Considerable Variability of Procedural Sedation and Analgesia Practices for Gastrointestinal Endoscopic Procedures in Europe

Nurse-Administered Propofol Sedation Training Curricula and Propofol Administration in Digestive Endoscopy Procedures: A Scoping Review of the Literature

Although efficacy and safety of nonanesthesiologist administration of propofol and nurse-administered propofol sedation practices have been amply demonstrated in patients at low American Society of Anesthesiologists physical status risk, they are still severely limited. To date, it is quite difficult to find a protocol or a shared training program. The aim of the study was to verify requirements, types of training, and operating methods described in the literature for the administration of propofol by a nurse. A scoping review of the literature was conducted in accordance with the PRISMA-ScR guidelines and in line with Arksey and O'Malley's framework, within four main databases of biomedical interest: MEDLINE, CINAHL, Scopus, and Web of Science. We selected studies published during the last 20 years, including only nurses not trained in anesthesia. Seventeen articles were eligible. Despite the differences between the training and administration methods, efficacy and safety of deep sedation managed by trained nurses were comparable, just like when sedation was administered by certified registered nurse anesthetists. Training programs have been investigated in detail by only a small number of studies, although its efficacy and safety have been widely demonstrated. It is important, then, to collect evidence that allows developing of unified international guidelines for training methods to offer safe and cost-effective quality sedation.

Comparison of 95% effective dose of remimazolam besylate and propofol for gastroscopy sedation on older patients: A single-centre randomized controlled trial

AIMS

Advanced age is an important risk factor for adverse events during procedural sedation. Remimazolam is safe and effective in gastroscopic sedation. However, the ideal dose and application for older patients are not well known. We aim to investigate its 95% effective dose (ED95) for older patients undergoing gastroscopy and to assess its safety and efficacy, with propofol as the comparison.

METHODS

The trial consists of 2 parts, patients aged >65 years and scheduled for outpatient painless gastroscopy were enrolled. In the first part, Dixon's up-and-down methodology was used to determine the ED95 of remimazolam besylate and propofol for gastroscopic insertion, in combination with 0.2 μg/kg remifentanil. In the second part, patients in each group received 0.2 μg/kg remifentanil and ED95 dose of the study drugs for sedation induction, supplemental doses were added to maintain sedation depth when necessary. The primary outcome was the incidence of adverse events. The secondary outcome was the recovery time.

RESULTS

The ED95 of remimazolam besylate and propofol induction were 0.2039 (95% confidence interval 0.1753-0.3896) mg/kg and 1.9733 (95% confidence interval 1.7346-3.7021) mg/kg respectively. Adverse events were reported in 26 (40.6%) patients in the remimazolam group and 54 (83.1%) in the propofol group (P < .0001), whereas the remimazolam group presented a higher incidence of hiccups (P = .0169). Besides, the median time to awakening was approximately 1 min shorter with remimazolam than with propofol (P < .05).

CONCLUSION

For older patients undergoing gastroscopy, the ED95 dose of remimazolam is a safer alternative than propofol when inducing the same sedation depth.

Up-to-date literature review and issues of sedation during digestive endoscopy

Sedation is common during digestive endoscopy to provide comfort and pain relief for patients. However, the use of sedation in endoscopy also poses potential risks, and recent issues have been raised regarding its safety and administration. This literature review paper will discuss the most recent developments in the field of sedation in digestive endoscopy, including the adverse events that might be associated with sedation and how to manage it, the legal issues associated with administration, the impact of COVID-19 on sedation practices, and sedation in special situations. It will also touch upon the current guidelines and recommendations for sedation, including the importance of patient selection and monitoring and the need for training and certification for endoscopists administering sedation. The review will also analyse studies evaluating the safety and efficacy of various sedation techniques, including propofol, midazolam, and others. It will examine the benefits and drawbacks of these agents.

Economic benefits of remimazolam compared to midazolam and propofol for procedural sedation in colonoscopies and bronchoscopies

BACKGROUND

Sedation is common practice in endoscopic procedures to suppress a patient's level of consciousness while maintaining the cardio-respiratory function. Midazolam and propofol are the sedatives most frequently used for procedural sedation at the hospitals in Scandinavia. Remimazolam is a new ultra-short-acting benzodiazepine sedative and the present analysis aimed at estimating the economic benefits of introducing remimazolam for procedural sedation in colonoscopies and bronchoscopies in hospitals in Scandinavia.

METHOD

We developed a cost model applying a micro-costing approach that comprised the cost components that are affected by differences in the efficacy of remimazolam, midazolam and propofol, and the model estimated the cost per successful colonoscopy and bronchoscopy when using remimazolam, midazolam or propofol as sedation. A micro-costing approach was applied, and the model consisted of six stages representing the journey for patients undergoing endoscopies and was informed primarily by data from clinical studies on remimazolam.

RESULTS

We found a total cost of DKK 1,200 per successful colonoscopy procedure when using remimazolam, a total cost of DKK 1,320 when using midazolam and a total cost of DKK 1,255 when using propofol. Hence, the incremental saving per successful colonoscopy procedure of using remimazolam was estimated to be DKK 120 compared to midazolam and DKK 55 compared to propofol. The total cost per successful bronchoscopy procedure when using remimazolam was DKK 1,353 and DKK 1,724 for midazolam, resulting in an incremental saving per bronchoscopy of DKK 372 when using remimazolam. Performed sensitivity analyses identified the time in recovery as the largest contributor to uncertainty in the analyses of remimazolam compared to midazolam in colonoscopies and bronchoscopies. In the comparison of remimazolam and propofol in colonoscopies, procedure time was the largest contributor to uncertainty.

CONCLUSION

We found that procedural sedation with remimazolam was associated with economically meaningful savings compared to procedural sedation with midazolam and propofol in colonoscopies and to midazolam in bronchoscopies.

Evaluation of 30-day mortality in patients undergoing gastrointestinal endoscopy in a tertiary hospital: a 3-year retrospective survey

Objective

Despite international guidelines recommendations to use mortality as a quality criterion for gastrointestinal (GI) procedures, recent studies reporting these data are lacking. Our objective was to report death causes and rate following GI endoscopies in a tertiary university hospital.

Design

We retrospectively reviewed all GI procedures made between January 2017 and December 2019 in our tertiary hospital in Switzerland. Data from patients who died within 30 days of the procedure were recorded.

Results

Of 18 233 procedures, 251 patients died within 30 days following 345 (1.89%) procedures (244/9180 gastroscopies, 53/5826 colonoscopies, 23/2119 endoscopic ultrasound, 19/911 endoscopic retrograde cholangiopancreatography, 6/197 percutaneous endoscopic gastrostomies). Median age was 70 years (IQR 61–79) and 173/251 (68.92%) were male. Median Charlson Comorbidity Index was 5 (IQR 3–7), and 305/345 procedures (88.4%) were undertaken on patients with an ASA score ≥3. Most frequent indications were suspected GI bleeding (162/345; 46.96%) and suspected cancer or tumourous staging (50/345; 14.49%). Major causes of death were oncological progression (72/251; 28.68%), cardiopulmonary failure or cardiac arrest of unkown origin (62/251; 24,7%) and liver failure (20/251; 7.96%). No deaths were caused by complications such as perforation or bleeding.

Conclusions

Progression of malignancies unrelated to the procedure was the leading cause of short-term death following a GI procedure. After improvements in periprocedural care in the last decades, we should focus on patient selection in this era of new oncological and intensive care therapies. Death rate as a quality criterion is subject to caution as it depends on indication, setting and risk benefit ratio.

Effect of intravenous lidocaine on the ED50 of propofol for inserting gastroscope without body movement in adult patients: a randomized, controlled study

Background

Circulatory and respiratory depression are common  problems that occur in propofol alone sedation during gastroscopy. As a widely used analgesic adjuvant, intravenous lidocaine can reduce the consumption of propofol during Endoscopic retrograde cholangiopancreatography (ERCP) or colonoscopy. However, it is still unknown the median effective dose (ED₅₀) of propofol when combined with lidocaine intravenously. This study aimed to compare the ED₅₀ of propofol with or without intravenous lidocaine for inserting gastrointestinal endoscope successfully.

Methods

Fifty nine patients undergoing gastroscopy or gastrointestinal (GI) endoscopy were randomly divided into control group (Group C, normal saline + propofol) or lidocaine group (Group L, lidocaine + propofol). Patients were initially injected a bolus of 1.5 mg/kg lidocaine in Group L, whereas equivalent volume of 0.9% saline in Group C. Anaesthesia was then induced with a single bolus of propofol in all subjects. The induction dose of propofol was determined by the modified Dixon’s up-and-down method, and the initial dose was 1.5 mg/kg in both groups. The primary outcome was the ED₅₀ of propofol induction dose with or without intravenous lidocaine. The secondary outcomes were the induction time, the first propofol bolus time (FPBT: from MOAA/S score ≤ 1 to first rescue bolus propofol), and adverse events (AEs: hypoxemia, bradycardia, hypotension, and body movements).

Results

Totally, 59 patients were enrolled and completed this study. The ED₅₀ of propofol combined with lidocaine was 1.68 ± 0.11 mg/kg, significantly reduced compared with the normal saline group, 1.88 ± 0.13 mg/kg (P = 0.002). There was no statistical difference in induction time (P = 0.115) and the FPBT (P = 0.655) between the two groups. There was no significantly difference about the AEs between the two groups.

Conclusion

The ED₅₀ of propofol combined with intravenous lidocaine for successful endoscope insertion in adult patients, was 1.68 ± 0.11 mg/kg significantly reduced compared with the control group.

Trial registration

Chinese Clinical Trial Registry, No: ChiCTR2200059450. Registered on 29 April 2022. Prospective registration. http://www.chictr.org.cn.

Effective dose of propofol combined with a low-dose esketamine for gastroscopy in elderly patients: A dose finding study using dixon’s up-and-down method

Objective: This study aimed to determine the optimal dose of propofol combined with esketamine to inhibit the response to gastroscope insertion in elderly patients.

Methods: This is a prospective, non-controlled, non-randomized, single-center study. Elderly patients aged 65–80 years were enrolled in the study with the American society of anesthesiologists (ASA) physical status I or II undergoing elective gastroscopy. All patients were administered propofol after an intravenous esketamine at the dosage of 0.3 mg/kg 30 s, the subsequent dose of propofol was determined by the response of the previous patient to gastroscope insertion (choking, body movement, etc.) using Dixon’s up-and-down method. The initial dose of propofol administered to the first elderly patient was 3.0 mg/kg, and the standard ratio of propofol dose in adjacent patients was 0.9. At least six crossover points were obtained before the conclusion of the study. By using Probit analysis the median effective dose (ED₅₀), 95% effective dose (ED₉₅), and the corresponding 95% confidence interval (CI) for propofol were determined.

Results: The study continued until we obtained seven crossover points and 32 elderly patients (17 males and 15 females) were collected. The ED₅₀ of propofol combined with esketamine inhibiting response to gastroscope insertion in elderly patients were found to be 1.479 mg/kg (95% CI 1.331–1.592 mg/kg), and ED₉₅ was found to be 1.738 mg/kg (95% CI 1.614–2.487 mg/kg).

Conclusion: According to the present study, propofol combined with 0.3 mg/kg esketamine is safe and effective for elderly patients undergoing gastroscopy. The ED₅₀ and ED₉₅ doses of propofol inhibiting response to gastroscope insertion in elderly patients when combined with 0.3 mg/kg esketamine were 1.479 and 1.738 mg/kg, respectively, without apparent adverse effects.

The median effective doses of propofol combined with two different doses of nalbuphine for adult patients during painless gastroscopy

Objective: Propofol is the most widely administered intravenous anesthetic to induce deep sedation for gastroscopy procedures. Coadministration of nalbuphine can provide analgesia and sedation to patients experiencing visceral pain, thereby decreasing the amount of propofol needed and reducing the risk of propofol-induced adverse events. We carried out this study to determine the median effective dose (ED50) of propofol in combination with different dosages of nalbuphine and the optimal dosage of nalbuphine during painless gastroscopy.

Methods: We recruited sixty-five patients aged 18–60 years who underwent elective painless gastroscopy. A total of sixty-one patients were allocated randomly to the N1 group (nalbuphine 0.1 mg/kg) or N2 group (nalbuphine 0.15 mg/kg). Three minutes after administration of nalbuphine, patients received a preset dose of propofol at 2.0 mg/kg with a dose gradient of 0.2 mg/kg according to Dixon’s “up-and-down” method. The primary outcome was the ED50 of propofol in combination with nalbuphine. Hemodynamic parameters, recovery time, pain score, and adverse events were recorded as secondary outcomes.

Results: The ED50 of propofol in the N2 group was significantly lower than that observed in the N1 group (p < 0.01). Using probit analysis, the ED50 and ED95 of propofol were 1.632 mg/kg and 2.759 mg/kg in the N1 group and 1.111 mg/kg and 2.243 mg/kg in the N2 group, respectively. The incidence of hypotension in the N2 group was lower than that in the N1 group (p < 0.05), and the recovery time was shorter than that of the N1 group (p < 0.05).

Conclusion: In adult patients, 0.15 mg/kg nalbuphine led to a significant reduction in the ED50 and ED95 of propofol during gastroscopy. This dose of nalbuphine also reduced the incidence of hypotension and shortened the recovery time. Therefore, nalbuphine (0.15 mg/kg) combined with propofol is a safe option for enhancing recovery after painless gastroscopy in adult patients.

Clinical Trial Registration: [https://www.chictr.org.cn/edit.aspx?pid=126699&htm=4], identifier [ChiCTR2100053204].

The effectiveness of esketamine and propofol versus dezocine and propofol sedation during gastroscopy: A randomized controlled study

WHAT IS KNOWN AND OBJECTIVE

Propofol is widely used in painless gastroscopy. However, sedation with propofol alone might increase the risk of respiratory and circulatory complications. This randomized clinical study compares the efficacy and safety of esketamine or dezocine combined with intravenous (IV) propofol in patients undergoing gastroscopy.

METHODS

A total of 102 patients were enrolled in this study and randomized into two groups. All patients were adults aged 18-64 years who underwent upper gastrointestinal gastroscopy. Patients were randomly assigned to two groups to receive esketamine (0.3 mg/kg) combined with propofol (group E) or dezocine (0.05 mg/kg) combined with propofol (group D). In both groups, the drugs were administered intravenously. The primary outcome was the dose of propofol which provided a satisfactory sedative effect, both to the endoscopist and the patients. Secondary outcomes included recovery time, side effects (such as hypotension, nausea and vomiting and agitation), and the number of adverse circulatory and respiratory events.

RESULTS

Data of 83 patients were analysed in the present study. Dosage of propofol required in group E (1.44 mg/kg ± 0.67 mg/kg) was significantly lower compared with that in group D (2.12 mg/kg ± 0.37 mg/kg) (p < 0.0001). There was no statistically significant difference in recovery time, side effects, and the frequency of sedation-related adverse events between the two groups.

WHAT IS NEW AND CONCLUSION

The study indicates that intravenous injection of propofol and esmketamine is more effective for gastroscopy. Use of esketamine reduces the total amount of propofol required in ASA I-II patients undergoing gastroscopy compared with single use of dezocine. It also provides more stable hemodynamics, without affecting the recovery time and side effects such as respiratory and circulatory adverse events.

TRIAL REGISTRATION

The study was registered at the Chinese Clinical Trial Registry (www.chictr.org.cn; registration number: ChiCTR2100051814) on 05/10/2021.

A plea for a unified approach to sedation in gastrointestinal endoscopy in Romania: results from a prospective multicentric trial

Background. Adequate sedation is a prerequisite for quality endoscopic examination of the digestive tract. We aimed to evaluate the current practices and safety profile of sedation for gastrointestinal endoscopy in Romania and its impact on the technical success of the procedure and procedure-related adverse events.

Methods. We conducted a prospective, multicentric, observational study including all patients undergoing digestive endoscopic procedures under various degrees of sedation. We collected data regarding the endoscopic procedure, type and degree of sedation, drug regimens, personnel in charge of sedation, and relevant patient related information. The main study outcome was the rate of sedation-related adverse events; secondary study outcomes included procedure-related adverse events and the impact of sedation on procedure success.

Results. 1,043 consecutive endoscopic procedures from eight Romanian endoscopy units were included in our study. Sedation regimens were highly variable between participating centers, with 566 (54%) of procedures being performed under sedation provided by an anaesthesiologist. Sedation-related adverse events occurred in 40 cases (3.8%), most of them were mild respiratory and cardiovascular events and all reversed spontaneously.

On multivariate analysis, male gender, procedure type (endoscopic ultrasound and endoscopic retrograde cholangiopancreatography) and deep sedation were risk factors for complications. The endoscopy unit, ASA status, age and type of sedative did not influence the complication rate.

Conclusion. In conclusion, sedation for endoscopic procedures is generally safe, despite a high variability in sedation practices between centers in Romania. Establishing a national guideline on sedation for gastrointestinal endoscopy will ensure consistent and safe practice for these procedures.

Confocal laser endomicroscopy under propofol-based sedation for early gastric cancer and pre-cancerous lesions is associated with better diagnostic accuracy: a retrospective cohort study in China

Background

Confocal laser endomicroscopy (CLE) has advantages in detecting gastric neoplastic lesions, meanwhile it requires strict patient cooperation. Sedation could improve patient cooperation and quality of endoscopy. However, sedation is still not very popular in some resource-limited countries and regions. The purpose of this study was to compare propofol-based sedated versus un-sedated CLE in the value of diagnosing early gastric cancer (EGC) and precancerous lesions.

Methods

A retrospective, cohort, single center study of 226 patients who underwent CLE between January 1, 2015 and December 31, 2017 was performed. Patients enrolled were allocated into the propofol-based sedated group (n = 126) and the un-sedated group (n = 100). The comparison of validity and reliability of CLE for identifying EGC and precancerous lesions between the two groups was performed through analyzing CLE diagnosis and pathological diagnosis. Reporting followed the STROBE guidelines.

Results

The area under receiver operating characteristic curve (AUROC) of diagnosing EGC in the sedated group was 0.97 (95 % CI: 0.95 to 0.99), which was higher than that in the un-sedated group (0.88 (95 % CI: 0.80 to 0.97), P = 0.0407). CLE with sedation performed better than without sedation in diagnosing intraepithelial neoplasia and intestinal metaplasia (P = 0.0008 and P = 0.0001, respectively). For patients considered as high-grade intraepithelial neoplasia or EGC by endoscopists, they would not get biopsy during CLE but receive endoscopic submucosal dissection (ESD) subsequently, and the misdiagnosis rate of CLE was 0 % in the sedated group and 27.59 % (95 % CI: 10.30–44.91 %) in the un-sedated group (P = 0.006).

Conclusions

Propofol based sedation was associated with improved diagnostic value of CLE for detecting EGC as well as precancerous lesions (intraepithelial neoplasia OR intestinal metaplasia).

Efficacy and Safety of a Novel Mouthpiece for Esophagogastroduodenoscopy: A Multi-Center, Randomized Study

This randomized trial aimed to compare the safety and efficacy of the GAGLESS mouthpiece for esophagogastroduodenoscopy (EGD) with that of the conventional mouthpiece. In all, 90 participants were divided into the GAGLESS mouthpiece and conventional mouthpiece groups. The primary endpoint was the severity of pain using the visual analog scale (VAS), and secondary endpoints were examination time, past history of endoscopy, success of the procedure, systolic (SBP) and diastolic (DBP) blood pressure, oxygen saturation, pulse rate before and after EGD, and adverse events. Endoscopy was completed in all cases, and no complications were observed. VAS, when passing the scope through the pharynx, was 2.5 ± 2.4 and 2.0 ± 1.9 cm (p = 0.24) in the conventional and GAGLESS groups, respectively, and that, throughout the examination, was 2.5 ± 2.4 and 1.7 ± 1.5 cm (p = 0.06), respectively. The difference in blood pressure between the GAGLESS and conventional groups was not significant for SBP (p = 0.08) and significant for DBP (p = 0.03). The post-EGD difference in DBP was significantly lower in the GAGLESS group than in the conventional group. The results indicate that GAGLESS mouthpieces had a lower VAS during endoscopy than the conventional mouthpieces, and the changes in blood pressure were smaller with the GAGLESS mouthpiece.

Risk Factors for Prolonged Hospital Stay after Endoscopy

Background/Aims

The recovery room used after endoscopy has limited capacity, and an efficient flow of the endoscopy unit is desired. We investigated the duration of hospital stay after endoscopy and the risk factors for prolonged hospital stay among outpatients.

Methods

We retrospectively studied consecutive patients who underwent esophagogastroduodenoscopy or colonoscopy at the Toyoshima Endoscopy Clinic. We collected data on age, sex, body weight, midazolam and pethidine dosage, respiratory depression during endoscopy, and duration of hospital stay after endoscopy (scope out to check out). Risk factors for prolonged hospital stay (>100 minutes) were identified using multiple logistic regression analysis.

Results

We enrolled 3,898 patients, including 3,517 (90.2%) patients tested under sedation and 381 (9.8%) patients tested without sedation. Overall, 442 (11.3%) patients had prolonged stay (>100 min). The mean time difference between sedation group and non-sedation group was 44.2 minutes for esophagogastroduodenoscopy and 39.1 minutes for colonoscopy. Age (odds ratio [OR], 1.025; 95% confidence interval [CI], 1.014−1.036), female sex (OR, 1.657; 95% CI, 1.220−2.249), and midazolam dose (OR, 1.019; 95% CI, 1.013−1.026) were independently associated with prolonged hospital stay after esophagogastroduodenoscopy, with similar results for colonoscopy.

Conclusions

Old age, female sex, and midazolam dose were independent risk factors for prolonged hospital stay after endoscopy.

Safety and Recipient Satisfaction of Propofol Sedation in Outpatient Endoscopy: A 24-Hour Prospective Investigation Using a Questionnaire Survey

Background/Aims

The aim of this study was to evaluate the safety of sedation with propofol as an alternative to benzodiazepine drugs in outpatient endoscopy.

Methods

In this prospective study, examinees who underwent outpatient endoscopy under propofol sedation and submitted a nextday questionnaire with providing informed consent were evaluated. Periprocedural acute responses, late adverse events within 24 hours, and examinee satisfaction were evaluated.

Results

Among the 4,122 patients who received propofol in the 17,978 outpatient-based endoscopic examinations performed between November 2016 and March 2018, 2,305 eligible examinees (esophagogastroduodenoscopy for 1,340, endoscopic ultrasonography for 945, and total colonoscopy for 20) were enrolled, and their responses to a questionnaire were analyzed. The mean propofol dose was 69.6±24.4 mg (range, 20–200 mg). Diazepam, midazolam, and/or pentazocine in combination with propofol was administered to 146 examinees. Mild oxygen desaturation was observed in 59 examinees (2.6%); and mild bradycardia, in 2 (0.09%). Other severe reactions or late events did not occur. After eliminating 181 invalid responses, 97.7% (2,065/2,124) of the patients desired propofol sedation in future examinations.

Conclusions

Propofol sedation was found to be safe-without severe adverse events or accidents-for outpatient endoscopy on the basis of the patients’ next-day self-evaluation. Given the high satisfaction level, propofol sedation might be an ideal tool for painless endoscopic screening.

Estimation of effective dose of propofol mono-sedation for successful insertion of upper gastrointestinal endoscope in healthy, non-obese Chinese adults

WHAT IS KNOWN AND OBJECTIVE

Propofol is effective in sedation for upper gastrointestinal (UGI) endoscopy. However, the optimum dose is ill-defined. This study aimed to estimate the effective dose of propofol mono-sedation for successful endoscope insertion in healthy, non-obese Chinese adults undergoing single UGI endoscopy.

METHODS

Twenty-six adult patients undergoing elective single UGI endoscopy were enrolled in this study. A modified Dixon's up-and-down method was utilized to assess the effective dose of propofol for successful endoscope insertion. The initial dose of propofol administered, 1.6 mg/kg, was adjusted with 0.1 mg/kg as a step size. The patient's responses to endoscope insertion were classified as either 'movement' or 'no movement'. When patient's responses were changed from 'movement' to 'no movement' or from 'no movement' to 'movement', a crossover was defined. After eight crossovers had been obtained, patient recruitment was stopped. The mean of midpoints of all crossovers obtained by the modified Dixon's up-and-down method in all 26 patients was defined as calculated median effective dose (ED₅₀ ) of propofol for successful endoscope insertion. Furthermore, probit regression analysis was used to determine the dose of propofol where 50% (ED₅₀ ) and 95% (ED₉₅ ) of endoscope insertion attempts were successful.

RESULTS

The calculated ED₅₀ of propofol for successful endoscope insertion was 1.89 ± 0.12 mg/kg. The probit regression analysis showed that ED₅₀ and ED₉₅ of propofol for successful endoscope insertion were 1.90 mg/kg (95% CI, 1.78-2.10 mg/kg) and 2.15 mg/kg (95% CI, 2.01-3.56 mg/kg), respectively. No any patient had hypoxaemia and gag reflex during the UGI endoscopy with propofol mono-sedation.

WHAT IS NEW AND CONCLUSION

In healthy, non-obese Chinese adults, propofol mono-sedation can provide excellent conditions of UGI endoscopy and the estimated ED₅₀ of propofol for successful endoscope insertion is 1.89 ± 0.12 mg/kg.

A focused ethnography of how endoscopy practitioners utilize capnography in sedated patients

The literature shows that respiratory complications are common with sedation. Given the inherent risk, capnography monitoring is recommended whenever sedation is administered. We aimed to explore sedation practitioners’ behavior patterns and perceptions regarding capnography monitoring during endoscopy sedation and examine how capnography influenced clinical decision making when assessing respiration. We conducted a focused ethnography with triangulated observations and semi-structured interviews, and we purposively sampled and recruited five sedation practitioners as participants at a hospital in Saudi Arabia. Through data analysis, we identified representative themes and found cultural differences between anesthesia practitioners and nurses when using capnography during sedation. Anesthesia practitioners linked safety and the use of capnography to maintain adequate respiration, while nurses believed capnography was a secondary supportive monitor to patient observation and assessment. Findings also captured the unique cultures and values of each professional group to be associated with the varying perceptions. We also identified several factors facilitating and barring adequate utilization of capnography. In conclusion, professional culture, hospital policy, knowledge and previous experience with capnography guided the monitoring practice of endoscopy practitioners when assessing respiration during sedation.

Nonoperating room anesthesia in different parts of the world

PURPOSE OF REVIEW

Advances in early diagnosis and treatment of diseases using minimally invasive procedures has led to an increase in the number of cases in locations outside the operating room. This surge created the need for anesthesia services to expand to these areas to provide well tolerated and favorable procedural conditions. The present review describes nonoperating room anesthesia patterns in different parts of the world.

RECENT FINDINGS

Nonoperating room anesthesia has grown exponentially over the last years. Patients scheduled in these areas are sicker and older compared to the operating room patients. Anesthesiologist-directed care has proven to be well tolerated, with less serious complications and improvement in patients and proceduralist satisfaction.

SUMMARY

There are marked variations in how anesthesia services are delivered in out of operating room locations in different parts of the world. Although there are some data available from the United States, expansion of minimally invasive procedures across continents will likely lead to the emergence of various models of delivering anesthetic care.

A survey on colonoscopy shows poor understanding of its protective value and widespread misconceptions across Europe

Background

Colonoscopy is a valuable screening tool for colorectal cancer. However, patients experience anxiety when faced with attending a first colonoscopy, and negative attitudes may contribute to non-attendance. Few studies in Europe have explored these attitudes, despite increasing colorectal cancer incidence.

Study aim

We conducted an online survey of the public in five European Union countries (France, Germany, Italy, Spain, and the UK), with the aim of understanding public knowledge of, perceptions of, and attitudes towards, colonoscopy and bowel preparation, amongst colonoscopy-naïve respondents. Attitudes towards colonoscopy were also gathered from colonoscopy-experienced patients.

Methods

Survey answers were gathered from 2,500 colonoscopy-naïve respondents and 500 colonoscopy-experienced patients, divided equally between countries.

Results

Across Europe, 72% of colonoscopy-naïve respondents showed receptiveness to colonoscopy if advised by their doctor to receive one, but only 45% understood its use to prevent colorectal cancer. Forty-three percent of colonoscopy-experienced respondents would still be embarrassed about having another colonoscopy, although 59% said that the experience had been better than expected. Colonoscopy-experienced respondents had greater aversion to bowel preparation than colonoscopy-naïve respondents (47% vs 26%), and 67% of colonoscopy-naïve respondents thought that only 1 litre of bowel preparation or less is required. Italians and the Spanish wanted more information than on average in Europe, while Germans had more realistic expectations of bowel preparation.

Discussion

There are perceptual gaps amongst the public around the purpose of colonoscopies, the subjective experience of the colonoscopy procedure, and the quantity of bowel preparation needed. These concerns could be mitigated by better education and using lower-volume bowel preparation techniques.

Conclusion

Europeans would have a colonoscopy, but its preventive medical purpose is poorly understood and there are misconceptions around the process. Further education about the procedure, its benefits and bowel preparation is vital to improve understanding and compliance.

Propofol versus midazolam with or without short-acting opioids for sedation in colonoscopy: a systematic review and meta-analysis of safety, satisfaction, and efficiency outcomes

BACKGROUND AND AIMS

Propofol is increasingly being used for sedation in colonoscopy; however, its benefits over midazolam (± short-acting opioids) are not well quantified. The objective of this study was to compare safety, satisfaction, and efficiency outcomes of propofol versus midazolam (± short-acting opioids) in patients undergoing colonoscopy.

METHODS

We systematically searched Medline, Embase, and the Cochrane library (to July 30, 2018) for randomized controlled trials of colonoscopies performed with propofol versus midazolam (± short-acting opioids). We pooled odds ratios for cardiorespiratory outcomes using mixed-effects conditional logistic models. We pooled standardized mean differences (SMDs) for patient and endoscopist satisfaction and efficiency outcomes using random-effects models.

RESULTS

Nine studies of 1427 patients met the inclusion criteria. There were no significant differences in cardiorespiratory outcomes (hypotension, hypoxia, bradycardia) between sedative groups. Patient satisfaction was high in both groups, with most patients reporting willingness to undergo a future colonoscopy with the same sedative regimen. In the meta-analysis, patients sedated with propofol had greater satisfaction than those sedated with midazolam (± short-acting opioids) (SMD, .54; 95% confidence interval [CI], .30-.79); however, there was considerable heterogeneity. Procedure time was similar between groups (SMD, .15; 95% CI, .04-.27), but recovery time was shorter in the propofol group (SMD, .41; 95% CI, .08-.74). The median difference in recovery time was 3 minutes, 6 seconds shorter in patients sedated with propofol.

CONCLUSIONS

Both propofol and midazolam (± short-acting opioids) result in high patient satisfaction and appear to be safe for use in colonoscopy. The marginal benefits to propofol are small improvements in satisfaction and recovery time.

A Prospective Study of Factors Associated with Abdominal Pain in Patients during Unsedated Colonoscopy Using a Magnifying Endoscope

Objective With the advent of endoscopic treatment, the detailed diagnosis of colorectal neoplasms made using magnifying colonoscopy has become increasingly important. However, insertion difficulty causes pain in unsedated colonoscopy. The aim of this prospective observational study was to clarify the factors associated with a patient's pain in unsedated colonoscopy using a magnifying endoscope. Methods Patient pain was assessed using a numerical rating scale (0-10) immediately after the procedure. We defined 5 as mild enough pain that patients would not be reluctant to undergo another colonoscopy. Acceptable pain was defined as 5 or less and severe pain was defined as 8 to 10. Univariate and multivariate linear regression analyses were performed using the pain scale score as a dependent variable. Results A total of consecutive 600 patients undergoing unsedated colonoscopies were evaluated to assess their abdominal pain. The completion rate was 99.5% (597/600). The mean pain scale score was 3.88±2.38. The rate of acceptable pain was 80.5% (483/600). The rate of severe pain was 6.7% (40/600) including the incomplete cases. A comparison of polyp-positive and polyp-negative cases revealed no marked difference in patient pain (3.82±2.24 vs. 3.94±2.49, respectively; p=0.590) or insertion time (6.62±3.98 vs. 6.29±4.21, p=0.090), while more observation time was needed in polyp-positive cases than in polyp-negative ones (16.30±4.95 vs. 13.08±4.69, p<0.01). Univariate and multivariate linear regression analyses revealed that an older age, colectomy, antispasmodic agent use, and a small-diameter endoscope were significant factors associated with less patient pain. In particular, a small-diameter endoscope induces significantly more acceptable pain than a non-small diameter endoscope [85.63% (274/320) vs. 73.93% (207/280), p=0.00003]. Conclusion Unsedated colonoscopy using a magnifying endoscope by an expert may result in acceptable pain levels. The use of an antispasmodic agent, particularly hyoscine N-butyl bromide, and a small-diameter endoscope are recommended for reducing abdominal pain during unsedated colonoscopy.

Assessment of the Quality of Outpatient Endoscopic Procedures by Using a Patient Satisfaction Questionnaire

INTRODUCTION

Endoscopic procedures represent an important part of daily practice, both for gastroenterologists and nurses, enabling diagnosis and treatment of digestive diseases. An optimal level of quality needs to be obtained for endoscopic procedures to be efficient, which is reflected directly by patient satisfaction. The Gastrointestinal Endoscopy Satisfaction Questionnaire (GESQ) has already been validated in a multicenter trial as an efficient method for measuring patient satisfaction. Aim The aim of our study was to evaluate the quality of endoscopic procedures and patient satisfaction by applying a modified version of the GESQ in an outpatient facility, with or without deep sedation performed under the supervision of an anesthesiologist.

MATERIAL AND METHODS

Our study included 552 patients undergoing diagnostic and therapeutic upper and lower GI endoscopies, including endoscopic ultrasound procedures (EUS) performed under propofol sedation, from September 2015 to February 2016. Consecutive patients examined during these 6 months received the questionnaire which was handed by the endoscopy nurse two hours after procedure. The GESQ was modified to include different sections for: 1) communication skills with questions regarding the quantity and clarity of the information delivered to the patient before and after the procedures; 2) pain and discomfort related to the examination with an added question about the specific procedure the patient had undergone; 3) staff manners; 4) physician's technical skills; 5) facility organization (waiting time, comfort in the recovery room, good facilities and equipment) and 6) overall satisfaction. The questionnaire did not include personal data, while answers were analyzed in a confidential manner.

RESULTS

A total number of 552 patients agreed to answer our questionnaire, 192 (34,7%) underwent gastroscopies, 288 (52,1%) colonoscopies and 72 (13,2%) EUS examinations. Regarding the overall level of satisfaction (assessed on a five-point scale), 476 (86,2%) were very satisfied or satisfied, 69 (12,5%) dissatisfied and the remainder 7 (1,3%) were indifferently. For the communication section 16 (3%) patients were not satisfied with the explanations received before the procedure or with the answers to their questions. Pain and discomfort were mentioned by 29 (5,2%) of the patients, usually related to colonoscopies or EUS examinations. 13 (2,3%) of the patients considered the comfort or intimacy of the recovery room to be poor, and 11 (2%) patients were not satisfied with the waiting time before the procedure.

CONCLUSION

Our modified questionnaire showed good overall patient satisfaction with our endoscopy unit, while also suggesting some areas in need of improvement, such as staff communication skills, better time management and reorganization of the recovery area. Our study demonstrates the importance of such questionnaires in providing feedback information meant to improve standards in endoscopy, including staff skills and organization.

Paradigm shift: should the elderly undergo propofol sedation for DBE? A prospective cohort study

OBJECTIVE

Evaluate the safety of propofol-assisted double balloon enteroscopy (DBE) in elderly patients against a younger cohort.

DESIGN

Prospective cohort study.

SETTING

All patients undergoing DBE over a 30-month period were recruited at our tertiary centre.

PATIENTS

215 procedures in 161 patients were performed. An age cut-off of 65 years and above was used to define those who were elderly.

INTERVENTIONS

Patients were subcategorised into four groups: elderly or young undergoing DBE with propofol or conventional sedation (with midazolam±fentanyl).

MAIN OUTCOME MEASURES

Patient demographics, comorbidities, procedural data, complications, diagnostic and therapeutic yield were compared.

RESULTS

Cardiovascular disease and a higher American Society of Anaethesiologists (ASA) status were more prevalent in elderly patients undergoing DBE with propofol (p<0.05). Common indications for DBE were occult and overt obscure gastrointestinal bleeding and suspected Crohn's disease (elderly vs young: 50.7% vs 42.3%, 17.8% vs 12% and 19.2% vs 26.1%, respectively). Diagnostic yield was higher in elderly compared with young patients (75.3% vs 58.5%, p=0.016). The most common findings in elderly and young patients were angioectasia (30.1% and. 18.3%, respectively) and ulcers (17.8% and 9.2%, respectively), while therapeutic intervention rates were comparable (42.5% vs 32.4%, p=0.18). ASA status did not affect propofol dose (p=0.55) or procedure duration (p=0.31). Tolerance scores were favourable in those receiving propofol compared with conventional sedation (p<0.05). There was no difference in complications between the four groups (p=0.17).

CONCLUSION

Compared with young patients, propofol-assisted DBE in the elderly is safe and has a high diagnostic yield.

Do we really need an anesthesiologist for routine colonoscopy in American Society of Anesthesiologist 1 and 2 patients?

PURPOSE OF REVIEW

In an era where healthcare costs are being heavily scrutinized, every expenditure is reviewed for medical necessity. Multiple national gastroenterology societies have issued statements regarding whether an anesthesiologist is necessary for routine colonoscopies in American Society of Anesthesiologist (ASA) 1 and 2 patients.

RECENT FINDINGS

A large percentage of patients are undergoing screening colonoscopy without any sedation at all, which would not require an independent practitioner to administer medications. Advances in technique and technology are making colonoscopies less stimulating. Advantages to administering sedation, including propofol, have been seen even when not administered under the direction of an anesthesiologist and complications seem to be rare. The additional cost of having monitored anesthesia care appears to be a driving factor in whether a patient receives it or not.

SUMMARY

A large multiinstitutional randomized control trial would be necessary to rule out potential confounders and to determine whether there is a safety benefit or detriment to having anesthesiologist-directed care in the setting of routine colonoscopies in ASA 1 and 2 patients. Further discussion would be necessary regarding what the monetary value of that effect is if a small difference were to be detected.

Assessment of sedation level for endoscopic retrograde cholangiopancreatography - a prospective validation study

BACKGROUND AND AIMS

There is no consensus on how to assess the depth of sedation for endoscopic retrograde cholangiopancreatography (ERCP). This study was carried out in order to evaluate different methods of assessment of depth of sedation: bispectral index (BiS), modified Richmond Agitation/Sedation Scale (mRASS), modified Ramsay Sedation Scale (mRSS) and modified Observer Assessment of Alertness and Sedation (mOAAS) and their applicability to clinical practice.

METHODS

Two hundred patients were recruited. Sedation was given by standard clinical practice using propofol sedation or patient controlled sedation. Sedation was assessed on all patients using the above-mentioned methods. BiS was considered the reference point for sedation scales. Cronbach's alpha was calculated to determine the consistency of different scales in respect to each other and prediction probability and Spearman's correlation coefficients of sedation scales were calculated to show the relationship between sedation scales and BiS.

RESULTS

All scales showed high reliability with overall Cronbach's alpha 0.943. Dropping scales suggested better consistency between mOAAS, mRSS and mRASS than with BiS. Spearman's correlation and prediction probability showed similar results with all tested scales: mOAAS (0.695, 0.739), mRSS (0.673, 0.735), mRASS (0.683, 0.738), p < .01 for all scales.

CONCLUSIONS

All tested methods were found to be reliable in the assessment of the depth of sedation when compared with each other. However, mRASS, mRSS and mOAAS require the patient to respond to verbal or tactile stimulus, which may impair execution of ERCP, whereas BiS information is collected directly from electroencephalogram and thus may be preferable in clinical setting.

Clinical and economic burden of procedural sedation-related adverse events and their outcomes: analysis from five countries

Background

Studies have reported on the incidence of sedation-related adverse events (AEs), but little is known about their impact on health care costs and resource use.

Methods

Health care providers and payers in five countries were recruited for an online survey by independent administrators to ensure that investigators and respondents were blinded to each other. Surveys were conducted in the local language and began with a “screener” to ensure that respondents had relevant expertise and experience. Responses were analyzed using Excel and R, with the Dixon’s Q statistic used to identify and remove outliers. Global and country-specific average treatment patterns were calculated via bootstrapping; costs were mean values. The sum product of costs and intervention probability gave a cost per AE.

Results

Responses were received from 101 providers and 26 payers, the majority having >5 years of experience. At a minimum, the respondents performed a total of 3,430 procedural sedations per month. All AEs detailed occurred in clinical practice in the last year and were reported to cause procedural delays and cancellations in some patients. Standard procedural sedation costs ranged from €74 (Germany) to $2,300 (US). Respondents estimated that AEs would increase costs by between 16% (Italy) and 179% (US). Hypotension was reported as the most commonly observed AE with an associated global mean cost (interquartile range) of $43 ($27–$68). Other frequent AEs, including mild hypotension, bradycardia, tachycardia, mild oxygen desaturation, hypertension, and brief apnea, were estimated to increase health care spending on procedural sedation by $2.2 billion annually in the US.

Conclusion

All sedation-related AEs can increase health care costs and result in substantial delays or cancellations of subsequent procedures. The prevention of even minor AEs during procedural sedation may be crucial to ensuring its value as a health care service.