More than half of hypoxemia cases occurred during the recovery period after completion of esophagogastroduodenoscopy with planned moderate sedation

Comparison of high-flow nasal cannula and conventional nasal cannula during deep sedation for endoscopic submucosal dissection: a randomized controlled trial

PURPOSE

Adequate oxygenation and airway management during deep sedation can be challenging. We investigated the effect of high-flow nasal cannula (group HF) and conventional nasal cannula (group CO) during sedation for endoscopic submucosal dissection (ESD).

METHODS

Patients undergoing ESD with deep sedation were enrolled. The primary outcome was difference in lowest oxygen saturation (SpO2) between the groups. Incidence of hypoxia (SpO2 < 90%), patients with SpO2 < 95%, hypercapnia, and airway interventions; operator satisfaction; and adverse events were recorded.

RESULTS

Thirty-two patients in each group completed the study. The mean of minimum SpO2 values was significantly higher in group HF than in group CO (96.8% ± 4.2% vs. 93.3% ± 5.3%, p = 0.005). The incidence of hypoxia was comparable between the groups (4 [12.5%] vs. 6 [18.8%], p = 0.491); however, patients with SpO2 < 95% were significantly less in group HF (5 [15.6%] vs. 18 [56.3%], p = 0.003). Incidence of hypercapnia was higher in group HF than in group CO (14 [46.7%] vs. 5 [16.7%], p = 0.013). Airway rescue interventions were significantly less common in group HF. Satisfaction of operators and post-procedural complications were comparable between the two groups. In multivariable analysis, group CO and higher body mass index were risk factors for airway managements (odds ratio [95% confidence interval]: 6.204 [1.784-21.575], p = 0.004; 1.337 [1.043-1.715], p = 0.022, respectively).

CONCLUSIONS

Compared to conventional nasal cannula, high-flow nasal cannula maintained higher minimum SpO2 value during deep sedation with propofol-remifentanil for ESD.

TRIAL REGISTRATION

Clinical Trial Registry of the Republic of Korea (KCT0006618, https://cris.nih.go.kr ; registered September 29, 2021; principal investigator: Ji Won Choi).

The effects of remimazolam combined with sufentanil on respiration, circulation and sedation level in patients undergoing colonoscopy

BACKGROUND

The main sedative which is propofol in painless gastroenteroscopy, has a high risk of reducing blood pressure and respiratory depression. Remimazolam (a short-acting benzodiazepine) is expected to be widely used in painless gastroenteroscopy due to its rapid onset, rapid metabolism and light respiratory and circulation inhibition.

METHODS

A randomized, single-blind, parallel, controlled study, 123 outpatients who were undergoing painless colonoscopy and ramdomly divided into group A, B and C, in Hangzhou First People's Hospital, July-December 2021. All patients were intravenously injected with 5 µg sufentanil for analgesic preconditioning. The group A was induced by 0.2 mg/kg remimazolam besylate. The group B was induced by 0.25 mg/kg remimazolam besylate. And the group C was inducted by 2.0 mg /kg propofol. If the patients had limb movement or MOAA/S score > 3 and so on, remimazolam besylate was added at 2.5 mg/ time in group A and B, and propofol emulsion injection was added at 0.5 mg/kg/ time in group C. During the operation, according to the actual situation, remimazolam was per added 2.5 mg in the experimental group, and propofol was 0.5 mg/kg in the control group. Heart rate (HR), non-invasive blood pressure (BP), respiratory rate (RR), pulse oxygen saturation (SpO2), and improved vigilance/sedation score (MOAA/S) of patients was recorded from entering endoscopy room to get out of the anesthesia recovery room, also including perioperative adverse events, other medications or treatments, the time of patients waking up and leaving the hospital.

RESULTS

The successful rate of induction in three groups was 100%. There was no significant difference in the sedation completion rate among the three groups (Group A:90.2%, Group B: 92.7%, Group C: 92.7%, P = 1.000). The rate of adverse events after administration: group A(27.0%) and B(36.8%) both lower than group C(71.0%),P < 0.001;There was no significant difference between group A and group B, P > 0.744;The average time from the last drug administration to meet the discharge criteria of the subjects in three groups was as follows: The average time of group A(16.2 min) and Group B(16.5 min) both shorter than group C(19.6 min), P = 0.001; There was no significant difference between group A and group B, P = 0.742.

CONCLUSIONS

This study revealed that remimazolam is a safe and effective medication for colonoscopy sedation, the security of remimazolam is better than propofol, and the sedative effect with the initial dose of 0.25 mg/kg of remimazolam is optimal.

TRIAL REGISTRATION

China Clinical Trial Center with registration number: 2100052615,02/11/2021.

Efficiency and safety of nasal positive airway pressure systems during endoscopic procedures in high-risk patients: Endo-Breath study

Background and study aims Sedation of high-risk patients is a relevant issue in interventional endoscopy. This is especially because standard oximetric monitors display only hypoxia and not the preceding hypercapnia. Therefore, the question arises whether use of a nasal positive airway pressure (nPAP) system can decrease the rate of sedation-associated events. Patients and methods A randomized, prospective trial was conducted at University Hospital Ulm, including 98 consecutive patients, identified as high-risk (American Society of Anesthesiologists physical status ≥3) and scheduled for prolonged (>15 minutes) endoscopic procedures. Patients underwent 1:1 randomization to two groups: interventional (nPAP-Mask) and control (conventional oxygen supplementation). Levels of CO 2 were measured noninvasively by transcutaneous capnometry device. The primary outcome was incidence of hypoxia (SpO 2 <90% over 10 seconds) and incidence of severe hypoxia was incidence of SpO 2 <80% over 10 seconds. One of our secondary objectives was to determine if the nPAP-Mask could result in significant CO 2 retention among high-risk patients. Results Data analysis showed lower incidence of hypoxia in the interventional group (10/47 vs. 31/251) P <0.05. Episodes of severe hypoxia (SpO 2 <80% over 10 seconds) were more frequent in the control group (8/51) compared with the intervention group (2/47) P <0.05. There was no significant difference in ΔCO 2 levels in the interventional vs. control group (-6.01±7.66 vs. -7.35±8.59 mm Hg). Conclusions In high-risk patients use of a nasal positive airway pressure system could significantly lower risk of hypoxia, especially in prolonged procedures. The nPAP-Mask does not induce CO 2 retention when compared with conventional oxygen supplementation.

Remimazolam and Remifentanil Use Induced Severe Respiratory Depression and Laryngeal Spasm During Intravenous Sedation and Analgesia: A Case Report

INTRODUCTION

Intravenous sedation and analgesia are widely used in minor surgeries. Remifentanil and remimazolam are advantageous in this setting because of their rapid onset of action, and short duration of action leading to a rapid recovery. However, the two drugs combined need to be titrated to avoid airway-related adverse events.

CASE PRESENTATION

This article reports a case of severe respiratory depression and severe laryngeal spasm induced by remifentanil and remimazolam when they were used for analgesia and sedation in a patient undergoing oral biopsy.

CONCLUSION

We aim to improve awareness about the safety of these drugs among anesthesiologists and increase their ability to manage the risk associated with their use.

High-flow nasal oxygenation reduces the risk of desaturation in adults receiving procedural sedation: a meta-analysis of randomized controlled trials

Background

Procedural sedation reduces patients’ discomfort and anxiety, facilitating performance of the examination and intervention. However, it may also cause adverse events, including airway obstruction and hypoxia. We conducted this systematic review and meta-analysis to evaluate the efficacy of high-flow nasal oxygenation (HFNO) compared with that of standard oxygen therapy in adult patients undergoing procedural sedation.

Methods

We identified randomized controlled trials published before November 2020 based on PubMed, Embase, and Cochrane Library databases and ClinicalTrials.gov registry. Intraprocedural desaturation [peripheral oxygen saturation (SpO₂) < 90%] was evaluated as the primary outcome. The secondary outcomes were the lowest SpO₂, need for airway intervention, oxygen therapy-related complications, and patient, operator, and anesthetist’s satisfaction.

Results

Six trials with a total of 2633 patients were reviewed. Patients using HFNO compared with standard oxygen therapy had a significantly lower risk of intraprocedural desaturation [risk ratio 0.18, 95% confidence interval (CI) 0.04-0.87]. The lowest intraprocedural SpO₂ in HFNO group was significantly higher than that in standard oxygen therapy group (mean difference 4.19%, 95% CI 1.74-6.65).

Conclusions

Compared with standard oxygen therapy, HFNO may reduce the risk of desaturation and increase the lowest SpO₂ in adult patients undergoing sedation for medical procedures.

Anastomotic Leak: Toward an Understanding of Its Root Causes

BACKGROUND

When an anastomotic leak is discussed at a typical surgical morbidity and mortality conference, it is often presented as a due to an error in surgical technique involving ischemia, tension, or device failure. Here we assert that without direct visual analysis of the leak site and its tissue histology, an ex post facto claim that an anastomotic leak is due to an error in surgical technique remains speculative.

METHODS

The arguments and rationale used to conclude that an anastomotic leak is due to an error in surgical technique are critically reviewed and assessed for their validity.

RESULTS

No case series or literature exists in which a root cause analysis has been carried out with visual and tissue level evidence to determine the root cause(s) of an anastomotic leak.

CONCLUSIONS

At the individual case level, declaring that an anastomotic leak is due to an error in surgical technique without clear and compelling evidence either visually and/or at the tissue level to substantiate such a claim remains speculative.

Emerging Approaches in Intravenous Moderate and Deep Sedation

Successful pharmacological innovations that have made a difference in daily practice are rare in the world of anesthesia and sedation. After many years of research, it seems that we finally have two new drug innovations that are likely to change the paradigm of moderate and deep sedation. These are oliceridine and remimazolam. Both have been in development for over a decade. Oliceridine was synthesized in a lab as an entirely new molecule. It is a biased μ- receptor agonist that acts preferentially on the G-protein pathway (which is responsible for analgesia). At least in lower doses, it has minimal effect on the beta-arrestin pathway, which is responsible for unwanted effects of μ-opioid receptor activation such as respiratory depression and gastrointestinal dysfunction. Like any other μ- receptor agonist, it produces appropriate dose-dependent analgesia. Remimazolam is structurally similar to midazolam; however, it has an additional ester linkage that delivers the kinetics of remifentanil. As a result, while pharmacodynamically identical to midazolam, remimazolam is metabolized by ester hydrolysis and subsequently its elimination is rapid and predictable. The present review discusses the two drugs in detail with a particular emphasis on their potential role in moderate and deep sedation.

Neuropathologic findings of patients with COVID-19: a systematic review

BACKGROUND

Despite the expanding literature that discusses insights into the clinical picture and mechanisms by which the SARS-CoV-2 virus invades the nervous system, data on the neuropathologic findings of patients who died following SARS-CoV-2 infection is limited.

METHODS

A broad literature search was done for published articles that reported on histopathological findings of the brain in patients with COVID-19 in PubMed by MEDLINE, Embase, CENTRAL by the Cochrane Library, and SCOPUS from December 31, 2019 to October 31, 2020.

RESULTS

The systematic literature search strategy used resulted in a total of 1608 articles of which 14 were included in the analysis (PROSPERO registration number: CRD42020221022). There were ten case series, two case reports, one retrospective cohort, and one prospective cohort. The age of the patients ranged between 38 and 90 years old, most of them older than 65 years old (n=66, 45.2%) and males (n=79, 54.1%). Most tested negative in SARS-CoV-2 immunohistochemistry (n=70, 47.9%). The striking pathologic changes included diffuse edema (n=25, 17.1%), gliosis with diffuse activation of microglia and astrocytes (n=52, 35.6%), infarctions involving cortical and subcortical areas of the brain (n=4, 2.7%), intracranial bleed (subarachnoid hemorrhage and punctate hemorrhages) (n=18, 12.4%), arteriosclerosis (n=43, 29.5%), hypoxic-ischemic injury (n=41, 28.1%), and signs of inflammation (n=52, 35.6%). The cause of death was attributed to the cardiorespiratory system (n=66, 45.2%).

CONCLUSIONS

The neuropathologic changes observed likely represent direct cytopathic effects and indirect effects secondary to host-specific inflammatory response induced by the viral infection. Further studies however are required to better elucidate the pathologic mechanism.