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Zhang B, Lang Z, Zhang L, Gao B, Wang Y, Liu Y. Comparison of intratracheal intubation or not during endoscopic retrograde cholangiopancreatography: a meta-analysis and systematic review. Eur J Med Res 2025; 30:285. [PMID: 40229855 PMCID: PMC11998158 DOI: 10.1186/s40001-025-02558-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2025] [Accepted: 04/05/2025] [Indexed: 04/16/2025] Open
Abstract
OBJECTIVES In endoscopic retrograde cholangiopancreatography anesthesia, both intubation and non-intubation techniques have their own advantages and disadvantages. However, whether either approach is associated with postoperative and anesthesia-related adverse events remains controversial. METHODS We searched the literature in PubMed, Web of Science, Cochrane Library, Scopus, Ovid and Embase databases up to October 2024. All studies comparing intubated vs. non-intubation anesthesia for endoscopic retrograde cholangiopancreatography were included. The main outcome measures were sedation-related adverse events and death. Data were combined using risk ratio with 95% confidence intervals. The study protocol was prospectively registered with PROSPERO (CRD42024608807). RESULTS We finally included 8 studies with a total of 21,433 patients. Endotracheal intubation was associated with a lower risk of sedation-related adverse events (RR: 2.85, 95% CI 1.33-6.09, p = 0.007). However, the risks of death (RR: 0.59, 95% CI 0.36-0.96, p = 0.03) and intraoperative hypotension (RR: 0.43, 95% CI 0.26-0.69, p = 0.0006) were lower without intubation. In the trial-sequence analysis, the trial-sequence monitoring boundary is crossed, indicating conclusive evidence of a statistically significant effect. CONCLUSIONS Our findings suggest that endotracheal intubation during endoscopic retrograde cholangiopancreatography is associated with a lower risk of sedation-related adverse events but a higher risk of mortality and intraoperative hypotension compared to non-intubation. However, these associations do not establish direct causality and should be interpreted with caution. Further high-quality randomized controlled trials are needed to validate these findings. Clinicians should adopt a patient-centered approach, carefully balancing the potential benefits and risks of intubation to optimize airway management strategies in endoscopic retrograde cholangiopancreatography.
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Affiliation(s)
- Binfeng Zhang
- Department of Anesthesia and Surgery, First Hospital of Lanzhou University, No. 1 Donggang West Road, Chengguan District, Lanzhou, Gansu, 730000, People's Republic of China
- The First Clinical Medical College, Lanzhou University, Lanzhou, 730000, Gansu, People's Republic of China
| | - Zekun Lang
- The First Clinical Medical College, Lanzhou University, Lanzhou, 730000, Gansu, People's Republic of China
| | - Lei Zhang
- The First Clinical Medical College, Lanzhou University, Lanzhou, 730000, Gansu, People's Republic of China
| | - Boxiong Gao
- The First Clinical Medical College, Lanzhou University, Lanzhou, 730000, Gansu, People's Republic of China
| | - Yutong Wang
- The First Clinical Medical College, Lanzhou University, Lanzhou, 730000, Gansu, People's Republic of China
| | - Yatao Liu
- Department of Anesthesia and Surgery, First Hospital of Lanzhou University, No. 1 Donggang West Road, Chengguan District, Lanzhou, Gansu, 730000, People's Republic of China.
- The First Clinical Medical College, Lanzhou University, Lanzhou, 730000, Gansu, People's Republic of China.
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2
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Smith ZL, Kayal A, Ruan Y, Lethebe BC, Siersema PD, Padrón AT, Alshammari Y, Samnani S, Koury HF, Chau M, Howarth M, Cartwright S, Brenner DR, Tavakkoli A, Keswani RN, Elmunzer BJ, Wani S, Forbes N. Adverse events, success, and tolerability of biliary endoscopic retrograde cholangiopancreatography with conscious sedation vs anaesthesia: a multi-centre prospective study. J Can Assoc Gastroenterol 2025; 8:63-70. [PMID: 40224576 PMCID: PMC11991873 DOI: 10.1093/jcag/gwae061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/15/2025] Open
Abstract
Background and Aims Endoscopic retrograde cholangiopancreatography (ERCP) is performed using anaesthesia or conscious sedation, though the effectiveness, adverse events (AEs), and tolerability of each approach remain unclear. Thus, we compared these approaches prospectively. Methods We performed a multi-centre prospective cohort study including patients with native papillae undergoing ERCP for biliary indications between 2018 and 2023. The primary outcome was sedation-related AEs, defined as sustained hypoxaemia or hypotension, unplanned mask ventilation or intubation, vasopressor or reversal agent use, cardiorespiratory arrest, or death. Secondary outcomes included other AEs, technical success measures, and patient-reported tolerability using a validated scale. Multivariable logistic regression was performed in addition to propensity score-matched analyses. Results At 8 centres, a total of 3174 first-time biliary ERCPs were performed, 433 (13.6%) employing anaesthesia. Nine sedation-related AEs occurred with conscious sedation (0.3%), while 2 (0.5%) occurred with anaesthesia (odds ratio, OR, 0.35, 0.07-2.37). Only 25 (0.9%) conscious sedation-supported ERCPs were aborted due to the inability to appropriately sedate patients. There were no significant differences in other AE rates, cannulation success, time, or attempts, use of pre-cut or needle-knife access methods, or inadvertent pancreatic duct cannulation. Odds of significant patient-reported intra-procedural awareness and discomfort were both higher with conscious sedation (ORs 16.19, 4.81-54.53, and 21.25, 4.44-101.61, respectively). Propensity score-matched analyses yielded no differences in any outcome compared with primary analyses. Conclusions Routine biliary ERCP is equally safe and effective with conscious sedation (vs anaesthesia). Given regional resource limitations, conscious sedation is justified as a primary option for routine biliary ERCP.
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Affiliation(s)
- Zachary L Smith
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Ahmed Kayal
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Medicine, Faculty of Medicine, Rabigh, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Yibing Ruan
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Cancer Epidemiology and Prevention Research, Cancer Care Alberta, AHS, Calgary, AB, Canada
| | - Brendan Cord Lethebe
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Erasmus MC—University Medical Center, Rotterdam, The Netherlands
| | - Alejandra Tepox Padrón
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Yousef Alshammari
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Sunil Samnani
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Hannah F Koury
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Millie Chau
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Megan Howarth
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Shane Cartwright
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Darren R Brenner
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Cancer Epidemiology and Prevention Research, Cancer Care Alberta, AHS, Calgary, AB, Canada
| | - Anna Tavakkoli
- Division of Gastroenterology, Department of Medicine, University of Texas Southwestern, Dallas, TX, United States
| | - Rajesh N Keswani
- Division of Gastroenterology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Badih Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, SC, United States
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Nauzer Forbes
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, United States
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3
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Melita G, Tripodi VF, Pallio S, Shahini E, Vitello A, Sinagra E, Facciorusso A, Mazzeo AT, Choudhury A, Dhar J, Samanta J, Maida MF. Moderate Sedation or Deep Sedation for ERCP: What Are the Preferences in the Literature? Life (Basel) 2024; 14:1306. [PMID: 39459606 PMCID: PMC11509070 DOI: 10.3390/life14101306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Revised: 09/26/2024] [Accepted: 10/10/2024] [Indexed: 10/28/2024] Open
Abstract
One of the most essential procedures for individuals with biliopancreatic disorders is endoscopic retrograde cholangiopancreatography (ERCP). It is based on the combination of endoscopy and radiology to study the biliopancreatic ducts and apply therapeutic solutions. ERCP is currently used to treat choledocholithiasis with or without cholangitis, as well as pancreatic duct stones, benign bile, and pancreatic leaks. On the other hand, ERCP is an unpleasant procedure that must be conducted under anesthetic (moderate sedation, deep sedation, or general anesthesia). With procedures becoming more challenging, the role of anesthesia in ERCP has become even more relevant, and the use of general anesthesia has become better defined. In the last decades, many drugs have been used and some new drugs, like dexmedetomidine, have been recently introduced for sedation or anesthesia during ERCP. Moreover, the scientific community is still divided on the level of sedation to be applied, as well as on appropriate airway management. We therefore performed a narrative review of the literature to assess currently available anesthetic medications for elective ERCP and evidence supporting their effectiveness.
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Affiliation(s)
| | | | - Socrate Pallio
- Clinical and Experimental Medicine Department, University of Messina, 98124 Messina, Italy;
| | - Endrit Shahini
- Gastroenterology Unit, National Institute of Gastroenterology, IRCCS “Saverio de Bellis”, Castellana Grotte, 70013 Bari, Italy;
| | - Alessandro Vitello
- Gastroenterology and Endoscopy Unit, S. Elia-Raimondi Hospital, 93100 Caltanissetta, Italy;
| | - Emanuele Sinagra
- Gastroenterology and Endoscopy Unit, Fondazione Istituto San Raffaele Giglio, 90015 Cefalù, Italy;
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Medical and Surgical Sciences, University of Foggia, 71100 Foggia, Italy;
| | - Anna Teresa Mazzeo
- Anesthesia and Intensive Care, Human Pathology Department, University of Messina, 98124 Messina, Italy;
| | - Arup Choudhury
- Gastroenterology Unit, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India; (A.C.); (J.D.); (J.S.)
| | - Jahnvi Dhar
- Gastroenterology Unit, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India; (A.C.); (J.D.); (J.S.)
| | - Jayanta Samanta
- Gastroenterology Unit, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India; (A.C.); (J.D.); (J.S.)
| | - Marcello Fabio Maida
- Department of Medicine and Surgery, University of Enna “Kore”, 94100 Enna, Italy
- Gastroenterology Unit, Umberto I Hospital, 94100 Enna, Italy
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4
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Kang H, Lee B, Jo JH, Lee HS, Park JY, Bang S, Park SW, Song SY, Park J, Shim H, Lee JH, Yang E, Kim EH, Kim KJ, Kim MS, Chung MJ. Machine-Learning Model for the Prediction of Hypoxaemia during Endoscopic Retrograde Cholangiopancreatography under Monitored Anaesthesia Care. Yonsei Med J 2023; 64:25-34. [PMID: 36579376 PMCID: PMC9826962 DOI: 10.3349/ymj.2022.0381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 11/29/2022] [Accepted: 12/02/2022] [Indexed: 12/23/2022] Open
Abstract
PURPOSE Hypoxaemia is a significant adverse event during endoscopic retrograde cholangiopancreatography (ERCP) under monitored anaesthesia care (MAC); however, no model has been developed to predict hypoxaemia. We aimed to develop and compare logistic regression (LR) and machine learning (ML) models to predict hypoxaemia during ERCP under MAC. MATERIALS AND METHODS We collected patient data from our institutional ERCP database. The study population was randomly divided into training and test sets (7:3). Models were fit to training data and evaluated on unseen test data. The training set was further split into k-fold (k=5) for tuning hyperparameters, such as feature selection and early stopping. Models were trained over k loops; the i-th fold was set aside as a validation set in the i-th loop. Model performance was measured using area under the curve (AUC). RESULTS We identified 6114 cases of ERCP under MAC, with a total hypoxaemia rate of 5.9%. The LR model was established by combining eight variables and had a test AUC of 0.693. The ML and LR models were evaluated on 30 independent data splits. The average test AUC for LR was 0.7230, which improved to 0.7336 by adding eight more variables with an l1 regularisation-based selection technique and ensembling the LRs and gradient boosting algorithm (GBM). The high-risk group was discriminated using the GBM ensemble model, with a sensitivity and specificity of 63.6% and 72.2%, respectively. CONCLUSION We established GBM ensemble model and LR model for risk prediction, which demonstrated good potential for preventing hypoxaemia during ERCP under MAC.
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Affiliation(s)
- Huapyong Kang
- Division of Gastroenterology, Department of Internal Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
- Department of Medicine, Yonsei University Graduate School, Seoul, Korea
| | - Bora Lee
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Hyun Jo
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Hee Seung Lee
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jeong Youp Park
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Seungmin Bang
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Woo Park
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Si Young Song
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Joonhyung Park
- Graduate School of AI, Korea Advanced Institute of Science and Technology, Daejeon, Korea
| | - Hajin Shim
- School of Computing, Korea Advanced Institute of Science and Technology, Daejeon, Korea
| | - Jung Hyun Lee
- Graduate School of AI, Korea Advanced Institute of Science and Technology, Daejeon, Korea
| | - Eunho Yang
- Graduate School of AI, Korea Advanced Institute of Science and Technology, Daejeon, Korea
- School of Computing, Korea Advanced Institute of Science and Technology, Daejeon, Korea
| | - Eun Hwa Kim
- Biostatistics Collaboration Unit, Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, Korea
| | - Kwang Joon Kim
- Division of Geriatrics, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Min-Soo Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea.
| | - Moon Jae Chung
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.
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5
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Alzanbagi AB, Jilani TL, Qureshi LA, Ibrahim IM, Tashkandi AMS, Elshrief EEA, Khan MS, Abdelhalim MAH, Zahrani SA, Mohamed WMK, Nageeb AM, Abbushi B, Shariff MK. Randomized trial comparing general anesthesia with anesthesiologist-administered deep sedation for ERCP in average-risk patients. Gastrointest Endosc 2022; 96:983-990.e2. [PMID: 35690151 DOI: 10.1016/j.gie.2022.06.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 05/09/2022] [Accepted: 06/01/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS General anesthesia (GA) or monitored anesthesia care (MAC) is increasingly used to perform ERCP. The definitive choice between the 2 sedative types remains to be established. This study compared outcomes of GA with MAC in ERCP performed in patients at average risk for sedation-related adverse events (SRAEs). METHODS At a tertiary referral center, patients with American Society of Anesthesiologists (ASA) class ≤III were randomly assigned to undergo ERCP with MAC or GA. The main outcome was a composite of hypotension, arrhythmia, hypoxia, hypercapnia, apnea, and procedural interruption or termination defined as SRAEs. In addition, ERCP procedural time, success, adverse events, and endoscopist and patient satisfaction were compared. RESULTS Of 204 randomized, 203 patients were evaluated for SRAEs (MAC, n = 96; GA, n = 107). SRAEs developed in 35% of the MAC cohort (34/96) versus 9% in the GA cohort (10/107), which was statistically significant (P < .001). Mean induction time for GA was significantly longer than that for MAC (10.3 ± 10 minutes vs 6.5 ± 10.8 minutes, respectively; P < .001). ERCP procedure time, recovery time, cannulation time and success, and procedure-related adverse events were not statistically different between the 2 sedative groups. The use of GA improved endoscopist and patient satisfaction (P < .001). CONCLUSION GA is safe with fewer SRAEs than MAC in patients with ASA scores ≤III undergoing ERCP. Apart from prolonging induction time, use of GA does not change the procedural success or ERCP-related adverse events and offers greater endoscopist and patient satisfaction. Hence, GA is a consideration in patients undergoing ERCP in this population group. (Clinical trial registration number: NCT04099693.).
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Affiliation(s)
- Adnan B Alzanbagi
- Department of Gastroenterology and Hepatology, King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
| | - Tariq L Jilani
- Department of Anesthesia, King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
| | - Laeeque A Qureshi
- Department of Gastroenterology and Hepatology, King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
| | - Ibrahim M Ibrahim
- Department of Anesthesia, King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
| | - Abdulaziz M S Tashkandi
- Department of Gastroenterology and Hepatology, King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
| | - Eman E A Elshrief
- Department of Anesthesia, King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
| | - Mohammed S Khan
- Department of Gastroenterology and Hepatology, King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
| | - Manal A H Abdelhalim
- Department of Anesthesia, King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
| | - Saad A Zahrani
- Department of Gastroenterology and Hepatology, King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
| | - Wafaa M K Mohamed
- Department of Anesthesia, King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
| | - Ahmed M Nageeb
- Department of Anesthesia, King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
| | - Belal Abbushi
- Department of Anesthesia, King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
| | - Mohammed K Shariff
- Department of Gastroenterology and Hepatology, King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
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6
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Henriksson A, Thakrar S. Anaesthesia and sedation for endoscopic retrograde cholangiopancreatography. BJA Educ 2022; 22:372-375. [PMID: 36132880 PMCID: PMC9482865 DOI: 10.1016/j.bjae.2022.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2022] [Indexed: 11/16/2022] Open
Affiliation(s)
- A.M. Henriksson
- Chelsea and Westminster Hospital, Chelsea and Westminster NHS Trust, London, UK
| | - S.V. Thakrar
- Hammersmith Hospital, Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare Trust, London, UK
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7
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Cummings LC, Liang C, Mascha EJ, Saager L, Smith ZL, Bhavani S, Vargo JJ, Cummings KC. Incidence of sedation-related adverse events during ERCP with anesthesia assistance: a multicenter observational study. Gastrointest Endosc 2022; 96:269-281.e1. [PMID: 35381231 DOI: 10.1016/j.gie.2022.03.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 03/25/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Anesthesia assistance is commonly used for ERCP. General anesthesia (GA) may provide greater airway protection but may lead to hypotension. We aimed to compare GA versus sedation without planned intubation (SWPI) on the incidence of hypoxemia and hypotension. We also explored risk factors for conversion from SWPI to GA. METHODS This observational study used data from the Multicenter Perioperative Outcomes Group. Adults with American Society of Anesthesiologists physical status class I to IV undergoing ERCP between 2006 and 2019 were included. We compared GA and SWPI on incidence of hypoxemia (oxygen saturation <90% for ≥3 minutes) and hypotension (mean arterial pressure <65 mm Hg for ≥5 minutes) using joint hypothesis testing. The association between anesthetic approach and outcomes was assessed using logistic regression. The noninferiority delta for hypoxemia and hypotension was an odds ratio of 1.20. One approach was deemed better if it was noninferior on both outcomes and superior on at least 1 outcome. To explore risk factors associated with conversion from SWPI to GA, we constructed a logistic regression model. RESULTS Among 61,735 cases from 42 institutions, 38,830 (63%) received GA and 22,905 (37%) received SWPI. The GA group had 1.27 times (97.5% confidence interval, 1.19-1.35) higher odds of hypotension but .71 times (97.5% confidence interval, .63-.80) lower odds of hypoxemia. Neither group was noninferior to the other on both outcomes. Conversion from SWPI to GA occurred in 6.5% of cases and was associated with baseline comorbidities and higher institutional procedure volume. CONCLUSIONS GA for ERCP was associated with less hypoxemia, whereas SWPI was associated with less hypotension. Neither approach was better on the combined incidence of hypotension and hypoxemia.
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Affiliation(s)
- Linda C Cummings
- Division of Gastroenterology and Liver Disease, Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA; Department of Medicine, Case Western Reserve University School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Chen Liang
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA; Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - Edward J Mascha
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA; Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - Leif Saager
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany; Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Zachary L Smith
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Sekar Bhavani
- Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - John J Vargo
- Department of Medicine, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio, USA; Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Kenneth C Cummings
- Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA; Department of Anesthesiology, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
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8
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Janik LS, Stamper S, Vender JS, Troianos CA. Pro-Con Debate: Monitored Anesthesia Care Versus General Endotracheal Anesthesia for Endoscopic Retrograde Cholangiopancreatography. Anesth Analg 2022; 134:1192-1200. [PMID: 35595693 DOI: 10.1213/ane.0000000000005851] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Over the past several decades, anesthesia has experienced a significant growth in nonoperating room anesthesia. Gastrointestinal suites represent the largest volume location for off-site anesthesia procedures, which include complex endoscopy procedures like endoscopic retrograde cholangiopancreatography (ERCP). These challenging patients and procedures necessitate a shared airway and are typically performed in the prone or semiprone position on a dedicated procedural table. In this Pro-Con commentary article, the Pro side supports the use of monitored anesthesia care (MAC), citing fewer hemodynamic perturbations, decreased side effects from inhalational agents, faster cognitive recovery, and quicker procedural times leading to improved center efficiency (ie, quicker time to discharge). Meanwhile, the Con side favors general endotracheal anesthesia (GEA) to reduce the infrequent, but well-recognized, critical events due to impaired oxygenation and/or ventilation known to occur during MAC in this setting. They also argue that procedural interruptions are more frequent during MAC as anesthesia professionals need to rescue patients from apnea with various airway maneuvers. Thus, the risk of hypoxemic episodes is minimized using GEA for ERCP. Unfortunately, neither position is supported by large randomized controlled trials. The consensus opinion of the authors is that anesthesia for ERCP should be provided by a qualified anesthesia professional who weighs the risks and benefits of each technique for a given patient and clinical circumstance. This Pro-Con article highlights the many challenges anesthesia professionals face during ERCPs and encourages thoughtful, individualized anesthetic plans over knee-jerk decisions. Both sides agree that an anesthetic technique administered by a qualified anesthesia professional is favored over an endoscopist-directed sedation approach.
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Affiliation(s)
- Luke S Janik
- From the Department of Anesthesiology, Critical Care and Pain Medicine, NorthShore University HealthSystem, Evanston, Illinois.,Department of Anesthesia & Critical Care, The University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Samantha Stamper
- Anesthesiology Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio
| | - Jeffery S Vender
- From the Department of Anesthesiology, Critical Care and Pain Medicine, NorthShore University HealthSystem, Evanston, Illinois.,Department of Anesthesia & Critical Care, The University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Christopher A Troianos
- Anesthesiology Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio
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9
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Dhaliwal A, Dhindsa BS, Saghir SM, Ramai D, Chandan S, Mashiana H, Bhogal N, Sayles H, Bhat I, Singh S, Dam A, Taunk P, Esquivel RG, Klapman J, McDonough S, Adler DG. Choice of sedation in endoscopic retrograde cholangiopancreatography: is monitored anesthesia care as safe as general anesthesia? A systematic review and meta-analysis. Ann Gastroenterol 2021; 34:879-887. [PMID: 34815655 PMCID: PMC8596211 DOI: 10.20524/aog.2021.0650] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 04/20/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Monitored anesthesia care (MAC) and general anesthesia (GA) are the 2 most common methods of sedation used for endoscopic retrograde cholangiopancreatography (ERCP). We performed a systematic review and meta-analysis to compare the overall safety between MAC vs. GA in ERCP. METHODS We conducted a comprehensive search of electronic databases to identify studies reporting the use of MAC or GA as a choice of sedation for ERCP. The primary outcome was to compare the overall rate of sedation-related adverse events in MAC vs. GA groups. The secondary endpoint was to investigate the total duration of the procedure, recovery time, ERCP cannulation rates, and conversion rate of MAC to GA. The meta-analysis was performed using a Der Simonian and Laird random-effects model. RESULTS A total of 21 studies reporting on 11,592 patients were included. The overall sedation-related side-effects were similar in the GA (12.76%, 95% confidence interval [CI] 5.80-21.73; I2=95%) and MAC (12.08%, 95%CI 5.38-20.89; I2=99%) groups (P=0.956). Hypoxia, arrhythmias, hypotension, aspiration and other sedation-related side-effects were similar between the 2 groups. The mean duration of the procedure was longer in the MAC group, but the mean recovery time was shorter. Significant heterogeneity was noted in our meta-analysis. CONCLUSIONS In our meta-analysis, the overall sedation-related side-effects were similar between the MAC and GA groups. MAC could be used as a safer alternative to GA when performing ERCP. However, large multicenter randomized control trials are needed to further validate our findings.
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Affiliation(s)
- Amaninder Dhaliwal
- Division of Gastroenterology and Hepatology, Moffitt Cancer Center, Tampa, FL (Amaninder Dhaliwal, Aamir Dam, Jason Klapman)
| | - Banreet Singh Dhindsa
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, NE (Banreet Singh Dhindsa)
| | - Syed Mohsin Saghir
- Department of Internal Medicine, University of Nevada Las Vegas School of Medicine, Las Vegas (Syed Mohsin Saghir)
| | - Daryl Ramai
- Department of Internal Medicine, The Brooklyn Hospital Center, Brooklyn, New York (Daryl Ramai)
| | - Saurabh Chandan
- Division of Gastroenterology and Hepatology, Creighton University School of Medicine, Omaha, NE (Saurabh Chandan)
| | - Harmeet Mashiana
- Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, NE (Harmeet Mashiana, Ishfaq Bhat, Shailender Singh)
| | - Neil Bhogal
- Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, NE (Neil Bhogal)
| | - Harlan Sayles
- Department of Biostatistics, University of Nebraska Medical Center, Omaha, NE (Harlan Sayles)
| | - Ishfaq Bhat
- Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, NE (Harmeet Mashiana, Ishfaq Bhat, Shailender Singh)
| | - Shailender Singh
- Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, NE (Harmeet Mashiana, Ishfaq Bhat, Shailender Singh)
| | - Aamir Dam
- Division of Gastroenterology and Hepatology, Moffitt Cancer Center, Tampa, FL (Amaninder Dhaliwal, Aamir Dam, Jason Klapman)
| | - Pushpak Taunk
- Division of Digestive Diseases and Nutrition, University of South Florida Morsani College of Medicine, Tampa, FL (Pushpak Taunk, Rene Gomez Esquivel)
| | - Rene Gomez Esquivel
- Division of Digestive Diseases and Nutrition, University of South Florida Morsani College of Medicine, Tampa, FL (Pushpak Taunk, Rene Gomez Esquivel)
| | - Jason Klapman
- Division of Gastroenterology and Hepatology, Moffitt Cancer Center, Tampa, FL (Amaninder Dhaliwal, Aamir Dam, Jason Klapman)
| | - Stephanie McDonough
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, UT (Stephanie McDonough, Douglas G. Adler), USA
| | - Douglas G. Adler
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, UT (Stephanie McDonough, Douglas G. Adler), USA
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10
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Thiruvenkatarajan V, Dharmalingam A, Arenas G, Wahba M, Liu WM, Zaw Y, Steiner R, Tran A, Currie J. Effect of high-flow vs. low-flow nasal plus mouthguard oxygen therapy on hypoxaemia during sedation: a multicentre randomised controlled trial. Anaesthesia 2021; 77:46-53. [PMID: 34182603 DOI: 10.1111/anae.15527] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2021] [Indexed: 11/29/2022]
Abstract
Whether high-flow vs. low-flow nasal oxygen reduces hypoxaemia for sedation during endoscopic retrograde cholangiopancreatography is currently unknown. In this multicentre trial, 132 patients ASA physical status 3 or higher, BMI > 30 kg.m-2 or with known or suspected obstructive sleep apnoea were randomly allocated to high-flow nasal oxygen up to 60 l.min-1 at 100% FI O2 or low-flow nasal oxygen at 4 l.min-1 . The low-flow nasal oxygen group also received oxygen at 4 l.min-1 through an oxygenating mouthguard, totalling 8 l.min-1 . Primary outcome was hypoxaemia, defined as Sp O2 < 90% regardless of duration. Hypoxaemia occurred in 7.7% (5/65) of patients with high-flow and 9.1% (6/66) with low-flow nasal oxygen (percentage point difference -1.4%, 95%CI -10.9 to 8.0; p = 0.77). Between the groups, there were no significant differences in frequency of hypoxaemic episodes; lowest Sp O2 ; peak transcutaneous carbon dioxide; hypercarbia (transcutaneous carbon dioxide > 2.66 kPa from baseline); requirement of chin lift/jaw thrust; nasopharyngeal airway insertion; bag-mask ventilation; or tracheal intubation. Following adjustment for duration of the procedure, the primary outcome remained non-significant. In high-risk patients undergoing endoscopic retrograde cholangiopancreatography, oxygen therapy with high-flow nasal oxygen did not reduce the rate of hypoxaemia, hypercarbia or the need for airway interventions, compared with combined oral and nasal low-flow oxygen.
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Affiliation(s)
- V Thiruvenkatarajan
- Department of Anaesthesia, Queen Elizabeth Hospital, Woodville, SA, Australia.,Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia
| | - A Dharmalingam
- Department of Anaesthesia, John Hunter Hospital, New Lambton Heights, NSW, Australia.,School of Medicine and Public Health, University of Newcastle, Callagen, NSW, Australia
| | - G Arenas
- Department of Anaesthesia, Royal Adelaide Hospital, Adelaide, SA, Australia.,Discipline of Acute Care Medicine, University of Adelaide, Adelaide,, SA, Australia
| | - M Wahba
- Department of Anaesthesia, Queen Elizabeth Hospital, Woodville, SA, Australia
| | - W-M Liu
- Research School of Finance, Actuarial Studies and Statistics, Australian National University, Canberra, ACT, Australia
| | - Y Zaw
- Queen Elizabeth Hospital, Woodville, SA, Australia
| | - R Steiner
- Department of Anaesthesia, Queen Elizabeth Hospital, Woodville, SA, Australia
| | - A Tran
- Royal Adelaide Hospital, Adelaide, SA, Australia
| | - J Currie
- Queen Elizabeth Hospital, Woodville, SA, Australia
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11
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Prospective Comparison of Moderate Conscious Sedation and Anesthesia Assistance for the Performance of Endoscopic Retrograde Cholangiopancreatography (ERCP). Can J Gastroenterol Hepatol 2021; 2021:8892085. [PMID: 33954156 PMCID: PMC8060076 DOI: 10.1155/2021/8892085] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 03/21/2021] [Accepted: 03/27/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES Recent trends have favored the use of anesthesia personnel more frequently for advanced endoscopic procedures. We hypothesize a selective sedation approach based on patient and procedural factors using either moderate conscious sedation (MCS) or general anesthesia (GA) will result in similar outcomes and safety with significant cost savings. METHODS A 12-month prospective study of all adult endoscopic retrograde cholangiopancreatography (ERCPs) performed at a tertiary medical center was enrolled. Technical success, cannulation rates, procedural related complications, procedure time, and cost were compared between MCS and GA. RESULTS A total of 876 ERCPs were included in the study with 74% performed with MCS versus 26% with GA. The intended intervention was completed successfully in 95% of cases with MCS versus 96% cases with GA (p = 0.59). Cannulation success rates with MCS were 97.5 versus 97.8% with GA (p = 0.81). Overall, adverse event rates were similar in both groups (MCS: 6.6% vs. GA: 9.2%, p = 0.21). Mean procedure time was less for MCS versus GA, 18.3 and 26 minutes, respectively (p < 0.0001). Selective use of MCS vs. universal sedation with GA resulted in estimated savings of $8,190 per case and $4,735,202 per annum. CONCLUSIONS Preselection of ERCP sedation of moderate conscious sedation versus general anesthesia based upon patient risk factors and planned therapeutic intervention allows for the majority of ERCPs to be completed with MCS with similar rates of technical success and improvement in resource utilization and cost savings compared to performing ERCPs universally with anesthesia assistance.
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12
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Gastroscope-Facilitated Endotracheal Intubation During ERCP: When Is the Best Time to GETA (Big) MAC? Dig Dis Sci 2021; 66:938-940. [PMID: 32643057 DOI: 10.1007/s10620-020-06431-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
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13
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Barakat MT, Angelotti TP, Banerjee S. Use of an Ultra-slim Gastroscope to Accomplish Endoscopist-Facilitated Rescue Intubation During ERCP: A Novel Approach to Enhance Patient and Staff Safety. Dig Dis Sci 2021; 66:1285-1290. [PMID: 32504349 DOI: 10.1007/s10620-020-06360-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 05/21/2020] [Indexed: 12/09/2022]
Abstract
BACKGROUND ERCP is often performed under monitored anesthesia care (MAC) rather than general anesthesia (GA), with patients positioned semi-prone on the fluoroscopy table. Rarely, a MAC ERCP must be converted to GA due to hypoxia or retained food in the stomach. In these circumstances, standard intubation is associated with a significant delay and potential for patient/staff injury during repositioning. We report a novel endoscopist-driven approach to intubation during ERCP using an ultra-slim, flexible gastroscope with an endotracheal tube backloaded onto it. MATERIALS AND METHODS We identified patients who underwent ERCP from 2014 to 2019, and MAC to GA conversion events. Mode of intubation (standard vs. endoscopist-facilitated) and patient/procedure characteristics were evaluated. All endoscopist-facilitated intubations were performed under anesthesiologist supervision. RESULTS A total of 3409 patients underwent ERCP; 1568 (46%) GA and 1841 (54%) MAC. Of these, 42 (2.3%) required intubation during ERCP and 16 underwent endoscopist-facilitated intubation due to retained food in the stomach and/or hypoxia. In 3 patients, aspirated material was suctioned from the trachea and bronchi using the ultra-slim gastroscope. Immediate post-procedure extubation was successful in all endoscopist-facilitated intubation patients and none exhibited radiographic evidence of aspiration pneumonia. CONCLUSIONS Endoscopist-facilitated intubation using an ultra-slim flexible gastroscope is feasible and expeditious for MAC to GA conversion during ERCP. This technique is readily accomplished in the semi-prone position, while standard intubation requires patient transfer from fluoroscopy table to gurney, with associated delay/risks. These data suggest that further study of this approach is warranted, and this may be the most favorable approach for intubation during ERCP.
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Affiliation(s)
- Monique T Barakat
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 300 Pasteur Drive, MC 5244, Stanford, CA, 94305, USA.,Division of Pediatric Gastroenterology, Lucille Packard Children's Hospital at Stanford University Medical Center, Stanford, CA, 94305, USA
| | - Timothy P Angelotti
- Department of Anesthesia Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Subhas Banerjee
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 300 Pasteur Drive, MC 5244, Stanford, CA, 94305, USA.
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14
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Goudra B, Gouda G, Singh PM. Recent Developments in Devices Used for Gastrointestinal Endoscopy Sedation. Clin Endosc 2021; 54:182-192. [PMID: 33730777 PMCID: PMC8039741 DOI: 10.5946/ce.2020.057] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 03/25/2020] [Indexed: 12/14/2022] Open
Abstract
Hypoxemia is a frequent and potentially fatal complication occurring in patients during gastrointestinal endoscopy. The administration of propofol sedation increases the risk of most complications, especially hypoxemia. Nevertheless, propofol has been increasingly used in the United States, and the trend is likely to increase in the years to come. Patient satisfaction and endoscopist satisfaction along with rapid turnover are some of the touted reasons for this trend. However, propofol sedation generally implies deep sedation or general anesthesia. As a result, hypopnea and apnea frequently occur. Inadequate sedation and presence of irritable airway often cause coughing and laryngospasm, both leading to hypoxemia and potential cardiac arrest. Hence, prevention of hypoxemia is of paramount importance. Traditionally, standard nasal cannula is used to administer supplement oxygen. However, it cannot sufficiently provide continuous positive airway pressure (CPAP) or positive pressure ventilation. Device manufacturers have stepped in to fill this void and created many types of cannulas that provide apneic insufflation of oxygen and CPAP and eliminate dead space. Such measures decrease the incidence of hypoxemia. This review aimed to provide essential information of some of these devices.
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Affiliation(s)
- Basavana Goudra
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Gowri Gouda
- Burrell College of Osteopathic Medicine, Las Cruces, NM, USA
| | - Preet Mohinder Singh
- Department of Anesthesiology, Washington University in Saint Louis, St Louis, MO, USA
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15
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Peck J, Nguyen ATH, Dey A, Amankwah EK, Rehman M, Wilsey M. Airway Management for Initial PEG Insertion in the Pediatric Endoscopy Unit: A Retrospective Evaluation of 168 Patients. Pediatr Gastroenterol Hepatol Nutr 2021; 24:100-108. [PMID: 33505899 PMCID: PMC7813569 DOI: 10.5223/pghn.2021.24.1.100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 09/01/2020] [Accepted: 09/26/2020] [Indexed: 11/24/2022] Open
Abstract
PURPOSE Percutaneous endoscopic gastrostomy (PEG) tube placements are commonly performed pediatric endoscopic procedures. Because of underlying disease, these patients are at increased risk for airway-related complications. This study compares patient characteristics and complications following initial PEG insertion with general endotracheal anesthesia (GETA) vs. anesthesia-directed deep sedation with a natural airway (ADDS). METHODS All patients 6 months to 18 years undergoing initial PEG insertion within the endoscopy suite were considered for inclusion in this retrospective cohort study. Selection of GETA vs. ADDS was made by the anesthesia attending after discussion with the gastroenterologist. RESULTS This study included 168 patients (GETA n=38, ADDS n=130). Cohorts had similar characteristics with respect to sex, race, and weight. Compared to ADDS, GETA patients were younger (1.5 years vs. 2.9 years, p=0.04), had higher rates of severe American Society of Anesthesiologists (ASA) disease severity scores (ASA 4-5) (21% vs. 3%, p<0.001), and higher rates of cardiac comorbidities (39.5% vs. 18.5%, p=0.02). Significant associations were not observed between GETA/ADDS status and airway support, 30-day readmission, fever, or pain medication in unadjusted or adjusted models. GETA patients had significantly increased length of stay (eβ=1.55, 95% confidence interval [CI]=1.11-2.18) after adjusting for ASA class, room time, anesthesia time, fever, and cardiac diagnosis. GETA patients also had increased room time (eβ=1.20, 95% CI=1.08-1.33) and anesthesia time (eβ=1.50, 95% CI=1.30-1.74) in adjusted models. CONCLUSION Study results indicate that younger and higher risk patients are more likely to undergo GETA. Children selected for GETA experienced longer room times, anesthesia times, and hospital length of stay.
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Affiliation(s)
- Jacquelin Peck
- Department of Anesthesiology, Mount Sinai Medical Center, Miami Beach, FL, USA
| | - Anh Thy H Nguyen
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Aditi Dey
- Office of Medical Education, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Ernest K Amankwah
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Mohamed Rehman
- Pediatric Anesthesiology, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Michael Wilsey
- Pediatric Gastroenterology, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
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16
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Lin YJ, Wang YC, Huang HH, Huang CH, Liao MX, Lin PL. Target-controlled propofol infusion with or without bispectral index monitoring of sedation during advanced gastrointestinal endoscopy. J Gastroenterol Hepatol 2020; 35:1189-1195. [PMID: 31802534 DOI: 10.1111/jgh.14943] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 11/11/2019] [Accepted: 11/19/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND AIM Target-controlled infusion (TCI) uses averaged pharmacokinetic datasets derived from population samples to automatically control the infusion rate. Bispectral index (BIS) technology non-invasively measures levels of consciousness during surgical procedures. We compared the efficacy and safety of propofol TCI with or without BIS monitoring for sedation during advanced gastrointestinal endoscopy. METHODS This prospective study enrolled 200 patients who were premedicated with midazolam 2 mg and alfentanil 0.4 mg before undergoing advanced gastrointestinal endoscopy. The initial target blood concentration of propofol was set at 1.0 μg/mL, and adjustments of 0.2 μg/mL were made as necessary to maintain moderate-to-deep sedation. Patients were randomized to either the BIS-blind group and evaluated for depth of anesthesia by monitoring scores of 1-2 on the Modified Observer's Assessment of Alertness/Sedation scale (n = 100) or to the BIS-open group and monitored by BIS scores of 60-80 (n = 100). The primary outcome was the total amount of propofol required to maintain anesthesia. Secondary outcomes were sedation-induced adverse events, recovery, and quality of sedation (endoscopist and patient satisfaction). RESULTS The mean propofol infusion rate was significantly higher in patients not monitored by BIS scores than in those who were (5.44 ± 2.12 vs 4.76 ± 1.84 mg/kg/h; P = 0.016). Levels of satisfaction were higher for endoscopists who used BIS monitoring than in those who did not. CONCLUSIONS Mean infusion rates were higher in propofol TCI without BIS monitoring compared with propofol TCI with BIS during advanced gastrointestinal endoscopy. Endoscopists expressed satisfaction with BIS monitoring.
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Affiliation(s)
- Yueh-Juh Lin
- Department of Cardiology, En Chu Kong Hospital, New Taipei City, Taiwan
| | - Yi-Chia Wang
- Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Hui-Hsun Huang
- Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chi-Hsiang Huang
- Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Min-Xiu Liao
- Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Pei-Lin Lin
- Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
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17
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Hung K, Kuo C, Tsai C, Chiu Y, Lu L, Wu C, Sou F, Huang P, Tai W, Kuo C, Liang C, Chuah S. Single‐stage retrograde endoscopic common bile duct stone removal might be sufficient in moderate acute cholangitis with a stone size ≤12 mm: A retrospective cohort study with propensity score matching. ADVANCES IN DIGESTIVE MEDICINE 2020. [DOI: 10.1002/aid2.13173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Affiliation(s)
- Kuo‐Tung Hung
- Division of Hepatogastroenterology, Department of Internal Medicine Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine Kaohsiung Taiwan
| | - Chung‐Mou Kuo
- Division of Hepatogastroenterology, Department of Internal Medicine Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine Kaohsiung Taiwan
| | - Cheng‐En Tsai
- Division of Hepatogastroenterology, Department of Internal Medicine Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine Kaohsiung Taiwan
| | - Yi‐Chun Chiu
- Division of Hepatogastroenterology, Department of Internal Medicine Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine Kaohsiung Taiwan
| | - Lung‐Sheng Lu
- Division of Hepatogastroenterology, Department of Internal Medicine Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine Kaohsiung Taiwan
| | - Cheng‐Kun Wu
- Division of Hepatogastroenterology, Department of Internal Medicine Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine Kaohsiung Taiwan
| | - Fai‐Meng Sou
- Division of Hepatogastroenterology, Department of Internal Medicine Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine Kaohsiung Taiwan
| | - Pao‐Yuan Huang
- Division of Hepatogastroenterology, Department of Internal Medicine Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine Kaohsiung Taiwan
| | - Wei‐Chen Tai
- Division of Hepatogastroenterology, Department of Internal Medicine Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine Kaohsiung Taiwan
| | - Chung‐Huang Kuo
- Division of Hepatogastroenterology, Department of Internal Medicine Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine Kaohsiung Taiwan
| | - Chih‐Ming Liang
- Division of Hepatogastroenterology, Department of Internal Medicine Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine Kaohsiung Taiwan
| | - Seng‐Kee Chuah
- Division of Hepatogastroenterology, Department of Internal Medicine Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine Kaohsiung Taiwan
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18
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Armas A, Primm AN. Anesthetic Management of a Patient With an Anterior Mediastinal Mass Undergoing Endoscopic Retrograde Cholangiopancreatography in the Prone Position: A Case Report. A A Pract 2020; 14:25-27. [PMID: 31770129 PMCID: PMC6948792 DOI: 10.1213/xaa.0000000000001142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Patients with anterior mediastinal masses pose a significant challenge to anesthesiologists. Catastrophic outcomes have been described in patients with mediastinal masses undergoing anesthesia. However, despite an abundance of literature discussing anesthetic management of these patients, there is a lack of reports detailing the management of this population undergoing advanced endoscopic procedures under sedation. We report on a 28-year-old man with a large anterior mediastinal mass who underwent endoscopic retrograde cholangiopancreatography in the prone position under moderate to deep sedation without complication.
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Affiliation(s)
- Alfredo Armas
- From the Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Langone Medical Center, New York, New York
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19
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Anesthesia-administered sedation for endoscopic retrograde cholangiopancreatography: monitored anesthesia care or general endotracheal anesthesia? Curr Opin Anaesthesiol 2019; 32:531-537. [PMID: 30994476 DOI: 10.1097/aco.0000000000000741] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW The decision to undertake monitored anesthesia care (MAC) or general endotracheal anesthesia (GEA) for patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) is influenced by many factors. These include locoregional practice preferences, procedure complexity, patient position, and comorbidities. We aim to review the data regarding anesthesia-administered sedation for ERCP and identify the impact of airway management on procedure success, adverse event rates and endoscopy unit efficiency. RECENT FINDINGS Several studies have consistently identified patients at high risk for sedation-related adverse events during ERCP. This group includes those with higher American Society of Anesthesiologists class and (BMI). ERCP is commonly performed in the prone position, which can make the placement of an emergent advanced airway challenging. Although this may be alleviated by performing ERCP in the supine position, this technique is more technically cumbersome for the endoscopist. Data regarding the impact of routine GEA on endoscopy unit efficiency remain controversial. SUMMARY Pursuing MAC or GEA for patients undergoing ERCP is best-approached on an individual basis. Patients at high risk for sedation-related adverse events likely benefit from GEA. Larger, multicenter randomized controlled trials will aid significantly in better delineating which sedation approach is best for an individual patient.
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20
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Nielsen LBJ, Shabanzadeh DM, Aaresøn A, Sørensen LT. The clinical course of common bile duct stone clearance with endoscopic retrograde cholangio-pancreaticography. Scand J Gastroenterol 2019; 54:1166-1171. [PMID: 31526285 DOI: 10.1080/00365521.2019.1663259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Objectives: Two-stage treatment of common bile duct stones by Endoscopic Retrograde Cholangio-Pancreatography and subsequent laparoscopic cholecystectomy is well established. In many cases multiple procedures are needed before clearance of the common bile duct is obtained. This study aimed to describe the clinical course from common bile duct stone diagnosis to successful clearance. Materials and Methods: A prospective observational study from 2011 to 2014 of consecutive patients diagnosed with common bile duct stones undergoing Endoscopic Retrograde Cholangio-Pancreatography at a public university hospital. Results: In this study 297 patients with common bile duct stones were identified. More than one Endoscopic Retrograde Cholangio-Pancreatography was performed in 174 (59%) patients and more than two in 51(17%) before clearance. A sphincterotomy was performed in 269 (91%) patients and 189 (64%) had a stent inserted. Bleeding occurred in 17 (6%) requiring injection treatment and post procedure complications occurred in 38 (13%). Subsequent laparoscopic cholecystectomy was performed in 180 (61%) patients. Overall, the patients were hospitalized for 11 (8.5) days and the length of treatment from diagnose to stone clearance was 49 (84.5) days. Overweight, pancreatitis at admission, universal anesthesia, and expert level endoscopist inversely determined common bile duct clearance failure. Conclusions: Common bile duct clearance by Endoscopic Retrograde Cholangio-Pancreatography requires multiple procedures and complications are frequent leading to prolonged treatment and hospitalization suggesting a limited efficacy.
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Affiliation(s)
- Liv Bjerre Juul Nielsen
- Department of Digestive Disease Center - K, Bispebjerg Hospital, University of Copenhagen , Copenhagen , Denmark
| | - Daniel Mønsted Shabanzadeh
- Department of Digestive Disease Center - K, Bispebjerg Hospital, University of Copenhagen , Copenhagen , Denmark
| | - Anna Aaresøn
- Department of Digestive Disease Center - K, Bispebjerg Hospital, University of Copenhagen , Copenhagen , Denmark
| | - Lars Tue Sørensen
- Department of Digestive Disease Center - K, Bispebjerg Hospital, University of Copenhagen , Copenhagen , Denmark
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Smith ZL, Mullady DK, Lang GD, Das KK, Hovis RM, Patel RS, Hollander TG, Elsner J, Ifune C, Kushnir VM. A randomized controlled trial evaluating general endotracheal anesthesia versus monitored anesthesia care and the incidence of sedation-related adverse events during ERCP in high-risk patients. Gastrointest Endosc 2019; 89:855-862. [PMID: 30217726 DOI: 10.1016/j.gie.2018.09.001] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Accepted: 09/03/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS ERCP is a complex procedure often performed in patients at high risk for sedation-related adverse events (SRAEs). However, there is no current standard of care with regard to mode of sedation and airway management during ERCP. The aim of this study was to assess the safety of general endotracheal anesthesia (GEA) versus propofol-based monitored anesthesia care (MAC) without endotracheal intubation in patients undergoing ERCP at high risk for SRAEs. METHODS Consecutive patients undergoing ERCP at high risk for SRAEs at a single center were invited to participate in this randomized controlled trial comparing GEA and MAC. Inclusion criteria were STOP-BANG score ≥3, abdominal ascites, body mass index ≥35, chronic lung disease, American Society of Anesthesiologists class >3, Mallampati class 4 airway, and moderate to heavy alcohol use. Exclusion criteria were preceding EUS, emergent ERCP, tracheostomy, unstable airway, gastric outlet obstruction or delayed gastric emptying, and altered foregut anatomy. The primary endpoint was composite incidence of SRAEs: hypoxemia, use of airway maneuvers, hypotension requiring vasopressors, sedation-related procedure interruption, cardiac arrhythmia, and respiratory failure. Secondary outcomes included procedure duration, cannulation success, in-room time, and immediate adverse events. RESULTS Two hundred patients (mean age, 61.1 ± 13.6 years; 36.5% women) were randomly assigned to GEA (n = 101) or MAC (n = 99) groups. Composite SRAEs were significantly higher in the MAC group compared with the GEA group (51.5% vs 9.9%, P < .001). This was primarily driven by the frequent need for airway maneuvers in the MAC group. Additionally, ERCP was interrupted in 10.1% of patients in the MAC group to convert to GEA because of respiratory instability refractory to airway maneuvers (n = 8) or significant retained gastric contents (n = 2). There were no statistically significant differences in cannulation, in-room, procedure, or fluoroscopy times between the 2 groups. All patients undergoing GEA were successfully extubated in the procedure room at completion of ERCP, and Aldrete scores in recovery did not differ between the 2 groups. There were no immediate adverse events. CONCLUSION In patients at high risk for SRAEs undergoing ERCP, sedation with GEA is associated with a significantly lower incidence of SRAEs, without impacting procedure duration, success, recovery, or in-room time. These data suggest that GEA should be used for ERCP in patients at high risk for SRAEs (Clinical trial registration number: NCT02850887.).
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Affiliation(s)
- Zachary L Smith
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Daniel K Mullady
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Gabriel D Lang
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Koushik K Das
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Robert M Hovis
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Riddhi S Patel
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Thomas G Hollander
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Jeffery Elsner
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Catherine Ifune
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Vladimir M Kushnir
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
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Stone AB, Brovman EY, Greenberg P, Urman RD. A medicolegal analysis of malpractice claims involving anesthesiologists in the gastrointestinal endoscopy suite (2007–2016). J Clin Anesth 2018; 48:15-20. [DOI: 10.1016/j.jclinane.2018.04.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 04/13/2018] [Accepted: 04/15/2018] [Indexed: 11/26/2022]
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Pérez Roldán F. Is the education available to anesthetists adequate to provide sedation in endoscopy units? REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2018; 110:260-261. [PMID: 29620409 DOI: 10.17235/reed.2018.5515/2018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
It is a letter that aims to emphasize the type of sedation that is sometimes used by anesthetists to perform a standard endoscopy and the excessive use of the operating room, which increases the cost of endoscopy and reduces the resources of surgical time.
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Pérez-Cuadrado Robles E, González Ramírez A, Lancho Seco Á, Martí Marqués E, Dacal Rivas A, Castro Ortiz E, González Soler R, Álvarez Suárez B, Tardáguila García D, López Baz A, Fernández López A, López Roses L. Safety and risk factors for difficult endoscopist-directed ERCP sedation in daily practice: a hospital-based case-control study. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2016; 108:240-245. [PMID: 26912376 DOI: 10.17235/reed.2016.4206/2016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2025]
Abstract
BACKGROUND There are limited data concerning endoscopist-directed endoscopic retrograde cholangiopancreatography deep sedation. The aim of this study was to establish the safety and risk factors for difficult sedation in daily practice. PATIENTS AND METHODS Hospital-based, frequency matched case-control study. All patients were identified from a database of 1,008 patients between 2014 and 2015. The cases were those with difficult sedations. This concept was defined based on the combination of the receipt of high-doses of midazolam or propofol, poor tolerance, use of reversal agents or sedation-related adverse events. The presence of different factors was evaluated to determine whether they predicted difficult sedation. RESULTS One-hundred and eighty-nine patients (63 cases, 126 controls) were included. Cases were classified in terms of high-dose requirements (n = 35, 55.56%), sedation-related adverse events (n = 14, 22.22%), the use of reversal agents (n = 13, 20.63%) and agitation/discomfort (n = 8, 12.7%). Concerning adverse events, the total rate was 1.39%, including clinically relevant hypoxemia (n = 11), severe hypotension (n = 2) and paradoxical reactions to midazolam (n = 1). The rate of hypoxemia was higher in patients under propofol combined with midazolam than in patients with propofol alone (2.56% vs. 0.8%, p < 0.001). Alcohol consumption (OR: 2.674 [CI 95%: 1.098-6.515], p = 0.030), opioid consumption (OR: 2.713 [CI 95%: 1.096-6.716], p = 0.031) and the consumption of other psychoactive drugs (OR: 2.015 [CI 95%: 1.017-3.991], p = 0.045) were confirmed to be independent risk factors for difficult sedation. CONCLUSIONS Endoscopist-directed deep sedation during endoscopic retrograde cholangiopancreatography is safe. The presence of certain factors should be assessed before the procedure to identify patients who are high-risk for difficult sedation.
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Goudra B, Nuzat A, Singh PM, Borle A, Carlin A, Gouda G. Association between Type of Sedation and the Adverse Events Associated with Gastrointestinal Endoscopy: An Analysis of 5 Years' Data from a Tertiary Center in the USA. Clin Endosc 2016; 50:161-169. [PMID: 27126387 PMCID: PMC5398365 DOI: 10.5946/ce.2016.019] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 03/14/2016] [Accepted: 03/14/2016] [Indexed: 02/06/2023] Open
Abstract
Background/Aims The landscape of sedation for gastrointestinal (GI) endoscopic procedures and the nature of the procedures themselves have changed over the last decade. In this study, an attempt is made to analyze the frequency and etiology of all major adverse events associated with GI endoscopy.
Methods All adverse events extracted from the electronic database and local registry were analyzed. Although the data analysis was retrospective, the adverse events themselves were documented prospectively. These events were evaluated after subdivision into propofol-based anesthesia and intravenous conscious sedation groups.
Results Cardiorespiratory events, including cardiac arrest, were the most common adverse events during esophagogastroduodenoscopy, while bleeding was more frequent in patients undergoing colonoscopy. Pancreatitis was the most frequent adverse event in patients undergoing endoscopic retrograde cholangiopancreatography. The frequencies of most adverse events were significantly higher in patients anesthetized with propofol. Automatic regression modeling showed that the type of sedation, the American Society of Anesthesiologists physical status classification, and the procedure type were some of the predictors of immediate life-threatening complications.
Conclusions Clearly, our regression modeling suggests a strong association between the type of sedation as well as various patient factors and the frequency of adverse events. The possible reasons for our results are the changing demographics, the worsening comorbidities of the patient population, and the increasing technical complexity of these procedures. Although extensive use of propofol has increased patient satisfaction and procedure acceptability, its use is also associated with more frequent adverse events.
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Affiliation(s)
- Basavana Goudra
- Department of Clinical Anesthesiology and Critical Care, Perelman School of Medicine, Philadelphia, PA, USA
| | - Ahmad Nuzat
- Department of Endoscopy, Hospital of the University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, PA, USA
| | - Preet Mohinder Singh
- Department of Anesthesiology and Critical Care Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Anuradha Borle
- Department of Anesthesia, All India Institute of Medical Sciences, New Delhi, India
| | - Augustus Carlin
- Department of Clinical Anesthesiology and Critical Care, Perelman School of Medicine, Philadelphia, PA, USA
| | - Gowri Gouda
- Department of Clinical Anesthesiology and Critical Care, Perelman School of Medicine, Philadelphia, PA, USA
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Goudra B, Singh PM, Borle A, Gouda G. Effect of introduction of a new electronic anesthesia record (Epic) system on the safety and efficiency of patient care in a gastrointestinal endoscopy suite-comparison with historical cohort. Saudi J Anaesth 2016; 10:127-31. [PMID: 27051360 PMCID: PMC4799601 DOI: 10.4103/1658-354x.168798] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Use of electronic medical record systems has increased in the recent years. Epic is one such system gaining popularity in the USA. Epic is a private company, which invented the electronic documentation system adopted in our hospital. In spite of many presumed advantages, its use is not critically analyzed. Some of the perceived advantages are increased efficiency and protection against litigation as a result of accurate documentation. MATERIALS AND METHODS In this study, retrospective data of 305 patients who underwent endoscopic retrograde cholangiopancreatography (wherein electronic charting was used - "Epic group") were compared with 288 patients who underwent the same procedure with documentation saved on a paper chart ("paper group"). Time of various events involved in the procedure such as anesthesia start, endoscope insertion, endoscope removal, and transfer to the postanesthesia care unit were routinely documented. From this data, the various time durations were calculated. RESULTS Both "anesthesia start to scope insertion" times and "scope removal to transfer" times were significantly less in the Epic group compared to the paper group. Use of Epic system led to a saving of 4 min of procedure time per patient. However, the mean oxygen saturation was significantly less in the Epic group. CONCLUSION In spite of perceived advantages of Epic documentation system, significant hurdles remain with its use. Although the system allows seamless flow of patients, failure to remove all artifacts can lead to errors and become a source of potential litigation hazard.
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Affiliation(s)
- B Goudra
- Department of Anesthesiology and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - P M Singh
- Department of Anesthesiology and Critical Care Medicine, All India Institutes of Medical Sciences, New Delhi, India
| | - A Borle
- Department of Anesthesia, All India Institutes of Medical Sciences, New Delhi, India
| | - G Gouda
- Department of Biological Sciences, Drexel University, Philadelphia, PA 19104, USA
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Safety of Non-anesthesia Provider-Administered Propofol (NAAP) Sedation in Advanced Gastrointestinal Endoscopic Procedures: Comparative Meta-Analysis of Pooled Results. Dig Dis Sci 2015; 60:2612-27. [PMID: 25732719 DOI: 10.1007/s10620-015-3608-x] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Accepted: 02/21/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS The aim of the study was to evaluate the safety of non-anesthesia provider (NAAP)-administered propofol sedation for advanced endoscopic procedures with those of anesthesia provider (AAP). METHODS PubMed, EMBASE, Cochrane Central Register of Controlled Trials, Scopus, and Web of Science databases were searched for prospective observational trials involving advanced endoscopic procedures. From a total of 519 publications, 26 were identified to meet inclusion criteria (10 AAPs and 16 NAAPs) and were analyzed. Data were analyzed for hypoxia rate, airway intervention rates, endoscopist, and patient satisfaction scores and total propofol administered. RESULTS Total number of procedures in NAAP and AAP groups was 3018 and 2374, respectively. Pooled hypoxia (oxygen saturation less than 90 %) rates were 0.133 (95 % CI 0.117-0.152) and 0.143 (95 % CI 0.128-0.159) in NAAP and AAP, respectively. Similarly, pooled airway intervention rates were 0.035 (95 % CI 0.026-0.047) and 0.133 (95 % CI 0.118-0.150), respectively. Pooled patient satisfaction rate, pooled endoscopist satisfaction rate, and mean propofol administered dose for NAAP were 7.22 (95 % CI 7.17-7.27), 6.03 (95 % CI 5.94-6.11), and 251.44 mg (95 % CI 244.39-258.49) in that order compared with 9.82 (95 % CI 9.76-9.88), 9.06 (95 % CI 8.91-9.21), and 340.32 mg (95 % CI 327.30-353.33) for AAP. CONCLUSIONS The safety of NAAP sedation compared favorably with AAP sedation in patients undergoing advanced endoscopic procedures. However, it came at the cost of decreased patient and endoscopist satisfaction.
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Lightdale JR. Sedation for Pediatric Gastrointestinal Procedures. PEDIATRIC SEDATION OUTSIDE OF THE OPERATING ROOM 2015:351-366. [DOI: 10.1007/978-1-4939-1390-9_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
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Chawla S, Willingham FF. Cardiopulmonary complications of endoscopic retrograde cholangiopancreatography. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2014; 16:144-149. [DOI: 10.1016/j.tgie.2014.07.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Goudra B, Singh PM. ERCP: the unresolved question of endotracheal intubation. Dig Dis Sci 2014; 59:513-9. [PMID: 24221339 DOI: 10.1007/s10620-013-2931-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2013] [Accepted: 10/18/2013] [Indexed: 12/09/2022]
Abstract
The anesthesia community is still divided as to the appropriate airway management in patients undergoing endoscopic retrograde cholangiopancreatography. Increasingly, gastroenterologists are comfortable with deep sedation (normally propofol) without endotracheal intubation. There are no comprehensive reviews addressing the various pros and cons of an un-intubated airway management. It is hoped that the present review will benefit both anesthesia providers and gastroenterologists. The reasons to avoid routine endotracheal intubation and the approaches for an un-intubated anesthetic management are discussed. The special situations where endotracheal intubation is the preferred approach are mentioned. Many special techniques to manage airway are illustrated.
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Affiliation(s)
- Basavana Goudra
- Clinical Anesthesiology and Critical Care, Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA,
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Thosani N, Banerjee S. Deep sedation or general anesthesia for ERCP? Dig Dis Sci 2013; 58:3061-3063. [PMID: 23990001 DOI: 10.1007/s10620-013-2849-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Accepted: 08/15/2013] [Indexed: 12/18/2022]
Affiliation(s)
- Nirav Thosani
- Division of Gastroenterology, Stanford University School of Medicine, Stanford, CA, USA
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