Acute sedation-associated complications in GI endoscopy (ProSed 2 Study): results from the prospective multicentre electronic registry of sedation-associated complications

Hypoxemia during procedural sedation in adult patients: a retrospective observational study

PURPOSE

Since 2010, new guidelines for procedural sedation and the Helsinki Declaration on Patient Safety have increased patient safety, comfort, and acceptance considerably. Nevertheless, the administration of sedatives and opioids during sedation procedures may put the patient at risk of hypoxemia. However, data on hypoxemia during procedural sedation are scarce. Here, we studied the incidence and severity of hypoxemia during procedural sedations in our hospital.

METHODS

A historical, single-centre cohort study was performed at the University Medical Centre Utrecht (UMCU), a tertiary centre in the Netherlands. Data from procedural sedation in our hospital between 1 January 2011 and 31 December 2018 (3,459 males and 2,534 females; total, 5,993) were extracted from our Anesthesia Information Management System. Hypoxemia was defined as peripheral oxygen saturation < 90% lasting at least two consecutive minutes. The severity of hypoxemia was calculated as area under the curve. The relationship between the severity of hypoxemia and body mass index (BMI), American Society of Anesthesiologists (ASA) Physical Status classification, and duration of the procedure was investigated. The primary outcome was the incidence of hypoxemia.

RESULTS

Twenty-nine percent of moderately to deeply sedated patients developed hypoxemia. A high incidence of hypoxemia was found in patients undergoing procedures in the heart catheterization room (54%) and in patients undergoing bronchoscopy procedures (56%). Hypoxemia primarily occurred in longer lasting procedures (> 120 min) and especially in the latter phases of the procedures. There was no relationship between severity of hypoxemia and BMI or ASA Physical Status.

CONCLUSIONS

This study showed that a considerable number of patients are at risk of hypoxemia during procedural sedation with a positive correlation shown with increasing duration of medical procedures. Additional prospective research is needed to investigate the clinical consequences of this cumulative hypoxemia.

Efficacy and safety of dexmedetomidine in patients receiving mechanical ventilation: Evidence from randomized controlled trials

At present, the efficacy and safety of dexmedetomidine in patients receiving mechanical ventilation (MV) is still controversial. Therefore, the purpose of this research was to assess the efficacy and safety of dexmedetomidine in MV patients by reviewing the results of randomized controlled trials (RCT). RCTs evaluating the efficacy of dexmedetomidine in the treatment of MV patients were obtained by searching relevant online databases, including PubMed, EMbase, Web of Science, the Cochrane Library, Medline, OVID, and ClinicalTrials.gov. Literature meeting the inclusion criteria were selected and evaluated by two researchers independently. Risk ratio (RR)/standardized mean difference (SMD) and 95% confidence interval (CI) were used to express the differences between groups. Seven RCTs were included in our study, with 986 participants in the dexmedetomidine group and 862 participants in the control group. Summary analysis results displayed no reduction in 30-day mortality (RR = 0.77, 95% CI: 0.59 to 1.02), delirium (RR = 0.77, 95% CI: 0.57 to 1.03), and adverse events (RR = 1.06, 95% CI: 0.22 to 5.08) in the dexmedetomidine group compared with the control group. As the length of stay in the intensive care unit (ICU) were presented as median and interquartile range (IQR)/standard deviation (SD), descriptive analysis of the results were performed. Generally, for 99.65% (953/986) of patients, dexmedetomidine was not better than the control group in reducing ICU length of stay. Our results demonstrate that for patients requiring MV, dexmedetomidine was not superior to the control group. However, analysis of more RCTs is required to confirm this conclusion.

Comparison of two supplemental oxygen methods during gastroscopy with propofol mono-sedation in patients with a normal body mass index

BACKGROUND

Hypoxemia due to respiratory depression and airway obstruction during upper gastrointestinal endoscopy with sedation is a common concern. The Wei nasal jet tube (WNJT) is a new nasopharyngeal airway with the ability to provide supraglottic jet ventilation and oxygen insufflation via its built-in wall channel. The available evidence indicates that with a low oxygen flow, compared with nasal cannula, the WNJT does not decrease the occurrence of hypoxemia during upper gastrointestinal endoscopy with propofol sedation. To date, there has been no study assessing the performance of WNJT for supplemental oxygen during upper gastrointestinal endoscopy with sedation when a moderate oxygen flow is used.

AIM

To determine whether the WNJT performs better than the nasal prongs for the prevention of hypoxemia during gastroscopy with propofol mono-sedation when a moderate oxygen flow is provided in patients with a normal body mass index.

METHODS

This study was performed in 291 patients undergoing elective gastroscopy with propofol mono-sedation. Patients were randomized into one of two groups to receive either the WNJT (WNJT group, n = 147) or the nasal cannula (nasal cannula group, n = 144) for supplemental oxygen at a 5-L/min flow during gastroscopy. The lowest SpO2 during gastroscopy was recorded. The primary endpoint was the incidence of hypoxemia or severe hypoxemia during gastroscopy.

RESULTS

The total incidence of hypoxemia and severe hypoxemia during gastroscopy was significantly decreased in the WNJT group compared with the nasal cannula group (P = 0.000). The lowest median SpO2 during gastroscopy was significantly higher (98%; interquartile range, 97-99) in the WNJT group than in the nasal cannula group (96%; interquartile range, 93-98). Epistaxis by device insertion in the WNJT group occurred in 7 patients but stopped naturally without any treatment. The two groups were comparable in terms of the satisfaction of physicians, anesthetists and patients.

CONCLUSION

With a moderate oxygen flow, the WNJT is more effective for the prevention of hypoxemia during gastroscopy with propofol mono-sedation compared with nasal prongs, but causing slight epistaxis in a few patients.

Estimation of effective dose of propofol mono-sedation for successful insertion of upper gastrointestinal endoscope in healthy, non-obese Chinese adults

WHAT IS KNOWN AND OBJECTIVE

Propofol is effective in sedation for upper gastrointestinal (UGI) endoscopy. However, the optimum dose is ill-defined. This study aimed to estimate the effective dose of propofol mono-sedation for successful endoscope insertion in healthy, non-obese Chinese adults undergoing single UGI endoscopy.

METHODS

Twenty-six adult patients undergoing elective single UGI endoscopy were enrolled in this study. A modified Dixon's up-and-down method was utilized to assess the effective dose of propofol for successful endoscope insertion. The initial dose of propofol administered, 1.6 mg/kg, was adjusted with 0.1 mg/kg as a step size. The patient's responses to endoscope insertion were classified as either 'movement' or 'no movement'. When patient's responses were changed from 'movement' to 'no movement' or from 'no movement' to 'movement', a crossover was defined. After eight crossovers had been obtained, patient recruitment was stopped. The mean of midpoints of all crossovers obtained by the modified Dixon's up-and-down method in all 26 patients was defined as calculated median effective dose (ED₅₀ ) of propofol for successful endoscope insertion. Furthermore, probit regression analysis was used to determine the dose of propofol where 50% (ED₅₀ ) and 95% (ED₉₅ ) of endoscope insertion attempts were successful.

RESULTS

The calculated ED₅₀ of propofol for successful endoscope insertion was 1.89 ± 0.12 mg/kg. The probit regression analysis showed that ED₅₀ and ED₉₅ of propofol for successful endoscope insertion were 1.90 mg/kg (95% CI, 1.78-2.10 mg/kg) and 2.15 mg/kg (95% CI, 2.01-3.56 mg/kg), respectively. No any patient had hypoxaemia and gag reflex during the UGI endoscopy with propofol mono-sedation.

WHAT IS NEW AND CONCLUSION

In healthy, non-obese Chinese adults, propofol mono-sedation can provide excellent conditions of UGI endoscopy and the estimated ED₅₀ of propofol for successful endoscope insertion is 1.89 ± 0.12 mg/kg.

Comparison of the Effects of Midazolam/Fentanyl, Midazolam/Propofol, and Midazolam/Fentanyl/Propofol on Cognitive Function After Gastrointestinal Endoscopy

BACKGROUND

Drugs used for sedation/analgesia during gastrointestinal (GI) endoscopy, including midazolam, fentanyl, and propofol, result in short-term, reversible decline in cognitive function. This prospective cohort trial aimed to identify the sedative/analgesic regimen associated with the least impairment of cognition at the time of discharge.

METHODS

Patients undergoing elective GI endoscopy were included. Patients investigated at the Prince of Wales Hospital, Sydney, received midazolam/fentanyl (M/F), whereas patients investigated at the Prince of Wales Private Hospital, Sydney, received midazolam/fentanyl/propofol (M/F/P) or midazolam/propofol (M/P). Patients underwent a computerized neurocognitive test, the CogState Brief Battery, before sedation and at discharge.

RESULTS

Patients in the M/F group who received gastroscopy (n=22) were administered midazolam 3.36 mg (±0.79 mg) and fentanyl 61.36 μg (±16.77 μg), those who received colonoscopy (n=50) were administered midazolam 3.98 mg (±1.06 mg) and fentanyl 74.50 μg (±24.48 μg), and those who received gastroscopy/colonoscopy (n=28) were administered midazolam 4.82 mg (±1.41 mg) and fentanyl 94.64 μg (±24.35 μg). Patients in the M/F/P group who received colonoscopy (n=45) were administered midazolam 2.77 mg (±0.55 mg), fentanyl 45.11 μg (±25.78 μg), and propofol 148.64 mg (±57.65 mg), and those who received gastroscopy/colonoscopy (n=36) were administered midazolam 2.64 mg (±0.472 mg), fentanyl 35.28 μg (±19.16 μg), and propofol 168.06 mg (±60.75 mg). Nineteen patients in the M/P group who received gastroscopy (n=19) were administered midazolam 2.37 mg (±0.04 mg) and propofol 13.68 mg (±37.74 mg). Neurocognitive scores were significantly lower in the postprocedure test compared with baseline scores for detection, identification, and one card learning (P<0.001). Postprocedure detection test scores were significantly impaired in the M/F group compared with the M/F/P and M/P groups. Predictors of poorer neurocognitive function were midazolam dosage >3 mg (P<0.006) and fentanyl dosage >50 μg (P<0.009).

CONCLUSION

The use of propofol in GI endoscopy allows for less exposure to midazolam and fentanyl and is associated with improved cognition at the time of discharge.

Endoscopist-Directed Propofol as an Adjunct to Standard Sedation: A Canadian Experience

Background

Sedation practices vary widely by region. In Canada, endoscopist-directed administration of a combination of fentanyl and midazolam is standard practice. A minority of cases are performed with propofol.

Aims

To describe the safety of nonanaesthetist administered low-dose propofol as an adjunct to standard sedation.

Methods

This was a single-centre retrospective study of patients having undergone endoscopic procedures with propofol sedation between 2004 and 2012 in a teaching hospital in Montreal. Procedures were performed by gastroenterologists trained in Advanced Cardiovascular Life Support. Sedation was administered by intravenous bolus by a registered nurse, under the direction of the endoscopist. Outcomes of procedures were collected in the context of a retrospective chart review using the hospital's endoscopy database.

Results

Of patients undergoing endoscopies at our centre, 4930 patients received propofol as an adjunct to standard sedation with fentanyl and midazolam. Cecal intubation rate for colonoscopies (n = 2921) was 92.0%. Gastroscopies (n = 1614), flexible sigmoidoscopies (n = 28), endoscopic retrograde cholangiopancreatography (n = 331) and percutaneous endoscopic gastrostomy insertion (n = 36) had success rates, defined as successful completion of the procedure within anatomical limits, of 99.0, 96.4, 94.0 and 91.7%, respectively. The average dose of propofol used for each procedure was 34.5 ± 20.8 mg. Fentanyl was used in 67.4% of procedures at an average dose of 94.3 ± 17.5 mcg. Midazolam was used in 92.7% of cases at an average dose of 3.0 ± 0.7 mg. Reversal agents (naloxone or flumazenil) were used in 0.43% of the cases (n = 21). Patients who received propofol were discharged uneventfully within the usual postprocedure recovery time. One patient required sedation-related hospitalization. For patients having received propofol in addition to standard sedation agents, 99.6% experienced no adverse events. There were no mortalities.

Conclusion

The use of low-dose propofol as an adjunct to fentanyl and midazolam, administered by a registered nurse under the direction of the endoscopist was safe and effective in patients at our centre.

Indications, contraindications, and safety aspects of procedural sedation

PURPOSE OF REVIEW

There is a steadily increasing demand for procedural sedation outside the operating room, frequently performed in comorbid high-risk adult patients. This review evaluates the feasibility and advantages of sedation vs. general anesthesia for some of these new procedures.

RECENT FINDINGS

Generally, sedation performed by experienced staff is safe. Although for some endoscopic or transcatheter interventions sedation is feasible, results of the intervention might be improved when performed under general anesthesia. For elected procedures like intra-arterial treatment after acute ischemic stroke, avoiding general anesthesia and sedation at all might be the optimal treatment.

SUMMARY

Anesthesiologists are facing continuously new indications for procedural sedation in sometimes sophisticated diagnostic or therapeutic procedures. Timely availability of anesthesia staff will mainly influence who is performing sedation, anesthesia or nonanesthesia personal. While the number of absolute contraindications for sedation decreased to almost zero, relative contraindications are becoming more relevant and should be tailored to the individual procedure and patient.

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.

Deep sedation and anaesthesia in complex gastrointestinal endoscopy: a joint position statement endorsed by the British Society of Gastroenterology (BSG), Joint Advisory Group (JAG) and Royal College of Anaesthetists (RCoA)

In the UK, more than 2.5 million endoscopic procedures are carried out each year. Most are performed under conscious sedation with benzodiazepines and opioids administered by the endoscopist. However, in prolonged and complex procedures, this form of sedation may provide inadequate patient comfort or result in oversedation. As a result, this may have a negative impact on procedural success and patient outcome. In addition, there have been safety concerns on the high doses of benzodiazepines and opioids used particularly in prolonged and complex procedures such as endoscopic retrograde cholangiopancreatography. Diagnostic and therapeutic endoscopy has evolved rapidly over the past 5 years with advances in technical skills and equipment allowing interventions and procedural capabilities that are moving closer to minimally invasive endoscopic surgery. It is vital that safe and appropriate sedation practices follow the inevitable expansion of this portfolio to accommodate safe and high-quality clinical outcomes. This position statement outlines the current use of sedation in the UK and highlights the role for anaesthetist-led deep sedation practice with a focus on propofol sedation although the choice of sedative or anaesthetic agent is ultimately the choice of the anaesthetist. It outlines the indication for deep sedation and anaesthesia, patient selection and assessment and procedural details. It considers the setup for a deep sedation and anaesthesia list, including the equipment required, the environment, staffing and monitoring requirements. Considerations for different endoscopic procedures in both emergency and elective setting are also detailed. The role for training, audit, compliance and future developments are discussed.

Rates of infection after colonoscopy and osophagogastroduodenoscopy in ambulatory surgery centres in the USA

OBJECTIVE

Over 15 million colonoscopies and 7 million osophagogastroduodenoscopies (OGDs) are performed annually in the USA. We aimed to estimate the rates of infections after colonoscopy and OGD performed in ambulatory surgery centres (ASCs).

DESIGN

We identified colonoscopy and OGD procedures performed at ASCs in 2014 all-payer claims data from six states in the USA. Screening mammography, prostate cancer screening, bronchoscopy and cystoscopy procedures were comparators. We tracked infection-related emergency department visits and unplanned in-patient admissions within 7 and 30 days after the procedures, examined infection sites and organisms and analysed predictors of infections. We investigated case-mix adjusted variation in infection rates by ASC.

RESULTS

The rates of postendoscopic infection per 1000 procedures within 7 days were 1.1 for screening colonoscopy, 1.6 for non-screening colonoscopy and 3.0 for OGD; all higher than screening mammography (0.6) but lower than bronchoscopy (15.6) and cystoscopy (4.4) (p<0.0001). Predictors of postendoscopic infection included recent history of hospitalisation or endoscopic procedure; concurrence with another endoscopic procedure; low procedure volume or non-freestanding ASC; younger or older age; black or Native American race and male sex. Rates of 7-day postendoscopic infections varied widely by ASC, ranging from 0 to 115 per 1000 procedures for screening colonoscopy, 0 to 132 for non-screening colonoscopy and 0 to 62 for OGD.

CONCLUSION

We found that postendoscopic infections are more common than previously thought and vary widely by facility. Although screening colonoscopy is not without risk, the risk is lower than diagnostic endoscopic procedures.

Research status and prospect on risk assessment of sedation and anesthesia in endoscopy

Digestive endoscopy plays an important role in the prevention and treatment of gastrointestinal cancer. Although the safety of anesthesia for digestive endoscopy is very high, pre-anesthesia evaluation is still a key step to ensure the safety of the patients. Due to the lack of anesthesia risk assessment procedures and methods worldwide, we need to establish an anesthesia nurse training management system with Chinese characteristics to facilitate convenient and cost-effective anesthesia assessment on an outpatient basis or by telephone. Moreover, an anesthesia risk assessment system for digestive endoscopy should be established. With the wide use of digestive endoscopy, it is believed that China will construct a comprehensive assessment system as well as an assessment form for pre-anesthesia evaluation as soon as possible.

Propofol for gastrointestinal endoscopy

Most gastrointestinal endoscopic procedures are now performed with sedation. Moderate sedation using benzodiazepines and opioids continues to be widely used, but propofol sedation is becoming more popular because its unique pharmacokinetic properties make endoscopy almost painless, with a very predictable and rapid recovery process. There is controversy as to whether propofol should be administered only by anesthesia professionals. According to published values, endoscopist-directed propofol has a lower mortality rate than endoscopist-delivered benzodiazepines and opioids, and a comparable rate to general anesthesia by anesthesiologists. Rapid recovery has a major impact on patient satisfaction, post-procedure education and the general flow of the endoscopy unit. According to estimates, the absolute economic benefit of endoscopist-directed propofol implementation in a screening setting is probably substantial, with 10-year savings of $3.2 billion in the USA. Guidelines concerning the use of propofol emphasize the need for adequate training and certification in sedation by non-anesthetists.