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Wehrmann T, Riphaus A, Eckardt AJ, Klare P, Kopp I, von Delius S, Rosien U, Tonner PH. Updated S3 Guideline "Sedation for Gastrointestinal Endoscopy" of the German Society of Gastroenterology, Digestive and Metabolic Diseases (DGVS) - June 2023 - AWMF-Register-No. 021/014. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:e654-e705. [PMID: 37813354 DOI: 10.1055/a-2165-6388] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Affiliation(s)
- Till Wehrmann
- Clinic for Gastroenterology, DKD Helios Clinic Wiesbaden, Wiesbaden, Germany
| | - Andrea Riphaus
- Internal Medicine, St. Elisabethen Hospital Frankfurt Artemed SE, Frankfurt, Germany
| | - Alexander J Eckardt
- Clinic for Gastroenterology, DKD Helios Clinic Wiesbaden, Wiesbaden, Germany
| | - Peter Klare
- Department Internal Medicine - Gastroenterology, Diabetology, and Hematology/Oncology, Hospital Agatharied, Hausham, Germany
| | - Ina Kopp
- Association of the Scientific Medical Societies in Germany e.V. (AWMF), Berlin, Germany
| | - Stefan von Delius
- Medical Clinic II - Internal Medicine - Gastroenterology, Hepatology, Endocrinology, Hematology, and Oncology, RoMed Clinic Rosenheim, Rosenheim, Germany
| | - Ulrich Rosien
- Medical Clinic, Israelite Hospital, Hamburg, Germany
| | - Peter H Tonner
- Anesthesia and Intensive Care, Clinic Leer, Leer, Germany
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Wehrmann T, Riphaus A, Eckardt AJ, Klare P, Kopp I, von Delius S, Rosien U, Tonner PH. Aktualisierte S3-Leitlinie „Sedierung in der gastrointestinalen Endoskopie“ der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS). ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:1246-1301. [PMID: 37678315 DOI: 10.1055/a-2124-5333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Affiliation(s)
- Till Wehrmann
- Klinik für Gastroenterologie, DKD Helios Klinik Wiesbaden, Wiesbaden, Deutschland
| | - Andrea Riphaus
- Innere Medizin, St. Elisabethen Krankenhaus Frankfurt Artemed SE, Frankfurt, Deutschland
| | - Alexander J Eckardt
- Klinik für Gastroenterologie, DKD Helios Klinik Wiesbaden, Wiesbaden, Deutschland
| | - Peter Klare
- Abteilung Innere Medizin - Gastroenterologie, Diabetologie und Hämato-/Onkologie, Krankenhaus Agatharied, Hausham, Deutschland
| | - Ina Kopp
- Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V. (AWMF), Berlin, Deutschland
| | - Stefan von Delius
- Medizinische Klinik II - Innere Medizin - Gastroenterologie, Hepatologie, Endokrinologie, Hämatologie und Onkologie, RoMed Klinikum Rosenheim, Rosenheim, Deutschland
| | - Ulrich Rosien
- Medizinische Klinik, Israelitisches Krankenhaus, Hamburg, Deutschland
| | - Peter H Tonner
- Anästhesie- und Intensivmedizin, Klinikum Leer, Leer, Deutschland
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Kim DB, Kim JS, Huh CW, Ma DW, Ji JS, Kim BW, Choi H. Propofol compared with bolus and titrated midazolam for sedation in outpatient colonoscopy: a prospective randomized double-blind study. Gastrointest Endosc 2021; 93:201-208. [PMID: 32504701 DOI: 10.1016/j.gie.2020.05.045] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 05/07/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS The safest and most efficient method of sedation for outpatient colonoscopy remains unclear. This study aimed to compare the efficiency and safety of bolus administration of midazolam compared with titrated administration and propofol administration for patients undergoing outpatient colonoscopy. METHODS We randomly divided patients undergoing colonoscopy into the propofol group, bolus midazolam group, and titrated midazolam group. We compared total procedure time, induction time, recovery time, and discharge time among the 3 groups. We also compared patient satisfaction and the incidence of adverse events. RESULTS In total, 267 patients (89 in each study group) were enrolled during the study period. Patients in the propofol group had a shorter total procedure time (39.5 vs 59.4 vs 58.1 minutes; P < .001), induction time (4.6 vs 6.3 vs 7.6 minutes; P < .001), recovery time (11.5 vs 29.5 vs 29.2 minutes; P < .001), and discharge time (20.6 vs 34.9 vs 34.7 minutes; P < .001) than patients in the bolus midazolam group and titrated midazolam group. Patients in the propofol group reported higher degrees of satisfaction than patients in the bolus or titrated midazolam plus meperidine groups (9.9 vs 9.6 vs 9.6 [P = .007] and 4.9 vs 4.7 vs 4.8 [P = .008], respectively). Adverse events were not significantly different between groups. CONCLUSIONS In this randomized trial, propofol was superior to bolus or titrated midazolam in terms of endoscopy unit efficiency and patient satisfaction during outpatient colonoscopy. (Clinical trial registration number: KCT0002805.).
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Affiliation(s)
- Dae Bum Kim
- Division of Gastroenterology, Department of Internal Medicine, St Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Joon Sung Kim
- Division of Gastroenterology, Department of Internal Medicine, Incheon St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Cheal Wung Huh
- Division of Gastroenterology, Department of Internal Medicine, Incheon St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dae Won Ma
- Division of Gastroenterology, Department of Internal Medicine, Incheon St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jeong-Seon Ji
- Division of Gastroenterology, Department of Internal Medicine, Incheon St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Byung-Wook Kim
- Division of Gastroenterology, Department of Internal Medicine, Incheon St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hwang Choi
- Division of Gastroenterology, Department of Internal Medicine, Incheon St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Fisher WE, Cruz-Monserrate Z, McElhany AL, Lesinski GB, Hart PA, Ghos R, Van Bure G, Fishman DS, Rinaudo JAS, Serrano J, Srivastava S, Mace T, Topazian M, Feng Z, Yadav D, Pandol SJ, Hughes SJ, Liu RY, Lu E, Orr R, Whitcomb DC, Abouhamze AS, Steen H, Sellers ZM, Troendle DM, Uc A, Lowe ME, Conwell DL. Standard Operating Procedures for Biospecimen Collection, Processing, and Storage: From the Consortium for the Study of Chronic Pancreatitis, Diabetes, and Pancreatic Cancer. Pancreas 2019; 47:1213-1221. [PMID: 30325860 PMCID: PMC6197069 DOI: 10.1097/mpa.0000000000001171] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
High-quality and well-annotated biorepositories are needed to better understand the pathophysiology and biologic mechanisms of chronic pancreatitis (CP) and its consequences. We report a methodology for the development of a robust standard operating procedure (SOP) for a biorepository based on the experience of the clinical centers within the consortium to study Chronic Pancreatitis, Diabetes and Pancreas Cancer Clinical Centers (CPDPC), supported by the National Cancer Institute and the National Institute for Diabetes and Digestive and Kidney Diseases as a unique multidisciplinary model to study CP, diabetes, and pancreatic cancer in both children and adults. Standard operating procedures from the CPDPC centers were evaluated and consolidated. The literature was reviewed for standard biorepository operating procedures that facilitated downstream molecular analysis. The existing literature on biobanking practices was harmonized with the SOPs from the clinical centers to produce a biorepository for pancreatic research. This article reports the methods and basic principles behind the creation of SOPs to develop a biorepository for the CPDPC. These will serve as a guide for investigators developing biorepositories in pancreas research. Rigorous and meticulous adherence to standardized biospecimen collection will facilitate investigations to better understand the pathophysiology and biologic mechanisms of CP, diabetes, and pancreatic cancer.
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Affiliation(s)
- William E. Fisher
- The Elkins Pancreas Center, Michael E. DeBakey Department of Surgery, and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX
| | - Zobeida Cruz-Monserrate
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, and Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Amy L. McElhany
- The Elkins Pancreas Center, Michael E. DeBakey Department of Surgery, and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX
| | - Gregory B. Lesinski
- Winship Cancer Institute, Department of Hematology and Medical Oncology, Emory University, Atlanta, GA
| | - Phil A. Hart
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, and Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Ria Ghos
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - George Van Bure
- The Elkins Pancreas Center, Michael E. DeBakey Department of Surgery, and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX
| | | | - Jo Ann S. Rinaudo
- Cancer Biomarkers Research Group, Division of Cancer Prevention, National Cancer Institute (NCI), Rockville, MD
| | - Jose Serrano
- Division of Digestive Diseases and Nutrition, National Institutes of Diabetes and Digestive and Kidney Diseases (NIDDK), Bethesda, MD
| | - Sudhir Srivastava
- Cancer Biomarkers Research Group, Division of Cancer Prevention, National Cancer Institute (NCI), Rockville, MD
| | - Thomas Mace
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, and Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Mark Topazian
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Ziding Feng
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Stephen J. Pandol
- Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Steven J. Hughes
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Robert Y. Liu
- Clinical Research Support Center, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Emily Lu
- Clinical Research Support Center, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Robert Orr
- Indiana Clinical and Translational Sciences Institute, Specimen Storage Facility, Indianapolis, IN
| | - David C. Whitcomb
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Amer S. Abouhamze
- Clinical and Translational Sciences, University of Florida, Gainesville, FL
| | - Hanno Steen
- Departments of Pathology, Boston Children’s Hospital and Harvard Medical School, Boston, MA
| | - Zachary M. Sellers
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Lucile Packard Children’s Hospital and Stanford University School of Medicine, Stanford, CA
| | - David M. Troendle
- Department of Pediatrics, University of Texas Southwestern Medical School, Dallas, TX
| | - Aliye Uc
- Stead Family Department of Pediatrics, University of Iowa, Stead Family Children’s Hospital, Iowa City, IA
| | - Mark E. Lowe
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Darwin L. Conwell
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, and Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH
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Abstract
Supplemental Digital Content is available in the text.
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Finn RT, Boyd A, Lin L, Gellad ZF. Bolus Administration of Fentanyl and Midazolam for Colonoscopy Increases Endoscopy Unit Efficiency and Safety Compared With Titrated Sedation. Clin Gastroenterol Hepatol 2017; 15:1419-1426.e2. [PMID: 28365484 DOI: 10.1016/j.cgh.2017.03.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 02/23/2017] [Accepted: 03/02/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Guidelines recommend slow titration of sedatives for moderate sedation. Bolus sedation, in which a larger weight-based dose of medication is given upfront, has been shown in a single trial to be beneficial. We evaluated the effects of bolus sedation on procedural safety, efficiency, and patient experience. METHODS We performed a retrospective analysis of colonoscopies performed between April 2010 and April 2011 at Duke Medical Center. Colonoscopies before October 2010 were performed with nurse-directed titration of sedative (n = 966); colonoscopies performed after October 2010 were performed with physician-directed administration of bolus sedative (n = 699). We compared sedation and recovery times, medication doses, and adverse events between groups. We also compared patient satisfaction in a subset of patients from each group. Data were compared using the chi-square test for categorical variables and Wilcoxon rank sum test for continuous and ordinal categorical variables. RESULTS Patients in the bolus group had a shorter sedation time (6.0 min) than patients in the titration group (13.0 min; P < .01) and a slightly longer colonoscopy time (25.0 min vs 24.0 min in the titration group; P < .01). Recovery time did not differ significantly between groups (53.0 min in the bolus group vs 52.1 min in the titration group; P = .07). Patients in the bolus group received lower weight-adjusted doses of fentanyl (1.71 μg/kg vs 1.89 μg/kg in the titration group) and midazolam (0.065 mg/kg vs 0.075 mg/kg in the titration group). A smaller proportion of patients in the bolus sedative group developed hypotension (12.7% vs 17.9% in the titration group; P < .01). These findings persisted even after adjustment for baseline patient age, race, sex, smoking status, alcohol use, body mass index, and American Society of Anesthesiologists' classification. CONCLUSIONS In a retrospective study of patients undergoing colonoscopy, we found that compared with titrated administration of sedative, bolus dosing improves endoscopy unit efficiency and safety and decreases the amount of sedative required. This benefit does not come at the expense of the patient experience.
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Affiliation(s)
- R Thomas Finn
- Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina
| | - Amanda Boyd
- Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina
| | - Li Lin
- Duke Clinical Research Institute, Durham, North Carolina
| | - Ziad F Gellad
- Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina; Durham VA Medical Center, Durham, North Carolina.
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Ashraf JM, Schweiger M, Vallurupalli N, Bellantonio S, Cook JR. Effects of oral premedication on cognitive status of elderly patients undergoing cardiac catheterization. J Geriatr Cardiol 2015; 12:257-62. [PMID: 26089850 PMCID: PMC4460169 DOI: 10.11909/j.issn.1671-5411.2015.03.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2014] [Revised: 02/11/2015] [Accepted: 02/14/2015] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Sedatives and analgesics are often administered to achieve conscious sedation for diagnostic and therapeutic procedures. Appropriate concerns have been raised regarding post procedure delirium related to peri-procedural medication in the elderly. The objective of this study was to investigate the effect of premedication on new onset delirium and procedural care in elderly patients. METHODS Patients ≥ 70 years old and scheduled for elective cardiac catheterization were randomly assigned to receive either oral diphenhydramine and diazepam (25 mg/5 mg) or no premedication. All patients underwent a mini mental state exam and delirium assessment using confusion assessment method prior to the procedure and repeated at 4 h after the procedure and prior to discharge. Patients' cooperation during the procedure and ease of post-procedure were measured using Visual Analog Scale (VAS). The degree of alertness was assessed immediately on arrival to the floor, and twice hourly afterwards using Observer's Assessment of Alertness/Sedation Scale (OAA/S). RESULTS A total of 93 patients were enrolled. The mean age was 77 years, and 47 patients received premedication prior to the procedure. None of the patients in either group developed delirium. Patients' cooperation and the ease of procedure was greater and pain medication requirement less both during and after the procedure in the pre-medicated group (P < 0.05 for both). Nurses reported an improvement with patient management in the pre-medicated group (P = 0.08). CONCLUSIONS In conclusion, premedication did not cause delirium in elderly patients undergoing cardiac catheterization. The reduced pain medication requirement, perceived procedural ease and post procedure management favors premedication in elderly patients undergoing cardiac catheterization.
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Affiliation(s)
- Javed M Ashraf
- Department of Cardiology, Truman Medical Center, UMKC School of Medicine, Kansas City, MO, USA
| | - Marc Schweiger
- Departments of Cardiology, Baystate Medical Center, Tufts University School of Medicine, MA, USA
| | - Neelima Vallurupalli
- Departments of Cardiology, Baystate Medical Center, Tufts University School of Medicine, MA, USA
| | - Sandra Bellantonio
- Department of Internal Medicine and Geriatrics, Baystate Medical Center, Tufts University School of Medicine, Springfield, MA, USA
| | - James R Cook
- Departments of Cardiology, Baystate Medical Center, Tufts University School of Medicine, MA, USA
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Cheon YK. Can postendoscopic retrograde cholangiopancreatography pancreatitis be prevented by a pharmacological approach? Korean J Intern Med 2013; 28:141-8. [PMID: 23525264 PMCID: PMC3604601 DOI: 10.3904/kjim.2013.28.2.141] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Accepted: 12/14/2012] [Indexed: 02/07/2023] Open
Abstract
Acute pancreatitis remains the most frequent complication of endoscopic retrograde cholangiopancreatography (ERCP), with reported incidence rates that have changed little over several decades. Patient- and procedure-related risk factors for post-ERCP pancreatitis (PEP) are well-defined. Effective measures to prevent PEP have been identified, including improvements in cannulation techniques and pancreatic stenting, as well as pharmacological intervention. Pharmacotherapy has been widely studied in the prevention of PEP, but the effect in averting PEP has been inconclusive. Although pharmacological prophylaxis is appealing, attempts to find an ideal drug are incomplete. Most available data on the efficacy of pharmacological agents for PEP prophylaxis have been obtained from patients at average risk for PEP. However, recently, a randomized prospective controlled trial of rectal nonsteroidal anti-inflammatory drugs (NSAIDs) to prevent PEP in high-risk patients was published. The results revealed that rectal indomethacin reduced the incidence of PEP significantly. Thus, rectal administration of diclofenac or indomethacin immediately before or after ERCP is used routinely to prevent PEP. However, additional studies with NSAIDs using large numbers of subjects are necessary to confirm the prophylactic effect of these drugs and to establish whether they act synergistically with other prophylactic interventions, including pancreatic stenting.
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Affiliation(s)
- Young Koog Cheon
- Digestive Disease Center, Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea.
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Law R, Lopez R, Costanzo A, Parsi M, Stevens T. Endoscopic pancreatic function test using combined secretin and cholecystokinin stimulation for the evaluation of chronic pancreatitis. Gastrointest Endosc 2012; 75:764-8. [PMID: 22281107 PMCID: PMC4474136 DOI: 10.1016/j.gie.2011.11.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Accepted: 11/09/2011] [Indexed: 12/13/2022]
Abstract
BACKGROUND Current endoscopic pancreatic function test (ePFT) methods use either secretin or cholecystokinin (CCK) to measure pancreatic function. OBJECTIVE To evaluate a novel ePFT protocol that includes both secretin and CCK stimulation and to assess which fluid parameters best discriminate patients with chronic pancreatitis (CP). DESIGN Prospective, cross-sectional diagnostic study. SETTING Single, tertiary-care institution. PATIENTS Healthy volunteers and patients evaluated for CP were included. INTERVENTIONS All patients underwent a combined secretin-CCK ePFT. Patients evaluated for CP also underwent EUS during the same endoscopic session. MAIN OUTCOME MEASUREMENTS Duodenal fluid bicarbonate, lipase, and amylase concentrations were measured after CCK and secretin stimulation. Results were compared based on the presence of CP detected by EUS (≥5 features). RESULTS Twenty healthy volunteers and 69 patients evaluated for CP completed the secretin and CCK ePFT. Patients with an EUS score of 5 or higher had significantly decreased peak bicarbonate concentrations (72 mmol) compared with patients with an EUS score lower than 5 (90 mmol) and healthy subjects (108 mmol) (P < .001). Peak concentrations of amylase and lipase and total fluid volume were not significantly different between patients with CP and controls. Receiver-operating characteristic analysis revealed that peak bicarbonate concentration had superior discrimination for CP (area under the curve [AUC] 0.738) compared with peak amylase (AUC 0.677) and peak lipase (AUC 0.627). The addition of enzyme concentration measurement did not improve discrimination compared with peak bicarbonate alone. LIMITATIONS Secretin and cholecystokinin endoscopic pancreatic function test (SC ePFT) results were not compared with those of single hormone ePFTs. CONCLUSIONS The addition of CCK infusion and enzyme concentration measurement to a standard secretin ePFT does not enhance the diagnosis of CP.
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Affiliation(s)
- Ryan Law
- Medicine Institute, The Cleveland Clinic, Cleveland, Ohio
| | - Rocio Lopez
- Department of Quantitative Health Sciences, The Cleveland Clinic, Cleveland, Ohio
| | - Adele Costanzo
- Digestive Disease Institute, The Cleveland Clinic, Cleveland, Ohio
| | - Mansour Parsi
- Digestive Disease Institute, The Cleveland Clinic, Cleveland, Ohio
| | - Tyler Stevens
- Digestive Disease Institute, The Cleveland Clinic, Cleveland, Ohio
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Radaelli F, Paggi S, Amato A, Terruzzi V. Warm water infusion versus air insufflation for unsedated colonoscopy: a randomized, controlled trial. Gastrointest Endosc 2010; 72:701-9. [PMID: 20883846 DOI: 10.1016/j.gie.2010.06.025] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2010] [Accepted: 06/14/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND Uncontrolled data suggest that warm water infusion (WWI) instead of air insufflation (AI) during the insertion phase of unsedated colonoscopy improves patient tolerance and satisfaction. OBJECTIVE We tested the hypothesis that water could increase the proportion of patients able to complete unsedated colonoscopy and improve patient tolerance compared with the conventional procedure. DESIGN Randomized, controlled trial. SETTING Single center, community hospital. PATIENTS Consecutive outpatients agreeing to start colonoscopy without premedication. METHODS Patients were randomly assigned to either WWI or AI insertion phase of colonoscopy. Sedation and/or analgesia were administered on patient request if significant pain or discomfort occurred. MAIN OUTCOME MEASUREMENTS Percentage of patients requiring sedation/analgesia. Pain and tolerance scores were assessed at discharge by using a 100-mm visual analog scale. RESULTS A total of 230 subjects (116 in the WWI group and 114 in the AI group) were enrolled. Intention-to-treat analysis showed that the proportion of patients requesting sedation/analgesia during the procedure (main outcome measurement) was 12.9% in the WWI group and 21.9% in AI group (P = .07). Cecal intubation rates were 94% in the WWI group and 95.6% in the AI group (P = .57). Median (interquartile range) scores for pain were 28 (12-44) and 39 (14-54) in WWI and AI groups, respectively (P = .05); corresponding figures for tolerance were 10 (3-18) and 14 (5-42), respectively (P = .01). The adenoma detection rates were 25% and 40.1% for the WWI and AI groups, respectively (P = .013). LIMITATIONS Single-center study, endoscopists not blinded to randomization. CONCLUSIONS WWI instead of AI is not associated with a statistically significant decrease in the number of patients requiring on-demand sedation, although it significantly improves the overall patient tolerance of colonoscopy. The finding of a lower adenoma detection rate in the WWI group calls for further evaluations. ( CLINICAL TRIAL REGISTRATION NUMBER NCT00905554).
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Affiliation(s)
- Franco Radaelli
- Division of Gastroenterology, Valduce Hospital, Como, Italy.
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Zuccaro P, Stevens T, Repas K, Diamond R, Lopez R, Wu B, Conwell DL. Magnetic resonance cholangiopancreatography reports in the evaluation of chronic pancreatitis: a need for quality improvement. Pancreatology 2010; 9:764-9. [PMID: 20110743 DOI: 10.1159/000201304] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2008] [Accepted: 01/31/2009] [Indexed: 12/11/2022]
Abstract
BACKGROUND Numerous publications from academic centers suggest that magnetic resonance cholangiopancreatography (MRCP) can diagnose early chronic pancreatitis (CP) and assess pancreatic secretory reserve/function. However, the rigorous composite interpretation methods and quantitative secretory dynamics reported in these studies are not routinely measured in clinical practice. Therefore, the utility of routine MRCP reports in the clinical setting is unknown. STUDY DESIGN Cross-sectional study of patients referred to a tertiary center who underwent both MRCP and endoscopic pancreas function testing (ePFT) for assessment of chronic pancreatitis and abdominal pain. AIMS To compare MRCP and sMRCP reports to a reference standard pancreas function test for diagnosis of chronic pancreatitis. METHODS Source population: patients seen within a pancreas clinic at a tertiary referral center. MRCP and sMRCP reports were reviewed to record pancreas duct (dilation, side-branch changes), parenchyma enhancement (T(1), T(2) signal) and physiologic response (duodenal filling, pancreas duct response) to secretin. ePFT was categorized based on previously published data (normal peak bicarbonate >80 mEq/l). Referent values were calculated for MRCP and sMRCP using secretin ePFT as gold standard. RESULTS A total of 69 patients were identified (mean age 43.5 +/- 12; 65.2% female). 28 (40.6%) patients had abnormal ePFT based on their peak bicarbonate level. The mean bicarbonate values in the abnormal PFT and normal PFT groups were 59 +/- 13.9 and 95.3 +/- 12.6 mEq/l, respectively. Peak bicarbonate decreased with severity of chronic pancreatitis on MRCP (p = 0.0016). There was fair agreement of MRCP and ePFT (kappa 0.335 [0.113, 0.557]). The pre-stimulation pancreas duct changes reported were found to be the only predictor of abnormal pancreas function (p = 0.002). The post-stimulation findings of duodenal filling (p = 0.47), T(2)enhancement (p = 0.21) or change in pancreas duct caliber (p = 0.3) reported did not improve MRCP agreement with ePFT. Overall diagnostic accuracy, sensitivity and specificity were 70, 85 and 46%, respectively, for MRCP reports using ePFT as the gold standard. CONCLUSIONS Pancreas ductal features described on routine MRCP reports correlate with abnormal pancreas function. Current MRCP reports should be standardized to include all radiologic information available in hopes of predicting early chronic pancreatitis.
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Stevens T, Conwell DL, Zuccaro G, Van Lente F, Lopez R, Purich E, Fein S. A prospective crossover study comparing secretin-stimulated endoscopic and Dreiling tube pancreatic function testing in patients evaluated for chronic pancreatitis. Gastrointest Endosc 2008; 67:458-66. [PMID: 18294508 DOI: 10.1016/j.gie.2007.07.028] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2007] [Accepted: 07/09/2007] [Indexed: 02/07/2023]
Abstract
BACKGROUND Direct pancreatic function tests (PFT) are conventionally performed with use of double-lumen "Dreiling" collection tubes. We have developed an endoscopic collection method (ePFT) that eases the performance of these tests. OBJECTIVE Our aim was to compare the bicarbonate results obtained from the secretin ePFT and Dreiling PFT methods in patients evaluated for chronic pancreatitis. DESIGN A prospective crossover design was used to compare the PFT methods. SETTING Tertiary care referral center. PATIENTS AND INTERVENTIONS Twenty-four patients undergoing an evaluation for chronic pancreatitis underwent the secretin-stimulated ePFT and Dreiling PFT methods on separate days. MAIN OUTCOME MEASUREMENTS Duodenal fluid bicarbonate concentrations and estimated bicarbonate outputs were compared. RESULTS The mean difference in peak bicarbonate concentration (Dreiling PFT minus ePFT) was 7 mEq/L (SD 20) and not statistically significant (P = .11). A good correlation in peak bicarbonate concentrations (r = 0.74, 95% CI, 0.48-0.88) and estimated bicarbonate output (r = 0.78, 95% CI, 0.54-0.90) was observed between the two PFT methods. LIMITATION The sensitivities and specificities of the secretin ePFT and Dreiling PFT could not be compared because of the lack of a histologic gold standard. CONCLUSION The secretin ePFT yields results similar to those of the Dreiling PFT in patients evaluated for chronic pancreatitis.
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Affiliation(s)
- Tyler Stevens
- Department of Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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Lubarsky DA, Candiotti K, Harris E. Understanding modes of moderate sedation during gastrointestinal procedures: a current review of the literature. J Clin Anesth 2007; 19:397-404. [PMID: 17869995 DOI: 10.1016/j.jclinane.2006.11.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2006] [Revised: 11/08/2006] [Accepted: 11/09/2006] [Indexed: 12/26/2022]
Abstract
Recommendations for routine screening for colorectal cancer with colonoscopy are likely to substantially increase the demand for provision of sedation for these procedures. Because of this burgeoning caseload and associated economic constraints, it is unlikely that anesthesiologists will be available for all such procedures, particularly those involving average-risk patients. Thus, sedative agents that can be safely administered by nonanesthesiologists, appropriately trained in monitoring and managing the patient's airway, are desperately needed. New concepts in sedation for colonoscopy include enhanced mechanisms for drug delivery such as patient-controlled sedation/analgesia and target-controlled infusion, along with the development of new drugs such as a modified cyclodextrin-based formulation of propofol and fospropofol disodium (Aquavan Injection), a water-soluble prodrug of propofol.
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Affiliation(s)
- David A Lubarsky
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL 33136, USA.
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Martínez J, Casellas JA, Aparicio JR, Garmendia M, Amorós A. [Safety of propofol administration by the staff of a gastrointestinal endoscopy unit]. GASTROENTEROLOGIA Y HEPATOLOGIA 2007; 30:105-9. [PMID: 17374321 DOI: 10.1157/13100070] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Deep sedation controlled by the staff of gastrointestinal endoscopy units is currently controversial. In the last few years, numerous studies have provided data supporting the safety of propofol use in these techniques. We present a large series of patients who underwent gastroscopy or colonoscopy under endoscopist-controlled deep sedation. A total of 875 procedures (297 gastroscopies and 578 colonoscopies) were included. In all procedures intravenous propofol with or without intravenous midazolam was administered. In gastroscopies, complications attributable to the sedation were found in only 6.7% of the patients, mostly due to desaturation, which was resolved without the need for intubation. In colonoscopies, complications were found in 11.2%, the most frequent being bradycardia and desaturation, none of which were serious. No association was found between the presence of complications and the propofol dose administered. In the group of patients undergoing colonoscopy, simultaneous midazolam administration allowed reduction of the propofol dose required to achieve deep sedation. In conclusion, propofol shows a good safety profile and excellent tolerance in patients undergoing gastroscopy and colonoscopy and can be administrated by the endoscopy team. At least in the case of colonoscopy, the associated use of midazolam allows the propofol dose to be decreased, thus, theoretically, reducing the drug's adverse effects.
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Affiliation(s)
- Juan Martínez
- Unidad de Endoscopia Digestiva, Hospital General Universitario de Alicante, España.
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15
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Abstract
BACKGROUND Moderate sedation is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands with or without light tactile stimulation. Moderate sedation is typically accepted in the anaesthesia community as an appropriate target for sedation by non-anaesthesiologists. AIM To describe drug regimens that can be successfully and safely targeted to moderate sedation for endoscopy by non-anaesthesiologists. RESULTS Moderate sedation can be achieved using narcotics and benzodiazepines. There is interest in some countries in propofol for endoscopy, which is often viewed as an agent for deep sedation. Indeed, propofol cannot be targeted to moderate sedation for endoscopy as a single agent because of coughing during upper endoscopy and pain withdrawal responses during colonoscopy. Pre-treatment with low doses of narcotic and/or benzodiazepine blocks these effects, allowing propofol to be targeted to moderate sedation. Fospropofol, a prodrug of propofol in clinical development, can also be targeted to moderate sedation if co-administered with narcotic. CONCLUSION Moderate sedation provides a safety margin when compared with deep sedation and general anaesthesia. Development of protocols that target agents such as propofol to moderate sedation will expand the sedation agents available to non-anaesthesiologists and help ensure that this expansion occurs safely.
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Affiliation(s)
- D K Rex
- Indiana University Hospital, Indianapolis, IN 46202, USA.
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Stevens T, Conwell DL, Zuccaro G, Van Lente F, Purich E, Khandwala F, Fein S. A randomized crossover study of secretin-stimulated endoscopic and dreiling tube pancreatic function test methods in healthy subjects. Am J Gastroenterol 2006; 101:351-5. [PMID: 16454842 DOI: 10.1111/j.1572-0241.2006.00407.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES We have developed an endoscopic method of secretin endoscopic pancreatic function testing (ePFT) to simplify duodenal fluid collection. Validation of the ePFT requires a direct comparison to the traditional PFT using a Dreiling tube (DT). Our aim was to compare bicarbonate concentrations [HCO3-] obtained by the ePFT and DT methods in healthy subjects (HS). METHODS HS were randomized to either DT or ePFT, then crossed over to the other test after a minimum 1-wk washout. An age/weight-based sedation bolus was used for each test. DT protocol: Endoscopic placement of a DT was confirmed by fluoroscopy. After a baseline 15-min collection and administration of IV synthetic secretin, fluid was continuously collected in 15-min aliquots for an hour. ePFT protocol: Endoscopy was performed using a 6-mm endoscope. After gastric aspiration and discard and IV secretin, duodenal aspirates were obtained every 15-min for an hour. Fluid specimens were auto-analyzed for [HCO3-]. RESULTS Twelve HS were enrolled (6F, mean age 37 yr). The difference in [HCO3-] between the two methods was not significant at the 0-, 30-, 45-, or 60-min collections. An excellent correlation in peak [HCO3-] was observed (R2 = 0.84, p < 0.001). Using a peak [HCO3-] cutpoint 80 mEq/L, there was 100% agreement between the methods; using cutpoint 90 mEq/L, there was 83% agreement. CONCLUSIONS The accuracy of the ePFT is similar to DT: There were minimal differences in [HCO3-] at each of the timed collections and at peak. There is an excellent correlation in peak [HCO3-] and high level of diagnostic agreement between the tests.
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Affiliation(s)
- Tyler Stevens
- Department of Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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Patel S, Vargo JJ, Khandwala F, Lopez R, Trolli P, Dumot JA, Conwell DL, Zuccaro G. Deep sedation occurs frequently during elective endoscopy with meperidine and midazolam. Am J Gastroenterol 2005; 100:2689-95. [PMID: 16393221 DOI: 10.1111/j.1572-0241.2005.00320.x] [Citation(s) in RCA: 132] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Although moderate (conscious) sedation is intended during elective gastrointestinal endoscopy, unintended levels of deep sedation occur. The aims of this study were to prospectively evaluate the incidence and risk factors of deep sedation during elective endoscopy with meperidine and midazolam intended to maintain a level of moderate sedation. METHODS Eighty American Society of Anesthesiology class 1-2, outpatients presenting for elective esophagogastroduodenoscopy (EGD), colonoscopy, endoscopic retrograde cholangiopancreatography (ERCP), and endoscopic ultrasonography (EUS) were offered enrollment. Intravenous meperidine and midazolam were administered according to a standardized protocol. Hemodynamic parameters and levels of sedation were assessed and recorded by a single observer at 3-min intervals. The Modified Observer's Assessment of Alertness/Sedation (MOAA/S) scale (ranging 1-5) is a subjective sedation assessment scale used to assess sedation levels. Occurrence of deep sedation, defined by MOAA/S 1-2, was recorded. Univariable and multivariable analyses were used to assess predictors of deep sedation. RESULTS Deep sedation occurred in 54/80 (68%) patients for a total of 204/785 (26%) of total sedation assessments. The percentage of deep sedation episodes of all sedation-level observations by procedure was 26% for EGD, 11% for colonoscopy, 35% for ERCP, and 29% for EUS. Deep sedation occurred at least once in 60% of EGD, 45% of colonoscopy, 85% of ERCP, and 80% of EUS. Multivariable analysis showed that only ERCP and EUS were independent risk factors of deep sedation. CONCLUSIONS Deep sedation occurs frequently during elective endoscopy with meperidine and midazolam used with the intent of moderate sedation. ERCP and EUS are risk factors for the occurrence of deep sedation, independent of sedation dose or length of procedure.
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Affiliation(s)
- Sandeep Patel
- Section of Endoscopy, Department of Gastroenterology and Hepatology, The Cleveland Clinic Foundation, Cleveland, Ohio 44118, USA
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Qadeer MA, Vargo JJ, Khandwala F, Lopez R, Zuccaro G. Propofol versus traditional sedative agents for gastrointestinal endoscopy: a meta-analysis. Clin Gastroenterol Hepatol 2005; 3:1049-56. [PMID: 16271333 DOI: 10.1016/s1542-3565(05)00742-1] [Citation(s) in RCA: 161] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Even though propofol has better recovery profile than traditional agents, its use is limited because of the perception of increased complication rates. Because an adequately powered trial comparing risk of propofol with traditional agents is lacking, we performed a meta-analysis of the current literature. METHODS We searched Medline (1966-October 2004), EMBASE (1980-October 2004), and Cochrane controlled trials registry. The following 4 cardiopulmonary complications were assessed: hypoxia, hypotension, arrhythmias, and apnea. Procedures were divided into 3 groups: esophagogastroduodenoscopy group, colonoscopy group, and endoscopic retrograde cholangiopancreatography/endoscopic ultrasonography group. Pooled odds ratios for complications were calculated for all the procedures combined and then separately for the 3 groups. Random effects models were used for 2-proportion comparisons. RESULTS Of the 90 citations identified, 12 original studies qualified for this meta-analysis and included 1161 patients. Of these, 634 received propofol, and 527 received midazolam, meperidine, and/or fentanyl. Most of the included studies were randomized trials of moderate quality and nonsignificant heterogeneity (Cochran Q = 4.81, P = .90). Compared with traditional sedative agents, the pooled odds ratio with the use of propofol for developing hypoxia or hypotension for all the procedures combined was 0.74 (95% confidence interval [CI], 0.44-1.24); for EGD, 0.85 (95% CI, 0.33-2.17); for colonoscopy, 0.4 (95% CI, 0.2-0.79); and for ERCP/EUS, 1.07 (95% CI, 0.38-3.01). CONCLUSIONS Propofol sedation during colonoscopy appears to have lower odds of cardiopulmonary complications compared with traditional agents, but for other procedures, the risk of complications is similar.
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Affiliation(s)
- Mohammed A Qadeer
- Department of Gastroenterology and Hepatology, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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Abstract
The use of sedation for routine endoscopic procedures, including colonoscopy, varies widely across cultures. This variation in sedation practice is greater than any other culturally based variation in the technical performance of endoscopy. This article sequentially reviews the technical performance of colonoscopy in patients who undergo unsedated colonoscopy, sedation with narcotics and benzodiazepines, and deep sedation with propofol. For each of these approaches to colonoscopy, the advantages and disadvantages also are listed and discussed.
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Affiliation(s)
- Douglas K Rex
- Indiana University Hospital, 550 North University Boulevard, Indianapolis, IN 46202, USA.
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Conwell DL, Zuccaro G, Purich E, Fein S, Vanlente F, Vargo J, Dumot J, O'laughlin C, Trolli P. The effect of moderate sedation on exocrine pancreas function in normal healthy subjects: a prospective, randomized, cross-over trial using the synthetic porcine secretin stimulated Endoscopic Pancreatic Function Test (ePFT). Am J Gastroenterol 2005; 100:1161-6. [PMID: 15842594 DOI: 10.1111/j.1572-0241.2005.41386.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND We have developed a purely endoscopic collection method for the assessment of pancreatic secretory function (ePFT). The pancreatic secretory effects of sedation medications utilized during endoscopic procedures are not completely known. AIMS To study the effect of moderate sedation on the exocrine pancreas gland in a prospective, randomized trial. METHODS Healthy volunteers were randomized by computers to one of two treatments (A-no sedation, B-sedation) in period 1 and crossed-over to the other treatment in period 2 with a minimal washout interval of 7 days. Sedation dosage was standardized for each patient based on age, gender and weight from a previously published dosing nomogram. Synthetic porcine secretin (ChiRhoClin, Inc., Burtonsville, Maryland) was used as the pancreatic stimulant. Duodenal fluid samples were aspirated via the endoscope every 5 min for 1 h and sent on ice to our hospital laboratory for the measurement of pancreatic secretory electrolyte concentrations by autoanalyzer. RESULTS A total of 17 healthy volunteers were enrolled. Sixteen subjects (8 males and 8 females) completed the randomized prospective trial. Median intravenous meperidine and midazolam sedation dose was 62.5 mg and 2.5 mg, respectively. Maximum pancreatic juice flow occurred during the early phase of secretion and maximum bicarbonate concentration occurred during the late phase of secretion. Analysis of the electrolyte composition of the endoscopically collected duodenal drainage fluid revealed a constant cation concentration for both sodium and potassium over the 1 h collection period. The anions, chloride and bicarbonate, exhibited a reciprocal relationship identical to that seen in traditional gastroduodenal tube collection studies. There was no statistical difference observed between the sedation and no sedation groups. The estimated total bicarbonate output (area under curve, AUC) for the sedated and non-sedated groups were 5,017 meq + 724 (range 3,663-6,173) and 5,364 meq +/- 583 (range 4,323-6563) respectively (p= 0.0656). The mean peak bicarbonate concentrations for sedated (n = 8) versus non-sedated (n = 8) groups were 103 +/- 11 meq/L (range 78-125) and 106 +/- 11 meq/L (range 87-138), respectively (p= 0.1346). There was excellent correlation of peak bicarbonate concentrations when sedation and no sedation groups were compared (r= 0.744, p < 0.05; Spearman rank correlation). There were no episodes of pancreatitis. CONCLUSIONS (a) Moderate sedation used for upper endoscopy does not effect the clinical diagnostic parameters (peak bicarbonate concentration or total bicarbonate output) utilized to diagnose pancreatic insufficiency. (b) Analysis of duodenal drainage fluid collected endoscopically after synthetic secretin stimulation produces an identical pancreatic secretory curve described with traditional gastroduodenal tube collection methods.
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Affiliation(s)
- Darwin L Conwell
- The Pancreas Clinic, Section of Endoscopy and Pancreaticobiliary Disease, Department of Gastroenterology and Hepatology, and Laboratory Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Radaelli F, Meucci G, Terruzzi V, Spinzi G, Imperiali G, Strocchi E, Lenoci N, Terreni N, Mandelli G, Minoli G. Single bolus of midazolam versus bolus midazolam plus meperidine for colonoscopy: a prospective, randomized, double-blind trial. Gastrointest Endosc 2003; 57:329-35. [PMID: 12612511 DOI: 10.1067/mge.2003.104] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND The aim of this study was to determine whether a single bolus of meperidine in addition to midazolam improves patient tolerance during colonoscopy. METHODS Consecutive patients undergoing outpatient colonoscopy were randomly assigned in double-blind fashion to receive a single rapid intravenous bolus of 5 mg of midazolam and placebo (Group A, n = 125) or 5 mg midazolam plus 50 mg meperidine (Group B, n = 128). Tolerance (4-point scale: 1 excellent, 4 unbearable), pain (4-point scale: 1 none, 4 severe) and willingness to undergo another colonoscopy were assessed 24 to 48 hours later in a telephone interview conducted by an independent observer blinded to the regimen of sedative medication. RESULTS Significantly more patients in Group A reported moderate or severe pain (28% vs. 9%; p < 0.001), poor or unbearable tolerance (18% vs. 6%; p < 0.01) and unwillingness to undergo colonoscopy again in the future (14% vs. 5%; p < 0.05). By multivariate analysis, randomization to the midazolam group and younger age were the only variables independently associated with the risk of reporting at least one of these outcomes. Recovery time, frequency of oxygen desaturation, and need for supplemental oxygen were not significantly different between the 2 groups. CONCLUSIONS The addition of a single bolus of meperidine to midazolam improves patient tolerance and lessens pain during colonoscopy without significantly increasing the frequency of side effects or prolonging recovery time.
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Vargo JJ, Zuccaro G, Dumot JA, Shermock KM, Morrow JB, Conwell DL, Trolli PA, Maurer WG. Gastroenterologist-administered propofol versus meperidine and midazolam for advanced upper endoscopy: a prospective, randomized trial. Gastroenterology 2002; 123:8-16. [PMID: 12105827 DOI: 10.1053/gast.2002.34232] [Citation(s) in RCA: 250] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Propofol is increasingly used for gastrointestinal endoscopy because of its rapid recovery profile. There has been no prospective, randomized comparison of gastroenterologist-administered propofol to meperidine and midazolam for endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography. Additionally, its cost-effectiveness has not been studied. METHODS Seventy-five randomized patients received either gastroenterologist-administered propofol (n = 38) or meperidine/midazolam (n = 37) for endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography. Monitoring with capnography allowed for rapid titration of propofol at the earliest signs of respiratory depression. Visual analogue scales measured tolerance and satisfaction. A cost-effectiveness analysis was performed by using return to baseline for both activity and food intake 24 hours after the procedure as the effectiveness measure. RESULTS The groups had similar physiological outcomes and satisfaction. Patients receiving propofol had shorter recovery times (P < 0.001) and a higher recovery of both baseline activity level and dietary intake 24 hours after the procedure (P = 0.028). With incremental cost-effectiveness analysis, gastroenterologist-administered propofol cost an additional $403.00 per additional patient at 100% of baseline for both activity level and food intake when compared with standard sedation and analgesia. Sensitivity analysis indicated that the only model in which propofol administration would become the dominant strategy was with its administration by a registered nurse. CONCLUSIONS Gastroenterologist-administered propofol using monitoring with capnography is similar to meperidine/midazolam for both physiological outcomes and patient/endoscopist satisfaction. Propofol leads to significantly improved recovery of baseline activity and food intake 24 hours after the procedure. Our model suggests that propofol would be more cost-effective than meperidine and midazolam for endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography if registered nurse administration were possible.
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Affiliation(s)
- John J Vargo
- Department of Gastroenterology, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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Sipe BW, Rex DK, Latinovich D, Overley C, Kinser K, Bratcher L, Kareken D. Propofol versus midazolam/meperidine for outpatient colonoscopy: administration by nurses supervised by endoscopists. Gastrointest Endosc 2002; 55:815-25. [PMID: 12024134 DOI: 10.1067/mge.2002.124636] [Citation(s) in RCA: 226] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Propofol is under evaluation as a sedative for endoscopic procedures. METHODS Eighty outpatients (ASA Class I or II) undergoing colonoscopy were randomized to receive either propofol or midazolam plus meperidine, administered by a nurse and supervised by an endoscopist. Endpoints were patient satisfaction, procedure and recovery times, neuropsychological function, and complications. RESULTS The mean dose of propofol administered was 218 mg; mean doses of midazolam and meperidine were, respectively, 4.7 mg and 89.7 mg. Mean time to sedation was faster in the propofol patients (2.1 min vs. 7.0 min; p < 0.0001), and depth of sedation was greater (p < 0.0001). On average, after the procedure, the propofol patients could stand at the bedside sooner (14.2 vs. 30.2 min), reached full recovery faster (14.4 vs. 33.0 min), and were discharged sooner (40.5 vs. 71.1 min) (all p < 0.0001). Patients who received propofol also expressed greater overall mean satisfaction on a 10-point visual analog scale (9.3 vs. 8.6; p < 0.05). At discharge, the propofol group had better scores on tests reflective of learning, memory, working memory span, and mental speed. Four patients in the midazolam/meperidine group developed minor complications (1 hypotension and bradycardia, 2 hypotension alone, and 1 tachycardia) and 1 patient in the propofol group had oxygen desaturation develop during an episode of epistaxis. CONCLUSION For outpatient colonoscopy, propofol administered by nurses and supervised by endoscopists has several advantages over midazolam plus meperidine and deserves additional investigation.
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Affiliation(s)
- Brian W Sipe
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis 46202, USA
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Abstract
In the United States sedation and analgesia is the standard of practice when performing upper and lower gastrointestinal endoscopy. Many of these endoscopic procedures are performed in ambulatory endoscopy centers, including ambulatory surgery centers. This article reviews new Joint Commission on Accreditation of Healthcare Organizations standards for sedation and analgesia, drugs used for sedation and analgesia (including side effects), patient assessment and monitoring (before, during, and postprocedure), and discharge of patients from the ambulatory endoscopy center.
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Affiliation(s)
- Joseph J Vicari
- Department of Medicine, University of Illinois College of Medicine, 1601 Parkview Ave., Rockford, IL 6407, USA.
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Abstract
Anesthetists and other providers are seeing an increased demand for sedation or anesthesia for challenging patients undergoing diagnostic procedures. Regardless of the specialty of the provider, proper attention must be paid to patient evaluation, monitoring, and drug dosage. The present review summarizes recommendations regarding sedation, as well as recent literature on sedation and anesthesia for endoscopy, radiology, pediatric oncology procedures, and pediatric electroencephalography.
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Affiliation(s)
- L L Everett
- Department of Anesthesiology, University of Washington, Children's Hospital and Regional Medical Center, Seattle, Washington 98125, USA.
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Rex DK, Lieberman DA. Feasibility of colonoscopy screening: discussion of issues and recommendations regarding implementation. Gastrointest Endosc 2001; 54:662-7. [PMID: 11677497 DOI: 10.1067/mge.2001.117594] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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