Is routine sedation or topical pharyngeal anesthesia beneficial during upper endoscopy?

Relation of viscous lidocaine combined with propofol deep sedation during elective upper gastrointestinal endoscopy to discharge

Fusing topical pharyngeal anesthetics (TPAs) to intravenous sedation during esophagogastroduodenoscopy (EGD) has been controversial. This double-blind, randomized, placebo-controlled trial assessed the association of TPA with patient recovery time, post-EGD to discharge. Supplementary aims were to determine the association of TPA with patient and practitioner satisfaction (both measured on a 100-mm visual analog scale), total propofol dose, and side effects. The study included 93 patients (mean age 53.8 years, range 44-67; 37 men and 56 women) undergoing elective EGD at a single academic medical center from September 2015 to October 2016. Urgent or therapeutic EGDs were excluded. Interventions were 7.5 mL 2% lidocaine viscous solution and 7.5 mL placebo solution (3% methylcellulose). There were no statistically significant differences between the lidocaine (n = 46) and placebo (n = 47) groups with respect to recovery time (42 ± 17.8 vs 39 ± 15.9 minutes; P = 0.23), procedure time (6.5 ± 2.7 vs 7 ± 3.6 minutes; P = 0.77), endoscopist satisfaction (83.2 ± 24.4 vs 77 ± 27.7, P = 0.23), patient discomfort (16.6 ± 19.8 vs 24.0 ± 29.7, P = 0.37), or total propofol administered (2.3 ± 1.3 vs 2.3 ± 1.0 mg/kg, P = 0.55). Compared to placebo, topical viscous lidocaine does not appear to delay recovery time or adversely affect sedation-related outcomes.

Factors associated with oesophagogastric cancers missed by gastroscopy: a case-control study

INTRODUCTION

There is increasing demand for gastroscopy in the United Kingdom. In around 10% of patients, gastroscopy is presumed to have missed oesophagogastric (OG) cancer prior to diagnosis. We examine patient, endoscopist and service level factors that may affect rates of missed OG cancers.

METHODS

Gastroscopies presumed to have missed OG cancers performed up to 3 years prior to diagnosis were identified over 6 years in Sheffield, UK. Factors related to the patient, endoscopist and endoscopy lists were examined in a case-control study. Procedures which missed cancer were compared with two procedure controls: the procedures which subsequently diagnosed cancer in the same patient, and second, endoscopist matched procedures diagnostic of small benign focal lesions.

RESULTS

We identified 48 (7.7%) cases of missed OG cancer. Endoscopy lists on which OG cancer diagnoses were missed contained a greater number of total procedures compared with lists on which diagnoses were subsequently made (OR 1.42 95% CI 1.13 to 1.78) and when compared with lists during which matched endoscopists diagnosed benign small focal lesions (OR 1.25, 95% CI 1.02 to 1.52). The use of sedation, endoscopist profession and experience, or time of procedure were not associated with a missed cancer.

CONCLUSION

7.7% of patients diagnosed with OG cancer could have been diagnosed and treated earlier. Our study suggests that endoscopy lists with greater numbers of procedures may be associated with missed OG cancers. The use of sedation, endoscopist background or time of procedure did not increase the risk of missed cancer procedures.

Topical Anesthesia for Endoscopic Office-based Procedures of the Upper Aerodigestive Tract

OBJECTIVE

Over the last two decades, an increase in office-based procedures under topical anesthesia in laryngology and head and neck oncology has occurred. Adequate anesthesia in the nasal cavity, pharynx, and larynx is essential for successful performance of these procedures. Our goal is to provide an objective summary on the available local anesthetics, methods of application, local secondary effects, efficacy, and complications.

MATERIAL AND METHODS

A descriptive review of literature on topical anesthesia for office-based procedures in laryngology and head and neck oncology was performed.

RESULTS

Lidocaine is the most applied and investigated topical anesthetic. Topical anesthesia results in decreased sensory function without impairing motor function of the pharynx and larynx. For the nasal cavity, cotton pledgets soaked in anesthetic spray and decongestant, or anesthetic gel, are effective. For the pharynx, anesthetic spray is the most frequently used and effective method. For the larynx, applying local anesthesia through a catheter through the working channel of the endoscope or anesthetic injection through the cricothyroid membrane is effective. Studies comparing the most effective application methods for each anatomical site are lacking. Complications of topical lidocaine administration are rare.

CONCLUSIONS

By properly applying topical anesthesia to the upper aerodigestive tract, several surgical procedures in laryngology and head and neck oncology can be performed in the outpatient clinic under topical anesthesia instead of the operating room under general anesthesia. Lidocaine is the most investigated anesthetic, with adequate efficacy and few complications. Studies that determine the most effective application methods are still wanting.

Topical pharyngeal anesthesia provides no additional benefit to propofol sedation for esophagogastroduodenoscopy: a randomized controlled double-blinded clinical trial

Propofol sedation has been applied during esophagogastroduodenoscopy procedures, but whether topical pharyngeal anesthesia should be administered at the same time has rarely been reported. Our study examined the role of topical pharyngeal anesthesia in sedated endoscopies in a randomized controlled double-blinded clinical trial. A total of 626 patients who underwent sedated esophagogastroduodenoscopy were randomized into the experimental group (n = 313) or the control group (n = 313). The discomfort score, immediately and one day after the procedure, was not statistically significant [7.2 (5-9) vs. 7.5 (6-9), P = 0.210; 2.3 (0-3) vs. 2.6 (0-4), P = 0.095, respectively]. Two patients in the experimental group and three patients in the control group needed oral medication for pharyngeal discomfort (P = 0.354). The satisfaction score was 9.2 (8-10) in the experimental group and 8.9 (7-10) in the control group (P = 0.778). Lidocaine topical pharyngeal anesthesia in propofol-sedated esophagogastroduodenoscopy did not further reduce the pharyngeal discomfort or improve the satisfaction. This clinical trial was registered at ClinicalTrials.gov (ClinicalTrials.gov ID: NCT03070379).

Quality standards in upper gastrointestinal endoscopy: a position statement of the British Society of Gastroenterology (BSG) and Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland (AUGIS)

This document represents the first position statement produced by the British Society of Gastroenterology and Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland, setting out the minimum expected standards in diagnostic upper gastrointestinal endoscopy. The need for this statement has arisen from the recognition that while technical competence can be rapidly acquired, in practice the performance of a high-quality examination is variable, with an unacceptably high rate of failure to diagnose cancer at endoscopy. The importance of detecting early neoplasia has taken on greater significance in this era of minimally invasive, organ-preserving endoscopic therapy. In this position statement we describe 38 recommendations to improve diagnostic endoscopy quality. Our goal is to emphasise practices that encourage mucosal inspection and lesion recognition, with the aim of optimising the early diagnosis of upper gastrointestinal disease and improving patient outcomes.

Flavored anesthetic lozenge versus Xylocaine spray used as topical pharyngeal anesthesia for unsedated esophagogastroduodenoscopy: a randomized placebo-controlled trial

BACKGROUND

The use of Xylocaine spray has been the common practice in many endoscopy centers, but scientific evidence is not conclusive on its superiority over other forms of topical anesthesia. This study aimed to compare the effectiveness of Xylocaine spray as a topical pharyngeal anesthesia for upper endoscopy and that of anesthetic lozenges with a characteristic flavor.

METHODS

A randomized placebo-controlled trial was performed in a single endoscopy center. For this study, 191 consecutive patients ages 18 to 70 undergoing outpatient esophagogastroduodenoscopy were randomized before the procedure into either a spray group (10% Xylocaine pump spray plus plain Strepsils) or a lozenge group (Strepsils Dual Action anesthetic lozenge plus distilled water spray). The primary outcome was the patient tolerance score, calculated according to the taste of the anesthetic agent, the intensity of numbness, the amount of cough or gag, and the degree of discomfort at esophageal intubation. The secondary outcomes included difficulty of esophageal intubation and the patients' and endoscopists' satisfaction score for the procedure.

RESULTS

Randomization assigned 97 patients to the lozenge group and 94 patients to the spray group. The demographic data were similar in the two groups. The spray group had a significantly higher patient tolerance score, a greater intensity of numbness, less gag reflex, and less discomfort than the lozenge group. The lozenge group had a better taste than the spray group. The difficulty of esophageal intubation and the patients' and endoscopists' satisfaction were comparable between the two groups.

CONCLUSIONS

Topical Xylocaine spray is superior to the flavored anesthetic lozenge as a topical pharyngeal anesthesia in unsedated esophagogastroduodenoscopy.

Sedation for gastroscopy: Is it an adequately understood and informed choice?

INTRODUCTION

Sedation uptake rates for oesophagogastroduodenoscopy (OGD) vary greatly. Issues concerning adequate information and consent have been raised. Additionally, patient comprehension of sedation options is inconsistent.

METHODS

A closed ended questionnaire was created and delivered to assess patient understanding regarding sedation prior to OGD. The questionnaire was based on British Society of Gastroenterology guidelines.

RESULTS

One hundred and eleven patients were recruited. 90 % of the sedated and 73 % of the unsedated patients were satisfied with their respective decisions (OR 0.283, *p = 0.01). 65 % were unaware of basic differences between conscious sedation and general anesthesia, and 37 % were unaware that driving is permitted after having throat spray alone. The most informed of the age groups had the lowest uptake of sedation and the least informed had the highest uptake.

CONCLUSION

The decision to undergo gastroscopy with or without sedation is not a sufficiently informed one. This study highlights the need for the widespread dissemination of good quality information to inform patients better regarding sedation prior to OGD.

Propofol sedation alone or in combination with pharyngeal lidocaine anesthesia for routine upper GI endoscopy: a randomized, double-blind, placebo-controlled, non-inferiority trial

BACKGROUND

In patients undergoing routine upper EGD, propofol is increasingly used without pharyngeal anesthesia because of its excellent sedative properties. It is unclear whether this practice is non-inferior in regard to ease of endoscopic intubation and patient comfort.

OBJECTIVE

To assess the relevance of local pharyngeal anesthesia regarding the ease of EGD performance in patients sedated with propofol as monotherapy.

DESIGN

Randomized, double-blind, placebo-controlled, non-inferiority trial.

SETTING

One community hospital and one university hospital in Switzerland.

PATIENTS

We enrolled 300 consecutive adult patients undergoing elective EGD.

INTERVENTION

Pharyngeal anesthesia with 4 squirts of lidocaine spray versus placebo spray immediately before propofol sedation.

MAIN OUTCOME MEASUREMENTS

Number of gag reflexes (primary endpoint), number of intubation attempts, and degree of salivation during intubation (secondary endpoints) assessed by the endoscopists and staff.

RESULTS

In the lidocaine group, 122 patients (82%) had no gag events, and 25 patients had a total of 39 gag events, whereas in the placebo group 104 patients (71%) had no gag events, and 43 patients had a total of 111 gag events. The rate ratio of gagging with quasi-likelihood estimation of placebo compared with lidocaine was 2.85 (95% confidence interval [CI], 1.42-6.19; P = .005). In adjusted logistic regression analysis, the odds ratio for gagging for placebo pharyngeal anesthesia compared with lidocaine was 1.9 (95% CI, 1.03-3.54). The number of intubation attempts and the degree of salivation were similar in both groups. Two patients in the placebo group experienced oxygen desaturation and needed short-term mask ventilation.

LIMITATIONS

The level of sedation and possible long-term side effects of pharyngeal anesthesia were not assessed.

CONCLUSION

Topical pharyngeal anesthesia reduces the gag reflex in patients sedated with propofol even though it does not seem to have an influence on the ease of the procedure and on patient or endoscopist satisfaction in adequately sedated patients.

Which should go first during same-day bidirectional endosocopy with propofol sedation?

BACKGROUND AND AIM

Same-day bidirectional endoscopy, including esophagogastroduodenoscopy (EGD) and colonoscopy, is frequently performed to screen for cancer and gastrointestinal bleeding. However, the optimal sequence for the procedures is unclear thus far. The aim of this study was to evaluate the optimal sequence for same-day bidirectional endoscopy.

METHODS

Consecutive patients undergoing same-day bidirectional endoscopy under propofol sedation were randomized to either the colonoscopy-first group (colonoscopy followed by EGD, n = 87) or the EGD-first group (EGD followed by colonoscopy, n = 89). We evaluated the propofol dose, procedure duration, patient tolerance and recovery, adverse events, and endoscopic findings. The patient tolerance was assessed with a 0-10 visual analog scale.

RESULTS

Total procedure times, patients' tolerance and recovery, adverse events, and endoscopic findings were similar between the two groups. The total propofol dose was significantly higher for the colonoscopy-first group than for the EGD-first group (mean 95% credibility limit: 135.7 [70-201.4] mg vs 124.7 [64.1-185.3] mg, respectively, P = 0.024). Patients in the colonoscopy-first group moved significantly more during colonoscopy than those in the EGD-first group: 1.1 (0-3.8) versus 0.6 (0-2.9) scores, respectively (P = 0.024).

CONCLUSION

The optimal sequence for same-day bidirectional endoscopy is EGD followed by colonoscopy. In this order, the procedure is better tolerated, and patients require a lower overall dose of propofol.

Optimal sedation for gastrointestinal endoscopy: review and recommendations

Sedation practices for endoscopy vary widely. The present review focuses on the commonly used regimens in endoscopic sedation and the associated risks and benefits together with the appropriate safety measures and monitoring practices. In addition, alternatives and additions to intravenous sedation are discussed. Personnel requirements for endoscopic sedation are reviewed; there is evidence presented to indicate that non-anesthetists can administer sedative drugs, including propofol, safely and efficaciously in selected cases. The development of endoscopic sedation as a multi-disciplinary field is highlighted with the formation of the Australian Tripartite Endoscopy Sedation Committee. This comprises representatives of the Australian and New Zealand College of Anaesthetists, the Gastroenterological Society of Australia and the Royal Australasian College of Surgeons. Possible future directions in this area are also briefly summarized.

Cardiac autonomic regulation during gastroscopy

BACKGROUND

Gastroscopy is sometimes associated with adverse cardiovascular events.

AIMS

We evaluated the effects of sedation and pharyngeal anaesthesia on cardiac autonomic regulation during gastroscopy.

PATIENTS

Two hundred thirteen outpatients undergoing gastroscopy.

METHODS

The patients were assigned to 4 groups: (1) sedation with intravenous midazolam and placebo throat spray (midazolam group), (2) placebo sedation and pharyngeal anaesthesia with lidocaine (lidocaine group), (3) placebo sedation and placebo throat spray (placebo group), and (4) no intravenous cannula nor throat spray (control group). Continuous electrocardiogram was recorded. Heart rate variability was assessed; the powers of low frequency (0.04-0.15 Hz) and high frequency (0.15-0.40 Hz) components as well as total power (0.0-0.4 Hz) were calculated.

RESULTS

Gastroscopy was associated with a decrease in high frequency normalized units, increases in low frequency normalized units and low frequency/high frequency ratio indicating activation of sympathetic and withdrawal of vagal modulation. Sympathetic activation resulted in a decrease in total power and all components of heart rate variability. The decrease was most prominent in the midazolam treated patients (p<0.001 vs the lidocaine group and p<0.01 vs placebo and control groups during the postendoscopy phase).

CONCLUSION

Gastroscopy induces a shift towards dominance of the sympathetic modulation of the heart. Premedication with midazolam potentiates this shift.

Anesthesia for gastrointestinal endoscopic procedures

Traditionally, sedation for gastrointestinal endoscopic procedures was provided by the gastroenterologist. Increasingly, however, complex procedures are being performed on seriously ill patients. As a result, anesthesiologists now are providing anesthesia and sedation in the gastrointestinal endoscopy suite for many of these patients. This article reviews the challenges encountered in this environment and anesthetic techniques that can be used successfully for these procedures.

Unkilned and large amounts of oats in the coeliac disease diet: a randomized, controlled study

OBJECTIVE

There is evidence for the long-term safety of oats as part of a gluten-free diet in coeliac disease (CD). Oats is generally processed by kilning, which theoretically may change its antigenic properties and be the reason that it is tolerated by patients with CD. The aim of this study was to investigate the suitability of large amounts of unkilned oats, comparing its use with kilned oats in adult coeliac patients.

MATERIAL AND METHODS

The study group included 13 men and 19 women with CD in remission. The goal of daily intake of oats was 100 g during one year. These patients using oats as part of their gluten-free diet were randomized to two treatment groups. One group used regular oats and the other unkilned oats. After 6 months the patients changed the treatment groups. Food intake, symptoms, histology of the small intestine and the levels of endomysial antibodies were noted.

RESULTS

No marked changes were found in the duodenal biopsies, in the levels of endomysial antibodies or in the well-being of the patients. Compliance with the diet did not change during the follow-up.

CONCLUSIONS

Large amounts of both unkilned and regular kilned oats are well tolerated by adult patients with CD. Oats is therefore not harmful, even in its unkilned form, which indicates that its antigenic nature is not changed by common industrial food processing in such a way that would prevent the provoking of CD.

The pre- and postprocedure assessment of patients undergoing sedation for gastrointestinal endoscopy

A thorough and efficient pre-procedure evaluation of the patient's readiness to undergo sedation for endoscopy is essential. This evaluation will allow the formulation of an appropriate sedation plan for the patient, resulting in a safe and effective examination. The post procedure assessment of the patient confirms readiness for discharge and allows for appropriate patient education and follow-up planning.

Effect of adipose-derived mesenchymal stem and regenerative cells on lameness in dogs with chronic osteoarthritis of the coxofemoral joints: a randomized, double-blinded, multicenter, controlled trial

Autologous stem cell therapy in the field of regenerative veterinary medicine involves harvesting tissue, such as fat, from the patient, isolating the stem and regenerative cells, and administering the cells back to the patient. Autologous adipose-derived stem cell therapy has been commercially available since 2003, and the current study evaluated such therapy in dogs with chronic osteoarthritis of the hip. Dogs treated with adipose-derived stem cell therapy had significantly improved scores for lameness and the compiled scores for lameness, pain, and range of motion compared with control dogs. This is the first randomized, blinded, placebo-controlled clinical trial reporting on the effectiveness of stem cell therapy in dogs.

Sedation, topical pharyngeal anesthesia and cardiorespiratory safety during gastroscopy

GOALS

In a prospective, double-blind study, we examined the effects of routine sedation and pharyngeal anesthesia on cardiorespiratory parameters during gastroscopy.

BACKGROUND

Intravenous sedation and topical pharyngeal anesthesia are used to alleviate the discomfort during upper gastrointestinal endoscopy. Cardiorespiratory changes during gastroscopy are common.

STUDY

Two hundred fifty two consecutive outpatients undergoing gastroscopy were assigned into 4 groups: (1) sedation with intravenous midazolam and placebo throat spray (midazolam group), (2) placebo sedation and pharyngeal anesthesia with lidocaine throat spray (lidocaine group), (3) placebo sedation and placebo throat spray (placebo group), and (4) no intravenous cannula nor throat spray (control group). Arterial oxygen saturation (SaO2), systolic and diastolic blood pressure and continuous electrocardiogram were recorded before, during, and after the endoscopic procedure.

RESULTS

Gastroscopy increased heart rate in all study groups. Premedication with intravenous midazolam or lidocaine spray alleviated this rise (P<0.001, repeated measures analysis of variance) and decreased the incidence of tachycardia. Similarly, sedation with midazolam or topical pharyngeal anesthesia decreased the rise in systolic blood pressure (P<0.001). Midazolam produced lower SaO2 values during gastroscopy compared with lidocaine, placebo or control groups (P<0.001). However, episodes of desaturation (SaO2 </=92) were no more common in the midazolam group than in other groups.

CONCLUSIONS

Premedication with midazolam alleviated the rise in heart rate and systolic blood pressure but induced a statistically significant decrease in arterial oxygen saturation. However, gastroscopy proved to be a safe procedure both with and without sedation.

Evaluation of topical pharyngeal anaesthesia by benzocaine lozenge for upper endoscopy

BACKGROUND

Among the randomized controlled trials evaluating the effect of pharyngeal anaesthesia only some suggest benefit. Spray is irritating for some people and leaves bitter taste in the throat. We hypothesized that delivering the local anaesthetic as a sucking lozenge would benefit the patients in terms of decreasing anxiety and will improve procedure performance and patient tolerance.

AIM

To determine whether benzocaine/tyrothricin sucking lozenges with conscious sedation is superior to conscious sedation alone, with respect to procedure performance and tolerance in patients undergoing upper endoscopy.

METHODS

One hundred and seventy-four adult patients undergoing upper endoscopy with conscious sedation completed the study. They were randomized to receive sucking lozenge containing benzocaine or placebo before the procedure. Patients were asked to rate prestudy anxiety, tolerance for topical pharyngeal anaesthesia, comfort during endoscopy, degree of difficulty of intubation, postprocedure throat discomfort and willingness to undergo subsequent examinations using a 10-cm visual analogue scale. Endoscopists were asked to estimate the ease of oesophageal intubation and procedure performance.

RESULTS

No significant statistical differences regarding all the points studied were found between the groups.

CONCLUSIONS

Topical pharyngeal anaesthesia with benzocaine/tyrothricin lozenges with conscious sedation has no advantages over conscious sedation alone in patients undergoing upper endoscopy.