Anesthesia Related Complications of Gastrointestinal Endoscopies; A Retrospective Descriptive Study

BACKGROUND

Gastrointestinal endoscopic procedures are widely used for diagnostic and therapeutic measures. Analgesia and sedation/anesthesia are inseparable parts of these studies and their related complications are inevitable.

METHODS

In a retrograde descriptive study in Shahid Beheshti Hospital, affiliated to Qom University of Medical Sciences, Qom, Iran from March 2013 to March 2017, we gathered information regarding common anesthesia related complications and analyzed them.

RESULTS

44659 procedures were performed during the study period and records of 21342 men (47.79%) and 23317 women (52.21%) were evaluated. Hemodynamic instability (9998; 22.39%), dysrhythmia (1600; 3.58%), desaturation (608; 1.36%), prolonged apnea (34; 0.08%), aspiration (43; 0.10%), postoperative nausea and vomiting (PONV) (636; 1.42%), headache (106; 0.24%), delirium (51; 0.11%), aphasia (1; 0.00%), masseter muscle spasm (1; 0.01%), myocardial infarction (2; 0.00%), and death (5; 0.01%) were seen in the patients.

CONCLUSION

Sedation/anesthesia is enough safe in gastrointestinal endoscopic procedures to enhance the patients’ satisfaction and cooperation. If anesthesia with spontaneous breathing and unsecure airway is selected for this purpose, vigilance of anesthesia provider will be the key element of uneventful and safe procedure.

Prevalence of Anesthetic and Gastrointestinal Complications of Endoscopic Retrograde Cholangiopancreatography

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is an endoscopic method for treatment of many biliary diseases. With respect to rapid recovery and more patient comfort, this procedure is currently performed under light general anesthesia (GA) or conscious sedation.

OBJECTIVES

The current study aimed to clarify that intravenous sedation or light general anesthesia can be performed without great fear of anesthesia related complications in ERCP patients and sedative doses of propofol can be used safely in outpatient settings under the supervision of an expert anesthesiologist.

METHODS

This is a cross-sectional study on 1023 ERCP patients under light GA during 2014 - 2018 in Qom, Shahid Beheshti Hospital. Data were collected by a checklist and were analyzed by using chi-square test in SPSS V.22.

RESULTS

From 1023 patients, 501 (48.97 %) were male and 522 (51.03 %) were female with a mean age of 47.2 ± 6.7 years. The most common finding in ERCP was choledocholithiasis (76.15 %). The most common complication was hemodynamic instability (37.01 %) followed by desaturation (11.65 %) both of them ware anesthesia related. Prevalence of GI (gastrointestinal) related complications was 13.39 %. The most common GI related complications were pancreatitis (7.92 %) and bleeding (3.32 %). Total mortality rate was 0.88 %.

CONCLUSIONS

ERCP-related complications are inevitable but can be controlled by early diagnosis and clinical experience. Severe complications and high risk patients may increase the mortality and morbidity of the procedure. Anesthesia related complications are more frequent than GI related unwanted events. Fortunately, the most common anesthesia related complications are readily manageable and are minor in nature when an expert anesthesiologist is present in the scene. Close monitoring of the patient's vital signs should be the mainstay of the safe procedure.

Effect of dexmedetomidine infusion on N-terminal pro-B-type natriuretic peptide level in patients with femoral shaft fractures under general anesthesia

<p>This study was performed to assess the effect of dexmedetomidine on the level of N-terminal pro–B-type natriuretic peptide (NT-pro-BNP) in patients undergoing major orthopedic surgery. Patients undergoing general anesthesia for femoral shaft fracture surgery were randomly assigned to either 0.5 µg/kg/hour dexmedetomidine or normal saline. Changes in levels of NT-pro-BNP and hemodynamic parameters were compared. Data of 46 patients were analyzed and it was found that the change in NT-pro-BNP levels in the dexmedetomidine group was significantly less than the control group (p = 0.001). In addition, bleeding, changes in systolic and diastolic blood pressure in dexmedetomidine group was significantly less than the control group (p˂0.001). It is likely that dexmedetomidine infusion can reduce the rise of NT–pro-BNP level and therefore is associated with better cardiac outcome. In addition, dexmedetomidine infusion can achieve hemodynamic stability in femoral shaft fracture under general anesthesia.</p><p> </p>

O-125 Development of an artificial intelligence embryo witnessing system to accurately track and identify patient specific embryos in a human IVF laboratory

Study question

Can convolutional neural networks (CNN) be used as a witnessing system to accurately track and identify patient specific embryos at the cleavage stage of development?

Summary answer

We developed the first artificial intelligence driven witnessing system to accurately track cleavage and blastocyst stage embryos in a human ART laboratory.

What is known already

There are reports of human errors in embryo tracking that have led to the births of children with different genetic makeup than their birth parents. Clinical practices rely on manual identification, barcodes or radio-frequency identification technology to track embryos. These systems are designed to track culture dishes but are unable to monitor developing embryos within the dish to help ensure an error-free patient match. Previously, we developed an AI witnessing system to track blastocysts with 100% accuracy. The goal of this study was to determine whether an AI witnessing system could be developed that accurately tracks cleavage stage embryos.

Study design, size, duration

A pre-developed deep neural network technology was first trained and tested on 4944 embryos images. The algorithm processed embryo images for each patient and produced a unique key that was associated with the patient ID at 60 hpi, which formed our library. When the algorithm evaluated embryos at 64 hpi it generated another key that was matched with the patient’s unique key available in the library.

Participants/materials, setting, methods

A total of 3068 embryos from 412 patients were examined by the CNN at both 60 hpi and 64 hpi. These timepoints were chosen as they reflect the time our laboratory evaluates Day 3 embryos (60 hpi) and the time we move them to another dish and prepare them for transfer (64 hpi). The patient cohorts ranged from 3-12 embryos per patient.

Main results and the role of chance

The accuracy of the CNN in correctly matching the patient identification with the patient embryo cohort was 100% (CI: 99.1% to 100.0%, n = 412).

Limitations, reasons for caution

Limitations of this study include that all embryos were imaged under identical conditions and within the same EmbryoScope. Additionally, this study only examined fresh Day 3 embryos cultured over a span of 4 hours. Future studies should include images of fresh and frozen/thawed embryos captured using different imaging systems.

Wider implications of the findings

This study describes the first artificial intelligence-based approach for cleavage stage embryo tracking and patient specimen identification in the IVF laboratory. This technology offers a robust witnessing step based on unique morphological features that are specific to each individual embryo.

Trial registration number

This work was partially supported by the Brigham Precision Medicine Developmental Award (Brigham Precision Medicine Program, Brigham and Women’s Hospital), Partners Innovation Discovery Grant (Partners Healthcare), and R01AI118502, and R01AI138800.

Intraperitoneally Located Tip of Femoral Vein Catheter; Clinical Suspicion for Avoidance of Unnecessary Laparotomy

Central venous catheterization is a common procedure in critical care and trauma patients. Complications are not rare and in some studies more than 15% incidence has been reported (1). Femoral vein is one of the commonest site for this purpose yet it carries complications, such as infection and misplacement. The current study reports an unexpected secondary malposition of right femoral CVC in the peritoneal cavity. It was concluded that in any case of acute abdominal issues, following insertion of femoral venous catheter, evaluation of catheter misplacement by the means of contrast injection through it can be helpful for better diagnosis, and may help avoid unnecessary surgical interventions.

Comparison of the Sedative Effect of Ketamine, Magnesium Sulfate, and Propofol in Patients Undergoing Upper Gastrointestinal Endoscopy: Double-Blinded Randomized Clinical Trial

BACKGROUND

Endoscopy provides valuable diagnostic information and intervention therapies for gastroenterologists. Therefore, various drugs have been used to induce sedation in patients undergoing endoscopy, whereas none have been considered preferred by endoscopists. In the current study, we decided to use the combination of magnesium sulfate, ketamine, and their synergistic effects for creating partial analgesia to increase the satisfaction of endoscopists and patients.

METHODS

This study is a Double-Blind Randomized Clinical Trial that investigates the sedative effect of ketamine, magnesium sulfate, and propofol in endoscopy. Patients were selected from individuals over 12 years old and with American Society of Anesthesia (ASA) physical status I or II. The study was performed on 210 patients classified as ASA (I have no underlying disease) or II (with underlying controlled disease). The whole group was relieved of pain through sedation according to Ramsay criteria, satisfaction with the operation, duration, recovery, nausea and vomiting, hypotension, and decreased oxygen saturation were compared.

RESULTS

A total of 155 patients were enrolled in our study, including 51 patients (midazolam and propofol), 55 patients (midazolam and ketamine), and 49 patients (midazolam and ketamine and magnesium). The results showed that preoperative heart rate, intraoperative systolic blood pressure, intraoperative diastolic blood pressure, postoperative heart rate, postoperative systolic blood pressure, and postoperative heart rate were significantly different between the groups.

CONCLUSION

The satisfaction of the endoscopic was achieved to a great extent, mainly in the group receiving midazolam and propofol and in the group receiving midazolam and ketamine. In most cases, the satisfaction of the endoscopic was acceptable, and the low satisfaction of the endoscopic was more in the group receiving midazolam. Ketamine and magnesium were observed. The two compounds midazolam-ketamine, and midazolam-propofol, have a more favorable effect than the combination of midazolam, ketamine, and magnesium.

P-294 Use of Artificial Intelligence to Assess the Effects of Assisted Hatching on Embryo Development and Implantation Potential

Study question

Does the use of laser-assisted hatching (AH) on cleavage stage embryos affect in vitro preimplantation embryo development or implantation potential?

Summary answer

There is no difference in blastocyst conversion rate or implantation potential of embryos following AH at the cleavage stage for patients under age 35 years.

What is known already

Laser-AH is the process of creating an opening within the zona pellucida on cleavage stage embryos to facilitate biopsy of trophectoderm cells for preimplantation genetic testing (PGT). Studies have shown that PGT for aneuploidy (PGT-A) in patients under 35 years have reduced pregnancy rates compared to those not undergoing biopsy. This is attributed to the additional micromanipulation events involved with PGT-A may decrease the viability of embryos and compromise their implantation potential. We aimed to objectively compare the impact of AH on embryo development using an artificial intelligence (AI)-algorithm trained to assess embryo quality and predict developmental fate.

Study design, size, duration

A retrospective dataset from patients under 35 years was generated from two timepoints: cleavage stage embryos immediately before AH between 60-64 hours post insemination (hpi); and blastocyst stage embryos between 110-115 hpi prior to transfer or vitrification. Time-lapse imaging was obtained using the EmbryoScope (Vitrolife). Cleavage stage embryo images were used to train a convolutional neural networks (CNN) to predict and classify the development and implantation potential of cleavage and blastocyst stage embryos.

Participants/materials, setting, methods

Time-lapse images were collected for 1444 cleavage stage embryos spanning 189 in vitro fertilization (IVF) cycles between January 2014 – December 2021 at a single academic fertility center in Boston. Embryos were categorized into two groups: Day 3 embryos with AH (D3+AH) and without AH (D3-No AH). Each patient had a single blastocyst embryo transfer with a known outcome. Two-tailed t-tests were used to compare differences, with p-value less than 0.05 set for statistical significance.

Main results and the role of chance

The dataset included 1035 embryos with AH (D3+AH) and 409 embryos without AH (D3-No AH). There were no differences in AI-predicted blastocyst development between Day 3 embryos with AH and without AH (64.1% vs 64.1%) or AI-predicted high quality blastocyst development rate between these two groups (43.8% vs 40.8%), respectively. On Day 5 there were no differences in the AI-categorization of embryos at the blastocyst stage between embryos with or without AH (62.3% vs 62.5%) or AI-categorization of high-quality blastocyst development (45.2% vs 41.8%), respectively. AI predicted a similar implantation potential between embryos with and without AH at the cleavage stage (61.1% vs 69.9%). When stratifying to only the embryos transferred, there were no differences in the AI-predicted blastocyst development between Day 3 embryos with AH and without AH (96.0% vs 97.1%) or in the AI-predicted high quality blastocyst development rate between these two groups (72.0% vs 82.7%). AI predicted a similar implantation potential between embryos with and without AH at the cleavage stage (72.0% vs 69.0%). These results correspond with the true clinical pregnancy rate between the AH and Non-AH groups (68.0% vs 61.9%, p = 0.44).

Limitations, reasons for caution

These retrospective findings were of patients who had time-lapse imaging of cleavage stage and blastocysts available. Additionally, we focused on high prognosis patients that were eligible for single blastocyst stage embryo transfer. Clinical pregnancy rate was examined, not spontaneous abortion or live birth rates.

Wider implications of the findings

Utilization of AI technology allows for more objective and standardized methods for examining the impact of laboratory procedures on the developmental fate of embryos. This study demonstrated the safety of utilizing laser-assisted hatching on embryo development within this study population.

Trial registration number

None

Comparing the efficacy and safety of Dexmedetomidine/Ketamine with Propofol/Fentanyl for sedation in colonoscopy patients: A double-blinded randomized clinical trial

BACKGROUND

In this double-blinded randomized clinical trial, we aimed to compare the safety and efficacy of a combination of dexmedetomidine and ketamine [DK] with propofol and fentanyl [PF] for sedation in colonoscopy patients.

METHODS

In this study, 64 patients who underwent colonoscopy were randomized into two groups: 1) A, which received PF, and 2) B, which received DK for sedation. Among 64 patients, 31 patients were included in PF, and 33 patients were included in the DK group. Both groups were similar in terms of demographics. Patients' sedation score (based on Ramsay sedation scale) and vital signs were recorded at 2, 5, 10, and 15 minutes. Complications including apnea, hypotension, hypoxia, nausea, and vomiting, along with gastroenterologist satisfaction and patients' pain score (based on Wong-Baker faces pain assessment scale), were recorded by a checklist. Data were analyzed by SPSS v.18 software, using chi-square, independent t-tests, and repeated measures analysis with p<0.05 as the criterion for significant differences.

RESULTS

The mean score of sedation was 4.82±0.49 in the DK group and 5.22±0.45 in the PF group [p value=0.001]. Serious complications, including hypotension [p value=0.005] and apnea [p value=0.10] were significantly higher in the PF group. Satisfaction of gastroenterologist [p value= 0.400] and patients' pain score [p value = 0.900] were similar among groups.

CONCLUSION

Combination of DK provides sufficient sedation with fewer complications in comparison with PF in colonoscopy patients.

Discharge of Confirmed COVID-19 Patients Based on WHO or Regional Criteria? A Cohort Study

BACKGROUND

Increasing the number of COVID-19 patients raises concerns about the capacity of the health care system. This issue emphasizes reducing the admission rate and expediting patient discharge.

OBJECTIVE

This study aimed to develop a discharge protocol for COVID-19 patients based on the existing capacity of the healthcare system and to assess its post-discharge outcomes.

METHODS

This is a multicenter cohort study. All COVID-19 patients referred to selected medical centers in Qom, Iran, from Feb. 19 to Apr. 19, 2020, were target populations. Eligible patients were classified into a) the criterion group and b) the non-criterion group. Patients were followed up daily for 14 days after discharge by phone, and the required data was gathered and recorded in follow-up form. Univariate (chi-square and t-tests) and multivariate multiple (multivariate probit regression) analysis were used.

RESULTS

A total of 2775 patients were included in the study (1440 people in the criterion group and 1335 in the non-criterion group). Based on multivariate probit regression, death was statistically associated with discharge outside our criteria (p<0.001), rising age (p<0.001), and being male (p=0.019), and readmission were associated with discharge outside our criteria (p<0.001), rising age (p=0.009), and having the history of underlying diseases (p=0.003). Furthermore, remission had statistically significant associations with discharge based on our criteria (p<0.001), decreasing age (p=0.001), and lack of a history of underlying diseases (p<0.001).

CONCLUSION

Mortality and readmission were significantly lower according to our discharge criteria. Our designed criteria apply to less developed and developing countries due to the limited capacity and resources available in the health care system.