Sedation-related complications during anesthesiologist-administered sedation for endoscopic retrograde cholangiopancreatography: a prospective study

Nurse-Administered Sedation in Digestive Endoscopy: A Systematic Review

Background/Objectives: Nurses are becoming increasingly common healthcare professionals who perform sedation in digestive endoscopy services. Efficacy, safety and patient satisfaction are indicators of quality and safety in the administration of sedation by nurses in patients undergoing digestive endoscopy. Therefore, the aim of this study was to synthesize the scientific evidence available to date on the efficacy, safety and patient satisfaction of nurse-administered sedation during digestive endoscopies. Methods: A systematic review was conducted according to PRISMA standards. The PubMed, Scopus, SciELO, Web of Science and LILACS databases were consulted. Narrative synthesis and descriptive statistics were used to explore complications arising from the use of sedation by nurses, using the percentage of complications and total events in the included studies. Owing to the methodology and heterogeneity of the included studies, a meta-analysis was not possible. Results: A total of 292 studies were collected, 13 of which were selected. In terms of efficacy, studies indicate that nurse sedation is effective in ensuring patient comfort and optimizing procedure times. On the other hand, studies have evaluated the safety of sedation, measured complications during sedation and reported incident and minor complication rates of less than 2.5%. Finally, studies analyzing patient satisfaction and patient experience have demonstrated high levels of satisfaction. Conclusions: Nurse-administered sedation demonstrates high efficacy in ensuring patient comfort and optimizing procedure times. Nurse-administered propofol sedation is safe for endoscopic procedures, with low rates of significant adverse events. Patients reported high levels of satisfaction with nurse-administered sedation, with reduced discomfort and improved perceptions of the quality of the procedure.

Sedative effects of propofol and risk factors for excessive sedation in the endoscopic treatment of biliary and pancreatic diseases

Objectives

The safety and effectiveness of propofol in more complex endoscopic procedures, such as endoscopic retrograde cholangiopancreatography, remain unknown. Thus, we aimed to evaluate propofol sedation during endoscopic cholangiopancreatography, ultrasound-guided intervention, and gastroduodenal stenting and examine risk factors for excessive sedation.

Methods

We retrospectively analyzed data from 870 patients who underwent endoscopic treatment with propofol sedation for biliary and pancreatic disease between October 2020 and September 2021. Sedation included propofol and fentanyl, with continuous monitoring of vital signs and the bispectral index. The assessed risk factors included age, complications, body mass index, treatment duration, and specialty.

Results

Distal bile duct treatment (n = 367), hilar bile duct treatment (n = 197), post-small-intestinal reconstruction treatment (n = 75), endoscopic ultrasound-guided intervention (n = 140), and gastrointestinal obstruction treatment (n = 91) were performed. The rates of excessive sedation, hypoxemia, and hypotension were 7.8%, 6.0%, and 1.8%, respectively. Post-small-intestinal reconstruction treatment had the highest incidence rate of excessive sedation (16%), whereas endoscopic ultrasound-guided intervention had the lowest incidence rate (4.3%). Multivariate analysis revealed significant associations between excessive sedation and comorbid sleep apnea, obesity, and prolonged procedural time.

Conclusions

Obesity, sleep apnea syndrome, and prolonged procedure time are risk factors for excessive sedation related to propofol use. Thus, sedation techniques should be tailored for these patients.

Patient satisfaction and safety in the administration of sedation by nursing staff in the digestive endoscopy service: a cross-sectional study

BACKGROUND

The satisfaction of patients with sedation by nursing staff is an issue of interest for the quality of health care, influencing the recovery and well-being of patients as well as their confidence in and adherence to treatment. One of the most frequently performed diagnostic and therapeutic tests requiring sedation are digestive endoscopies, so it would be interesting to study satisfaction in these services.

AIM

To determine the level of patient satisfaction and safety with sedation via digestive endoscopies by nurses.

METHODS

This was a cross-sectional study in the Digestive Endoscopy Service at the University Hospital of Toledo, Spain. The sample consisted of 660 adult patients from the digestive endoscopy service who were sedated between June-September 2023. The degree of satisfaction with the service was measured by the questionnaire: Survey of patient satisfaction with the digestive endoscopy service. The study was approved by the ethics committee.

RESULTS

Patients who reported satisfaction with the treatment were very satisfied with the sedation provided by the nurses. The most valued item was the attention of the nursing professionals. The least valued items were the waiting time for the appointment and the time spent in the waiting room on the same day. The incidence of complications recorded during the test were minimal (2% of all patients).

CONCLUSIONS

Most patients are satisfied with the sedation administered by nurses via digestive endoscopies, and complications were rare, supporting the efficacy and acceptance of this practice. Clinical practice guidelines and consensus documents in Spain guarantee that nurses have autonomy to administer sedation in digestive endoscopy services, but there is a lack of national regulations to support this technique. The current consensus in Spain is that specific training is necessary for such nurses.

Comparative Efficacy and Safety of Anesthetic and Sedative Regimens for Endoscopic Retrograde Cholangiopancreatography: A Network Meta-Analysis

INTRODUCTION

This study evaluates the efficacy and safety of various anesthetic and sedative regimens for endoscopic retrograde cholangiopancreatography (ERCP) procedures.

METHODS

A systematic search was conducted across PubMed, Web of Science, Scopus, and Embase to identify randomized controlled trials (RCTs) published until March 2024. Primary outcomes included procedure time, patient satisfaction, oxygen saturation (SpO2), incidence of SpO2 below 90%, and adverse events. The analysis was performed using R software, analyzing continuous outcomes with mean differences and dichotomous outcomes with risk ratios.

RESULTS

42 RCTs were included. Combination therapies such as remifentanil plus tramadol and propofol plus midazolam plus pethidine demonstrated significantly shorter procedure times. Propofol plus oxycodone yielded higher patient satisfaction. Oxygenation results indicated that propofol plus fentanyl, oxycodone, and ketamine improved SpO2. Propofol plus oxycodone (RR <0.01), dexmedetomidine plus fentanyl (RR <0.01), propofol plus nalbuphine (RR = 0.01), Mg sulfate plus propofol (RR = 0.01), and propofol plus fentanyl (RR = 0.02) showed a significant lower rate of patients with SpO2 below 90% compared to propofol. Midazolam plus pethidine plus dexmedetomidine (RR = 0.01), propofol plus oxycodone (RR = 0.09), and dexmedetomidine plus fentanyl (RR = 0.2) exhibited lower rates of adverse events compared to propofol.

CONCLUSION

This study provides comprehensive evidence to guide clinical decision-making and optimize anesthetic management for ERCP procedures.

INTRODUCTION

This study evaluates the efficacy and safety of various anesthetic and sedative regimens for endoscopic retrograde cholangiopancreatography (ERCP) procedures.

METHODS

A systematic search was conducted across PubMed, Web of Science, Scopus, and Embase to identify randomized controlled trials (RCTs) published until March 2024. Primary outcomes included procedure time, patient satisfaction, oxygen saturation (SpO2), incidence of SpO2 below 90%, and adverse events. The analysis was performed using R software, analyzing continuous outcomes with mean differences and dichotomous outcomes with risk ratios.

RESULTS

42 RCTs were included. Combination therapies such as remifentanil plus tramadol and propofol plus midazolam plus pethidine demonstrated significantly shorter procedure times. Propofol plus oxycodone yielded higher patient satisfaction. Oxygenation results indicated that propofol plus fentanyl, oxycodone, and ketamine improved SpO2. Propofol plus oxycodone (RR <0.01), dexmedetomidine plus fentanyl (RR <0.01), propofol plus nalbuphine (RR = 0.01), Mg sulfate plus propofol (RR = 0.01), and propofol plus fentanyl (RR = 0.02) showed a significant lower rate of patients with SpO2 below 90% compared to propofol. Midazolam plus pethidine plus dexmedetomidine (RR = 0.01), propofol plus oxycodone (RR = 0.09), and dexmedetomidine plus fentanyl (RR = 0.2) exhibited lower rates of adverse events compared to propofol.

CONCLUSION

This study provides comprehensive evidence to guide clinical decision-making and optimize anesthetic management for ERCP procedures.

Antegrade balloon dilatation of the duodenal papilla during laparoscopic cholecystectomy versus endoscopic retrograde cholangiography in patients with acute choledocholithiasis: a case control matched study

INTRODUCTION

In acute obstructive common bile duct (CBD) stones endoscopic retrograde cholangiography for CBD stone removal before cholecystectomy (ChE) ('ERC-first') is the gold standard of treatment. Intraoperative antegrade balloon dilatation of the duodenal papilla during ChE with flushing of CBD stones to the duodenum ('ABD-during-ChE') may be an alternative 'one-stop-shop' treatment option. However, a comparison of outcomes of the 'ABD-during-ChE' technique and the'ERC-first' approach has never been performed.

METHODS

Retrospective case control matched study of patients suffering from obstructive CBD stones (< 8 mm) without severe pancreatitis or cholangitis that underwent the traditional 'ERC-first' approach versus the 'ABD-during-ChE' technique. Primary endpoint was the overall Comprehensive Complication Index (CCI®) from diagnosis to complete CBD stone removal and performed ChE.

RESULTS

A total of 70 patients were included (35 patients each in the 'ERC first'- and 'ABD-during-ChE'-group). There were no statistical significant differences in terms of demographics and disease specific characteristics between the two study groups. However, there was a not significant difference towards an increased overall CCI® in the 'ERC-first' group versus the 'ABD-during-ChE' group (14.4 ± 15.4 versus 9.8 ± 11.1, p = 0.225). Of note, six major complications (Clavien-Dindo classification ≥ IIIa) occurred in the 'ERC-first' group versus two in the 'ABD-during-ChE' group (17% versus 6%, p = 0.136). In addition, significantly more interventions and a longer overall time from diagnosis to complete clearance of bile ducts and performed ChE was found, when comparing the 'ERC-first' group and the 'ABD-during-ChE' group (3.7 ± 0.8 versus 1.1 ± 0.4, p < 0.001; 160.5 ± 228.6 days versus 12.0 ± 18.0 days, p < 0.001).

CONCLUSION

In patients suffering from acute obstructive CBD stones smaller than 8 mm, compared to the 'ERC-first' approach, the 'ABD-during-ChE' technique resulted in significantly less interventions and reduced overall treatment time from diagnosis to complete clearance of bile ducts and performed ChE. This comes together with a strong trend of less intervention related complications in the 'ABD-during-ChE' group.

UK ERCP sedation practices, patient comfort and endoscopist characteristics: National Endoscopy Database (NED) analysis on behalf of the JAG and BSG

Objectives

This analysis assessed current endoscopic retrograde cholangiopancreatography (ERCP) practice within the UK, including use of sedation and patient comfort.

Methods

ERCPs conducted over 1 year (1 July 2021-30 June 2022) and uploaded to the National Endoscopy Database (NED) were analysed. The endoscopist workforce was classified by gender and specialty, use of sedation was analysed. Logistic regression was used to assess associations between patient age, gender and procedure indications on moderate to severe discomfort risk.

Results

27 812 ERCPs were performed by 491 endoscopists in 175 sites and uploaded to NED, an estimated 50% of total UK activity. 13% were training procedures, 94% of the endoscopists were male, with 72% being gastroenterologists. Most ERCPs were performed under conscious sedation (89%). The discomfort rate among patients aged 60-90 undergoing ERCP under conscious sedation was 4.2% (95% CI 3.9% to 4.5%), with only 5.5% (95% CI 5.2% to 5.9%) receiving greater than 5 mg midazolam or 100 µg fentanyl.Younger patients (<30 years) had a higher discomfort risk during conscious sedation ERCPs than those aged 70-79 (OR 3.0, 95% CI 2.2 to 4.3, p<0.05), while male patients had a lower discomfort risk compared with females (OR 0.9, 95% CI 0.8 to 1.0, p=0.05).Enhanced sedation (propofol or general anaesthetic) was associated with lower frequency of discomfort (0.3%, 95% CI 0.1 to 0.6) compared with conscious sedation (5.1%, 95% CI 4.9% to 5.4%, p<0.05).

Conclusions

Conscious sedation is well tolerated for most patients and prescribing practices have improved. However, triage of more patients, particularly young females, to enhanced sedation lists should be considered to reduce discomfort rates in future.

Incidence of sedation-related adverse events during ERCP with anesthesia assistance: a multicenter observational study

BACKGROUND AND AIMS

Anesthesia assistance is commonly used for ERCP. General anesthesia (GA) may provide greater airway protection but may lead to hypotension. We aimed to compare GA versus sedation without planned intubation (SWPI) on the incidence of hypoxemia and hypotension. We also explored risk factors for conversion from SWPI to GA.

METHODS

This observational study used data from the Multicenter Perioperative Outcomes Group. Adults with American Society of Anesthesiologists physical status class I to IV undergoing ERCP between 2006 and 2019 were included. We compared GA and SWPI on incidence of hypoxemia (oxygen saturation <90% for ≥3 minutes) and hypotension (mean arterial pressure <65 mm Hg for ≥5 minutes) using joint hypothesis testing. The association between anesthetic approach and outcomes was assessed using logistic regression. The noninferiority delta for hypoxemia and hypotension was an odds ratio of 1.20. One approach was deemed better if it was noninferior on both outcomes and superior on at least 1 outcome. To explore risk factors associated with conversion from SWPI to GA, we constructed a logistic regression model.

RESULTS

Among 61,735 cases from 42 institutions, 38,830 (63%) received GA and 22,905 (37%) received SWPI. The GA group had 1.27 times (97.5% confidence interval, 1.19-1.35) higher odds of hypotension but .71 times (97.5% confidence interval, .63-.80) lower odds of hypoxemia. Neither group was noninferior to the other on both outcomes. Conversion from SWPI to GA occurred in 6.5% of cases and was associated with baseline comorbidities and higher institutional procedure volume.

CONCLUSIONS

GA for ERCP was associated with less hypoxemia, whereas SWPI was associated with less hypotension. Neither approach was better on the combined incidence of hypotension and hypoxemia.

Safety, Efficacy and High-Quality Standards of Gastrointestinal Endoscopy Procedures in Personalized Sedoanalgesia Managed by the Gastroenterologist: A Retrospective Study

Performing GI endoscopy under sedoanalgesia improves the quality-indices of the examination, in particular for cecal intubation and adenoma detection rates during colonoscopy. The implementation of procedural sedoanalgesia in GI endoscopy is also strongly recommended by the guidelines of the major international scientific societies. Nevertheless, there are regional barriers that prevent the widespread adoption of this good practice. A retrospective monocentric analytic study was performed on a cohort of 529 patients who underwent EGDS/Colonoscopy in sedoanalgesia, with personalized dosage of Fentanyl and Midazolam. ASA class, age and weight were collected for each patient. The vital parameters were recorded during, pre- and post-procedure. The rates of cecal intubation and of procedure-related complications were entered. The VAS scale was used to evaluate the efficacy of sedoanalgesia, and the Aldrete score was used for patient discharge criteria. No clinically significant differences were found between vital signs pre- and post-procedure. Both anesthesia and endoscopic-related complications occurring were few and successfully managed. At the end of examination, both the mean Aldrete score (89.56), and the VAS score (<4 in 99.1%) were suitable for discharge. For the colonoscopies, the cumulative adenoma detection rate (25%) and the cecal intubation rate in the general group (98%) and in the colorectal cancer screening group (100%) were satisfying. Pain control management is an ethical and medical issue aimed at increasing both patient compliance and the quality of the procedures. The findings of this work underscore that in selected patients personalized sedoanalgesia in GI endoscopy can be safely managed by gastroenterologists.

The Clinical Application of Remimazolam Benzenesulfonate Combined with Esketamine Intravenous Anesthesia in Endoscopic Retrograde Cholangiopancreatography

In this project, algorithm-based image processing methods in 3D endoscopic image processing endoscopic retrograde cholangiopancreatography (ERCP) were analyzed. To enhance local information of images, an adaptive histogram equalization method with limited contrast is introduced. The influences of the algorithm on 3D endoscopic image peak signal-to-noise ratio (PSNR), image discrete information entropy (DE), and average mean brightness error (AMBE) of images before and after the optimization before were compared. A total of 92 patients receiving ERCP at Yuhuangding Hospital between December 2019 and December 2021 were selected and divided into the control group (fentanyl+propofol) and the observation group (remimazolam benzenesulfonate+esketamine). Mean arterial pressure heart rate (HR), oxygen saturation (SpO2), and respiratory rate (RR) of the patients at each time point including the entry into the operation room (T0), 2 minutes after the beginning of medication (T1), after endoscopy (T2), endoscopy withdrawal (T3), and postoperative awakening (T4) were recorded. The comparison of MAP between T1, T2, T3, and T4 and T0 among patients in the observation group and the control group showed statistical differences (P < 0.05). Besides, HR and RR at T4 in the observation group were obviously higher than those in the control group (P < 0.05). The comparison of SpO2 at T3 and T4 and that at T0 both showed statistical differences (P < 0.05). Awakening time and VAS scores in the observation group were obviously lower than those in the control group (P < 0.05). The incidence of bradycardia, nausea, vomiting, and chill in the observation group was all lower than that in the control group (P < 0.05). The results indicated that an effective endoscopic image processing method was established based on an image enhancement algorithm, and the combination of remimazolam benzenesulfonate and esketamine showed high safety and efficacy in ERCP.

Efficacy and Safety of Deep Sedation and Anaesthesia for Complex Endoscopic Procedures—A Narrative Review

Propofol sedation for advanced endoscopic procedures is a widespread technique at present, which generates controversy worldwide when anaesthetic or non-anaesthetic personnel administer this form of sedation. There is some evidence for safe administered propofol sedation by non-anaesthetic personnel in patients undergoing endoscopy procedures, but there are only few randomised trials addressing the safety and efficacy of propofol in patients undergoing advanced procedures. A serious possible consequence of propofol sedation is the rapid and unpredictable progression from deep sedation to general anaesthesia mostly when elderly and frail patients are involved in the diagnosis or treatment of various neoplasia. This situation requires rescue measures with skilled airway management. The aim of this paper is to review the safety and efficacy aspects of sedation techniques, with special reference to propofol administration covering the whole patient journey, including preassessment, sedation options and discharge when advanced endoscopic procedures are performed.

Pro-Con Debate: Monitored Anesthesia Care Versus General Endotracheal Anesthesia for Endoscopic Retrograde Cholangiopancreatography

Over the past several decades, anesthesia has experienced a significant growth in nonoperating room anesthesia. Gastrointestinal suites represent the largest volume location for off-site anesthesia procedures, which include complex endoscopy procedures like endoscopic retrograde cholangiopancreatography (ERCP). These challenging patients and procedures necessitate a shared airway and are typically performed in the prone or semiprone position on a dedicated procedural table. In this Pro-Con commentary article, the Pro side supports the use of monitored anesthesia care (MAC), citing fewer hemodynamic perturbations, decreased side effects from inhalational agents, faster cognitive recovery, and quicker procedural times leading to improved center efficiency (ie, quicker time to discharge). Meanwhile, the Con side favors general endotracheal anesthesia (GEA) to reduce the infrequent, but well-recognized, critical events due to impaired oxygenation and/or ventilation known to occur during MAC in this setting. They also argue that procedural interruptions are more frequent during MAC as anesthesia professionals need to rescue patients from apnea with various airway maneuvers. Thus, the risk of hypoxemic episodes is minimized using GEA for ERCP. Unfortunately, neither position is supported by large randomized controlled trials. The consensus opinion of the authors is that anesthesia for ERCP should be provided by a qualified anesthesia professional who weighs the risks and benefits of each technique for a given patient and clinical circumstance. This Pro-Con article highlights the many challenges anesthesia professionals face during ERCPs and encourages thoughtful, individualized anesthetic plans over knee-jerk decisions. Both sides agree that an anesthetic technique administered by a qualified anesthesia professional is favored over an endoscopist-directed sedation approach.