Benefits and harms of capnography during procedures involving moderate sedation: A rapid review and meta-analysis

British Society of Gastroenterology guidelines on sedation in gastrointestinal endoscopy

Over 2.5 million gastrointestinal endoscopic procedures are carried out in the United Kingdom (UK) every year. Procedures are carried out with local anaesthetic r with sedation. Sedation is commonly used for gastrointestinal endoscopy, but the type and amount of sedation administered is influenced by the complexity and nature of the procedure and patient factors. The elective and emergency nature of endoscopy procedures and local resources also have a significant impact on the delivery of sedation. In the UK, the vast majority of sedated procedures are carried out using benzodiazepines, with or without opiates, whereas deeper sedation using propofol or general anaesthetic requires the involvement of an anaesthetic team. Patients undergoing gastrointestinal endoscopy need to have good understanding of the options for sedation, including the option for no sedation and alternatives, balancing the intended aims of the procedure and reducing the risk of complications. These guidelines were commissioned by the British Society of Gastroenterology (BSG) Endoscopy Committee with input from major stakeholders, to provide a detailed update, incorporating recent advances in sedation for gastrointestinal endoscopy.This guideline covers aspects from pre-assessment of the elective 'well' patient to patients with significant comorbidity requiring emergency procedures. Types of sedation are discussed, procedure and room requirements and the recovery period, providing guidance to enhance safety and minimise complications. These guidelines are intended to inform practising clinicians and all staff involved in the delivery of gastrointestinal endoscopy with an expectation that this guideline will be revised in 5-years' time.

Association between capnography and recovery time after procedural sedation and analgesia in the emergency department

Aim

Capnography is recommended for use in procedural sedation and analgesia (PSA); however, limited studies assess its impact on recovery time. We investigated the association between capnography and the recovery time of PSA in the emergency department (ED).

Methods

This study was a secondary analysis of a multicenter PSA patient registry including eight hospitals in Japan. We included all patients who received PSA in the ED between May 2017 and May 2021 and divided the patients into capnography and no-capnography groups. The primary outcome was recovery time, defined as the time from the end of the procedure to the cessation of monitoring. The log-rank test and multivariable analysis using clustering for institutions were performed.

Results

Of the 1265 screened patients, 943 patients who received PSA were enrolled and categorized into the capnography (n = 150, 16%) and no-capnography (n = 793, 84%) groups. The median recovery time was 40 (interquartile range [IQR]: 25-63) min in the capnography group and 30 (IQR: 14-55) min in the no-capnography group. In the log-rank test, the recovery time was significantly longer in the capnography group (p = 0.03) than in the no-capnography group. In the multivariable analysis, recovery time did not differ between the two groups (adjusted hazard ratio, 0.95; 95% confidence interval, 0.77-1.17; p = 0.61).

Conclusion

In this secondary analysis of the multicenter registry of PSA in Japan, capnography use did not associate with shorter recovery time in the ED.

The Efficacy and Safety of Remimazolam Tosilate Versus Dexmedetomidine in Outpatients Undergoing Flexible Bronchoscopy: A Prospective, Randomized, Blind, Non-Inferiority Trial

Purpose: This study aimed to compare the efficacy and safety of remimazolam tosilate-remifentanil (RT-RF) vs dexmedetomidine-remifentanil (Dex-RF) for outpatients undergoing fiberoptic bronchoscopy (FB).

Patients and methods: We conducted a double-blind, randomized, prospective study involving a total of 146 outpatients undergoing FB divided into two groups. The RT-RF (RR) group (n = 73) received an initial dose of 12 mg/kg/h of RT for 10 min followed by a maintenance dose of 1–2 mg/kg/h, while the Dex-RF (DR) group (n = 73) received an initial dose of 0.5 μg/kg of Dex for 10 min followed by a maintenance dose of 0.2–0.7 μg/kg/h. All outpatients also received 0.05–0.2 μg/kg/min RF to maintain the Modified Observer’s Assessment of Alertness and Sedation (MOAA/S) scale <3. The primary outcome was rate of successful FB completed. Secondary outcomes were time metrics, hemodynamics, intubating conditions, oxygen saturation, coughing severity, number of remedies, total dose of fentanyl, RF, RT, and Dex, incidence of dreaming, patient and bronchoscopist satisfaction, willingness to repeat bronchoscopy, and adverse events.

Results: The FB successful completion rate was 94.52% (95% CI: 89.20–99.90) in the RR group and 91.78% (95% CI: 85.30–98.20) in the DR group. Compared with patients in the DR group, the onset time, time to fully alert, and hospital discharge were all significantly shorter in the RR group (p < 0.01), and hemodynamics were more stable in the RR group. Intubating conditions, clinically acceptable intubating conditions, lowest oxygen saturation, coughing severity, consumption of fentanyl and RF, number of remedies, and patient and bronchoscopist satisfaction were similar between the groups (p > 0.05), as were demographic characteristics, incidence of dreaming, willingness to repeat bronchoscopy, and adverse events (p > 0.05).

Conclusion: RT-RF has non-inferior efficacy, better time metrics and hemodynamic stability for outpatients undergoing FB than Dex-RF.

Systematic Review Registration: [http://www.chictr.org.cn/showproj.aspx?proj=66673], identifier [ChiCTR2000041524].

Procedural sedation in Belgium : guideline for safe patient care

Guideline produced by the Society for Anesthesia and Resuscitation of Belgium Working Group on Procedural Sedation (SARB-WG-PS).

Patient safety in dental care: an integrative review

Adverse events pose a serious problem for quality of healthcare. Dental practice is eminently invasive and involves close and routine contact with secretions; as such, it is potentially prone to the occurrence of adverse events. Various patient safety studies have been developed in the last two decades, but mostly in the hospital setting due to the organizational complexity, severity of the cases, and diversity and specificity of the procedures. The objective was to identify and explore studies on patient safety in Dentistry. An integrative literature review was performed in MEDLINE via PubMed, Scopus via Portal Capes, and the Regional Portal of the Virtual Health Library, using the terms patient safety and dentistry in English, Spanish, and Portuguese, starting in 2000. The research cycle in patient safety was used, as proposed by the World Health Organization to classify studies. We analyzed 91 articles. The most common adverse events were allergies, infections, diagnostic delay or failure, and technical error. Measures to mitigate the problem highlight the need to improve communications, encourage reporting, and search for tools to assist the management of care. The authors found a lack of studies on implementation and assessment of the impact of proposals for improvement. Dentistry has made progress in patient safety but still needs to transpose the results into practice, where efforts are crucial to prevent adverse events.

Nasopharyngeal Tube Effects on Breathing during Sedation for Dental Procedures: A Randomized Controlled Trial

WHAT WE ALREADY KNOW ABOUT THIS TOPIC

Dental procedures under sedation can cause hypoxic events and even death. However, the mechanism of such hypoxic events is not well understood.

WHAT THIS ARTICLE TELLS US THAT IS NEW

Apnea and hypopnea occur frequently during dental procedures under sedation. The majority of the events are not detectable with pulse oximetry. Insertion of a nasal tube with small diameter does not reduce the incidence of apnea/hypopnea.

BACKGROUND

Intravenous sedation is effective in patients undergoing dental procedures, but fatal hypoxemic events have been documented. It was hypothesized that abnormal breathing events occur frequently and are underdetected by pulse oximetry during sedation for dental procedures (primary hypothesis) and that insertion of a small-diameter nasopharyngeal tube reduces the frequency of the abnormal breathing events (secondary hypothesis).

METHODS

In this nonblinded randomized control study, frequency of abnormal breathing episodes per hour (abnormal breathing index) of the patients under sedation for dental procedures was determined and used as a primary outcome to test the hypotheses. Abnormal breathing indexes were measured by a portable sleep monitor. Of the 46 participants, 43 were randomly allocated to the control group (n = 23, no nasopharyngeal tube) and the nasopharyngeal tube group (n = 20).

RESULTS

In the control group, nondesaturated abnormal breathing index was higher than the desaturated abnormal breathing index (35.2 [20.6, 48.0] vs. 7.2 [4.1, 18.5] h, difference: 25.1 [95% CI, 13.8 to 36.4], P < 0.001). The obstructive abnormal breathing index was greater than central abnormal breathing index (P < 0.001), and half of abnormal breathing indexes were followed by irregular breathing. Despite the obstructive nature of abnormal breathing, the nasopharyngeal tube did not significantly reduce the abnormal breathing index (48.0 [33.8, 64.4] h vs. 50.5 [36.4, 63.9] h, difference: -2.0 [95% CI, -15.2 to 11.2], P = 0.846), not supporting the secondary hypothesis.

CONCLUSIONS

Patients under sedation for dental procedure frequently encounter obstructive apnea/hypopnea events. The majority of the obstructive apnea/hypopnea events were not detectable by pulse oximetry. The effectiveness of a small-diameter nasopharyngeal tube to mitigate the events is limited.

Capnography Detection Using Nasal Cannula Is Superior to Modified Nasal Hood in an Open Airway System: A Randomized Controlled Trial

PURPOSE

The nasal cannula and modified nasal hood are methods used by oral and maxillofacial surgeons to detect expired carbon dioxide during procedural sedation in an open airway system. The purpose of this study was to compare the accuracy of the detection of expired carbon dioxide between the nasal cannula and modified nasal hood.

MATERIALS AND METHODS

The authors designed a parallel-group randomized controlled trial to compare the nasal cannula and modified nasal hood. Patients presenting to the authors' institution for outpatient oral and maxillofacial surgery (OMS) using intravenous deep sedation or general anesthesia were randomized to have capnography detection by the modified nasal hood or the nasal cannula. The primary outcome variable was the percentage of accurately captured breaths, as determined by the average number of capnography waveforms per auscultated breath using a precordial stethoscope. The 2 groups were compared using t test.

RESULTS

Fifty patients were screened for enrollment in the study. Twenty-five patients were randomized to the nasal cannula group and 25 patients were randomized to the modified nasal hood group. The proportion of accurate waveforms, recorded as a percentage of total breaths, was 95.7 ± 4.7% for the nasal cannula and 75.8 ± 14.1% for the modified nasal hood (P < .0001).

CONCLUSIONS

When used for capnography for procedural sedation in an open airway system for routine OMS, the nasal cannula accurately recorded more breaths than the modified nasal hood.

The effect of dental scaling noise during intravenous sedation on acoustic respiration rate (RRa™)

BACKGROUND

Respiration monitoring is necessary during sedation for dental treatment. Recently, acoustic respiration rate (RRa™), an acoustics-based respiration monitoring method, has been used in addition to auscultation or capnography. The accuracy of this method may be compromised in an environment with excessive noise. This study evaluated whether noise from the ultrasonic scaler affects the performance of RRa in respiratory rate measurement.

METHODS

We analyzed data from 49 volunteers who underwent scaling under intravenous sedation. Clinical tests were divided into preparation, sedation, and scaling periods; respiratory rate was measured at 2-s intervals for 3 min in each period. Missing values ratios of the RRa during each period were measuerd; correlation analysis and Bland-Altman analysis were performed on respiratory rates measured by RRa and capnogram.

RESULTS

Respective missing values ratio from RRa were 5.62%, 8.03%, and 23.95% in the preparation, sedation, and scaling periods, indicating an increased missing values ratio in the scaling period (P < 0.001). Correlation coefficients of the respiratory rate, measured with two different methods, were 0.692, 0.677, and 0.562 in each respective period. Mean capnography-RRa biases in Bland-Altman analyses were -0.03, -0.27, and -0.61 in each respective period (P < 0.001); limits of agreement were -4.84-4.45, -4.89-4.15, and -6.18-4.95 (P < 0.001).

CONCLUSIONS

The probability of missing respiratory rate values was higher during scaling when RRa was used for measurement. Therefore, the use of RRa alone for respiration monitoring during ultrasonic scaling may not be safe.