Prospective description of coughing, hemodynamic changes, and oxygen desaturation during endoscopic sedation

Comparison of the Quality of Recovery-15 score in patients undergoing oncoplastic breast-conserving surgery under monitored anesthesia care versus general anesthesia: a prospective quality improvement study

PURPOSE

Whether changing the institutional practice from general anesthesia (GA) to monitored anesthesia care (MAC) affects postoperative quality of recovery for oncoplastic breast-conserving surgery (BCS) is currently unknown. We designed this quasi-experimental study to evaluate a quality improvement (QI) initiative instituted in Edmonton, AB, Canada.

METHODS

We chose a prospective controlled cohort study design for this QI study, where patients underwent oncoplastic BCS under MAC in one hospital and BCS under GA at another hospital (control). A total of 125 patients undergoing surgery between May 2021 and February 2022 were enrolled. Exclusion criteria were male sex, total mastectomy, or age under 18. All other patients were included. The primary outcome was the change in Quality of Recovery-15 score at 24 hr compared with a preoperative baseline. Secondary outcomes included intra- and postoperative time profiles, perioperative analgesic and antiemetic use and length of hospital stay. Statistical analysis included a propensity score analysis to account for confounding variables.

RESULTS

Sixty-four patients received GA and 61 MAC. No enrolled patients were lost to follow up but two were excluded secondarily. No patients receiving MAC needed conversion to GA or unplanned airway management. Monitored anesthesia care was associated with superior outcomes for the primary outcome (β/SE[β], 3.31; 99.5% confidence interval, 0.45 to 6.17; P = 0.001) and most secondary outcomes, when accounting for confounding factors.

CONCLUSIONS

A care transformation initiative for patients undergoing oncoplastic BCS under MAC was associated with a higher quality recovery profile and shorter length of stay without any increase in perioperative or postoperative adverse events.

Ultrasonographic Assessment of Gastric Volume in Fasted Patients Undergoing Gastrointestinal Endoscopy Under Sedation

Purpose

In this prospective observational study, an ultrasonographic measurement of antral cross-sectional area (ACSA) was conducted to evaluate the gastric content and volume as well as to identify high-risk stomach in non-pregnant adult surgical patients adhering to preanesthetic fasting guidelines.

Patients and Methods

Fasted patients undergoing gastrointestinal endoscopy under sedation were included. Ultrasonographic measurements of ACSA were conducted in both semi-recumbent and right lateral decubitus positions before endoscopic procedures. Gastroscopy was employed to guide the measurement of suctioned gastric volume (GV). Ultrasonography was performed to assess gastric contents and identify patients with high-risk stomach. The relationship between ACSA and suctioned GV was also evaluated.

Results

ACSA was evaluated in 736 out of 782 patients. A significant positive correlation was discovered between ACSA in the right lateral decubitus position and suctioned GV, which was more reliable than in the semi-recumbent position. To analyze high-risk stomach with a GV > 100 mL, the cutoff value of ACSA in the right lateral decubitus was found to be 7.5 cm2, with the AUC, sensitivity and specificity of 0.80 (95% CI, 0.76-0.82; P<0.001), 82.4% and 67.3%, respectively. A novel mathematical model based on ACSA to estimate GV in non-pregnant fasted adults was presented.

Conclusion

Ultrasonographic measurement of ACSA can assist anesthesiologists in estimating the risk of pulmonary aspiration of gastric contents during general anesthesia and sedation.

Application of topical pharyngeal anesthesia to reduce adverse reactions during painless gastroscopy: A prospective randomized study

BACKGROUND

Studies have reported that certain adverse reactions can occur during painless gastroscopy examination. Knowing how to decrease the risks and incidence of adverse reactions is of great importance.

OBJECTIVE

To investigate whether topical pharyngeal anesthesia combined with intravenous anesthesia is superior to intravenous anesthesia alone in patients undergoing painless gastroscopy and to determine whether this combined approach had any additional benefits.

METHODS

Three hundred patients undergoing painless gastroscopy were randomly assigned to either the control group or the experimental group. In the control group, patients were anesthetized with propofol, while patients in the experimental group received propofol combined with 2% lidocaine spray for topical pharyngeal anesthesia. Hemodynamic parameters before and after the procedure, including the heart rate (HR), mean arterial pressure (MAP), and pulse oxygen saturation (SPO2) were recorded. Any adverse reactions experienced by the patient, including choking and respiratory depression, and the total dosage of propofol required during each procedure were also documented.

RESULTS

Compared with pre-anesthetic data, the HR, MAP, and SPO2 were reduced after the completion of the painless gastroscopy procedure in both groups. However, the HR, MAP, and SPO2 measurements taken after the gastroscopy were significantly lower in the control group than those of the experimental group (P< 0.05); thus, the hemodynamic parameters of the experimental group were more stable. Compared with the control group, there was significant reduction in the total amount of propofol administered in the experimental group (P< 0.05). The incidence of adverse reactions, including choking and respiratory depression, was significantly lower in the experimental group (P< 0.05).

CONCLUSION

The results demonstrated that the application of topical pharyngeal anesthesia in painless gastroscopy can significantly reduce the incidence of adverse reactions. Thus, the combination of topical pharyngeal and intravenous anesthesia is worthy of clinical application and promotion.

Retained Food During Esophagogastroduodenoscopy Is a Risk Factor for Gastric-to-Pulmonary Aspiration

BACKGROUND

Residual food (RF) during esophagogastroduodenoscopy (EGD) is thought, but not proven, to be a risk factor for gastric-to-pulmonary aspiration.

AIMS

The aims of this study were to determine the prevalence of RF during EGD, to investigate whether RF was associated with an increased risk of aspiration, especially when monitored anesthesia care (MAC) or general anesthesia (GA) were administered, and to determine whether aspiration associated with RF led to a more severe clinical outcome.

METHODS

Patients undergoing EGD between October 2012 and September 2018 were identified. Patient age, sex, aspiration events, RF, sedation type, structural foregut abnormalities, and diagnoses associated with impaired esophageal or gastric motility were noted. The clinical course after an aspiration event was evaluated.

RESULTS

RF was identified during 4% of 81,367 EGDs. Aspiration events occurred during 41 (5/10,000) procedures. Aspiration was more likely to occur in patients with RF (odds ratio [OR] 15.1) or those receiving MAC or GA (OR 9.6 and 16.8 relative to conscious sedation, respectively). RF and MAC/GA were synergistically associated with increased odds of aspiration. In a multivariate nominal logistic regression model, older age (OR 2.6), MAC (OR 3.8), GA (OR 4.4), vagotomy (OR 5.2), achalasia (OR 3.8), and RF (OR 10.0) were risk factors for aspiration. Aspiration events in the presence or absence of RF led to similar clinical outcomes.

CONCLUSIONS

While aspiration events are rare in patients undergoing EGD, RF and the use of MAC or GA were associated with substantially increased odds of aspiration.

Pulmonary aspiration during procedural sedation for colonoscopy resulting from positional change managed without oral endotracheal intubation

Background

Pulmonary aspiration under anaesthesia is a feared complication. It is likely that the incidence of aspiration occurring during procedural sedation is underreported; although rare, fatalities do occur. The supine position increases the risk of pulmonary aspiration in gastrointestinal endoscopy during procedural sedation. Immediate oral endotracheal intubation has traditionally been the cornerstone of management for aspiration during anaesthesia; however, this may not be always beneficial when aspiration occurs during procedural sedation. To my knowledge, this is the first case report of aspiration pneumonitis resulting from surgical repositioning during colonoscopy under procedural sedation.

Case presentation

A 72-year-old female underwent elective outpatient diagnostic colonoscopy. Intravenous propofol infusion was commenced for the procedural sedation. A large amount of non-particulate vomitus was expelled from the oropharynx as the patient was repositioned from the left lateral to supine position. Oxygen saturation on pulse oximetry immediately dropped to below 90% during the event. The patient was managed successfully without oral endotracheal intubation.

Conclusions

Anaesthesiologists need to be mindful of factors that raise the risk of aspiration during procedural sedation. Gastrointestinal endoscopy poses a higher risk of aspiration than other procedures, and positional change may be a precipitant. Aspiration that occurs during procedural sedation may be more safely managed by avoiding immediate oral endotracheal intubation.

Gastrointestinal endoscopy under sedation is associated with pneumonia in older inpatients-results of a retrospective case-control study

Background and aims

Apparent aspiration is a notable adverse event during gastrointestinal endoscopy under sedation (GIES), but data about inapparent aspiration are scarce. Generally, particularly older patients are at higher risk of suffering from adverse events.

Objective

The objective of this article is to determine the risk of pneumonia, lower respiratory tract infection (LRI) and systemic inflammatory activation after GIES, especially in patients of at least 65 years.

Methods

The retrospective case-control study included 250 patients undergoing GIES and assigned age-, gender- and time of performance-matched controls without invasive procedure or sedation (ratio 1:1).

Results

On day 3 patients of advanced age presented with both pneumonia and LRI more often (2.6 vs. 0.0%, p = 0.041 and 7.8 vs. 2.5%, p = 0.034, respectively). In general, several inflammatory parameters increased significantly after GIES (i.e. white blood cell count (increase of ≥ 25%) 18.6 vs. 6.9%, p < 0.001), leading to more frequent antibiotic treatment (6.8 vs. 1.6%, p = 0.004). The effects were less pronounced on day 7.

Conclusions

Patients of advanced age carry an increased risk of pneumonia and LRI after GIES. Patients are generally more likely to feature inflammation and to receive antibiotic treatment.

Sedation in the Endoscopy Suite

OPINION STATEMENT

Sedation practices in the endoscopy suite have changed dramatically in the decades since the introduction of routine colonoscopy and esophagogastroduodenoscopy (EGD). Patients initially received moderate sedation (or even no sedation), but now frequently receive monitored anesthesia care (MAC). This significant shift has introduced anesthesiologists to the endoscopy suite along with new sedative medications and safety concerns. Appreciating the ramifications of this change requires an understanding of sedation depth, patient selection, drug use, sedation delivery, patient monitoring, recovery from sedation, and patient outcomes. Furthermore, the changing landscape of healthcare quality and reimbursement challenges us to provide the best possible care for our patients in the most economical way possible. The endoscopy suite is a unique sedation environment, and it is the purpose of this article to review those elements that contribute to a uniquely demanding work environment.

Complications following colonoscopy with anesthesia assistance: a population-based analysis

IMPORTANCE

Deep sedation for endoscopic procedures has become an increasingly used option but, because of impairment in patient response, this technique also has the potential for a greater likelihood of adverse events. The incidence of these complications has not been well studied at a population level.

DESIGN

Population-based study.

SETTING AND PARTICIPANTS

Using a 5% random sample of cancer-free Medicare beneficiaries who resided in one of the regions served by a SEER (Surveillance, Epidemiology, and End Results) registry, we identified all procedural claims for outpatient colonoscopy without polypectomy from January 1, 2000, through November 30, 2009.

INTERVENTION

Colonoscopy without polypectomy, with or without the use of deep sedation (identified by a concurrent claim for anesthesia services).

MAIN OUTCOME MEASURES

The occurrence of hospitalizations for splenic rupture or trauma, colonic perforation, and aspiration pneumonia within 30 days of the colonoscopy.

RESULTS

We identified a total of 165 527 procedures in 100 359 patients, including 35 128 procedures with anesthesia services (21.2%). Selected postprocedure complications were documented after 284 procedures (0.17%) and included aspiration (n = 173), perforation (n = 101), and splenic injury (n = 12). (Some patients had >1 complication.) Overall complications were more common in cases with anesthesia assistance (0.22% [95% CI, 0.18%-0.27%]) than in others (0.16% [0.14%-0.18%]) (P < .001), as was aspiration (0.14% [0.11%-0.18%] vs 0.10% [0.08%-0.12%], respectively; P = .02). Frequencies of perforation and splenic injury were statistically similar. Other predictors of complications included age greater than 70 years, increasing comorbidity, and performance of the procedure in a hospital setting. In multivariate analysis, use of anesthesia services was associated with an increased complication risk (odds ratio, 1.46 [95% CI, 1.09-1.94]).

CONCLUSIONS AND RELEVANCE

Although the absolute risk of complications is low, the use of anesthesia services for colonoscopy is associated with a somewhat higher frequency of complications, specifically, aspiration pneumonia. The differences may result in part from uncontrolled confounding, but they may also reflect the impairment of normal patient responses with the use of deep sedation.