screening intervals, in women and men with body mass index (BMI) ranging from normal to grade III obesity. Strategies included colonoscopy every 10 years (Colo10) or every 5 years (Colo5), or annual fecal immunochemical test.

RESULTS

Without screening, sex-specific total CRC deaths were similar for persons with overweight or obesity I-III, reflecting the counterbalancing of higher CRC risk by lower life expectancy as BMI rises. For all BMI and sex groups, Colo10 starting at 45 years of age or FIT starting at 40 years of age were cost-effective at a threshold of $100,000 per quality-adjusted life year gained. Colo10 starting at 40 years of age was cost-effective only for men with obesity II-III, at $93,300 and $80,400 per quality-adjusted life year gained, respectively. Shifting Colo10 to earlier starting ages was always preferred over Colo5 starting at later ages. Results were robust in sensitivity analysis, including varying all-cause mortality, complication, and BMI-specific CRC risks.

CONCLUSIONS

CRC screening starting at 45 years of age with colonoscopy, or at 40 years of age with FIT, appears cost-effective for women and men across the range of BMI. In men with obesity II-III, who have the highest CRC but also all-cause mortality risks, colonoscopy starting at 40 years of age appears cost-effective. It remains to be decided whether BMI should be used as a single predictor or incorporated into a multivariable tool to tailor CRC screening.

Utility of high-flow nasal oxygen in comparison to conventional oxygen therapy during upper gastrointestinal endoscopic procedures under sedation: A systematic review and meta-analyses

BACKGROUND

Sedation and analgesia are the integral components of modern-day upper gastrointestinal (GI) endoscopic procedures. Irrespective of the sedative agent, hypoxia is the most commonly encountered unwarranted event with sedation. The current study intends to scrutinize whether high-flow nasal oxygen (HFNO) is advantageous for providing respiratory support during upper GI endoscopic procedures over other conventional low-flow oxygen delivery modalities, e.g. nasal cannula, facemask, etc. METHODS: An extensive screening of electronic databases was done till July 31, 2022, after enlisting in International prospective register of systematic reviews (PROSPERO) (CRD42021245409). Randomized controlled trials (RCT), comparative cohort studies, case series, cross-sectional studies and case-control studies evaluating the utility of HFNO during upper GI endoscopy under sedation were included in this meta-analysis.

RESULTS

We retrieved eight randomized control studies and one longitudinal study with 3294 patients. The application of HFNO during endoscopy led to lesser incidence of desaturation spells (odds ratio [OR] = 0.23; 95% CI 0.11-0.48; I² = 71%), reduced procedural interruption (OR = 0.11; 95% CI 0.02-0.60; I² = 88%), better nadir SpO² level during procedure (mean difference [MD] = 3.16; 95% CI 0.54-5.78; I² = 73%), overall lesser incidence of sedation-related adverse events (OR = 0.63; 95% CI 0.42-0.93; I² = 25%), with no significant impact on the duration of endoscopy (MD = 0.15; 95% CI - 0.02 to 0.31, I² = 0%).

CONCLUSION

HFNO is a novel option for upper GI endoscopy under sedation.

CLINICAL TRIAL NUMBER AND REGISTRY URL

CRD42021245409 ( https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021245409 ).

Effect of Remimazolam Tosilate on Respiratory Depression in Elderly Patients Undergoing Gastroscopy: A Multicentered, Prospective, and Randomized Study

Background

Remimazolam tosilate (RT) is a new type of γ-aminobutyric acid subtype A (GABA_A) receptor agonist, having the possibility to be an ideal sedative drug for procedural sedation. At present, there are few studies on the effect of RT on respiratory depression in elderly patients. We aimed to evaluate the effect of RT on respiratory depression in elderly patients undergoing gastroscopy.

Methods

This prospective, randomized, single-blinded trial recruited patients from eight centers in China between May 2022 and July 2022. A total of 346 elderly patients undergoing gastroscopy were randomly divided into RT group (0.2 mg/kg) or propofol group (1.5 mg/kg), respectively. The primary outcome was the incidence of respiratory depression. Secondary outcomes include the incidence of sedative-related adverse events, the success rate of sedation, time to fully alert, time to loss of consciousness (LOC), time to ready for discharge, as well as the the patients, endoscopists and anethetists' satisfaction.

Results

The incidence of respiratory depression was significantly reduced in the RT group compared with the propofol group (9.8% vs 17.9%, P=0.042). The time of LOC and fully alert in the RT group were longer than that in the propofol group (P < 0.05). The incidences of hypotention (50.9% vs 32.4%, P=0.001) and hypotension requiring treatment (5.8% vs 1.7%, P=0.031) were significantly higher in the propofol group than that in the RT group. The incidence and severity of injection pain were more frequently recorded in the propofol group than that in the RT group (40.5% vs 12.1%, P<0.05). There were no statistically significant differences between the two groups in terms of sedation success rates, time to ready for discharge, endoscopists and anethetists' satisfaction and other sedative-related adverse events.

Conclusion

RT may be a suitable alternative sedative agent for elderly patients undergoing gastroscopy due to its safety profile.

Remimazolam versus propofol for deep sedation/anaesthesia in upper gastrointestinal endoscopy in elderly patients: A multicenter, randomized controlled trial

BACKGROUND AND OBJECTIVE

Propofol is the most commonly used sedative in gastrointestinal endoscopic procedures, but is associated with cardiorespiratory suppression, particularly in elderly patients. Remimazolam is a new short-acting GABA(A) receptor agonist with minimal impact on cardiorespiratory suppression, and may be a viable alternative in elderly patients undergoing endoscopic procedures.

METHODS

This multicenter, randomized controlled trial was conducted between September 2020 and September 2021. Elderly patients (65-85 years of age) scheduled to undergo upper gastrointestinal endoscopy were randomized in 1:1 ratio to receive remimazolam tosilate (300 mg/h) or propofol (3 g/h) in addition to 50-μg fentanyl, until the Modified Observer's Assessment of Alertness/Sedation Scale (MOAA/S) reached ≤1. MOAA/S was maintained at 0 or 1 throughout the procedure using 2.5 mg remimazolam or 0.5 mg/kg propofol boluses in the two groups, respectively. The primary outcome was the rate of hypotension (defined as systolic blood pressure at ≤90 mmHg or > 30% decline vs. the baseline). Bradycardia was defined as heart rate ≤50 per minute; respiratory depression was defined as respiratory rate <8 per minute and/or SpO₂  < 90%.

RESULTS

A total of 400 patients (161 men and 239 women; 70.4 ± 4.6 years of age) were enrolled (200 patients per group). Average body mass index was 22.2 ± 2.4 kg/m² . The rate of hypotension was 36.5% in the remimazolam group and 69.6% in the propofol group (p < 0.001). The remimazolam group also had a lower rate of bradycardia (1.5% vs. 8.5%, p < 0.001), respiratory depression (4.5% vs. 10.0%, p < 0.05) and pain at the injection site (0% vs. 12.0%, p < 0.001).

CONCLUSION

Remimazolam was associated with a lower rate of hypotension in elderly patients undergoing upper gastrointestinal endoscopy under deep sedation/anaesthesia than propofol.

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

Background

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

Methods

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

Results

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

Conclusions

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

Impact of High-Flow Nasal Cannula Oxygenation on the Prevention of Hypoxia During Endoscopic Retrograde Cholangiopancreatography in Elderly Patients: A Randomized Clinical Trial

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).

A self-assessment tool for predicting discomfort and tolerance in Chinese patients undergoing esophagogastroduodenoscopy

Background

For patients taking esophagogastroduodenoscopy (EGD), sedation should ideally be used individually based on patients’ comfort and tolerance level. However, currently there is no valid predictive tool. We undertook this study to develop and temporally validate a self-assessment tool for predicting discomfort and tolerance in Chinese patients undergoing EGD.

Methods

We recruited 1522 patients undergoing routine diagnostic EGD without sedation. We collected candidate predictor variables before endoscopy and evaluated discomfort and tolerance with a 5-point visual analogue scale after the procedure. We developed logistic regression predictive models based on the first 2/3 of participants, and evaluated the calibration and discrimination of the models in the later 1/3 of patients.

Results

30.2% and 23.0% participants reported severe discomfort or poor tolerance to EGD respectively. The predictive factors in the model for discomfort included sex, education, expected level of discomfort, and anxiety before endoscopy. The model for tolerance included income, expected level of discomfort, and anxiety before endoscopy. In the validation population, the established models showed a moderate discriminative ability with a c-index of 0.74 for discomfort and 0.78 for tolerance. Hosmer–Lemeshow test suggested the models had fine calibration ability (discomfort: P = 0.37, tolerance: P = 0.41).

Conclusions

Equations for predicting discomfort and tolerance in Chinese patients undergoing EGD demonstrated moderate discrimination and variable calibration. Further studies are still required to validate these tools in other population.

Trial registration

Chinese Clinical Trial Registry (ChiCTR1800020236).

Patient-reported experiences and views on the Cytosponge test: a mixed-methods analysis from the BEST3 trial

OBJECTIVES

The BEST3 trial demonstrated the efficacy and safety of the Cytosponge-trefoil factor 3, a cell collection device coupled with the biomarker trefoil factor 3, as a tool for detecting Barrett's oesophagus, a precursor of oesophageal adenocarcinoma (OAC), in primary care. In this nested study, our aim was to understand patient experiences.

DESIGN

Mixed-methods using questionnaires (including Inventory to Assess Patient Satisfaction, Spielberger State-Trait Anxiety Inventory-6 and two-item perceived risk) and interviews.

OUTCOME MEASURES

Participant satisfaction, anxiety and perceived risk of developing OAC.

SETTING

General practices in England.

PARTICIPANTS

Patients with acid reflux enrolled in the intervention arm of the BEST3 trial and attending the Cytosponge appointment (N=1750).

RESULTS

1488 patients successfully swallowing the Cytosponge completed the follow-up questionnaires, while 30 were interviewed, including some with an unsuccessful swallow.Overall, participants were satisfied with the Cytosponge test. Several items showed positive ratings, in particular convenience and accessibility, staff's interpersonal skills and perceived technical competence. The most discomfort was reported during the Cytosponge removal, with more than 60% of participants experiencing gagging. Nevertheless, about 80% were willing to have the procedure again or to recommend it to friends; this was true even for participants experiencing discomfort, as confirmed in the interviews.Median anxiety scores were below the predefined level of clinically significant anxiety and slightly decreased between baseline and follow-up (p < 0.001). Interviews revealed concerns around the ability to swallow, participating in a clinical trial, and waiting for test results.The perceived risk of OAC increased following the Cytosponge appointment (p<0.001). Moreover, interviews suggested that some participants had trouble conceptualising risk and did not understand the relationships between test results, gastro-oesophageal reflux and risk of Barrett's oesophagus and OAC.

CONCLUSIONS

When delivered during a trial in primary care, the Cytosponge is well accepted and causes little anxiety.

TRIAL REGISTRATION NUMBER

ISRCTN68382401.

Effect of remimazolam tosilate on early cognitive function in elderly patients undergoing upper gastrointestinal endoscopy

BACKGROUND AND AIM

Remimazolam tosilate (RT) is under evaluation as a sedative for endoscopic procedures. Herein, we aimed to evaluate safety including cognition recovery of RT administered in elderly patients undergoing upper gastrointestinal endoscopy and assess its safety dosage.

METHODS

Ninety-nine patients presenting for upper gastrointestinal endoscopy were randomized to receive 0.1 mg/kg RT (R1) or 0.2 mg/kg RT (R2), or propofol (P). Cognitive functions (memory, attention, and executive function) were measured via neuropsychological tests conducted before sedation and 5 min after recovery to full alertness. Adverse events were also assessed.

RESULTS

There were no statistical differences between postoperative and baseline results for R1 group and P group, whereas those for R2 group revealed worsened postoperative cognitive functions (immediate recall and short delay recall) than baseline (P < 0.05). Compared with P group, Scores demonstrated worse restoration of immediate recall in R1 group, immediate recall, short-delayed recall, and attention function in R2 group (P < 0.05). Patients in R2 group had a longer sedation time (12.09 vs 8.27 vs 8.21 min; P < 0.001) and recovery time (6.85 vs 3.82 vs 4.33 min; P < 0.001) than that in R1 group and P group. Moreover, the incidence of hypotension was 3.0% in R1 group, whereas it was 21.2% in R2 group and 48.5% in P group (P < 0.05).

CONCLUSION

The addition of 0.1 mg/kg RT as an adjunct to opiate sedation for upper gastrointestinal endoscopy not only achieves more stable perioperative hemodynamics but also achieves acceptable neuropsychiatric functions in elderly patients.

Academy of Medicine, Singapore clinical guideline on the use of sedation by non-anaesthesiologists during gastrointestinal endoscopy in the hospital setting

INTRODUCTION

In Singapore, non-anaesthesiologists generally administer sedation during gastrointestinal endoscopy. The drugs used for sedation in hospital endoscopy centres now include propofol in addition to benzodiazepines and opiates. The requirements for peri-procedural monitoring and discharge protocols have also evolved. There is a need to develop an evidence-based clinical guideline on the safe and effective use of sedation by non-anaesthesiologists during gastrointestinal endoscopy in the hospital setting.

METHODS

The Academy of Medicine, Singapore appointed an expert workgroup comprising 18 gastroenterologists, general surgeons and anaesthesiologists to develop guidelines on the use of sedation during gastrointestinal endoscopy. The workgroup formulated clinical questions related to different aspects of endoscopic sedation, conducted a relevant literature search, adopted Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology and developed recommendations by consensus using a modified Delphi process.

RESULTS

The workgroup made 16 recommendations encompassing 7 areas: (1) purpose of sedation, benefits and disadvantages of sedation during gastrointestinal endoscopy; (2) pre-procedural assessment, preparation and consent taking for sedation; (3) Efficacy and safety of drugs used in sedation; (4) the role of anaesthesiologist administered sedation during gastrointestinal endoscopy; (5) performance of sedation; (6) post-sedation care and discharge after sedation; and (7) training in sedation for gastrointestinal endoscopy for non-anaesthesiologists.

CONCLUSION

These recommendations serve to guide clinical practice during sedation for gastrointestinal endoscopy by non-anaesthesiologists in the hospital setting.

Oliceridine- Opioid of the 21st Century

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

Implementing capnography to help improve patient safety during procedural sedation: quality improvement in a high-volume gastroenterology department

OBJECTIVE

Respiratory compromise is a major cause of adverse events during procedural sedation; continuous monitoring is vital for identifying and halting decompensation. We performed a quality improvement investigation to assess patient safety during procedural sedation in gastroenterology and the impact of implementing capnography monitoring.

PATIENTS AND METHODS

Sedation-related adverse events and interventions were prospectively recorded during the endoscopic procedure and in recovery. Assuming rates in published literature, power analysis determined that at least 1332 patients were required to show a 20% improvement in patient safety. Recorded sedation-related adverse events (mild and severe oxygen desaturations, bradycardia and tachycardia) and interventions were anonymized and aggregated to evaluate the quality improvement. Patient safety under current care was determined before capnography (Medtronic) was implemented in combination with training.

RESULTS

Between February 2018 and April 2018, a baseline (1092 patients) for outcomes under current care was completed, with 11.45 events per 100 procedures recorded. Between May 2018 and July 2018, 1044 procedures including capnography monitoring were performed with 5.08 events per 100 procedures recorded. The distribution of American Society of Anesthesiologists scores and procedure types between baseline and capnography were comparable. The absolute difference between baseline and capnography was -6.4 events per 100 procedures [95% confidence interval (CI), -4.1 to -8.7; P ≤ 0.0001]. The 55% reduction in adverse events surpassed the 20% improvement in patient safety set as the goal of this quality improvement. After multivariate regression, the adjusted odds ratio for events after implementation of capnography was 0.46 (95% CI, 0.32-0.66).

CONCLUSIONS

Addition of capnography to current care significantly decreased procedure-related safety events.

Efficacy and safety of endoscopic retrograde cholangiopancreatography in the very elderly by using a combination of intravenous midazolam, ketamine and pethidine

AIM

The number of therapeutic endoscopic procedures in elderly individuals keeps increasing and this population has a high risk of adverse events related to sedation and general anesthesia. However, there is a paucity on data about the efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) in this population.

METHODS

In total, 417 consecutive ERCP procedures were performed in 362 patients between September 2018 and January 2020. Of these, 59 patients (74 sessions) were aged ≥80 years (Group A) and 173 patients (193 procedures) were aged ≤65 years (Group B). We analyzed the prospectively collected data of patient- and procedure-related variables.

RESULTS

The procedure time was significantly longer in Group A (P < 0.05). The prevalence of comorbidities, use of anticoagulants and American Society of Anesthesiologists (ASA) physical status classification levels were significantly higher in Group A (P < 0.05). The incidence of periampullary diverticula, malignancy, rate of difficult cannulation, mean number of stones, use of biliary stents and stent dysfunction was also significantly higher in Group A (P < 0.05). The medication doses used were significantly higher and emergence symptoms were significantly more frequent in Group B (P < 0.05). The rates of bleeding, pancreatitis, perforation, cholangitis, hypoxia, hypotension and the length of hospital stay did not significantly differ between the two groups. The overall success rate of the procedure was comparable in the two groups (P = 0.874).

CONCLUSIONS

ERCP can be safely performed in elderly patients using a combination of midazolam and ketamine without propofol. The incidence of complications is comparable with that observed in younger patients. Geriatr Gerontol Int 2021; 21: 887-892.

The role of endoscopy and findings in COVID-19 patients, an early North American Cohort

Background and aims

Gastrointestinal manifestations in patients with COVID-19 are common but the role of endoscopy in this patient population remains unclear. We investigated the need for endoscopic procedures, their findings, and impact on patient care in a systematic and geographically diverse sample of patients hospitalized with COVID-19.

Methods

As part of the North American Alliance for the Study of Digestive Manifestations of COVID-19, we identified consecutive patients hospitalized with COVID-19 at 36 medical centers in the USA and Canada. We performed a secondary analysis of patients who underwent endoscopy, collecting information on endoscopic indications, findings, interventions, staffing, procedure location, anesthesia utilization, and adverse events.

Results

Data were collected on 1992 patients; 24 (1.2%) underwent 27 endoscopic procedures (18 upper endoscopies, 7 colonoscopies, 2 endoscopic retrograde cholangiopancreatographies). The most common indications were: gastrointestinal bleeding (13) and enteral access (6). The most common findings were erosive or inflammatory changes. Ten patients underwent an endoscopic intervention for hemostatic therapy (2), enteral access (6), or biliary obstruction (2). Half of cases employed anesthesiology support; no sedation-related adverse events were reported. One-third of cases were performed in the intensive care setting and one quarter in the endoscopy unit.

Conclusions

In this large, systematic, geographically diverse cohort of patients hospitalized with COVID-19 in North America, very few patients underwent endoscopy despite a high prevalence of gastrointestinal manifestations. Almost all endoscopic findings and interventions were thought related to critical illness rather than direct viral injury. This systematic assessment of endoscopic necessity and outcomes may help guide resource allocation in the event of ongoing and future surges.

Recent Developments in Devices Used for Gastrointestinal Endoscopy Sedation

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

Prospective audit of the safety of endoscopist-directed nurse-administered propofol sedation in an Australian referral hospital

BACKGROUND AND AIM

Endoscopist directed nurse administered propofol sedation (EDNAPS) is widely considered to be safe and efficient, but there are limited data from the Australian health-care setting, and Australian sedation guidelines do not support the practice. Thus, we report data from a prospective audit of EDNAPS over a 6.5-year period in an Australian referral hospital.

METHODS

Consecutive endoscopic procedures performed between January 2013 and June 2019. Sedation protocol was an initial dose of midazolam 1-3 mg intravenously (i.v.) and propofol 10-50 mg i.v.. Further aliquots of propofol 10-30 mg i.v. were given as required. ProvationMD® endoscopic reporting system was used to prospectively record patient demographics, medication and dose, American Society of Anesthesiologist's (ASA) class, and sedation-related complications.

RESULTS

During the 78-month period, 28 051 eligible procedures were performed; 3093 procedures performed with anesthetic support or without EDNAPS were excluded. In total, 24 958 procedures with EDNAPS were analyzed including 7563 gastroscopies, 12 941 colonoscopies, 2932 gastroscopy and colonoscopy, 1440 flexible sigmoidoscopies, and 82 combined gastroscopy and flexible sigmoidoscopy. Of these, 9539 were ASA 1 (38.2%), 13 680 were ASA 2 (54.8%), 1733 were ASA 3 (6.9%), and 4 were ASA 4 (0.02%). Sedation-related complications occurred in 66 patients (0.26%), predominantly transient hypoxic episodes. No patient required intubation for an airway emergency, and there was no sedation-related mortality. Sedation-related complications increased with ASA class and were significantly more common with gastroscopy.

CONCLUSIONS

Endoscopist directed nurse administered propofol sedation is a safe way of performing endoscopic sedation in low-risk patients in the hospital setting.

Propofol-Induced Severe Necrotizing Pancreatitis

Propofol is a widely used sedative for gastrointestinal endoscopic procedures. Drug-induced pancreatitis is a relatively rare disease possibly because of poor recognition. Propofol-induced pancreatitis is an extremely rare phenomenon. We present a 22-year-old healthy man who underwent esophagogastroduodenoscopy with propofol as a sedative. Soon after, he developed acute upper gastrointestinal symptoms and was diagnosed with pancreatitis. His prolonged hospital course was complicated with necrotizing pancreatitis, acute respiratory distress syndrome, septic shock, and other end-organ damages. We hope to increase awareness of a life-threatening adverse event of a commonly used anesthetic such as propofol.

Safety and Recipient Satisfaction of Propofol Sedation in Outpatient Endoscopy: A 24-Hour Prospective Investigation Using a Questionnaire Survey

Background/Aims

The aim of this study was to evaluate the safety of sedation with propofol as an alternative to benzodiazepine drugs in outpatient endoscopy.

Methods

In this prospective study, examinees who underwent outpatient endoscopy under propofol sedation and submitted a nextday questionnaire with providing informed consent were evaluated. Periprocedural acute responses, late adverse events within 24 hours, and examinee satisfaction were evaluated.

Results

Among the 4,122 patients who received propofol in the 17,978 outpatient-based endoscopic examinations performed between November 2016 and March 2018, 2,305 eligible examinees (esophagogastroduodenoscopy for 1,340, endoscopic ultrasonography for 945, and total colonoscopy for 20) were enrolled, and their responses to a questionnaire were analyzed. The mean propofol dose was 69.6±24.4 mg (range, 20–200 mg). Diazepam, midazolam, and/or pentazocine in combination with propofol was administered to 146 examinees. Mild oxygen desaturation was observed in 59 examinees (2.6%); and mild bradycardia, in 2 (0.09%). Other severe reactions or late events did not occur. After eliminating 181 invalid responses, 97.7% (2,065/2,124) of the patients desired propofol sedation in future examinations.

Conclusions

Propofol sedation was found to be safe-without severe adverse events or accidents-for outpatient endoscopy on the basis of the patients’ next-day self-evaluation. Given the high satisfaction level, propofol sedation might be an ideal tool for painless endoscopic screening.

Polypectomy Techniques

Polyps in the upper and lower gastrointestinal tract can be premalignant or malignant lesions that can be treated endoscopically in early stages to prevent morbidity and more invasive procedures. This article critically reviews the techniques available and provides recommendations for endoscopic polypectomy.

Safety of the LMA®Gastro™ for Endoscopic Retrograde Cholangiopancreatography

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) patients typically receive either tubeless anesthesia or general endotracheal anesthesia (GETA). Patients receiving propofol-based total intravenous anesthesia (TIVA) are at higher risk of sedation-related adverse events (SRAEs) than patients receiving GETA, primarily due to the need for additional airway maneuvers. The increasing use of non-operating room (OR) anesthesia and the perception of a higher incidence of adverse outcomes in non-OR areas has led to the development of devices to improve safety while maintaining efficiency. The purpose of this study was to evaluate if the LMA Gastro™ could be used as a safe alternative to tubeless anesthesia for successfully completing ERCPs.

METHODS

Eligible subjects were identified within the patient population at MD Anderson Cancer Center. Inclusion criteria consisted of adult patients (≥18 years old) scheduled for elective ERCP with TIVA. This was a prospective observational study in which the following data were collected: number of attempts and time to successful supraglottic airway (SGA) placement, vital signs, peripheral oxygen saturation (SpO2), median end-tidal CO2, practitioner satisfaction, and any complications.

RESULTS

A total of 30 patients were included in this study. The overall rate of successful SGA placement within 3 attempts was 96.7% (95% confidence interval [CI], 82.8-99.9) or 29/30. The rate of successful ERCP with SGA placement within 3 attempts was 93.3% (95% CI, 77.9-99.2) or 28/30. Both the gastroenterologist and anesthesiologist reported satisfaction with the device in 90% of the cases (in 66.7% of the cases both anesthesiologist and gastroenterologist scored the device a 7/7 for satisfaction). Patients maintained an SpO2 of 95%-100% from induction to discharge, with the exception of 1 patient who had an SpO2 of 93%. The median end-tidal CO2 during the procedure for all patients was 35 mm Hg. Observed aspiration did not occur in any patient. Symptoms of hoarseness (13.3%), mouth soreness (6.7%), sore throat (6.6%), and minor bleeding/cuts/redness/change in taste to the tongue (3.3%) were determined through patient questioning before postanesthesia care unit (PACU) discharge.

CONCLUSIONS

Our study suggests that the LMA Gastro might be a safe alternative for ERCP procedures. There was a high level of practitioner satisfaction. Only minor complications, such as hoarseness, mouth or throat soreness, or minor trauma to the tongue were experienced by patients. Similar incidences of complications may occur with GETA and tubeless anesthesia. The procedure was well tolerated by all patients; all patients maintained adequate oxygenation and required only minimal blood pressure support.

Comparison of the effects of methadone and butorphanol combined with acepromazine for canine gastroduodenoscopy

OBJECTIVE

To evaluate the feasibility of gastroduodenoscopy in dogs premedicated with acepromazine in combination with butorphanol or methadone.

STUDY DESIGN

Prospective, randomized, double-blinded clinical trial.

ANIMALS

A group of 40 client-owned dogs.

METHODS

Dogs were randomly allocated to one of two groups and give intramuscular acepromazine 0.02 mg kg^-1 combined with either butorphanol 0.3 mg kg^-1 (group ACEBUT) or methadone 0.2 mg kg^-1 (group ACEMET). General anaesthesia was induced with propofol and ketamine and maintained with sevoflurane (2.3%) in oxygen. Cardiopulmonary variables were recorded at 5 minute intervals during anaesthesia. Feasibility of the entire gastroduodenoscopy was evaluated with a visual analogue scale (VAS) from 0 (best) to 100 (worst) (primary outcome of the study). Lower oesophageal sphincter dilatation and duodenal intubation were scored. Pylorus diameter was measured with standard endoscopic inflatable balloons. Overall cardiovascular stability was assessed during anaesthesia, using a VAS (0-100), as was the presence of fluid in the oesophagus, regurgitation, need for mechanical ventilation, and intraoperative and postoperative rescue analgesia (secondary outcomes of the study). Differences between treatments were analysed with Mann-Whitney U, Student t test, Fisher exact test or mixed model analysis of variance as appropriate. Subsequently, feasibility VAS of the gastroduodenoscopy was assessed for noninferiority between groups. The noninferiority margin was set as -10.

RESULTS

All gastroduodenoscopies were successfully completed in both groups using an endoscope tip diameter of 12.8 mm in all but one dog. Feasibility of gastroduodenoscopy was evaluated as 2.9 ± 5.6 in group ACEBUT and 5.1 ± 5.8 in group ACEMET. No significant differences between groups were detected in any measured or assessed variables, and noninferiority was confirmed.

CONCLUSION AND CLINICAL RELEVANCE

In our study population, the effects of methadone and butorphanol when combined with acepromazine were comparable.

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 a simplified nasal continuous positive airways pressure device with nasal cannula in obese patients undergoing colonoscopy during deep sedation: A randomised clinical trial

BACKGROUND

Continuous positive airways pressure (CPAP) with a CPAP machine and mask has been shown to be more effective at minimising hypoxaemia than other devices under deep sedation. However, the efficacy of a new and simple CPAP device for spontaneously breathing obese patients during colonoscopy is unknown.

OBJECTIVE

We hypothesised that oxygenation and ventilation in obese patients under deep sedation during colonoscopy using CPAP via a new nasal mask (SuperNO2VA) would be better than routine care with oxygen supplementation via a nasal cannula.

DESIGN

Randomised study.

SETTING

Single-centre, June 2017 to October 2017.

PATIENTS

A total of 174 patients were enrolled and randomly assigned to Mask group or Control group. Thirty-eight patients were excluded and data from 136 patients underwent final analysis.

INTERVENTION

Patients in the Mask group were provided with nasal CPAP (10 cmH2O) at an oxygen flow rate of 15 l min. In the Control group, patients were given oxygen via a nasal cannula at a flow rate of 5 l min.

MAIN OUTCOME MEASURES

The primary outcome was elapsed time from anaesthesia induction to the first airway intervention.

RESULTS

The elapsed time from anaesthesia induction to the first airway intervention was 19 ± 10 min in the Mask group (n=63) vs. 10 ± 12 min in the Control group (n=73, P < 0.001). In all, 87.5% (56/64) of patients achieved the target CPAP value. More patients in the Control group (63%) received airway intervention than in the Mask group (22%) (P < 0.001). Hypoxaemia (pulse oximeter oxygen saturation, SpO2 < 90%) occurred more frequently in the Control group (22%) than in the Mask group (5%) (P = 0.004). Minute ventilationPostinduction/minute ventilationBaseline and minute ventilationProcedure-end/minute ventilationBaseline was lower in the Control group than in the Mask group (P = 0.007 and 0.001, respectively).

CONCLUSION

Application of a nasal mask at a target CPAP of 10 cmH2O improves ventilation and decreases the frequency and severity of hypoxaemia.

TRIAL REGISTRATION

NCT03139448, registered at ClinicalTrials.gov.

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

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

Comparative Analysis of Anesthetic Legal Disputes between Older and Younger Patients Referred to the Korean Society of Anesthesiologists in 2009-2018

BACKGROUND

Although the average age of patients undergoing surgical procedures or anesthesia is increasing, differences in anesthesia-related injuries among different age groups have been not reported. This study compared older and younger patients on the basis of disputes regarding anesthesia-related injuries referred to the Korean Society of Anesthesiologists (KSA).

METHODS

We retrospectively analyzed disputes regarding anesthesia-related injuries referred to the KSA between 2009 and 2018. After excluding duplicates, incomplete data, local anesthesia cases, and patients aged ≤18 or 55-64 years, the subjects were divided into older (≥65 years) and younger (19-54 years) age groups. The parameters included in the KSA database were compared between these two groups.

RESULTS

The 115 cases included in the study included 28 and 87 cases from the older and younger groups, respectively. The proportions of preventable cases of anesthesia-related adverse events differed significantly between the older (25%) and younger groups (48.3%). The most common medical disputes in the older group were related to general anesthesia, orthopedic surgery, local hospitals, and anesthesiologist, whereas those in the younger group were related to sedation, plastic surgery, local clinics, and non-anesthesiologists.

CONCLUSION

In addition to understanding the differences in anesthesia characteristics according to age group, it is also necessary to develop means for reducing preventable anesthesia-related adverse events. Furthermore, we must continue to register anesthesia-related disputes, and a voluntary reporting system should be established to prevent anesthesia-related accidents.

High-flow nasal cannula oxygen therapy and hypoxia during gastroscopy with propofol sedation: a randomized multicenter clinical trial

BACKGROUND AND AIMS

Hypoxia is one of the most frequent adverse events with sedated GI endoscopy and can lead to serious consequences. No modalities have been found previously to prevent hypoxia. High-flow nasal cannula (HFNC) supportive oxygen therapy provides heated and humidified oxygen up to 60 L/minute. Because of its ability to improve respiratory function and good tolerance, we aimed to evaluate the validity and safety of HFNC supportive oxygen therapy in preventing the incidence of hypoxia in patients undergoing gastroscopy with propofol sedation.

METHODS

In a multicenter, prospective randomized single-blinded study, 1994 outpatients undergoing routine gastroscopy with propofol sedation provided by an anesthesiologist were randomized into 2 groups: the nasal cannula group (O₂ [2 L/minute] was supplied via an HFNC) and the HFNC group (O₂ [30-60 L/minute] was supplied via an HFNC) at 3 centers from November 2017 to February 2018. The primary outcome was the incidence of hypoxia. Other adverse events were also recorded.

RESULTS

HFNC supportive oxygen therapy decreased the incidence of hypoxia (75% ≤ Spo₂ < 90% for <60 seconds) and severe hypoxia (Spo₂ < 75% for any duration or 75% ≤ Spo₂ < 90% for ≥60 seconds) from 8.4% to 0% (P < .001) and from 0.6% to 0% (P = .03), respectively. The only HFNC-related adverse event was xeromycteria/rhinalgia (1.7%), which was observed 1 minute after the procedure and disappeared after 30 minutes.

CONCLUSIONS

HFNC supportive oxygen therapy can prevent the incidence of hypoxia and severe hypoxia in patients in America Society of Anesthesiologists class I-II undergoing elective gastroscopy under propofol sedation, with minimal related adverse events and good tolerance. (Clinical trial registration number: NCT03332433.).

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Associations of anxiety with discomfort and tolerance in Chinese patients undergoing esophagogastroduodenoscopy

Objectives

To evaluate the associations of pre-endoscopy anxiety with discomfort and tolerance in patients undergoing unsedated esophagogastroduodenoscopy (EGD).

Methods

This is a hospital-based cohort study of 348 patients undergoing routine, non-advanced EGD without sedation. The primary outcomes were discomfort and tolerance. The anxiety before endoscopy was evaluated with a 10-point visual analogue scale (VAS). The associations of pre-endoscopy anxiety with the outcomes were evaluated with logistic regression adjusting for potential confounders like age, sex, and body mass index.

Results

Seventy patients reported severe discomfort and 56 patients reported poor tolerance after endoscopy. The risk of severe discomfort increased with pre-endoscopy anxiety and reached a platform around 7–10 points. Compared with the participants with low pre-endoscopy anxiety, those with moderate (adjusted odds ratio [OR] 2.70, 95% confidence interval [CI] 1.17 to 6.22) and high level of anxiety (adjusted OR 6.87, 95% CI 2.16 to 21.79) were associated with a gradual increase in the risk of severe discomfort (P-trend < 0.001). The association between pre-endoscopy anxiety and tolerance was linear, with an adjusted OR of 1.67(95% CI 1.33 to 2.08) for a 1-score increase in pre-endoscopy anxiety VAS. The associations were not modified by age, sex, pharyngitis, duration of endoscopy, and diameter of the endoscope.

Conclusions

Pre-endoscopy anxiety was an independent predictor of severe discomfort and poor tolerance in Chinese patients undergoing unsedated EGD. Our findings suggested the importance of the management of anxiety to reduce adverse endoscopic experience and taking high level of anxiety as an indication for sedation.

Acute pancreatitis associated with intravenous administration of propofol: evaluation of causality in a systematic review of the literature

Acute pancreatitis (AP) associated with intravenous administration of propofol has been described with unknown causal relation. We therefore assessed this causality in a systematic review. Multiple databases were searched on 16 August 2017; studies were appraised and selected by two reviewers based on a priori criteria. Propofol causality was evaluated with the Naranjo scale and Badalov classification. We identified 18 studies from 11 countries with a total of 21 patients, and the majority had adequate methodological quality. The median age was 35 years (range, 4-77) and 10 (48%) were males. Overall, propofol was administrated in 8 patients as sedative along with induction/maintenance of anesthesia in 13 patients; median dose was 200 mg, with intermediate latency (1-30 days) in 14 (67%). Serum triglycerides were >1000 mg/dL in four patients. Severe AP was observed in four patients (19%). AP recurrence occurred in one out of two patients who underwent rechallenge. Mortality related to AP was 3/21(14%). Propofol was the probable cause of AP according to the Naranjo scale in 19 patients (89%). Propofol-induced AP has a probable causal relation and evidence supports Badalov class Ib. Hypertriglyceridemia is not the only mechanism by which propofol illicit AP. Propofol-induced AP was severe in 19% of patients with a mortality rate related to AP of 14%. Future research is needed to delineate whether this risk is higher if combined with other procedures that portend inherent risk of pancreatitis such as endoscopic retrograde cholangiopancreatography.

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

Objective:

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

Method:

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

Results:

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

Conclusion:

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

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

No increased risk of perforation during colonoscopy in patients undergoing propofol versus traditional sedation: A meta-analysis

BACKGROUND AND AIMS

The safety of propofol sedation during colonoscopy remains unclear, and we performed a meta-analysis to assess the risk of perforation in patients undergoing propofol vs. traditional sedation.

METHODS

MEDLINE, CBM, VIP, CNKI, and Wanfang databases were searched up to December 2016. Two reviewers independently assessed abstract of those searched articles. Data about perforation condition in propofol and traditional sedation groups were extracted and combined using the random effects model.

RESULTS

A total of 19 studies were included in the current meta-analysis. Compared to traditional sedation, propofol sedation did not increase the risk of perforation (RD = - 0.00, 95% CI - 0.00~0.00, p = 0.98; subgroup analysis: OR = 1.30, 95% CI 0.83~2.05, p = 0.25).

CONCLUSION

This meta-analysis suggested that propofol sedation did not increase the risk of perforation compared to traditional sedation during colonoscopy.

Upper Gastrointestinal Endoscopy prior to Bariatric Surgery-Mandatory or Expendable? An Analysis of 801 Cases

BACKGROUND

Upper gastrointestinal pathologies are common in bariatric patients. Preoperative esophagogastroduodenal endoscopy (EGD) should detect and treat pathologies that might alter the type of bariatric surgery. However, clinical consequences of these findings are often insignificant. The aim of this study was to assess the influence of preoperative endoscopy in our cohort and its clinical consequences.

METHODS

We conducted a retrospective analysis of endoscopic findings in patients under evaluation for bariatric surgery. Endoscopic findings were compared to preoperative risk factors as well as postoperative complications, and its clinical consequences were analyzed.

RESULTS

Data was available for 801 patients. Abnormal endoscopic findings were found in 65.7% of all patients. The most common conditions were gastritis (32.1%) and gastroesophageal reflux (24.8%). Malignancies were observed in 0.5% of all patients. We observed early-stage adenocarcinoma of the esophagus in two patients through our routine preoperative evaluation. Helicobacter pylori infections were detected in preoperative biopsies in only 3.7% of all patients. Patients who reported reflux symptoms had a higher rate of pathological EGDs (74.2 vs. 64.9%, p .019). We did not find any other risk factors for a pathological endoscopy. The postoperative complication rate was 11.2%. Leakage rate was 1.1%. Mortality rate was 0.4%. We did not find any correlation between the incidence of postoperative complications and preoperative endoscopic findings.

CONCLUSIONS

Relevant findings in routine preoperative endoscopy are rare but have significant influence on decision-making in bariatric patients and should be assessed as a necessary diagnostic tool.

Needs assessment survey for simulation-based training for gastrointestinal endoscopy nurses

The optimal performance of gastrointestinal (GI) endoscopy nurses is required for patient safety and quality improvement. The aim of the present study was to assess the educational needs for simulation-based training for Korean GI endoscopy nurses using importance-performance analysis. A cross-sectional survey was conducted with 238 Korean nurses from 25 endoscopy units. The educational needs of these nurses were identified using the 35 item clinical competence importance-performance scale. Exploratory factor analysis of the scale identified the following eight factors: emergency care, patient monitoring, evidence-based practice, documentation and referral, patient safety, nursing process, patient assessment, and infection control. A significant overall mean difference was identified between importance and performance for all eight factors, with emergency care showing the largest difference. It was also ranked the highest priority for continuing education in the importance-performance analysis matrix. Therefore, simulation-based training should focus on enhancing emergency care competence for GI endoscopy nurses to improve patient safety and quality of care.