Sedation in digestive endoscopy: the Athens international position statements

The evolution of informed consent in gastroenterology

With medical litigation on the rise, physicians require a nuanced understanding of the legalities of consenting patients to reduce their liability while practising evidence-based medicine. This study aims to a) clarify the legal duties of gastroenterologists in the UK and USA when gaining informed consent and b) provide recommendations at the international and physician level to improve the consent process and reduce liability.A bibliometric analysis of the Web of Science database with the MeSH terms "gastroenterology" and "informed consent" yielded 383 articles, of which 228 were excluded due to not meeting the inclusion criteria. Of the top 50 articles, 48% were from American institutions and 16% were from the UK. Thematic analysis showed 72% of the articles discussed informed consent in relation to diagnostic procedures, 14% regarding treatment, and 14% regarding research participation.Both the USA and the UK have progressed from previously paternalistic Natanson case (1960) and Bolam test (1957), respectively, where physicians were held to the standard of a "reasonable and prudent medical doctor". The American Canterbury case (1972) and the British Montgomery case (2015) radically shifted the standard of disclosure during the consent process by requiring physicians to explain all information pertinent to a "reasonable patient".It is our recommendation that a two-pronged approach be taken; a) creation of international guidelines for consenting patients for invasive procedures in gastroenterology, and b) development of internationally standardised endoscopy consent forms containing all the details pertinent to a "reasonable patient".

Comparison of a novel mini-oral sulfate tablet and the conventional oral sulfate tablet in bowel preparation for colonoscopy: a prospective, randomized, investigator-blinded, multicenter, non-inferior, phase 3 trial

BACKGROUND AND AIMS

The use of conventional oral sulfate tablets (OSTs) has gained popularity; nonetheless, they may be not only inconvenient to swallow but also difficult to dissolve. A novel mini-OST has recently been developed to enhance compliance with conventional OST use. This study aimed to compare the efficacy, tolerability, and safety between mini-OST and conventional OST.

METHODS

This was a prospective, randomized, investigator-blinded, multicenter, and non-inferior phase 3 trial conducted between September 2022 and December 2022. The efficacy, safety, and tolerability were compared between mini-OST and conventional OST.

RESULTS

Exactly 83 patients were evaluated based on a full analysis set (FAS), whereas 82 patients were evaluated as a per-protocol set (PPS). With respect to the efficacy of preparation, successful and high-quality preparation was excellent in the mini-OST and conventional OST groups on both FAS and PPS analyses, without significant differences between the two groups. On the FAS analysis, the satisfaction and tolerability scores were high in both groups, without significant differences. The first bowel movement after taking the investigational product occurred 30 min earlier in the mini-OST group than in the OST group. Mild, moderate, and severe adverse events (AEs) were comparable between the two groups; however, any AEs were more common in the mini-OST group than in the conventional OST group overall.

CONCLUSIONS

Compared with conventional OST, the novel mini-OST preparation showed similar efficacy, tolerability, and safety, including mild eight solicited AEs and moderate-to-severe AEs. Clinical trial registration NCT05670470.

Safety Profile of Endoscopist-directed Balanced Propofol Sedation for Procedural Sedation: An Experience at a Hospital-based Endoscopy Unit

BACKGROUND

Nurse-administered propofol sedation was restricted to anesthesiologists in 2009, a practice that has contributed to spiraling health care costs in the United States.

AIM

The aim of this study was to evaluate the safety of endoscopist-directed balanced propofol sedation (EDBPS).

MATERIALS AND METHODS

We identified patients undergoing endoscopy with EDBPS from January 1, 2017, to June 20, 2017, and abstracted their medical records. Adverse events (AEs) included: hypoxia (oxygen saturation < 90%); hypotension [(a) systolic blood pressure < 90 mm Hg, (b) systolic blood pressure decline of >50 mm Hg, (c) decline in mean arterial pressure of >30%]; bradycardia (heart rate of < 40 beats/min). Logistic regression identified factors independently associated with AEs.

RESULTS

A total of 1897 patients received EDBPS during the study period [mean age: 55 y (SD=11.4 y); 56.4% women]. Patients received median doses of 50 µg fentanyl, 2 mg of midazolam, and a mean propofol dose of 160±99 mg. There were no major complications (upper 95% confidence interval, 0.19%). Overall, 334 patients (17.6%) experienced a clinically insignificant AE: 65 (3.4%) experienced transient hypoxia, 277 patients (14.6%) experienced hypotension, 2 had transient bradycardia. In bivariate analysis, older age was associated with risk for hypotension, propofol dose was associated with transient hypoxemia, and procedure duration was associated with both hypotension and transient hypoxia. In multivariate analysis, only procedure length was associated with AEs (odds ratio scale 10; odds ratio=1.07; 95% confidence interval, 1.05-1.09, P<0.001).

CONCLUSIONS

EDBPS is safe for endoscopic sedation. Given the higher cost of anesthesia-administered propofol, endoscopists should reinstate EDBPS by revising institutional sedation policies.

Factors Associated with Withdrawal Time in European Colonoscopy Practice: Findings of the European Colonoscopy Quality Investigation (ECQI) Group

The European Colonoscopy Quality Investigation (ECQI) Group aims to raise awareness for improvement in colonoscopy standards across Europe. We analyzed data collected on a sample of procedures conducted across Europe to evaluate the achievement of the European Society of Gastrointestinal Endoscopy (ESGE) mean withdrawal time (WT) target. We also investigated factors associated with WT, in the hope of establishing areas that could lead to a quality improvement. Methods: 6445 form completions from 12 countries between 2 June 2016 and 30 April 2018 were considered for this analysis. We performed an exploratory analysis looking at WT according to the ESGE definition. Stepwise multivariable logistic regression analysis was conducted to determine the most influential associated factors after adjusting for the other pre-specified variables. Results: In 1150 qualifying colonoscopies, the mean WT was 7.8 min. Stepwise analysis, including 587 procedures where all inputs were known, found that the variables most associated with mean WT were a previous total colonoscopy in the last five years (p = 0.0011) and the time of day the colonoscopy was performed (p = 0.0192). The main factor associated with a WT < 6 min was the time of day that a colonoscopy was performed. Use of sedation was the main factor associated with a higher proportion of WT > 10 min, along with a previous colonoscopy. Conclusions: On average, the sample of European practice captured by the ECQI survey met the minimum standard set by the ESGE. However, there was variation and potential for improvement.

Serum electrolytes, osmolality, and cleansing quality after bowel prep for colonoscopy with a PEG solution containing ascorbic acid and electrolytes

BACKGROUND

The cleansing procedure with PEG 3350 + ascorbic acid (PEG + Asc; Moviprep®) requires the additional ingestion of clear liquids. We aimed to determine the effects on serum electrolytes, osmolality and cleansing quality, and in a prospective "real world" trial.

PATIENTS AND METHODS

Patients underwent a standardized split-dose bowel preparation for colonoscopy with PEG + Asc. Serum electrolytes and osmolality were measured before and after the prep procedure. The volume of prep solution (PA) and additional clear liquid (CL) was recorded. Prep quality was assessed using the Ottawa Bowel Prep Grading Scale (OBPS). The primary outcome measures were changes of serum electrolytes and osmolality during the cleansing procedure. A secondary end point was the OPBS.

RESULTS

One hundred ninety-one of 219 patients entered the per protocol analysis. Prep quality was considered excellent in 57.6%, moderate in 20.9%, and insufficient in 21.5%. The number of patients with hyponatremia increased from 12 (6.3%) before to 25 (13.2%) after the prep procedure. Mean sodium concentration did not change significantly. The volume of CL correlated inversely with Na⁺ concentration (r =  - 0.409, p < 0.01) and a worse OBPS (r = 0.198, p < 0.01).

CONCLUSIONS

Bowel preparation with PEG-Asc in clinical routine is generally safe, but patients should be advised not to drink more than 2 l of clear liquid because of imminent electrolyte disturbances. Additionally, the quality of cleansing either remains unchanged or may even worsen.

1 L- versus 2 L-polyethylene glycol with ascorbic acid for bowel preparation in elderly patients: a randomized multicenter study

BACKGROUND

1 L-polyethylene glycol (PEG)/ascorbic acid (Asc) was developed to reduce the required oral preparation volume through increasing osmotic load through containing a greater quantity of ascorbate components. We aimed to compare the efficacy, tolerability, and safety of a split-dosing regimen of 1 L-PEG/Asc versus 2 L-PEG/Asc in elderly patients undergoing scheduled colonoscopy.

METHODS

This was a prospective, non-inferiority, randomized, investigator-blinded multicenter study conducted in Korea between July 2019 and December 2020. Patients aged between 65 and 85 years were randomized at a ratio of 1:1 to either the 1 L-PEG/Asc or 2 L-PEG/Asc group. The efficacy of the bowel preparation was evaluated using the Harefield Cleansing Scale (HCS) and the Boston Bowel Preparation Scale (BBPS).

RESULTS

A total of 202 patients were analyzed. Successful overall bowel preparation was similar between the 1 L-PEG/Asc and 2 L-PEG/Asc groups based on HCS (95.1% vs. 93.1%, P = 0.528) and BBPS (93.1% vs. 90.0%, P = 0.422). The perfect overall bowel preparation rate in the 1 L-PEG/Asc group was higher than that in the 2 L-PEG/Asc group (HCS, 40.2% vs. 25.0%, P = 0.021; BBPS, 80.4% vs. 68.0%, P = 0.044). There were more high-quality bowel preparations for the right colon in the 1 L-PEG/Asc group (HCS, 46.1% vs. 30.0%, P = 0.019; BBPS, 83.3% vs. 70.0%, P = 0.025). The adenoma detection rate (47.1% vs. 49.0%, P = 0.782), rate of adverse events (25.5% vs. 23.0%, P = 0.680), shifts in laboratory results, and tolerability were comparable between the groups.

CONCLUSION

1 L-PEG/Asc was as effective, safe, and tolerable as 2 L-PEG/Asc in elderly patients with comorbidities.

Pain Intensity at Injection Site during Esophagogastroduodenoscopy Using Long- and Medium-Chain versus Long-Chain Triglyceride Propofol: A Randomized Controlled Double-Blind Study

Background/Aims

The intensities of injection pain resulting from the use of long- and medium-chain triglyceride (LCT/MCT) propofol and conventional LCT propofol during esophagogastroduodenoscopy (EGD) have yet to be compared. We aimed to determine the pain intensity caused by different formulations of propofol and to evaluate the formulation that would be preferred by patients as a sedative agent during their next procedure.

Methods

This study was a single-center, randomized, controlled, and double-blind trial. Pain intensity was estimated 30 seconds after propofol injection by an examiner who was blinded to the group assignment using a numeric (0-10) pain rating scale (NPRS). After 1 week, the patients were asked whether they could recall the pain and were willing to receive the same agent for their next EGD.

Results

One hundred twenty-nine patients were randomly assigned to LCT/MCT or LCT group. Although there was no significant difference in pain incidence between the LCT/MCT and LCT groups (52.9% vs 65.6%, p=0.156), the pain intensity was significantly lower in the LCT/MCT group (NPRS median [interquartile range]; 1 (0-2) vs 2 (0-5), p=0.005). After 1 week, fewer patients in the LCT/MCT group recalled the pain (19.1% vs 63.9%, p<0.001) and more patients in the LCT/MCT group were more willing to use the same agent for their next procedure (86.8% vs 72.1%, p=0.048) than in the LCT group.

Conclusions

LCT/MCT propofol significantly reduced injection pain intensity compared to LCT propofol during EGD and preferred by patients as a sedative agent during their next EGD.

Safety and sedation-associated adverse event reporting among patients undergoing endoscopic cholangiopancreatography: a comparative systematic review and meta-analysis

BACKGROUND AND AIM

There is wide variation in choice of sedation and airway management for endoscopic retrograde cholangiopancreatography (ERCP). The aim of this study was to perform a systematic review and meta-analysis to investigate safety outcomes of deep sedation with monitored anesthesia care (MAC) versus general endotracheal anesthesia (GETA).

METHODS

Individualized search strategies were performed in accordance with PRISMA and MOOSE guidelines. This meta-analysis was performed by calculating pooled proportions using random effects models. Measured outcomes included procedure success, all-cause and anesthesia-associated adverse events, and post-procedure recovery time. Heterogeneity was assessed with I² statistics and publication bias by funnel plot and Egger regression testing.

RESULTS

Five studies (MAC: n = 1284 vs GETA: n = 615) were included. Patients in the GETA group were younger, had higher body mass index (BMI), and higher mean ASA scores (all P < 0.001) with no difference in Mallampati scores (P = 0.923). Procedure success, all-cause adverse events, and anesthesia-associated events were similar between groups [OR 1.16 (95% CI 0.51-2.64); OR 1.16 (95% CI 0.29-4.70); OR 1.33 (95% CI 0.27-6.49), respectively]. MAC resulted in fewer hypotensive episodes [OR 0.32 (95% CI 0.12-0.87], increased hypoxemic events [OR 5.61 (95% CI 1.54-20.37)], and no difference in cardiac arrhythmias [OR 0.48 (95% CI 0.13-1.78)]. Procedure time was decreased for MAC [standard difference - 0.39 (95% CI - 0.78-0.00)] with no difference in recovery time [standard difference - 0.48 (95% CI - 1.04-0.07)].

CONCLUSIONS

This study suggests MAC may be a safe alternative to GETA for ERCP; however, MAC may not be appropriate in all patients given an increased risk of hypoxemia.

Guidelines for sedation in gastroenterological endoscopy (second edition)

Sedation in gastroenterological endoscopy has become an important medical option in routine clinical care. Here, the Japan Gastroenterological Endoscopy Society and the Japanese Society of Anesthesiologists together provide the revised "Guidelines for sedation in gastroenterological endoscopy" as a second edition to address on-site clinical questions and issues raised for safe examination and treatment using sedated endoscopy. Twenty clinical questions were determined and the strength of recommendation and evidence quality (strength) were expressed according to the "MINDS Manual for Guideline Development 2017." We were able to release up-to-date statements related to clinical questions and current issues relevant to sedation in gastroenterological endoscopy (henceforth, "endoscopy"). There are few reports from Japan in this field (e.g., meta-analyses), and many aspects have been based only on a specialist consensus. In the current scenario, benzodiazepine drugs primarily used for sedation during gastroenterological endoscopy are not approved by national health insurance in Japan, and investigations regarding expense-related disadvantages have not been conducted. Furthermore, including the perspective of beneficiaries (i.e., patients and citizens) during the creation of clinical guidelines should be considered. These guidelines are standardized based on up-to-date evidence quality (strength) and supports on-site clinical decision-making by patients and medical staff. Therefore, these guidelines need to be flexible with regard to the wishes, age, complications, and social conditions of the patient, as well as the conditions of the facility and discretion of the physician.

Safety Protocols for Videolaryngoscopy During the COVID-19 Pandemic: A Prospective Review of 196 Cases

To prepare safety protocols for performing videolaryngoscopy (VLS) during COVID-19 pandemic, that would be feasible for patients, hospital and the health care providers. This was a prospective study performed from March 01, 2020 to June 30, 2020. It analyzed the precautions adapted for VLS initially and subsequently describes modifications with the time. The safety protocols are developed considering the safety aspect, the feasibility aspect (due to increase in number of the VLS), and the financial aspect. The VLS was performed with the personal protective equipment (PPE), including the face shield mask and head cover. The PPE was re-used after sterilization with ethylene oxide. For local anesthesia, the oropharynx was sprayed with 15% xylocaine and nose packed with 4% xylocaine soaked pledget. Following the VLS, the scope was wiped three times with 80% alcohol and then immersed in 5.25% sodium hypochlorite and 0.55% ortho-phthalaldehyde for 10 min each. Each VLS was spaced by at least 15 min gap. The endoscopy suite maintained with laminar air flow. It can be concluded that during the COVID-19 pandemic, the VLS must be performed using PPE with proper sterilization of the scope and the endoscopy suite after the procedure. The use of face shield mask and 15% xylocaine spray into the oropharynx were also highlighted. The financial burden should be minimized by reusing the materials whenever possible.

Performing High-resolution Impedance Manometry After Endoscopy With Conscious Sedation Has Negligible Effects on Esophageal Motility Results

Background/Aims

High-resolution manometry (HRM) performed without sedation is the standard procedure. However, some patients cannot tolerate transnasal placement of the manometry catheter. We aim to assess the practice of performing manometry after endoscopy with conscious sedation by evaluating its impact on esophageal motility findings.

Methods

Twelve asymptomatic adult volunteers and 7 adult patients completed high-resolution impedance manometry (HRIM) approximately 1 hour after conscious sedation with midazolam and fentanyl (post-sedation) and again on a different day with no-sedation. The nosedation HRIM involved 2 series of swallows separated in time by 20 minutes (no-sedation-1 and no-sedation-2) for the volunteers; patients completed only 1 series of swallows for no-sedation HRM.

Results

A motility diagnosis of normal motility was observed in all 12 volunteers post-sedation. Two volunteers had a diagnosis of borderline ineffective esophageal motility, one during the no-sedation-1 period and the other during the no-sedation-2 period; all of the other no-sedation HRIM studies yielded a normal motility diagnosis. Six of seven patients had the same diagnosis in both no-sedation and post-sedation HRM, including 1 distal esophageal spasm, 3 achalasia (2 type II and 1 type III), and 2 esophagogastric junction outflow obstruction. Only one patient's HRM classification changed from ineffective esophageal motility at no-sedation to normal esophageal motility at post-sedation.

Conclusions

Performing HRIM after endoscopy with conscious sedation had minimal clinical impact on the motility diagnosis or motility parameters. Thus, this approach may be a viable alternative for patients who cannot tolerate unsedated catheter placement.

The impact of sedation on quality metrics of colonoscopy: a single-center experience of 48,838 procedures

PURPOSE

Investigation of the role of sedation during colonoscopy is meaningful as the advantages of colonoscopy performing with sedation are still controversial.

METHODS

Medical records of patients who underwent colonoscopy in our institution were retrospectively analyzed. The sedation rate, adenoma detection rate (ADR), polyp detection rate (PDR), cecal intubation rate (CIR), iatrogenic colonic perforation rate (ICP) were calculated.

RESULTS

A total of 48,838 colonoscopies (24,498 in males) dated from July 2007 to February 2017 were analyzed. The median age was 50 years (range 16-85 years). An overall sedation rate was 80.38%. The PDR was 26.77%, and was not statistically different between colonoscopy with or without sedation (26.67% vs 27.22, p = 0.474). ADR was 12.9% regardless of applying sedation or not (13.0% vs 12.44%, p = 0.337). The CIR was 87.42% in all examinations with an adjusted CIR of 90.34%, and was higher when performed with sedation than without sedation (88.92% vs 80.64%, p < 0.0001). Five cases (0.01%) of ICP were reported, all of which occurred in patients under sedation.

CONCLUSIONS

The use of sedation is associated with increased CIR, but ADR and PDR remain unchanged with or without sedation. However, perforation rate, albeit very low, is significantly higher in sedated patients.

Endoscopist-Directed Propofol as an Adjunct to Standard Sedation: A Canadian Experience

Background

Sedation practices vary widely by region. In Canada, endoscopist-directed administration of a combination of fentanyl and midazolam is standard practice. A minority of cases are performed with propofol.

Aims

To describe the safety of nonanaesthetist administered low-dose propofol as an adjunct to standard sedation.

Methods

This was a single-centre retrospective study of patients having undergone endoscopic procedures with propofol sedation between 2004 and 2012 in a teaching hospital in Montreal. Procedures were performed by gastroenterologists trained in Advanced Cardiovascular Life Support. Sedation was administered by intravenous bolus by a registered nurse, under the direction of the endoscopist. Outcomes of procedures were collected in the context of a retrospective chart review using the hospital's endoscopy database.

Results

Of patients undergoing endoscopies at our centre, 4930 patients received propofol as an adjunct to standard sedation with fentanyl and midazolam. Cecal intubation rate for colonoscopies (n = 2921) was 92.0%. Gastroscopies (n = 1614), flexible sigmoidoscopies (n = 28), endoscopic retrograde cholangiopancreatography (n = 331) and percutaneous endoscopic gastrostomy insertion (n = 36) had success rates, defined as successful completion of the procedure within anatomical limits, of 99.0, 96.4, 94.0 and 91.7%, respectively. The average dose of propofol used for each procedure was 34.5 ± 20.8 mg. Fentanyl was used in 67.4% of procedures at an average dose of 94.3 ± 17.5 mcg. Midazolam was used in 92.7% of cases at an average dose of 3.0 ± 0.7 mg. Reversal agents (naloxone or flumazenil) were used in 0.43% of the cases (n = 21). Patients who received propofol were discharged uneventfully within the usual postprocedure recovery time. One patient required sedation-related hospitalization. For patients having received propofol in addition to standard sedation agents, 99.6% experienced no adverse events. There were no mortalities.

Conclusion

The use of low-dose propofol as an adjunct to fentanyl and midazolam, administered by a registered nurse under the direction of the endoscopist was safe and effective in patients at our centre.

Causative factors of discomfort in esophagogastroduodenoscopy: A large-scale cross-sectional study

BACKGROUND

It is important to reduce patient discomfort in esophagogastroduodenoscopy. Remedial measures can be taken to alleviate discomfort if the causative factors are determined; however, all the factors have not been elucidated yet.

AIM

To clearly determine the factors influencing discomfort in transoral esophagogastroduodenoscopy using a large-size cross-sectional study with readily available data.

METHODS

Consecutive patients who underwent screening transoral esophagogastroduodenoscopy consecutively between August 2017 and October 2017 at a health check-up center were included. Discomfort was evaluated using a face scale between 0 and 10 with a 6-level questionnaire. Univariate and multiple regression analyses were performed to investigate the factors related to the discomfort in esophagogastroduodenoscopy. Univariate analysis was performed in both the unsedated and sedated study groups. Age, sex, height, body mass index, smoking status, alcohol intake, hiatal hernia, history of gastrectomy, biopsy during examination, Lugol’s solution usage, administration of butylscopolamine with/without a sedative (pethidine, midazolam, or both), endoscope model, history of endoscopy, and endoscopists were considered as possible factors of discomfort.

RESULTS

Finally, 1715 patients were enrolled in this study. Overall, the median discomfort score was 2 and the interquartile range was 2-4. High discomfort (score ≥ 6) was recorded in 18% of the participants. According to univariate analysis, in the unsedated group, young age (P < 0.001), female sex (P < 0.001), and no history of endoscopy (P < 0.001) were factors associated with increased discomfort. Significant differences were also noted for height (P = 0.007), smoking status (P = 0.003), and endoscopists (P < 0.001). In the sedation group, young age (P < 0.001), female sex (P < 0.001), and no history of endoscopy (P = 0.004) were associated with increased discomfort; additionally, significant differences were found in smoking status (P < 0.001), type of sedation (P < 0.001), and endoscopists (P = 0.027). There was also a marginal difference due to alcohol intake (P = 0.055). Based on multiple regression analysis, young age, female sex, less height, current smoking status, and presence of hiatal hernia [regression coefficients of 0.08, P < 0.001 (for -1 years); 0.45, P = 0.013; 0.02, P = 0.024 (for -1 cm); 0.35, P = 0.036; and 0.34, P = 0.003, respectively] were factors that significantly increased discomfort in esophagogastroduodenoscopy. Alternatively, sedation significantly reduced discomfort and pethidine (regression coefficient: -1.47, P < 0.001) and midazolam (regression coefficient: -1.63, P = 0.001) significantly reduced the discomfort both individually and in combination (regression coefficient: -2.92, P < 0.001). A difference in the endoscopist performing the procedure was also associated with discomfort.

CONCLUSION

Young age, female sex, and smoking are associated with esophagogastroduodenoscopy discomfort. Additionally, heavy alcohol consumption diminished the effects of sedation. These factors are easily obtained and are thus useful.

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.

The Benefit of Fentanyl in Effective Sedation and Quality of Upper Endoscopy: A Double-Blinded Randomized Trial of Fentanyl Added to Midazolam Versus Midazolam Alone for Sedation

Aims

Our goals were to compare the effect of adding fentanyl to midazolam in a double-blinded, randomized, placebo-controlled trial and determine if fentanyl enhances sedation, increases adverse events or effects time of the procedure or discharge.

Methods

Patients 18 to 65 years scheduled for outpatient upper endoscopy were eligible for the study. Patients were randomized to receive either 100 mcg/2 mL of Fentanyl or 2 mL of placebo IV with a double-blinded protocol. All patients received 2 mg of intravenous midazolam initially. Additional midazolam could be given to achieve adequate sedation.

Results

There were 68 patients randomized to the Fentanyl group and 69 patients to the placebo group. The mean dose of midazolam was 4.0 mg for the Fentanyl group and 5.2 mg for placebo group (P=0.003). Both endoscopist and nurse independently rated sedation to be better in the fentanyl group (P=0001). The patient did not perceive any difference in sedation (P=0.4). Procedure time was significantly shorter in the Fentanyl group (8.5 versus 11.1 minutes, P=0.001), with no difference in the discharge time. There was significantly less retching observed in patients in the fentanyl group (P<0.001). There were no major complications.

Conclusions

Endoscopists and nurses found adding fentanyl significantly improved sedation, led to a shorter procedure time, and allowed for less midazolam to be used per case. It did not affect the patient experience of sedation and was safe. Fentanyl use for routine outpatient upper endoscopy should be considered as a safe option to improve procedural sedation.NCT:01514695 (www.clinicaltrials.gov)Accepted as an abstract for the Canadian Digestive Diseases Week meeting in February 2014.

Does 2-L Split-Dose Polyethylene Glycol Bowel Preparation Improve the Quality of Screening Colonoscopy?

Effectiveness of colonoscopy as a screening tool for colorectal cancer prevention depends on the quality of bowel preparation. The type of bowel preparation agent prescribed is largely dependent on the prescriber's preference, indicating a lack of standard. A retrospective study (N = 84) compared the quality of bowel preparation using 2-L split-dose polyethylene glycol prep (MoviPrep) to other standard bowel preparations. Colonic mucosa visualized using the Boston Bowel Preparation Scale, cecal intubation indicating successful completion of colonoscopy, scope withdrawal time, and procedure duration were measured as outcomes. Gastroenterologists from one academic practice prescribed 2-L split-dose bowel preparation (MoviPrep) (Group A) compared with Group B that did not prescribe MoviPrep. Results of an independent t test between the 2 provider groups demonstrated a statistically significant difference in colon visualization based on Boston Bowel Preparation Score (t [40] = - 2.1, p = .035). Similar statistically significant results were seen within Group A, which received 2-L split-dose polyethylene glycol bowel preparation and other preparations (t [61] = - 2.55, p = .013). All patients had successful completion of colonoscopy, with no statistical difference in procedure duration and scope withdrawal time. Future studies should confirm the benefits of 2-L split-dose polyethylene glycol preparation for improved colon visualization during screening colonoscopy.

Italian Society of Digestive Endoscopy (SIED) position paper on the non-anaesthesiologist administration of propofol for gastrointestinal endoscopy

Propofol sedation by non-anesthesiologists in GI endoscopy, despite generally considered a safe procedure, is still a matter of debate. Benefits of propofol sedation include rapid onset of action, greater patient comfort and fast recovery with prompt discharge from the endoscopy unit. The use of propofol for sedation in GI endoscopy, preceded by dedicated training courses, has been approved by several anaesthesiologist and gastroenterologist societies but an Italian position paper taking into account the Italian law is lacking. In the present document, the Italian Society of Digestive Endoscopy (SIED) Sedation Group, on behalf of the SIED, presents a series of updated position statements concerning propofol sedation in GI endoscopy. The paper summarizes the advantages of propofol, how it should be administered and how patients should be monitored. Moreover, details concerning proper training of non-anaesthesiologist personnel involved in its use are provided. Protocols concerning propofol use s must be shared with the hospital's anaesthesiology staff and approved by the hospital's Executive Director.

Similar Risk of Cardiopulmonary Adverse Events Between Propofol and Traditional Anesthesia for Gastrointestinal Endoscopy: A Systematic Review and Meta-analysis

BACKGROUND & AIMS

Even though propofol use for gastrointestinal endoscopic procedures has increased over the past decade, there is a perception that it causes a higher rate of cardiopulmonary adverse events. The aim of this study was to compare the sedation-related adverse events associated with use of propofol vs nonpropofol agents for endoscopic procedures. We also wanted to determine the influence of duration or complexity of the procedures and endoscopist-directed (gastroenterologist) vs non-gastroenterologist-directed sedation on the outcomes.

METHODS

A search was conducted using Medline, EMBASE, and the Cochrane controlled trials registry. The following cardiopulmonary adverse events were assessed: hypoxia, hypotension, and arrhythmias. The procedures were divided into 2 groups based on the procedure length: a nonadvanced endoscopic procedure group consisting of esophagogastroduodenoscopy, colonoscopy, and sigmoidoscopy, and an advanced endoscopic procedures group including endoscopic retrograde cholangiopancreatography, endoscopic ultrasonography, balloon enteroscopy, and endoscopic submucosal dissection. Pooled odds ratios for complications were calculated for all the procedures combined and then separately for the 2 groups. Random-effects models were used for 2-proportion comparisons.

RESULTS

Of the 2117 citations identified, 27 original studies qualified for this meta-analysis and included 2518 patients. Of these, 1324 received propofol, and 1194 received midazolam, meperidine, pethidine, remifentanil, and/or fentanyl. Most of the included studies were randomized trials of moderate quality and nonsignificant heterogeneity (Cochran Q, 26.07; P = .13). Compared with traditional sedative agents, the pooled odds ratio with the use of propofol for developing hypoxia for all the procedures combined was 0.82 (95% confidence interval [CI], 0.63-1.07), and for developing hypotension was 0.92 (95% CI, 0.64-1.32). In the nonadvanced endoscopic procedure group, those who received propofol were 39% less likely to develop complications than those receiving traditional sedative agents (odds ratio, 0.61; 95% CI, 0.38-0.99). There was no difference in the complication rate for the advanced endoscopic procedure group (odds ratio, 0.86; 95% CI, 0.56-1.34). A subgroup analysis did not show any difference in adverse events when propofol was administered by gastroenterologists or nongastroenterologists.

CONCLUSIONS

Propofol sedation has a similar risk of cardiopulmonary adverse events compared with traditional agents for gastrointestinal endoscopic procedures. Propofol use in simple endoscopic procedures was associated with a decreased number of complications. When used for gastrointestinal endoscopic procedures of a complex nature and longer duration, propofol was not associated with increased rates of hypoxemia, hypotension, or arrhythmias. Administration of propofol by gastroenterologists does not appear to increase the complication rates.

Patient safety under deep sedation for digestive endoscopic procedures

Deep sedation with Propofol has become popular in recent years. The safety of this technique when administered by non-anaesthesiologists has created much controversy which at times is masked in a contentious debate on the economic sustainability of the health system. In 2011, the Spanish Society of Anaesthesiology, Resuscitation and Pain Therapy, along with 20 other organisations from European countries, revoked the recommendations of the European Society of Gastrointestinal Endoscopy on the administration of Propofol by non-anaesthesiologists, citing that it is "extremely dangerous for the safety and quality of endoscopic procedures". The FDA in 2005 had already rejected the use of Propofol by non-anaesthesiologists in the United States, a prohibition which was reiterated in 2010 and is still in force, basing its evidence, among others, on the recommendations and guidelines of the Joint Commission and the Declaration of Helsinki. In Spain, the data sheet of Propofol restricts the use of the drug to anaesthesiologists and intensivists in intensive care units. In our opinion, the key elements to discuss (which we develop in our paper) are those related to: a) the morbidity and mortality of sedation (which is the same as speaking about the factors that influence its safety); b) the appropriate professionals to use this technique; and c) economic aspects related to the use of said technique. Our conclusion is that a technique cannot be declared safe when a high percentage of patients present with varying respiratory depression (and therefore hypoxaemia) and hypotension. We are confident that the collaboration of the Spanish Society of Digestive Pathology and the Spanish Society of Digestive Endoscopy with the Spanish Society of Anaesthesiology, Resuscitation and Pain Therapy is the first step towards finding a satisfactory solution for everyone, and especially for our patients.

A prospective, randomized, single-blind study evaluating the effectiveness, tolerability, and cost of colonoscopy bowel preparations

Colorectal cancer, the third most common cancer in U.S. adults, can be detected early through colonoscopy. Thorough bowel preparation facilitates successful colonoscopy. Effectiveness, tolerability, and costs of 3 bowel preparations were compared in patients undergoing outpatient screening colonoscopy. In this prospective, randomized, single-blind study, comparing three preparation protocols, 209 of 276 consented subjects completed (Protocol [N = 67] = HalfLytely© 1 L × 2 doses and bisacodyl 5 mg delayed release tablets × 2 tablets; Protocol 2 [N = 74] = MiraLAX® 5 tablespoons × 2 doses and bisacodyl 5 mg tablets × 2 tablets; and Protocol 3 [N = 68] = MoviPrep 1 L × 2 doses). Patients completed symptom diaries and a gastroenterologist rated effectiveness. Most subjects were White females, aged 59 years (mean). Protocol 1 was the most effective regimen, but Protocol 2 was the most tolerable and cost-effective. While the three bowel protocol differences were not statistically significant for all outcomes measured, there were clinically meaningful differences. As Protocol 1 was most effective, HalfLytely© and bisacodyl is recommended for patients prior to colonoscopy. For patients who cannot tolerate HalfLytely© or MoviPrep, or with financial concerns, Protocol 2 (MiraLAX® & bisacodyl) is alternatively recommended.

Addition of Lubiprostone to polyethylene glycol(PEG) enhances the quality & efficacy of colonoscopy preparation: a randomized, double-blind, placebo controlled trial

Background

Adequate bowel preparation is an essential prerequisite for complete mucosal visualization during colonoscopy. Polyethylene glycol (PEG) solutions are commonly used. However the large volume of the solution is often poorly tolerated. Addition of Lubiprostone (LB) could improve the adequacy of standard PEG preparation & reduce requirement. The aims to assess adequacy of PEG preparation with addition of single dose LB (24mcg) vs placebo and efficacy of reduced dose PEG + LB compared with full dose PEG + LB.

Methods

Single center prospective double blind randomized controlled trial. Part I: 442 patients for colonoscopy randomized to receive placebo (GrA) or single dose of LB (GrB) prior to PEG preparation. Quality of bowel preparation graded 0–9 according to Boston Bowel Preparation Scale (BBPS). BBPS-9: excellent and BBPS 0–4: repeat procedure.

Part II: 146 patients randomized to receive LB + 1.5 L PEG (GrC; 75) or LB + 1 L PEG (GrD; 71). BBPS score compared with GrB (2 L PEG).

Results

Part I: 442 patients (221 GrA & 221 Gr B). LB resulted in significant improvement in total BBPS (7.44 + 0.14 vs. 6.36 + 0.16, p < 0.0001). 66.5 % Gr B vs 38 % Gr A had excellent prep; 42.5 % GrB vs 24 % GrA had adequate prep. Repeat procedure needed 9.5 % Gr B vs 16.7 % Gr A (P < 0.01).

Part II: No difference in BBPS scores with lower doses (Gr C&D) compared to standard (GrB) (Mean BBPS 7.44 + 0.14 GrA,7.30 + 0.25 GrC;7.25 + 0.26 GrD;p >0.05).

Conclusion

Single dose LB prior to PEG significantly enhanced bowel preparation compared to PEG alone. There was no significant difference in quality of preparation with lower doses of PEG when combined with LB.

Trial registration

The study protocol was approved by institutional review board and the trial was registered on March 22, 2011 with clinicaltrials.gov (NCT01324284).

Practice guidelines for propofol sedation by non-anesthesiologists: the Korean Society of Anesthesiologists Task Force recommendations on propofol sedation

In South Korea, as in many other countries, propofol sedation is performed by practitioners across a broad range of specialties in our country. However, this has led to significant variation in propofol sedation practices, as shown in a series of reports by the Korean Society of Anesthesiologists (KSA). This has led the KSA to develop a set of evidence-based practical guidelines for propofol sedation by non-anesthesiologists. Here, we provide a set of recommendations for propofol sedation, with the aim of ensuring patient safety in a variety of clinical settings. The subjects of the guidelines are patients aged ≥ 18 years who were receiving diagnostic or therapeutic procedures under propofol sedation in a variety of hospital classes. The committee developed the guidelines via a de novo method, using key questions created across 10 sub-themes for data collection as well as evidence from the literature. In addition, meta-analyses were performed for three key questions. Recommendations were made based on the available evidence, and graded according to the modified Grading of Recommendations Assessment, Development and Evaluation system. Draft guidelines were scrutinized and discussed by advisory panels, and agreement was achieved via the Delphi consensus process. The guidelines contain 33 recommendations that have been endorsed by the KSA Executive Committee. These guidelines are not a legal standard of care and are not absolute requirements; rather they are recommendations that may be adopted, modified, or rejected according to clinical considerations.

Training and Competency in Sedation Practice in Gastrointestinal Endoscopy

The practice of endoscopic sedation requires a thorough understanding of preprocedural assessment, sedation pharmacology, intraprocedure monitoring, adverse event management, and postprocedural care. The training process has become increasingly standardized and entails knowledge and practice-based components. The use of propofol in particular requires a higher level of structured training owing to its narrow therapeutic window. Simulation has increased opportunities for practice-based training in a controlled environment. After completion of training, the endoscopist must demonstrate competence in theoretical understanding and technical ability to administer sedation. Although individual institutions have certification processes, there is a lack of validated, standardized methods to confirm competence.

Thoracoscopy: medical versus surgical-in the management of pleural diseases

Diseases of the pleura continue to affect a large population of patients worldwide and in the United States. Pleural fluid analysis and accompanying imaging of the pleura including chest X-rays, chest computed tomography (CT) scan and chest ultrasonography are among the first steps in the management of pleural effusions. When further diagnostic or therapeutic work up is necessary, open thoracotomy and thoracoscopy come to mind. However, given the significant morbidity and mortality associated with open thoracotomy, and the advances in medicine and medical instruments, thoracoscopy has now become a routine procedure in the management of the disease of the chest including pleura. Debates about surgical vs. medical thoracoscopy (MT) are ongoing. In the following pages we review the literature and discuss the similarities and differences between the two procedures, as well as their indications, contraindications, complications and efficacy in the management of pleural diseases.

The use of low-volume polyethylene glycol containing ascorbic acid versus 2 L of polyethylene glycol plus bisacodyl as bowel preparation for colonoscopy

OBJECTIVE

Low-volume polyethylene glycol (PEG) bowel preparations have been developed to improve compliance for colonoscopy. Our study aimed to compare the efficacy and tolerability of low-volume PEG containing ascorbic acid for colonoscopy against 2 L of PEG plus bisacodyl.

METHODS

We prospectively enrolled consecutive inpatients who had not undergone polypectomy at the index colonoscopy and were subsequently referred for polypectomy at our hospital. A total of 62 patients were randomized to receive either low-volume PEG containing ascorbic acid (n = 31) or 2 L of PEG plus bisacodyl (n = 31) as a split-dose regimen in inpatients. The efficacy of preparation was determined using the Ottawa Bowel Preparation Score (OBPS) and a 4-point scale. Adverse events, tolerability, and willingness were evaluated using a questionnaire.

RESULTS

Based on the OBPS and 4-point scale, we determined that the efficacy of low-volume PEG containing ascorbic acid was comparable to that of the 2 L of PEG plus bisacodyl (p = 0.071 for OBPS, p = 0.056 for the 4-point scale). Adverse events were comparable between the two groups (p = 1.000). A greater proportion of patients in the low-volume PEG containing ascorbic acid (90.6%) and the 2L of PEG plus bisacodyl (96.9%) were willing to repeat the same preparation for subsequent colonoscopy.

CONCLUSION

Low-volume PEG containing ascorbic acid had comparable efficacy and tolerability to 2 L of PEG plus bisacodyl, when given as a split dose, for colonoscopy in inpatients. Split-dose low-volume PEG containing ascorbic acid is a good alternative for bowel preparation for colonoscopy in inpatients.

Guidelines for sedation in gastroenterological endoscopy

Recently, the need for sedation in gastrointestinal endoscopy has been increasing. However, the National Health Insurance Drug Price list in Japan does not include any drug specifically used for the sedation. Although benzodiazepines are the main medication, their use in cases of gastrointestinal endoscopy has not been approved. This has led the Japan Gastrointestinal Endoscopy Society to develop the first set of guidelines for sedation in gastrointestinal endoscopy on the basis of evidence-based medicine in collaboration with the Japanese Society for Anesthesiologists. The present guidelines comprise 14 statements, five of which were judged to be valid on the highest evidence level and three on the second highest level. The guidelines are not intended to strongly recommend the use of sedation for gastrointestinal endoscopy, but rather to indicate the policy as to the choice of appropriate procedures when such sedation is deemed necessary. In clinical practice, the final decision as to the use of sedation should be made by physicians considering patient willingness and physical condition.

Comparison of the efficacy and safety of sedation between dexmedetomidine-remifentanil and propofol-remifentanil during endoscopic submucosal dissection

AIM: To compare the efficacy and safety of sedation protocols for endoscopic submucosal dissection (ESD) between dexmedetomidine-remifentanil and propofol-remifentanil.

METHODS: Fifty-nine patients scheduled for ESD were randomly allocated into a dexmedetomidine-remifentanil (DR) group or a propofol-remifentanil (PR) group. To control patient anxiety, dexmedetomidine or propofol was infused to maintain a score of 4-5 on the Modified Observer’s Assessment of Alertness/Sedation scale. Remifentanil was infused continuously at a rate of 6 μg/kg per hour in both groups. The ease of advancing the scope into the throat, gastric motility grading, and satisfaction of the endoscopist and patient were assessed. Hemodynamic variables and hypoxemic events were compared to evaluate patient safety.

RESULTS: Demographic data were comparable between the groups. The hemodynamic variables and pulse oximetry values were stable during the procedure in both groups despite a lower heart rate in the DR group. No oxygen desaturation events occurred in either group. Although advancing the scope into the throat was easier in the PR group (“very easy” 24.1% vs 56.7%, P = 0.010), gastric motility was more suppressed in the DR group (“no + mild” 96.6% vs 73.3%, P = 0.013). The endoscopists felt that the procedure was more favorable in the DR group (“very good + good” 100% vs 86.7%, P = 0.042), whereas patient satisfaction scores were comparable between the groups. En bloc resection was performed 100% of the time in both groups, and the complete resection rate was 94.4% in the DR group and 100% in the PR group (P = 0.477).

CONCLUSION: The efficacy and safety of dexmedetomidine and remifentanil were comparable to propofol and remifentanil during ESD. However, the endoscopists favored dexmedetomidine perhaps due to lower gastric motility.

Sedation in gastrointestinal endoscopy: a prospective study comparing nonanesthesiologist-administered propofol and monitored anesthesia care

INTRODUCTION

Adequate sedation is one of the cornerstones of good quality gastrointestinal endoscopy (GIE). Propofol sedation has increased significantly but there has been much debate over whether it can be administered by endoscopists. The aim of this prospective trial was to compare nonanesthesiologist-administered propofol (NAAP) and monitored anesthesia care (MAC).

METHODS

A total of 2000 outpatients undergoing GIE at Hospital Albert Einstein (São Paulo, Brazil), a tertiary-care private hospital, were divided into two matched groups: NAAP (n = 1000) and MAC (n = 1000). In NAAP, propofol doses were determined by the endoscopist. A second physician stayed in the room during the entire procedure, according to local regulations. In MAC, the anesthesiologist administered propofol.

RESULTS

In total, 1427 patients (71.3 %) were ASA (American Society of Anesthesiologists) class I and 573 were ASA class II. In NAAP, patients received more propofol + fentanyl (61.1 % vs. 50.5 %; P < 0.05) and there were fewer cases of deep sedation (44.7 % vs. 66.1 %; P < 0.05). Hypoxemia rates were similar (12.8 % for NAAP and 11.2 % for MAC; P = 0.3) but these reverted more rapidly in MAC (4.22 seconds vs. 7.26 seconds; P < 0.05). Agitation was more frequent in MAC (14.0 % vs. 5.6 %; P < 0.05). No later complications were observed. Patient satisfaction was very high and similar in both groups.

CONCLUSION

In this setting, NAAP was as safe and effective as MAC for healthy patients undergoing GIE. Clinical trial ref. no.: U1111-1134-4430.

Gastric emptying evaluation by ultrasound prior colonoscopy: An easy tool following bowel preparation

AIM: To investigate the gastric emptying after bowel preparation to allow general anaesthesia.

METHODS: A prospective, non-comparative, and non-randomized trial was performed and registered on Eudra CT database (2011-002953-80) and on www.trial.gov (NCT01398098). All patients had a validated indication for colonoscopy and a preparation using sodium phosphate (NaP) tablets. The day of the procedure, patients took 4 tablets with 250 mL of water every 15 min, three times. The gastric volume was estimated every 15 min from computed antral surfaces and weight according to the formula of Perlas et al (Anesthesiology, 2009). Colonoscopy was performed within the 6 h following the last intake.

RESULTS: Thirty patients were prospectively included in the study from November 2011 to May 2012. The maximum volume of the antrum was 212 mL, achieved 15 min after the last intake. 24%, 67% and 92% of subjects had an antral volume below 20 mL at 60, 120 and 150 min, respectively. 81% of patients had a Boston score equal to 2 or 3 in each colonic segment. No adverse events leading to treatment discontinuation were reported.

CONCLUSION: Gastric volume evaluation appeared to be a simple and reliable method for the assessment of gastric emptying. Data allow considering the NaP tablets bowel preparation in the morning of the procedure and confirming that gastric emptying is achieved after two hours, allowing general anaesthesia.

Effect of propofol anesthesia on force application during colonoscopy

BACKGROUND

Sedation is frequently used during colonoscopy to control patient discomfort and pain. Propofol is associated with a deeper level of sedation than is a combination of a narcotic and sedative hypnotic and, therefore, may be associated with an increase in force applied to the colonoscope to advance and withdraw the instrument.

OBJECTIVE

To compare force application to the colonoscope insertion tube during propofol anesthesia and moderate sedation.

DESIGN

An observational cohort study of 13 expert and 12 trainee endoscopists performing colonoscopy in 114 patients. Forces were measured by using the colonoscopy force monitor, which is a wireless, handheld device that attaches to the insertion tube of the colonoscope.

SETTING

Community ambulatory surgery center and academic gastroenterology training programs.

PATIENTS

Patients undergoing routine screening or diagnostic colonoscopy with complete segment force recordings.

MAIN OUTCOME MEASUREMENTS

Axial and radial forces and examination time.

RESULTS

Axial and radial forces increase and examination time decreases significantly when propofol is used as the method of anesthesia.

LIMITATIONS

Small study, observational design, nonrandomized distribution of sedation type and experience level, different instrument type and effect of prototype device on insertion tube manipulation.

CONCLUSIONS

Propofol sedation is associated with a decrease in examination time and an increase in axial and radial forces used to advance the colonoscope.

Endoscopic sedation: from training to performance

Adequate sedation and analgesia are considered essential requirements to relieve patient discomfort and pain and ultimately to improve the outcomes of modern gastrointestinal endoscopic procedures. The willingness of patients to undergo sedation during endoscopy has increased steadily in recent years and standard sedation practices are needed for both patient safety and successful procedural outcomes. Therefore, regular training and education of healthcare providers is warranted. However, training curricula and guidelines for endoscopic sedation may have conflicts according to varying legal frameworks and/or social security systems of each country, and well-recognized endoscopic sedation training systems are not currently available in all endoscopy units. Although European and American curricula for endoscopic sedation have been extensively developed, general curricula and guidelines for each country and institution are also needed. In this review, an overview of recent curricula and guidelines for training and basic performance of endoscopic sedation is presented based on the current literature.

Evaluation of Pharyngeal Function between No Bolus and Bolus Propofol Induced Sedation for Advanced Upper Endoscopy

This study aimed to assess pharyngeal function between no bolus and bolus propofol induced sedation during gastric endoscopic submucosal dissection. A retrospective study was conducted involving consecutive gastric cancer patients. Patients in the no bolus group received a 3 mg/kg/h maintenance dose of propofol after the initiation of sedation without bolus injection. All patients in the bolus group received the same maintenance dose of propofol with bolus 0.5 mg/kg propofol injection. Pharyngeal functions were evaluated endoscopically for the first 5 min following the initial administration of propofol. Fourteen patients received no bolus propofol induction and 13 received bolus propofol induction. Motionless vocal cords were observed in 2 patients (14%) in the no bolus group and 3 (23%) in the bolus group. Trachea cartilage was not observed in the no bolus group but was apparent in 6 patients (46%) in the bolus group (P < 0.01). Scope stimulated pharyngeal reflex was observed in 11 patients (79%) in the no bolus group and in 3 (23%) in the bolus group (P < 0.01). Propofol induced sedation without bolus administration preserves pharyngeal function and may constitute a safer sedation method than with bolus.

Safety of non-anaesthesiologist-administered propofol sedation in ERCP

BACKGROUND AND STUDY AIMS

Propofol is increasingly being used for sedation purposes during endoscopic retrograde cholangiopancreatography (ERCP). This study aimed to evaluate the safety of non-anaesthesiologist administration of propofol (NAAP) during therapeutic ERCP.

PATIENTS AND METHODS

Patients, who underwent ERCP at Centre for Liver and Digestive Diseases, Holy Family Hospital, Rawalpindi, were included in the study. Propofol sedation was administered by a physician who was a non-anaesthesiologist certified in basic and advanced cardiac life support. The total study duration was 6 months. The primary outcome variable was the frequency of any sedation-related complication.

RESULTS

A total of 156 patients (41% males and 59% females) were enrolled in the study. The mean propofol dose used during the procedure was 201±132 mg. The mean propofol dose, when adjusted to weight and duration of procedure, was 0.05±0.04 mg kg(-1)min(-1). According to the American Society of Anesthesiologists (ASA) classification, 136 (87%) patients were placed in ASA class I and II and 20 (13%) patients were of ASA class III. Only two patients developed sedation-related complication: one minor requiring bag-mask ventilation and other major requiring mechanical ventilation via endotracheal intubation. Both were managed by the trained non-anaesthesiologist and gastroenterologist at the place of procedure. No patients required cardiopulmonary resuscitation and admission to the intensive care unit. There were no sedation-related deaths.

CONCLUSION

NAAP sedation can be considered safe for low-risk patients (ASA class I and II) undergoing ERCP. The presence of a trained anaesthetist is advisable in high-risk patients (ASA class III and higher) with significant co-morbidities.

Target-controlled infusion of propofol versus intermittent bolus of a sedative cocktail regimen in deep sedation for gastrointestinal endoscopy: comparison of cardiovascular and respiratory parameters

OBJECTIVE

To investigate whether target-controlled infusion (TCI) with propofol, a method that has theoretically better control of drug concentration, produces less cardiovascular and respiratory suppression than an intermittent bolus of a sedative cocktail regimen in deep sedation for gastrointestinal endoscopy.

METHODS

In total 100 participants who had undergone esophagoduodenoscopy (EGD) and 120 who had undergone colonoscopy were prospectively and randomly enrolled to receive TCI with propofol or intermittent bolus of cocktail regimen containing midazolam, alfentanil and propofol until they were unresponsive to verbal commands. The target concentration was adjusted and the bolus of the cocktail regimen was added based on their responses. The nadir values of heart rate, blood pressure and oxygen saturation during and after the procedure were recorded.

RESULTS

The nadir systolic blood pressure during the endoscopy in the cocktail regimen group was significantly lower than that in the TCI with propofol group. In the cocktail regimen group, the incidence of hypotension during colonoscopy and that of bradycardia during EGD were higher than those in the TCI with propofol group. No participants in the TCI with propofol group experienced hypoxia during endoscopy. In the cocktail regimen group, six participants who had undergone EGD and six who had undergone colonoscopy showed transient hypoxic episodes during or after endoscopy.

CONCLUSION

TCI with propofol produced less cardiovascular and respiratory suppression than intermittent bolus of a sedative cocktail regimen in deep sedation for gastrointestinal endoscopy.

Complications of colonoscopy

Colonoscopy is a relatively invasive modality for the diagnosis and treatment of colorectal disease and for the prevention or early detection of colorectal neoplasia. Millions of colonoscopies are performed each year in the United States by endoscopists with varying levels of skill in colons that present varying levels of challenge. Although better scope technology has made colonoscopy gentler and more accurate, the sheer number of examinations performed means that complications inevitably occur. This article considers the most common complications of colonoscopy, and advises how to minimize their incidence and how to treat them if they do occur.

Classification of patients who experience a higher distress level to transoral esophagogastroduodenoscopy than to transnasal esophagogastroduodenoscopy

BACKGROUND

In Japanese routine clinical practice, endoscopy is generally carried out without sedation. The present study aimed to identify the factors essential for appropriate selection of transnasal esophagogastroduodenoscopy (TN-EGD) as an alternative to unsedated transoral esophagogastroduodenoscopy (TO-EGD).

PATIENTS AND METHODS

Subjects in this prospective cohort study comprised consecutive outpatients who underwent EGD at a single center. Factors predicting TO-EGD-induced distress were evaluated on a visual analog scale (VAS) and analyzed. Patients were classified into a two-layered system on the basis of these predictive factors, and the severity of distress between the TN-EGD and TO-EGD groups was compared using VAS and the change in the rate-pressure product as subjective and objective indices, respectively.

RESULTS

In total, 728 outpatients (390 male, 338 female; mean age, 63.1 ± 0.5 years; TO-EGD group, 630; TN-EGD group, 98)met the inclusion criteria. Multivariate logistic regression analysis confirmed that age <65 years (P < 0.01; odds ratio [OR], 1.69; 95% confidence interval [CI], 1.14-2.52), gender (female; P < 0.01; OR,1.97; 95% CI, 1.34-2.91), marital status (single; P < 0.01; OR, 1.96; 95% CI, 1.18-3.27), and anxiety towards TO-EGD (P < 0.001; OR, 3.62; 95% CI, 2.44-5.37) were independently associated with intolerance. Both indices were significantly higher in the TO-EGD subgroup than in the TN-EGD subgroup in the high predictive class, but not in the low predictive class.

CONCLUSION

Predictive factors for detecting intolerance to unsedated TO-EGD may be useful to appropriately select patients who transpose unsedated TO-EGD to TN-EGD.

Deep sedation during gastrointestinal endoscopy: propofol-fentanyl and midazolam-fentanyl regimens

AIM

To compare deep sedation with propofol-fentanyl and midazolam-fentanyl regimens during upper gastrointestinal endoscopy.

METHODS

After obtaining approval of the research ethics committee and informed consent, 200 patients were evaluated and referred for upper gastrointestinal endoscopy. Patients were randomized to receive propofol-fentanyl or midazolam-fentanyl (n = 100/group). We assessed the level of sedation using the observer's assessment of alertness/sedation (OAA/S) score and bispectral index (BIS). We evaluated patient and physician satisfaction, as well as the recovery time and complication rates. The statistical analysis was performed using SPSS statistical software and included the Mann-Whitney test, χ² test, measurement of analysis of variance, and the κ statistic.

RESULTS

The times to induction of sedation, recovery, and discharge were shorter in the propofol-fentanyl group than the midazolam-fentanyl group. According to the OAA/S score, deep sedation events occurred in 25% of the propofol-fentanyl group and 11% of the midazolam-fentanyl group (P = 0.014). Additionally, deep sedation events occurred in 19% of the propofol-fentanyl group and 7% of the midazolam-fentanyl group according to the BIS scale (P = 0.039). There was good concordance between the OAA/S score and BIS for both groups (κ = 0.71 and κ = 0.63, respectively). Oxygen supplementation was required in 42% of the propofol-fentanyl group and 26% of the midazolam-fentanyl group (P = 0.025). The mean time to recovery was 28.82 and 44.13 min in the propofol-fentanyl and midazolam-fentanyl groups, respectively (P < 0.001). There were no severe complications in either group. Although patients were equally satisfied with both drug combinations, physicians were more satisfied with the propofol-fentanyl combination.

CONCLUSION

Deep sedation occurred with propofol-fentanyl and midazolam-fentanyl, but was more frequent in the former. Recovery was faster in the propofol-fentanyl group.

[Role of pulse oximetric monitoring during gastrointestinal endoscopy. Prospective multicenter study of the Gastroenterology Working Group of the Veszprém Regional Committee of the Hungarian Academy of Sciences (VEAB)]

INTRODUCTION

Recent guidelines recommend routine pulse oximetric monitoring during endoscopy, however, this has not been the common practice yet in the majority of the local endoscopic units.

AIMS

To draw attention to the importance of the routine use of pulse oximetric recording during endoscopy.

METHOD

A prospective multicenter study was performed with the participation of 11 gastrointestinal endoscopic units. Data of pulse oximetric monitoring of 1249 endoscopic investigations were evaluated, of which 1183 were carried out with and 66 without sedation.

RESULTS

Oxygen saturation less than 90% was observed in 239 cases corresponding to 19.1% of all cases. It occurred most often during endoscopic retrograde cholangiopancreatography (31.2%) and proximal enteroscopy (20%). Procedure-related risk factors proved to be the long duration of the investigation, premedication with pethidine (31.3%), and combined sedoanalgesia with pethidine and midazolam (34.38%). The age over 60 years, obesity, consumption of hypnotics or sedatives, severe cardiopulmonary state, and risk factor scores III and IV of the American Society of Anestwere found as patient-related risk factors.

CONCLUSION

To increase the safety of patients undergoing endoscopic investigation, pulse oximeter and oxygen supplementation should be the standard requirement in all of the endoscopic investigation rooms. Pulse oximetric monitoring is advised routinely during endoscopy with special regard to the risk factors of hypoxemia.

Two dosages of remifentanil for patient-controlled analgesia vs. meperidine during colonoscopy: a prospective randomized controlled trial

BACKGROUND AND STUDY: Combined use of opiates and benzodiazepines often results in delayed discharge after colonoscopy.

AIMS

To compare sedation quality of two dosages of patient controlled analgesia remifentanil with one another and with that of a midazolam-meperidine association during colonoscopy.

METHODS

Ninety patients undergoing colonoscopy were randomly assigned to three groups. Group M received a meperidine bolus (0.7 mg/kg) and sham patient controlled analgesia. Group R1 received remifentanil 0.5 μg/kg and group R2 remifentanil 0.8 μg/kg together with a patient-controlled analgesia pump injecting further boluses (2-min lock-out). Technical difficulties of the examination, gastroenterologist's and patient's satisfaction with sedoanalgesia were evaluated after colonoscopy on a 100 mm Visual Analogue Scale. Patient's satisfaction was assessed 24 h later.

RESULTS

Group M had more adverse events (p = 0.044), required more rescue boluses (p = 0.0010), had lower Observer's Assessment of Alertness and Sedation Scale score at the end of the procedure (p = 0.0016) and longer discharge time (p = 0.0001). Groups R1 and R2 did not differ with respect to these variables. Patient's degree of pain and satisfaction with sedo-analgesia, endoscopist's technical difficulty and satisfaction were not different among groups.

CONCLUSIONS

Remifentanil patient controlled analgesia is a safe approach to sedation for colonoscopy.

Esophagogastroduodenoscopy with conscious sedation does not interfere with catheter-based 24-h pH monitoring

AIM: To investigate the impact of esophagogastroduodenoscopy with conscious sedation on the subsequent 24-h catheter-based pH monitoring.

METHODS: Fifty patients with extra-esophageal symptoms of gastroesophageal reflux disease undergoing ambulatory dual-probe 24-h pH monitoring were enrolled from March 2010 to August 2011. All of the data were collected prospectively and analyzed retrospectively. Thirty-six patients (72%, group A) underwent pH monitoring shortly after esophagogastroduodenoscopy (EGD) with conscious sedation, and 14 patients (28%, group B) underwent pH monitoring without conscious sedation. The 24-h pH data from two time periods were analyzed: the first 4 h (Period I) and the remaining time of the study (Period II).

RESULTS: The mean age of the patients was 49.6 ± 12.5 years; 20 patients (40%) were men. The baseline data, including age, sex, body mass index, reflux esophagitis, the Reflux Symptom Index, and the Reflux Findings Score, were comparable between the two groups. The percentage of total time with a pH < 4 and the frequency of acid reflux during Period I were not significantly different between the two groups, as measured using both pharyngeal (0.03% ± 0.10% vs 0.07% ± 0.16%, P = 0.32; and 0.07 ± 0.23 episodes/h vs 0.18 ± 0.47 episodes/h, P = 0.33, respectively) and esophageal probes (0.96% ± 1.89% vs 0.42% ± 0.81%, P = 0.59; and 0.74 ± 1.51 episodes/h vs 0.63 ± 0.97 episodes/h, P = 0.49, respectively). The percentage of total time with a pH < 4 and the frequency of acid reflux were also not significantly different between Periods I and II in group A patients, as measured using both pharyngeal (0.03% ± 0.10% vs 0.23% ± 0.85%, P = 0.21; and 0.07 ± 0.23 episodes/h vs 0.29 ± 0.98 episodes/h, P = 0.22, respectively) and esophageal probes (0.96% ± 1.89% vs 1.11% ± 2.57%, P = 0.55; and 0.74 ± 1.51 episodes/h vs 0.81 ± 1.76 episodes/h, P = 0.55, respectively).

CONCLUSION: EGD with conscious sedation does not interfere with the results of subsequent 24-h pH monitoring in patients with extra-esophageal symptoms of gastroesophageal reflux disease.

Recommended sedation and intraprocedural monitoring for gastric endoscopic submucosal dissection

Endoscopic submucosal dissection is associated with a longer treatment time and a higher risk of patient discomfort than conventional procedures. Adequate, safe sedation is therefore essential. Sedation can cause adverse effects such as hypoxemia and hypotension, requiring continuous intraoperative and postoperative monitoring of blood pressure, use of the electrocardiogram, and arterial blood oxygen saturation by pulse oximetry. A physician and a nurse solely responsible for sedating and monitoring the patient should be present during treatment.A combination of benzodiazepines and analgesics are generally used for sedation, but new sedatives such as propofol and dexmedetomidine hydrochloride are expected to be useful agents. Endoscopists should become more familiar with sedatives, analgesics, and emergency procedures in the future.

Sedation in gastrointestinal endoscopy: current issues

Diagnostic and therapeutic endoscopy can successfully be performed by applying moderate (conscious) sedation. Moderate sedation, using midazolam and an opioid, is the standard method of sedation, although propofol is increasingly being used in many countries because the satisfaction of endoscopists with propofol sedation is greater compared with their satisfaction with conventional sedation. Moreover, the use of propofol is currently preferred for the endoscopic sedation of patients with advanced liver disease due to its short biologic half-life and, consequently, its low risk of inducing hepatic encephalopathy. In the future, propofol could become the preferred sedation agent, especially for routine colonoscopy. Midazolam is the benzodiazepine of choice because of its shorter duration of action and better pharmacokinetic profile compared with diazepam. Among opioids, pethidine and fentanyl are the most popular. A number of other substances have been tested in several clinical trials with promising results. Among them, newer opioids, such as remifentanil, enable a faster recovery. The controversy regarding the administration of sedation by an endoscopist or an experienced nurse, as well as the optimal staffing of endoscopy units, continues to be a matter of discussion. Safe sedation in special clinical circumstances, such as in the cases of obese, pregnant, and elderly individuals, as well as patients with chronic lung, renal or liver disease, requires modification of the dose of the drugs used for sedation. In the great majority of patients, sedation under the supervision of a properly trained endoscopist remains the standard practice worldwide. In this review, an overview of the current knowledge concerning sedation during digestive endoscopy will be provided based on the data in the current literature.

Update on colonoscopy preparation, premedication and sedation

The advent of optical colonoscopy has enabled gastroenterologists to visualize the colonic mucosa. This procedure has since become the cornerstone of colon cancer screening programs. Clinicians and scientists have made great strides to fine-tune the technical aspects of this procedure and have also made important advances that allow for a more effective and safer colonoscopy. This article focuses on current research and expert opinion regarding colonoscopy preparation, premedication and sedation.

Bispectral index monitoring as an adjunct to nurse-administered combined sedation during endoscopic retrograde cholangiopancreatography

AIM: To determine whether bispectral index (BIS) monitoring is useful for propofol administration for deep sedation during endoscopic retrograde cholangiopancreatography (ERCP).

METHODS: Fifty-nine consecutive patients with a variety of reasons for ERCP who underwent the procedure at least twice between 1 July 2010 and 30 November 2010. This was a randomized cross-over study, in which each patient underwent ERCP twice, once with BIS monitoring and once with control monitoring. Whether BIS monitoring was done during the first or second ERCP procedure was random. Patients were intermittently administered a mixed regimen including midazolam, pethidine, and propofol by trained nurses. The nurse used a routine practice to monitor sedation using the Modified Observer’s Assessment of Alertness/Sedation (MOAA/S) scale or the BIS monitoring. The total amount of midazolam and propofol used and serious side effects were compared between the BIS and control groups.

RESULTS: The mean total propofol dose administered was 53.1 ± 32.2 mg in the BIS group and 54.9 ± 30.8 mg in the control group (P = 0.673). The individual propofol dose received per minute during the ERCP procedure was 2.90 ± 1.83 mg/min in the BIS group and 3.44 ± 2.04 mg in the control group (P = 0.103). The median value of the MOAA/S score during the maintenance phase of sedation was comparable for the two groups. The mean BIS values throughout the procedure (from insertion to removal of the endoscope) were 76.5 ± 8.7 for all 59 patients in using the BIS monitor. No significant differences in the frequency of < 80% oxygen saturation, hypotension (< 80 mmHg), or bradycardia (< 50 beats/min) were observed between the two study groups. Four cases of poor cooperation occurred, in which the procedure should be stopped to add the propofol dose. After adding the propofol, the procedure could be conducted successfully (one case in the BIS group, three cases in the control group). The endoscopist rated patient sedation as excellent for all patients in both groups. All patients in both groups rated their level of satisfaction as high (no discomfort). During the post-procedural follow-up in the recovery area, no cases of clinically significant hypoxic episodes were recorded in either group. No other postoperative side effects related to sedation were observed in either group.

CONCLUSION: BIS monitoring trend to slighlty reduce the mean propofol dose. Nurse-administered propofol sedation under the supervision of a gastroenterologist may be considered an alternative under anesthesiologist.

Sedation practices for routine diagnostic upper gastrointestinal endoscopy in Nigeria

AIM

To determine the sedation practices and preferences of Nigerian endoscopists for routine diagnostic upper gastrointestinal endoscopy.

METHODS

A structured questionnaire containing questions related to sedation practices and safety procedures was administered to Nigerian gastrointestinal endoscopists at the 2011 annual conference of the Society for Gastroenterology and Hepatology in Nigeria which was held at Ibadan, June 23-35, 2011.

RESULTS

Of 35 endoscopists who responded, 17 (48.6%) used sedation for less than 25% of procedures, while 14 (40.0%) used sedation for more than 75% of upper gastrointestinal endoscopies. The majority of respondents (22/35 or 62.9%) had less than 5 years experience in gastrointestinal endoscopy. The sedative of choice was benzodiazepine alone in the majority of respondents (85.7%). Opioid use (alone or in combination with benzodiazepines) was reported by only 5 respondents (14.3%). None of the respondents had had any experience with propofol. Non-anaesthesiologist-directed sedation was practiced by 91.4% of endoscopists. Monitoring of oxygen saturation during sedation was practiced by only 57.1% of respondents. Over half of the respondents (18/35 or 51.4%) never used supplemental oxygen for diagnostic upper gastrointestinal endoscopy.

CONCLUSION

Sedation for routine diagnostic upper gastrointestinal endoscopy in Nigeria is characterized by lack of guidelines, and differs markedly from that in developed countries.