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Sidhu R, Turnbull D, Haboubi H, Leeds JS, Healey C, Hebbar S, Collins P, Jones W, Peerally MF, Brogden S, Neilson LJ, Nayar M, Gath J, Foulkes G, Trudgill NJ, Penman I. British Society of Gastroenterology guidelines on sedation in gastrointestinal endoscopy. Gut 2024; 73:219-245. [PMID: 37816587 PMCID: PMC10850688 DOI: 10.1136/gutjnl-2023-330396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 09/06/2023] [Indexed: 10/12/2023]
Abstract
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.
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Affiliation(s)
- Reena Sidhu
- Academic Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
- Department of Infection, Immunity & Cardiovascular Disease, The University of Sheffield, Sheffield, UK
| | - David Turnbull
- Department of Anaesthetics, Royal Hallamshire Hospital, Sheffield, UK
| | - Hasan Haboubi
- Department of Gastroenterology, University Hospital Llandough, Llandough, South Glamorgan, UK
- Institute of Life Sciences, Swansea University, Swansea, UK
| | - John S Leeds
- Hepato-Pancreato-Biliary Unit, Freeman Hospital, Newcastle upon Tyne, UK
- Newcastle University Population Health Sciences Institute, Newcastle upon Tyne, UK
| | - Chris Healey
- Airedale NHS Foundation Trust, Keighley, West Yorkshire, UK
| | - Srisha Hebbar
- Department of Gastroenterology, University Hospital of North Midlands, Stoke-on-Trent, Staffordshire, UK
| | - Paul Collins
- Department of Gastroenterology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Wendy Jones
- Specialist Pharmacist Breastfeeding and Medication, Portsmouth, UK
| | - Mohammad Farhad Peerally
- Digestive Diseases Unit, Kettering General Hospital; Kettering, Kettering, Northamptonshire, UK
- Department of Population Health Sciences, College of Life Science, University of Leicester, Leicester, UK
| | - Sara Brogden
- Department of Gastroenterology, University College London, UK, London, London, UK
| | - Laura J Neilson
- Department of Gastroenterology, South Tyneside District Hospital, South Shields, Tyne and Wear, UK
| | - Manu Nayar
- Hepato-Pancreato-Biliary Unit, Freeman Hospital, Newcastle upon Tyne, UK
- Newcastle University Population Health Sciences Institute, Newcastle upon Tyne, UK
| | - Jacqui Gath
- Patient Representative on Guideline Development Group and member of Independent Cancer Patients' Voice, Sheffield, UK
| | - Graham Foulkes
- Patient Representative on Guideline Development Group, Manchester, UK
| | - Nigel J Trudgill
- Department of Gastroenterology, Sandwell General Hospital, West Bromwich, UK
| | - Ian Penman
- Centre for Liver and Digestive Disorders, Royal Infirmary Edinburgh, Edinburgh, Midlothian, UK
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Park K, Kim NY, Kim KJ, Oh C, Chae D, Kim SY. A Simple Risk Scoring System for Predicting the Occurrence of Aspiration Pneumonia After Gastric Endoscopic Submucosal Dissection. Anesth Analg 2021; 134:114-122. [PMID: 34673667 DOI: 10.1213/ane.0000000000005779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Aspiration pneumonia after endoscopic submucosal dissection (ESD) is rare, but can be fatal. We aimed to investigate risk factors and develop a simple risk scoring system for aspiration pneumonia. METHODS We retrospectively reviewed medical records of 7833 patients who underwent gastric ESD for gastric neoplasm under anesthesiologist-directed sedation. Candidate risk factors were screened and assessed for significance using a least absolute shrinkage and selection operator (LASSO)-based method. Top significant factors were incorporated into a multivariable logistic regression model, whose prediction performance was compared with those of other machine learning models. The final risk scoring system was created based on the estimated odds ratios of the logistic regression model. RESULTS The incidence of aspiration pneumonia was 1.5%. The logistic regression model showed comparable performance to the best predictive model, extreme gradient boost (area under receiver operating characteristic curve [AUROC], 0.731 vs 0.740). The estimated odds ratios were subsequently used for the development of the clinical scoring system. The final scoring system exhibited an AUROC of 0.730 in the test dataset with risk factors: age (≥70 years, 4 points), male sex (8 points), body mass index (≥27 kg/m2, 4 points), procedure time (≥80 minutes, 5 points), lesion in the lower third of the stomach (5 points), tumor size (≥10 mm, 3 points), recovery time (≥35 minutes, 4 points), and desaturation during ESD (9 points). For patients with total scores ranging between 0 and 33 points, aspiration pneumonia probabilities spanned between 0.1% and 17.9%. External validation using an additional cohort of 827 patients yielded AUROCs of 0.698 for the logistic regression model and 0.680 for the scoring system. CONCLUSIONS Our simple risk scoring system has 8 predictors incorporating patient-, procedure-, and sedation-related factors. This system may help clinicians to stratify patients at risk of aspiration pneumonia after ESD.
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Affiliation(s)
| | - Na Young Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ki Jun Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Chaerim Oh
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | - So Yeon Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
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Tang D, Yuan F, Ma X, Qu H, Li Y, Zhang W, Ma H, Liu H, Yang Y, Xu L, Gao Y, Zhan S. Incidence rates, risk factors, and outcomes of aspiration pneumonia after gastric endoscopic submucosal dissection: A systematic review and meta-analysis. J Gastroenterol Hepatol 2021; 36:1457-1469. [PMID: 33242356 DOI: 10.1111/jgh.15359] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 11/09/2020] [Accepted: 11/21/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM The risk and prognosis of aspiration pneumonia (AP) after endoscopic submucosal dissection (ESD) are inconsistent among studies. We aim to estimate the incidence, risk factors, and outcome of AP in patients after gastric ESD. METHODS PubMed, EMBASE, Cochrane Library, and Web of Knowledge were searched for relevant articles from inception until April 2020. Data involving the incidence, risk factors, and outcomes were extracted. Pooled incidence, odds ratios (ORs), or standardized mean difference (SMD) and 95% confidence intervals (CIs) were calculated. RESULTS Forty records involving 48 674 subjects were finally included. The pooled incidence of AP after gastric ESD was 1.9% (95% CI, 1.2-2.7) via the double arcsine transformation method and 1.6% (1.1-2.5%) via the logit transformation method. Risk factors analyses revealed that old age (OR, 2.52; 95% CI, 1.99-3.18), comorbid pulmonary disease (2.49; 1.66-3.74), comorbid cerebrovascular disease (2.68; 1.05-6.85), remnant stomach (4.91; 1.83-13.14), sedation with propofol (2.51; 1.48-4.28), and long procedural duration (count data: 5.20, 1.25-21.7; measurement data: 1.01, 1.01-1.02) were related to the occurrence of AP. Patients with AP had a longer hospital stay (SMD, 0.56; 95% CI, 0.25-0.87) than those without AP. CONCLUSIONS About 1.9% (1.2-2.7%) of the patients who receive gastric ESD may develop AP, resulting in prolonged hospital stay. More attention should be paid in patients who are older; have comorbidities such as pulmonary diseases, cerebrovascular diseases, or gastric remnant; or require a long procedural duration or deep sedation with propofol.
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Affiliation(s)
- Dong Tang
- Department of Gastroenterology, Qingdao Municipal Hospital, the Affiliated Municipal Hospital of Qingdao University, Qingdao, China
| | - Fuxiang Yuan
- Ophthalmologic Center, Qingdao Municipal Hospital, the Affiliated Municipal Hospital of Qingdao University, Qingdao, China
| | - Xiaoying Ma
- Department of Gastroenterology, Qingdao Municipal Hospital, the Affiliated Municipal Hospital of Qingdao University, Qingdao, China
| | - Haixia Qu
- Department of Gastroenterology, Qingdao Municipal Hospital, the Affiliated Municipal Hospital of Qingdao University, Qingdao, China
| | - Yuan Li
- Department of Gastroenterology, Qingdao Municipal Hospital, the Affiliated Municipal Hospital of Qingdao University, Qingdao, China
| | - Weiwei Zhang
- Department of Gastroenterology, Qingdao Municipal Hospital, the Affiliated Municipal Hospital of Qingdao University, Qingdao, China
| | - Huan Ma
- Department of Gastroenterology, Qingdao Municipal Hospital, the Affiliated Municipal Hospital of Qingdao University, Qingdao, China
| | - Haiping Liu
- Department of Gastroenterology, Qingdao Municipal Hospital, the Affiliated Municipal Hospital of Qingdao University, Qingdao, China
| | - Yan Yang
- Department of Gastroenterology, Qingdao Municipal Hospital, the Affiliated Municipal Hospital of Qingdao University, Qingdao, China
| | - Lin Xu
- Department of Gastroenterology, Qingdao Municipal Hospital, the Affiliated Municipal Hospital of Qingdao University, Qingdao, China
| | - Yuqiang Gao
- Department of Gastroenterology, Qingdao Municipal Hospital, the Affiliated Municipal Hospital of Qingdao University, Qingdao, China
| | - Shuhui Zhan
- Department of Gastroenterology, Qingdao Municipal Hospital, the Affiliated Municipal Hospital of Qingdao University, Qingdao, China
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Kang S, Lu J, Zhou HM. Anesthetic strategy for obese patients during gastroscopy: deep sedation or conscious sedation? A prospective randomized controlled trial. J Anesth 2021; 35:555-562. [PMID: 34052943 DOI: 10.1007/s00540-021-02951-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 05/22/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVE This paper aims to compare the incidence of SpO2 values < 95% and < 90% of the obese patients between conscious sedation and deep sedation and whether conscious sedation was superior to the deep sedation for obese patients during diagnostic gastroscopy. METHODS Obese patients undergoing diagnostic gastroscopy were randomly assigned to two different intervention groups: group CS (conscious sedation) or group DS (deep sedation). Group CS patients were managed by conscious sedation [Modified Observer Assessment of Alertness/Sedation (MOAA/S) at 4-5] protocol, and group DS patients were managed by deep sedation (MOAA/S at ≤ 2) protocol. Propofol and sufentanil (0.1 and 0.05 mg/kg) were, respectively, infused for sedation and analgesia in CS and DS protocols. The primary endpoints were to compare the incidence of SpO2 values < 95% and < 90% of the patients between the two groups. The incidence of successful sedation, satisfaction scores of patients and endoscopist were assessed as secondary endpoints. RESULTS 115 obese patients (59 in group CS and 56 in group DS) were enrolled in this study. The incidences of SpO2 < 95% and < 90% in group CS (42.4% and 6.8%) were significantly lower than those in group DS (69.6% and 19.6%, with P = 0.003 and 0.041, respectively). The incidence of successful sedation was similar between groups (86.4% vs 89.3%, P = 0.641). Patient satisfaction scores and endoscopist satisfaction scores were both similar between groups (P = 0.548 and 0.171). CONCLUSION Conscious sedation with propofol and sufentanil (0.1 mg/kg) reduced the incidence of hypoxic events without affecting gastroscopy procedure and satisfaction compared with the deep sedation for obese patients during diagnostic gastroscopy. TRIAL REGISTRATION ChiCTR-1900024894; registration date, July 31, 2019. http://www.chictr.org.cn .
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Affiliation(s)
- Shuai Kang
- Department of Anesthesiology, Second Affiliated Hospital of Jiaxing University, Jiaxing, 314000, Zhejiang Province, China
| | - Jian Lu
- Department of Anesthesiology, Second Affiliated Hospital of Jiaxing University, Jiaxing, 314000, Zhejiang Province, China
| | - Hong-Mei Zhou
- Department of Anesthesiology, Second Affiliated Hospital of Jiaxing University, Jiaxing, 314000, Zhejiang Province, China.
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Park CH, Park SW, Jung JH, Kim GG, Choi SY, Kim ES, In DH, Kim HD. Clinical outcomes of sedation during emergency endoscopic band ligation for variceal bleeding: Multicenter cohort study. Dig Endosc 2020; 32:894-903. [PMID: 31858649 DOI: 10.1111/den.13610] [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: 10/29/2019] [Accepted: 12/15/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Few studies have directly compared the efficacy of sedated- and un-sedated endoscopic variceal ligation (EVL) for acute variceal bleeding. We aimed to determine whether sedation during EVL in patients with variceal bleeding is safe and effective. METHODS We analyzed data from patients who underwent EVL for acute variceal bleeding according to sedation in six hospitals of Hallym University Medical Center. The primary endpoint was treatment failure, defined as a failure to control bleeding, death during EVL, or rebleeding within 5 days. Secondary endpoints included the procedure time, adverse events, and 30-day mortality. RESULTS Of 1,300 patients who were included, only 430 (33.1%) received sedation during EVL. Propofol alone was used for sedation in 85% of sedated-EVLs. The mean procedure time in the sedation group was shorter than that of the non-sedation group (12.4 ± 9.5 min versus 13.8 ± 9.4 min, P = 0.010). The proportion of treatment failure did not differ between the groups (7.4% versus 9.1%, P = 0.374). In the multivariable analysis, an AIMS65 score ≥2 and blood transfusion within 72 hours were associated with treatment failure of EVL; however, the use of sedation was not (odds ratio [95% confidence interval (CI)] = 0.96 [0.60-1.51]). Adverse events during EVL and hepatic encephalopathy did not differ between the two groups. Sedation also did not affect the 30-day mortality (hazard ratio [95% CI] = 0.99 [0.66-1.47]). CONCLUSION Sedation reduced the procedure time of EVL. Sedation is safe to use during EVL for variceal bleeding in patients with cirrhosis.
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Affiliation(s)
- Chan Hyuk Park
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Gyeonggi-do, Korea
| | - Se Woo Park
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
| | - Jang Han Jung
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
| | - Gyeong Guk Kim
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
| | - Se Young Choi
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
| | - Eun Sun Kim
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
| | - Dong Hyun In
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
| | - Hong Deok Kim
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
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Heo HJ, Lee JH, Kim YY, Baek SM, Kim KM, Jung DW. Invisible perforation during an endoscopic procedure of the esophagus under general anesthesia
- A case report -. Anesth Pain Med (Seoul) 2020; 15:383-387. [PMID: 33329840 PMCID: PMC7713842 DOI: 10.17085/apm.20034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 07/03/2020] [Accepted: 07/06/2020] [Indexed: 11/17/2022] Open
Abstract
Background Endoscopic procedures of the esophagus are more complicated than those of other regions of the gastrointestinal tract. They have a relatively long procedure time and high risk of complications, such as perforation and bleeding. Perforations that occur during the procedure can accompany pneumoperitoneum and pneumomediastinum through leakage of insufflation air and cause severe ventilatory impairment. Case A 58-year-old male patient underwent enucleation of leiomyoma in the esophagus using endoscopy under general anesthesia. Ventilatory impairment occurred 15 min after commencement of the procedure. Subsequently, subcutaneous emphysema and severe abdominal distension were observed. We suggested the possibility of microperforation during the procedure to the endoscopist, and he performed endoscopic clipping around the excision site of leiomyoma. Conclusions Providing anesthetic care by anesthesiologists during endoscopic procedures is considered necessary for patient safety. Complications of endoscopic procedures can be detected and managed early without sequelae during anesthetic care.
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Affiliation(s)
| | - Ji Hye Lee
- Corresponding author: Ji Hye Lee, M.D. Department of Anesthesiology and Pain Medicine, Presbyterian Medical Center, 365, Seowon-ro, Wansan-gu, Jeonju 54987, Korea Tel: 82-63-230-1591, Fax: 82-63-230-8919, E-mail:
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Lee B, Kim MS, Eum D, Min KT. The radiation environment of anaesthesiologists in the endoscopic retrograde cholangiopancreatography room. Sci Rep 2019; 9:9124. [PMID: 31235744 PMCID: PMC6591287 DOI: 10.1038/s41598-019-45610-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 06/10/2019] [Indexed: 12/16/2022] Open
Abstract
Anaesthesiologists are increasingly involved in nonoperating room anaesthesia (NORA) for fluoroscopic procedures. However, the radiation exposure of medical staff differs among NORA settings. Therefore, we aimed to investigate the radiation environment generated by fluoroscopic endoscopic retrograde cholangiopancreatography (ERCP) and the radiation exposure of anaesthesiologists. The dose area product (DAP), radiation entrance dose (RED), and fluoroscopy time (FT) according to the procedures and monthly cumulative radiation exposure were analysed at two sites (neck and wrist) from 363 procedures in 316 patients performed within 3 months. The total RED and DAP were 43643.1 mGy and 13681.1 Gy cm2, respectively. DAP and RED (r = 0.924) were strongly correlated and DAP and FT (r = 0.701) and RED and FT (r = 0.749) were moderately correlated. The radiation environment per procedure varied widely, DAP and RED per FT were the highest during stent insertion with esophagogastroduodenoscopy. Monthly cumulative deep dose equivalents at the wrist and neck ranged between 0.31-1.27 mSv and 0.33-0.59 mSv, respectively, but they were related to jaw thrust manipulation (r = 0.997, P = 0.047) and not to the radiation environment. The anaesthesiologists may be exposed to high dose of radiation in the ERCP room, which depends on the volume of procedures performed and perhaps the anaesthesiologists' practice patterns.
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Affiliation(s)
- Bora Lee
- Department of Anaesthesiology and Pain Medicine, Severance Hospital, Anaesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul, 03722, Republic of Korea
| | - Min-Soo Kim
- Department of Anaesthesiology and Pain Medicine, Severance Hospital, Anaesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul, 03722, Republic of Korea
| | - Darhae Eum
- Department of Anaesthesiology and Pain Medicine, Severance Hospital, Anaesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul, 03722, Republic of Korea
| | - Kyeong Tae Min
- Department of Anaesthesiology and Pain Medicine, Severance Hospital, Anaesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul, 03722, Republic of Korea.
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Park YS, Choi DK, Kang J, Park J, Joung KW, Choi IC. Comparison between monitored anesthesia care and general anesthesia in patients undergoing device closure of atrial septal defect. J Thorac Dis 2019; 11:1421-1427. [PMID: 31179084 DOI: 10.21037/jtd.2019.03.56] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Percutaneous atrial septal defect (ASD) device closure is usually performed under general anesthesia (GA) because it can ensure protection of the airway from the effects of insertion of the transesophageal echocardiogram probe insertion. However, recent studies have suggested that this procedure can be performed safely under deep sedation also. Thus, we compared the efficacy of using monitored anesthesia care (MAC) with deep sedation versus GA to perform this procedure and the post-procedural outcomes and incidence of complications associated with these two methods of anesthesia. Methods We retrospectively analyzed cases involving 311 patients who underwent ASD device closures from January 2011 to December 2015. The demographics, laboratory values, echocardiographic findings, and intraoperative data of these patients were assessed. GA was induced with a continuous infusion of propofol and remifentanil using a target control infusion pump. MAC with deep sedation was performed by using a continuous infusion of dexmedetomidine and remifentanil. The primary outcome of the study was the overall complication rate that included the incidence of aspiration pneumonia, sore throat, dysphagia, vocal cord palsy, neurologic complication, device-related complications, and other minor complications during the procedure; and the secondary outcomes were the turnover time, procedure time, and duration of hospital stay. Results No significant differences were observed in the complication rate and length of the hospital stay between the MAC group and the GA group. However, the turnover time was significantly longer in the GA group than in the MAC group (56.2±13.3 vs. 51.0±15.4 min, P=0.004). Conclusions MAC under deep sedation is an effective and safe anesthetic option comparable to GA for performing percutaneous ASD device closures.
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Affiliation(s)
- Yong-Seok Park
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dae-Kee Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jiwon Kang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jihoon Park
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyoung-Woon Joung
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - In-Cheol Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Green SM, Mason KP, Krauss BS. Pulmonary aspiration during procedural sedation: a comprehensive systematic review. Br J Anaesth 2018; 118:344-354. [PMID: 28186265 DOI: 10.1093/bja/aex004] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background Although pulmonary aspiration complicating operative general anaesthesia has been extensively studied, little is known regarding aspiration during procedural sedation. Methods We performed a comprehensive, systematic review to identify and catalogue published instances of aspiration involving procedural sedation in patients of all ages. We sought to report descriptively the circumstances, nature, and outcomes of these events. Results Of 1249 records identified by our search, we found 35 articles describing one or more occurrences of pulmonary aspiration during procedural sedation. Of the 292 occurrences during gastrointestinal endoscopy, there were eight deaths. Of the 34 unique occurrences for procedures other than endoscopy, there was a single death in a moribund patient, full recovery in 31, and unknown recovery status in two. We found no occurrences of aspiration in non-fasted patients receiving procedures other than endoscopy. Conclusions This first systematic review of pulmonary aspiration during procedural sedation identified few occurrences outside of gastrointestinal endoscopy, with full recovery typical. Although diligent caution remains warranted, our data indicate that aspiration during procedural sedation appears rare, idiosyncratic, and typically benign.
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Affiliation(s)
- S M Green
- Department of Emergency Medicine, Loma Linda University Medical Center and Children's Hospital, Loma Linda, CA, USA
| | - K P Mason
- Department of Anesthesia, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | - B S Krauss
- Division of Emergency Medicine, Boston Children's Hospital and the Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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Kim GE, Lee SH, Chung IS, Lee E, Shin HS, Choi JW. Severe respiratory depression precipitated by unrecognized gastric perforation during endoscopic submucosal dissection under deep sedation - A case report -. Anesth Pain Med (Seoul) 2017. [DOI: 10.17085/apm.2017.12.4.402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Go-Eun Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sang Hyun Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - In Sun Chung
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eunji Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyun Su Shin
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji-won Choi
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Kim GE, Kim DK, Choi JW, Chung IS, Jung DW. The safety of endoscopic esophageal procedures under general anesthesia. Korean J Anesthesiol 2017; 70:555-560. [PMID: 29046776 PMCID: PMC5645589 DOI: 10.4097/kjae.2017.70.5.555] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 04/01/2017] [Accepted: 04/03/2017] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND With the increasing demand for general anesthesia for endoscopic esophageal procedures, anesthesiologists should understand the clinical characteristics of post-procedural complications (PPCs). METHODS We retrospectively investigated the incidence of and risk factors associated with PPCs of endoscopic esophageal procedures performed under general anesthesia from July 2013 to November 2016. The final analysis included 129 patients; 114 who underwent esophageal endoscopic dissection for esophageal tumors and 15 cases of peroral endoscopic myotomy for achalasia. Frank perforation during the procedure was defined as an endoscopically recognizable or clinically detected perforation during the procedures. A multivariable logistic regression analysis was conducted to identify independent risk factors for PPCs. RESULTS The overall incidence of PPCs was 19.4% (25/129). All of the PPCs were managed successfully with conservative measures. The most common PPC was symptomatic, radiologically documented atelectasis (11/25, 44.0%), followed by esophageal perforation-related PPCs (symptomatic pneumomediastinum or pneumoperitoneum; 9/25, 36.0%). In the multivariable analysis, frank perforation during the procedure was the only independent risk factor for PPCs (odds ratio, 8.470, 95% CI, 2.051-34.974, P = 0.003). Although frank perforation during the procedure occurred in 13 patients, 38.5% (5/13) of them did not develop any clinical sequelae after their procedures. Compared with patients without PPCs, patients who developed PPCs took longer to their first oral intake and had prolonged hospital stays (P = 0.047 and 0.026, respectively). CONCLUSIONS Iatrogenic perforation during endoscopic esophageal procedures under general anesthesia was the only independent risk factor for PPCs; therefore, proactive measures and close follow-up are necessary.
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Affiliation(s)
- Go Eun Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Duk Kyung Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji Won Choi
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - In Sun Chung
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Da Woon Jung
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Shin S, Park CH, Kim HJ, Park SH, Lee SK, Yoo YC. Patient satisfaction after endoscopic submucosal dissection under propofol-based sedation: a small premedication makes all the difference. Surg Endosc 2016; 31:2636-2644. [DOI: 10.1007/s00464-016-5276-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 10/04/2016] [Indexed: 12/30/2022]
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Kim JE, Choi JB, Koo BN, Jeong HW, Lee BH, Kim SY. Efficacy of Intravenous Lidocaine During Endoscopic Submucosal Dissection for Gastric Neoplasm: A Randomized, Double-Blind, Controlled Study. Medicine (Baltimore) 2016; 95:e3593. [PMID: 27149489 PMCID: PMC4863806 DOI: 10.1097/md.0000000000003593] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Endoscopic submucosal dissection (ESD) is an advanced therapy for early gastric neoplasm and requires sedation with adequate analgesia. Lidocaine is a short-acting local anesthetic, and intravenous lidocaine has been shown to have analgesic efficacy in surgical settings. The aim of this study was to assess the effects of intravenous lidocaine on analgesic and sedative requirements for ESD and pain after ESD.Sixty-six patients scheduled for ESD randomly received either intravenous lidocaine as a bolus of 1.5 mg/kg before sedation, followed by continuous infusion at a rate of 2 mg/kg/h during sedation (lidocaine group; n = 33) or the same bolus and infusion volumes of normal saline (control group; n = 33). Sedation was achieved with propofol and fentanyl. The primary outcome was fentanyl requirement during ESD. We recorded hemodynamics and any events during ESD and evaluated post-ESD epigastric and throat pain.Fentanyl requirement during ESD reduced by 24% in the lidocaine group compared with the control group (105 ± 28 vs. 138 ± 37 μg, mean ± SD; P < 0.001). The lidocaine group reached sedation faster [40 (20-100) vs. 55 (30-120) s, median (range); P = 0.001], and incidence of patient movement during ESD decreased in the lidocaine group (3% vs. 26%, P = 0.026). Numerical rating scale for epigastric pain was significantly lower at 6 hours after ESD [2 (0-6) vs. 3 (0-8), median (range); P = 0.023] and incidence of throat pain was significantly lower in the lidocaine group (27% vs. 65%, P = 0.003). No adverse events associated with lidocaine were discovered.Administration of intravenous lidocaine reduced fentanyl requirement and decreased patient movement during ESD. Moreover, it alleviated epigastric and throat pain after ESD. Thus, we conclude that the use of intravenous adjuvant lidocaine is a new and safe sedative method during ESD.
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Affiliation(s)
- Ji Eun Kim
- From the Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon (JEK, JBC, HWJ, BHL), and Department of Anesthesiology and Pain Medicine, Severance Hospital, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul (BNK, SYK), Republic of Korea
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Yurtlu DA, Aslan F, Ayvat P, Isik Y, Karakus N, Ünsal B, Kizilkaya M. Propofol-Based Sedation Versus General Anesthesia for Endoscopic Submucosal Dissection. Medicine (Baltimore) 2016; 95:e3680. [PMID: 27196474 PMCID: PMC4902416 DOI: 10.1097/md.0000000000003680] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 04/18/2016] [Accepted: 04/21/2016] [Indexed: 12/20/2022] Open
Abstract
The main objective of this study is to evaluate general anesthesia or propofol-based sedation methods at gastric endoscopic submucosal dissection (ESD) procedures.The anesthetic method administered to cases undergoing upper gastrointestinal ESD between 2013 and 2015 was retrospectively investigated. Procedure time, lesion size, dissection speed, anesthesia time, adverse effects such as gag reflex, nausea, vomiting, cough, number of desaturation episodes (SpO2 < 90%), oropharyngeal suctioning requirements, hemorrhage, perforation, and amount of anesthetic medications were recorded.There were 54 and 37 patients who were administered sedation (group S) and general anesthesia (group G), respectively. The demographics of the groups were similar. The calculated dissection speed was significantly high in group G (36.02 ± 20.96 mm/min) compared with group S (26.04 ± 17.56 mm/min; P = 0.010). The incidence of nausea, cough, number of oropharyngeal suctioning, and desaturation episodes were significantly high in group S compared with that in group G (P < 0.5). While there was no difference between the groups in terms of hemodynamic parameters, in group S the use of propofol and in group G the use of midazolam and fentanyl were significantly higher (P < 0.05). Anesthesia time, postoperative anesthesia care unit, and hospital stay durations were not significantly different between the groups.General anesthesia increased dissection speed and enhanced endoscopist performance when compared with propofol-based sedation technique.
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Affiliation(s)
- Derya Arslan Yurtlu
- From the Anesthesiology and Reanimation Department (DAY, PA, YI, NK, MK); and Gastroenterology Department (FA, BÜ), Katip Çelebi University, İzmir Atatürk Education and Research Hospital, İzmir, Turkey
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Abstract
OPINION STATEMENT Sedation practices in the endoscopy suite have changed dramatically in the decades since the introduction of routine colonoscopy and esophagogastroduodenoscopy (EGD). Patients initially received moderate sedation (or even no sedation), but now frequently receive monitored anesthesia care (MAC). This significant shift has introduced anesthesiologists to the endoscopy suite along with new sedative medications and safety concerns. Appreciating the ramifications of this change requires an understanding of sedation depth, patient selection, drug use, sedation delivery, patient monitoring, recovery from sedation, and patient outcomes. Furthermore, the changing landscape of healthcare quality and reimbursement challenges us to provide the best possible care for our patients in the most economical way possible. The endoscopy suite is a unique sedation environment, and it is the purpose of this article to review those elements that contribute to a uniquely demanding work environment.
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