Clinical impact of gastroenterologist-administered propofol during esophagogastroduodenoscopy: a randomized comparison at a single medical clinic

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.

Tomentosin induces apoptotic pathway by blocking inflammatory mediators via modulation of cell proteins in AGS gastric cancer cell line

In this study, we investigated the in vitro effect of tomentosin on cell proliferation by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay, reactive oxygen species by 2',7'-dichlorofluorescein diacetate staining assay, apoptosis (AO/EtBr, propidium iodide, and 4',6-diamidino-2-phenylindole staining, mitochondrial membrane potential), cell adherent, cell migration, inflammation, apoptosis, and oxidative stress from gastric cancer cells (GCCs) AGS. Upon their relative cell proliferative, inflammatory, and apoptotic molecular markers were analyzed by using the enzyme-linked immunosorbent assay and Western blot analysis method. Treatment with tomentosin (IC₅₀  = 20 µM) significantly inhibited cell proliferation and oxidative stress-induced anti-cell proliferative (proliferating cell nuclear antigen and cyclin-D1) also regulated expression, drastically diminished tumor necrosis factor-α, nuclear factor-κB, interleukin-6, and interleukin-1β expression levels, significantly upregulated Bcl-2 and Bax expression. Thus, this tomentosin can significantly reduce GCC proliferation via cytotoxicity which is stimulated apoptosis markers via morphology staining changes and inhibitory inflammatory markers. The tomentosin-induced oxidative stress may be involved to stimulate apoptotic mechanisms via mitochondria-mediated signaling by the inhibition of inflammation. Taken together, our findings suggest a possible future use of chemotherapeutic agents for pharmacological benefits and as an anti-cancer treatment option.

Factors Affecting Recovery Time after Sedation for Upper Gastrointestinal Endoscopy

The purpose of this study was to investigate factors affecting recovery time after sedation for upper gastrointestinal endoscopy. The study population included 1310 patients in the national gastric cancer screening program who received sedation for upper gastrointestinal endoscopy from April 15, 2015 to December 31, 2018. Multivariate regression analysis was performed to identify factors related to recovery time. The mean recovery time after examination was 51.2 minutes (SD=13.3). Patients with a history of hypertension had a recovery time 2.59 minutes shorter than that of patients without hypertension (p=0.006, Bonferroni-corrected p=0.108). Patients with a history of stroke had a recovery time 9.41 minutes longer than that of patients without stroke (p=0.007, Bonferroni-corrected p=0.124). Patients who received 3 mg midazolam had a recovery time 2.99 minutes longer than that of patients received 2 mg (p=0.001, Bonferroni-corrected p=0.010), and patients who received less than 6 cc of propofol had a recovery time 2.90 minutes longer than those that of patients received 7-12 cc of propofol (p<0.001, Bonferroni-corrected p=0.005). These results suggest that receiving high doses of midazolam and having a history of stroke are associated with longer recovery times. Patients meeting these criteria should be managed carefully after sedation for upper gastrointestinal endoscopy.

An investigation on the cytotoxicity and caspase-mediated apoptotic effect of biologically synthesized gold nanoparticles using Cardiospermum halicacabum on AGS gastric carcinoma cells

Background

Gastric cancer is the fourth most common cancer and second leading cause of cancer death worldwide. Cardiospermum halicacabum is used to treat nerve disorders, stiffness, rheumatism, ear ache, snake bite, and so on.

Methods

In this study, the reaction parameters were optimized to control the size of the nanoparticle, which was confirmed by transmission electron microscopy. Various characterization techniques such as selected area diffraction pattern, UV-visible spectroscopy, energy-dispersive X-ray analysis, dynamic light scattering, Fourier-transform infrared spectroscopy, and atomic force microscopy were employed to analyze the synthesized AuNPs obtained from C. halicacabum (CH-AuNP) against gastric carcinoma cell line.

Results

The cytotoxic effect of CH-AuNP against AGS, SNU-5, and SNU-16 cell lines was detected by MTT assay. The induction of apoptosis by CH-AuNP in AGS was analyzed by double staining technique using TUNEL and DAPI staining assays. Further to confirm the molecular mechanism exhibited by CH-AuNP to induce apoptosis, the intracellular ROS level was assessed and immunoblotting was performed to assess the apoptotic signaling molecules that often deregulated in cancerous condition.

Conclusion

The results clearly prove that CH-AuNP increases ROS and induces apoptosis in AGS, suggesting that CH-AuNP may be an effective anticancer drug with no side effects to treat gastric cancer.

[Safety of Non-anesthesiologist Administration of Propofol for Gastrointestinal Endoscopy]

Propofol (2,6-diisopropylphenol) is a hypnotic drug with a very rapid onset and offset of action. It has increasingly been used in gastrointestinal endoscopy. Administration of propofol by nurses or endoscopists is commonly referred to as non-anesthesiologist-administered propofol (NAAP). There have been a lot of studies on the safety of NAAP compared with those by anesthesiologists. Safety results of those studies are summarized in this review.

Feasibility of non-anesthesiologist-administered propofol sedation for emergency endoscopic retrograde cholangiopancreatography

Background. The safety of non-anesthesiologist-administered propofol (NAAP) sedation in emergent endoscopic retrograde cholangiopancreatography (ERCP) has not been fully clarified. Thus, the aim of this study was to assess the safety of NAAP sedation in emergent ERCP. Materials and Methods. We retrospectively analyzed 182 consecutive patients who had obstructive jaundice and who underwent ERCP under NAAP sedation. The patients were divided into Group A (with mild acute cholangitis or without acute cholangitis) and Group B (moderate or severe acute cholangitis). And technical safety and adverse events were assessed. Results. The adverse events were hypoxia (31 cases), hypotension (26 cases), and bradycardia (2 cases). There was no significant difference in the rate of each adverse event of hypoxia and bradycardia in either group. Although the rate of transient hypotension associated in Group B was higher than that in Group A, it was immediately improved with conservative treatment. Moreover, there were no patients who showed delayed awakening, or who developed other complications. Conclusions. In conclusion, NAAP sedation is feasible even in emergent ERCP. Although some transient adverse events (e.g., hypotension) were observed, no serious adverse events occurred. Thus, propofol can be used in emergent ERCP but careful monitoring is mandatory.