Patient-controlled anesthesia for colonoscopy using propofol: results of a pilot study

BACKGROUND

We studied the feasibility of using patient-controlled anesthesia (PCA) for conscious sedation during colonoscopy.

METHODS

Patients having elective colonoscopy had medications delivered in bolus fashion by PCA pump (Abbot Lifecare Provider 5500 Infusion System). Four patients received propofol as 20 mg/dose boluses, and four patients received propofol in a 0.3 mg/kg/dose. Twelve patients received propofol at 0.2 mg/kg/dose with alfentanil at 4 microg/kg/dose.

RESULTS

There were no clinically unacceptable changes in continuously monitored blood pressure, pulse rate, ECG, or respiratory rate. There were no adverse effects from the sedation and no complications due to colonoscopy. Recovery time was rapid, but recall persisted in most subjects. Pain and overall discomfort in patients given propofol only were rated as moderate by most subjects.

CONCLUSION

Patient-controlled anesthesia is feasible for use in endoscopic sedation. Propofol alone did not allow adequate pain relief, but propofol and alfentanil together seemed to provide good control of pain.

Elevated tumor-associated antigen CA 19-9 in a patient with an enlarged pancreas: does it always imply malignancy?

Carbohydrate antigen 19-9 (CA 19-9) has been used as a serum tumor marker for adenocarcinoma of the upper gastrointestinal tract, particularly primary adenocarcinoma of the pancreas. This tumor marker has also been used to differentiate benign from malignant diseases of the pancreas. However, significant elevations of CA 19-9 levels in the absence of pancreatic malignancy have also been reported. This case illustrates a marked elevation of CA 19-9 due to an infectious process in a patient with a pancreatic mass suggestive of malignancy.

A fatal Sunday brunch: Amanita mushroom poisoning in a Gulf Coast family

Mushroom poisoning with resultant liver toxicity often occurs in experienced collectors. The increasing popularity of natural foods has lead to an increased incidence of mushroom poisoning among the general population. This report describes a grandmother with over 30 yr of self-taught expertise in selecting and preparing wild mushrooms, who prepared a mushroom dish that led to the poisoning of herself and three family members. A 3-yr-old child died of fulminant hepatic failure, and the others recovered completely. The clinical presentation, course, and management of patients with mushroom poisoning are discussed.

Urinary N1-acetylspermidine and N8-acetylspermidine excretion in normal humans and in patients with colorectal cancer

Urinary N1-acetylspermidine (N1SPD) and N8-acetylspermidine (N8SPD) were measured in 24-hr urine specimens from 42 patients with colon adenocarcinoma and 29 healthy controls to assess their use as markers for colon cancer screening. Serial spot urines in four controls demonstrated significant fluctuations in these polyamine levels throughout the day without a distinct circadian pattern and therefore all subsequent analyses were performed on 24-hr collections. Both N1SPD and N8SPD were significantly increased in colon cancer patients compared to controls. Neither test correlated with tumor stage or location, but N8SPD was elevated in patients with poorly differentiated adenocarcinoma when compared to moderate or well-differentiated tumors. Using receiver operator characteristic (ROC) analysis, N1SPD had a higher information content than N8SPD, N1SPD + N8SPD, or the ratio of N1SPD/N8SPD and at a normal cut-off value of 4.0 nmol/mg creatinine, yielded a 95% specificity and 50% sensitivity for colon cancer.

Molecular biology and colorectal cancer: genetic alterations, inherited syndromes, and applications to colon cancer screening

Molecular genetics has rapidly advanced our understanding of pathogenesis and biologic behavior of colorectal carcinoma. This article will review the genetic changes which occur in colonic mucosa as it progresses from benign to malignant as well as review the inherited forms of colorectal cancer. Current screening methods and anticipated future strategies for colorectal cancer screening will be discussed.

Setting realistic goals for quality assurance monitoring: patient falls versus patient days

In order to set criteria for determining an acceptable level of patient falls, Riverview Medical Center in Red Bank, New Jersey created a regression line predicting the expected frequency of patient falls by patient days. The regression line was derived from data reflecting the hospital's own experience with patient falls during a two-year period. The medical center now compares predicted and actual fall rates on a monthly basis. Corrective actions are implemented when the number of falls rises above the regression line during two consecutive months. The regression line thus serves as a useful method of determining the need for enhanced QA activities.

Pyruvate in Producer and Commingled Manufacturing Grade Milk

The automated test for pyruvate concentration, [P], was evaluated as a substitute for the direct microscopic count (DMC) in determining quality of manufacturing grade milk. Samples of manufacturing grade milk from producers and tank trucks as well as skim milk were collected at a large milk drying plant. Each sample was tested immediately for standard plate count (SPC), psychrotrophic plate count (PPC) and DMC. Portions of milk were heated to 85°C for 10 min to stabilize [P] before being returned to the laboratory for analysis of initial pyruvate concentration, [IP]. Unheated samples stored at 4°C were analyzed for [P] and DMC daily for up to 120 h. [IP] was a good indicator of PPC in milk from individual producers (r=0.81). However, [IP] was not highly correlated (r=0.26) with PPC in skim milk samples which were characteristically high in SPC and homogeneous in PPC. With skim milk, [IP] was more highly and significantly correlated with initial DMC (r=0.61) than with initial SPC (r=0.31) or initial PPC (r=0.26). [IP] was a good indicator of [P] in stored fluid samples until counts exceeded about 10⁷/ml. Initial DMC and initial PPC were about equally correlated with [P] determined at 24-h intervals, and the initial DMC was a reasonably good indicator of DMC determined at 24-h intervals. Using 6.5 mg of pyruvate/L to represent bacterial counts of 3 × 10⁶/ml by the three methods tested, the pyruvate test correctly classified 91% of 57 samples of producer milk based on PPC, 88% based on SPC and 82% based on DMC. Most of the error was of the false-negative type in which samples with high counts had less than 6.5 mg of pyruvate/L. This was probably because some bacteria catabolize pyruvate once their numbers exceed 10⁷/ml.

Pyruvate as an Indicator of Quality in Grading Nonfat Dry Milk 1

Samples of skim milk and nonfat dry milk (NDM) made from it were collected, paired and tested for pyruvate concentration, [P], and Direct Microscopic count (DMC). The skim milk was tested for Standard Plate Count (SPC) and Psychrotrophic Plate Count (PPC). The geometric average DMC of skim milk was more than three times higher than that of the paired NDM samples. However, [P] of NDM was not significantly different from that of the skim milk. Although [P] of skim milk was poorly correlated with SPC and PPC, r = .31 and .26, respectively, it was relatively well correlated with DMC, r = .64. Data were widely dispersed around the regression line when [P] was ≤ 4.0 mg/L. However, [P] increased rapidly when DMCs were > 10⁶/ml. A limit of 10 mg/L of [P] in NDM reconstituted 1:9 was chosen to represent the current U.S. Department of Agriculture Standard for DMC in NDM. This limit failed to classify about 10% of the samples correctly, assuming that each geometric mean DMC was correct. However, the probability that samples meeting the DMC standard would be rejected by the pyruvate test was quite low and the probability was moderate that samples which would be acceptable by the pyruvate test would be rejected by the DMC. For the latter, 28% of the samples having DMCs of ≥ 10⁷/ml contained < 10 mg/L of pyruvate. No sample having ≥ 10 mg/L of pyruvate had a DMC of ≤ 10⁷/ml. Pyruvate concentration in NDM did not change during storage at 5 or 32°C for 90 days.