Erratum: Hard-Candy Consumption Does Not Have an Effect on Volume and pH of Gastric Content in Patients Undergoing Elective Gastrointestinal Endoscopic Procedures: A Randomized Controlled Trial [Corrigendum]

[This corrects the article DOI: 10.2147/TCRM.S377421.].

Consensus guidelines for the perioperative management of patients undergoing endoscopic retrograde cholangiopancreatography

Deep sedation without tracheal intubation (monitored anaesthesia care) and general anaesthesia with tracheal intubation are commonly used anaesthesia techniques for endoscopic retrograde cholangiopancreatography (ERCP). There are distinct pathophysiological differences between monitored anaesthesia care and general anaesthesia that need to be considered depending on the nature and severity of the patient's underlying disease, comorbidities, and procedural risks. An international group of expert anaesthesiologists and gastroenterologists created clinically relevant questions regarding the merits and risks of monitored anaesthesia care vs general anaesthesia in specific clinical scenarios for planning optimal anaesthetic approaches for ERCP. Using a modified Delphi approach, the group created practical recommendations for anaesthesiologists, with the aim of reducing the incidence of perioperative adverse outcomes while maximising healthcare resource utilisation. In the majority of clinical scenarios analysed, our expert recommendations favour monitored anaesthesia care over general anaesthesia. Patients with increased risk of pulmonary aspiration and those undergoing prolonged procedures of high complexity were thought to benefit from general anaesthesia with tracheal intubation. Patient age and ASA physical status were not considered to be factors for choosing between monitored anaesthesia care and general anaesthesia. Monitored anaesthesia care is the favoured anaesthesia plan for ERCP. An individual risk-benefit analysis that takes into account provider and institutional experience, patient comorbidities, and procedural risks is also needed.

Hard-Candy Consumption Does Not Have an Effect on Volume and pH of Gastric Content in Patients Undergoing Elective Gastrointestinal Endoscopic Procedures: A Randomized Controlled Trial

Purpose

This study aimed to determine the effect of hard candies on gastric content volume and pH in patients undergoing elective esophagogastroduodenoscopy and colonoscopy. Additionally, the study evaluated the difficulty of the procedure, complications, and satisfaction levels of the endoscopist and patient.

Patients and Methods

A randomized controlled study equally recruited 108 outpatients to candy and control groups. The patients in the candy group could consume sugar-free candies within 2 hours before anesthesia, while the controls remained fasted. The endoscopic procedure began under topical pharyngeal anesthesia and intravenous sedation. A blinded endoscopist suctioned the gastric volume through an endoscope. A blinded anesthesia provider tested the gastric pH with a pH meter. The primary outcome variables were gastric volume and pH. The secondary outcome variables were complications, the difficulty of the procedure, and endoscopist and patient satisfaction.

Results

The characteristics of both patient groups were comparable. The mean gastric volume of the candy group (0.43 [0.27-0.67] mL/kg) was not significantly different from that of the control group (0.32 [0.19-0.55] mL/kg). The gastric pH of both groups was similar: 1.40 (1.10-1.70) for the candy group and 1.40 (1.20-1.90) for the control group. The procedure-difficulty score of the candy group was higher than that of the control group. The satisfaction scores rated by the endoscopist and the patients in both groups were comparable. In addition, most endoscopists and patients in the candy and control groups reported being "very satisfied". No complications were observed in either group.

Conclusion

Hard candies did not affect gastric volume or pH. Elective gastrointestinal endoscopic procedures in adult patients who preoperatively consume candies could proceed to prevent delays and disruption of workflows.

Anesthetic Consideration for Geriatric Patients

The geriatric population experiences significant alterations of numerous organ systems as a result of the aging process. They also have several co-morbidities including hypertension, cardiac disease, diabetes, cerebrovascular disease and renal dysfunction. Geriatric patients are considerably vulnerable and especially sensitive to the stress of trauma, surgery and anesthesia. A high incidence of postoperative complications in this population is observed. Appropriate perioperative care was required for geriatric patients. To date, development in anesthesia and surgical techniques has substantially reduced morbidity and mortality in the geriatric patients. Several anesthetic techniques have been utilized for these patients. However, anesthesia-related mortality in geriatric patients is quiet high. All geriatric patients undergoing surgical procedures require a preprocedural evaluation and preparation, monitoring patients during intraprocedural and postprocedural periods as well as postprocedural management. This chapter highlights the physiological changes, preprocedure assessment and preparation, anesthetic techniques, intraprocedural and postprocedural management in geriatric population.

Develop a validated anesthesia quality assessment to evaluate patients postoperatively

Objective: The study is aimed to develop a well-validated anesthesia quality assessment to evaluate patients postoperatively. Materials and Methods: After securing Institutional Review Board approval, the study was registered via ClinicalTrials.gov (NCT 0307996). The Siriraj Anesthesia Quality Assessment Questionnaire was developed and validated under the conceptual/theoretical framework of Maslow’s hierarchy of needs, Hospital Consumer Assessment of Healthcare Providers and System, Patient Satisfaction Questionnaire, Service Quality Questionnaire and Quality of Recover after Anesthesia. A total of 476 qualified responses with obtained consent were included in the study to verify the appropriateness of the tool. Results: The study involved 397 qualified patients (83.4%), aged 47.6±16.6, representing all anesthesia services. Significantly, a binary logistic regression revealed the predicted dependent variables as Process of Care (4.39±0.51) and Physical Support (4.35±0.66) in comparison with a sequence of Accessibility and Convenience (4.33±0.56), Communication and Information (4.00±0.70), Technical Quality (4.46±0.45) Psychological Support (4.57±0.65) and Loyalty (4.52±0.68) in anesthesia quality assessment. Conclusion: Process of Care and Physical Support appeared to be significantly valued features, whereas Communication and Information, Accessibility and Convenience, Technical Quality and Psychological Support were found to be weak points in anesthesia quality assessment.

Original article. Intravenous sedation for gastrointestinal endoscopy in very elderly patients of Thailand

Background: The use of sedation for gastrointestinal endoscopy (GIE) procedures in elderly patients has been established as a safe and effective technique. However, it is still uncertain whether the situation is valid for Asians.

Objective: Evaluate the outcome of intravenous sedation (IVS) for GIE procedures in very elderly patients (>86 years old) in Thailand and compare the clinical efficacy of IVS between very elderly and those younger (<86 years old)

Methods: We undertook a retrospective review of the sedation service records of patients who underwent GIE procedures between 2007 and 2008 at Siriraj Hospital, Thailand. All sedations were administered by anesthetic personnel in the endoscopy room. The cohort was divided into three groups, <65 years old (group 1), 65-85 years old (group 2), and >86 years old (group 3).

Results: Sedation was provided for 1,779 patients (965, 687, and 127 patients in group 1, 2, and 3, respectively) in 2,061 GIE procedures. Fentanyl, midazolam and propofol were the most common IVS drugs used in all three groups. Patients in group 3 required lower mean doses of these intravenous sedatives than those in group 1 or 2 (p <0.001). Mean procedure time in group 3 was longer than in group 1 or 2 (p=0.010). Adverse events in group 3 occurred more frequently when compared to group 1 or 2 (p <0.001). Transient hypotension was the main complication across all aged groups.

Conclusion: IVS for GIE procedure in very elderly patients was associated with higher minor advance events but relatively safe and effective when carried out by trained anesthetic personnel with appropriate monitoring and dose adjustment.

A Randomized Placebo-Controlled Trial of Oral Ramosetron for Prevention of Post Operative Nausea and Vomiting after Intrathecal Morphine in Patients Undergoing Gynecological Surgery

BACKGROUND

The incidence of postoperative nausea and vomiting (PONV) after intrathecal morphine is high. Ramosetron is a 5-HT₃ antagonist that has been shown to reduce PONV in general anesthesia. The objective of this study was to evaluate the efficacy of Ramosetron in preventing PONV MATERIAL AND METHOD: 165 patients undergoing elective gynecological surgery under spinal anesthesia were randomly allocated to two groups: the Ramosetron group (0.1 mg orally, n = 82), and the placebo group (oral corn starch, n = 83). The incidence of PONV severity of nausea and use of rescue antiemetic during the first 24 hour after surgery were evaluated.

RESULTS

The incidence of PONV was significantly lower in the Ramosetron group compared with the placebo group (24.4% vs. 44.6%, number needed to treat (NNT) = 5.0). The severity of nausea was significantly lower in the Ramosetron group compared with the placebo group (20.7% vs. 39.8%, NNT = 6.0) in the 24 hour period.

CONCLUSION

Oral Ramosetron 0.1 mg was more effective than placebo in PONV prevention and reduced the incidence of moderate to severe nausea after intrathecal morphine in the first 24 hour after gynecological surgery.

Quality of Anesthesia Care in a University Hospital in Thailand

BACKGROUND

Service quality is an important factor, which value differs between the patient's satisfaction and expectation. The patient's expectations are important factors for development. This service quality is a key part for improvement of our anesthesia service. In general, an improvement in service design and delivery helps to achieve higher levels of the service quality.

OBJECTIVE

To evaluate the level of patient's expectation, patient's satisfaction and the quality of anesthesia care in a university hospital in Thailand

MATERIAL AND METHOD

The patient satisfaction questionnaire, developed from service quality criteria and patient satisfaction questionnaire (PSQ-18), was applied to evaluate 467 in patients 24-72 hours after anesthesia care. The patients'expectation was also assessed A proportional stratified randomized allocation was done. The questionnaire consisted of three dimensions; 1) structure: reliability & empathy, 2) process: assurance & tangible and 3) result: responsiveness. Data expectation and satisfaction were analyzed with mean, standard deviation, t-test, ANOVA and normalized gain for the quality of anesthesia care.

RESULTS

The patient's satisfaction in our anesthesia care is relatively high. The mean patient's satisfaction score is significantly higher than the mean patient's expectation in all dimensions. This study indicated that an anesthesia service in our hospital was a high quality service in the inpatient aspects.

CONCLUSION

Patient's expectation and satisfaction with anesthesia services in our setting was relatively high. Although most patients never had been any expectation regarding anesthesia service, the information and the involvement in decision- making were the most requirements of the adult inpatients.

Development of An Assessment Test for An Anesthetic Machine

OBJECTIVE

The study is aimed to develop and assess the quality of an evaluation form used to evaluate the nurse anesthetic trainees' skills in undertaking a pre-use check of an anesthetic machine.

MATERIAL AND METHOD

An evaluation form comprising 25 items was developed, informed by the guidelines published by national anesthesiologist societies and refined to reflect the anesthetic machine used in our institution. The item-checking included the cylinder supplies and medical gas pipelines, vaporizer back bar, ventilator anesthetic breathing system, scavenging system and emergency back-up equipment. The authors sought the opinions of five experienced anesthetic trainers to judge the validity of the content. The authors measured its inter-rater reliability when used by two achievement scores evaluating the performance of 36 nurse anesthetic trainees undertaking 15-minute anesthetic machine checks and test-retest the reliability correlation scores between the two performances in the seven days interval.

RESULTS

The five experienced anesthesiologists agreed that the evaluation form accurately reflected the objectives of anesthetic machine checking, equating to an index of congruency of 1.00. The inter-rater reliability of the independent assessors scoring was 0.977 (p = 0.01) and the test-retest reliability was 0.883 (p = 0.01).

CONCLUSION

An evaluation form proved to be a reliable and effective tool for assessing the anesthetic nurse trainees' checking of an anesthetic machine before the use. This evaluation form was brief clear and practical to use, and should help to improve anesthetic nurse education and the patient safety.

Anesthetic Management for Esophageal Stent Placement in an Endoscopy Unit Outside Operating Room

BACKGROUND

Esophageal stent placement is a minimally invasive procedure for treatment of esophageal strictures that cannot be treated with surgical procedure. It requires some forms of anesthesia. This procedure could be performed in the operating room and in the endoscopy unit.

OBJECTIVE

The study is aimed to report and evaluate the choices and techniques, drugs used and complications of anesthesia in the patients undergoing esophageal stent placement procedure in an endoscopy unit outside the operating room in a developing country.

MATERIAL AND METHOD

Retrospectively analyzed the patients on whom esophageal stent placement had been performed during the period of January, 2010 to December, 2012 in Siriraj Hospital in Thailand. The patients' characteristics, pre-anesthetic problems, anesthetic techniques, drugs, duration of anesthesia, and anesthesia-related complications were assessed and summarized by using descriptive statistics.

RESULTS

During the study period, there were 48 procedures. Mean age 63.7 ± 13.4 years. The majority of them was male (72.9%) and classified in ASA physical status II (52.1%). Mean duration of anesthesia was 60.6 ± 36.1 minutes. Most common pre-anesthetic problems were hematologic disease (64.6%), electrolyte imbalance (50.0%), respiratory disease (31.3%) and hypertension (29.2%). General anesthesia with endotracheal tube (64.6%) was the main anesthetic technique. The mainly used sedoanalgesic agents were propofol, fentanyl and midazolam. The most common neuromuscular blocking drugs were succinylcholine and atracurium. Additionally, sevoflurane was the most inhalation agent. The overall anesthesia-related complication rate was 35.4%. Hypotension (31.3%) was the most frequent anesthetic complication.

CONCLUSION

All of the esophageal stent placement procedures, general anesthesia and intravenous sedation techniques could be performed effectively in the appropriate patients. However, clinical signs should be carefully observed and the anesthetic personnel had to optimize the patient's condition for safety and beware of complications.

Dexmedetomidine in gastrointestinal endoscopic procedures

Gastrointestinal endoscopy is the gold standard in the examination and the treatment of the diseases of gastrointestinal system, but the disadvantage of being painful process. At this point the sedative and analgesic agents may be important. Dexmedetomidine is a new sedoanalgesic agent which is alternative to benzodiazepines and opioids. It has analgesia, amnesia, sedative and anxiolytic properties. The use of dexmedetomidine as the sole anesthetic agent and as the adjuvant analgesic agent has been published but has not been approved because of the inconsistency of efficacy and safety. The author has been collected the published papers in the literature. This article is aimed to describe the use of dexmedetomidine in various gastrointestinal endoscopic procedures.

Registered nurse-administered sedation for gastrointestinal endoscopic procedure

The rising use of nonanesthesiologist-administered sedation for gastrointestinal endoscopy has clinical significances. Most endoscopic patients require some forms of sedation and/or anesthesia. The goals of this sedation are to guard the patient’s safety, minimize physical discomfort, to control behavior and to diminish psychological responses. Generally, moderate sedation for these procedures has been offered by the non-anesthesiologist by using benzodiazepines and/or opioids. Anesthesiologists and non-anesthesiologist personnel will need to work together for these challenges and for safety of the patients. The sedation training courses including clinical skills and knowledge are necessary for the registered nurses to facilitate the patient safety and the successful procedure. However, appropriate patient selection and preparation, adequate monitoring and regular training will ensure that the use of nurse-administered sedation is a feasible and safe technique for gastrointestinal endoscopic procedures.

Sedation-related complications in gastrointestinal endoscopy

Sedation practices for gastrointestinal endoscopic (GIE) procedures vary widely in different countries depending on health system regulations and local circumstances. The goal of procedural sedation is the safe and effective control of pain and anxiety, as well as to provide an appropriate degree of memory loss or decreased awareness. Sedation-related complications in gastrointestinal endoscopy, once occurred, can lead to significant morbidity and occasional mortality in patients. The risk factors of these complications include the type, dose and mode of administration of sedative agents, as well as the patient’s age and underlying medical diseases. Complications attributed to moderate and deep sedation levels are more often associated with cardiovascular and respiratory systems. However, sedation-related complications during GIE procedures are commonly transient and of a mild degree. The risk for these complications while providing any level of sedation is greatest when caring for patients already medically compromised. Significant unwanted complications can generally be prevented by careful pre-procedure assessment and preparation, appropriate monitoring and support, as well as post-procedure management. Additionally, physicians must be prepared to manage these complications. This article will review sedation-related complications during moderate and deep sedation for GIE procedures and also address their appropriate management.

Sedation and monitoring for gastrointestinal endoscopy

The safe sedation of patients for diagnostic or therapeutic procedures requires a combination of properly trained physicians and suitable facilities. Additionally, appropriate selection and preparation of patients, suitable sedative technique, application of drugs, adequate monitoring, and proper recovery of patients is essential. The goal of procedural sedation is the safe and effective control of pain and anxiety as well as to provide an appropriate degree of memory loss or decreased awareness. Sedation practices for gastrointestinal endoscopy (GIE) vary widely. The majority of GIE patients are ambulatory cases. Most of this procedure requires a short time. So, short acting, rapid onset drugs with little adverse effects and improved safety profiles are commonly used. The present review focuses on commonly used regimens and monitoring practices in GIE sedation. This article is to discuss the decision making process used to determine appropriate pre-sedation assessment, monitoring, drug selection, dose of sedative agents, sedation endpoint and post-sedation care. It also reviews the current status of sedation and monitoring for GIE procedures in Thailand.

Anesthetic management for small bowel enteroscopy in a World Gastroenterology Organization Endoscopy Training Center

AIM

To study the anesthetic management of patients undergoing small bowel enteroscopy in the World Gastroenterology Organization (WGO) Endoscopy Training Center in Thailand.

METHODS

Patients who underwent small bowel enteroscopy during the period of March 2005 to March 2011 in Siriraj Gastrointestinal Endoscopy Center were retrospectively analyzed. The patients' characteristics, pre-anesthetic problems, anesthetic techniques, anesthetic agents, anesthetic time, type and route of procedure and anesthesia-related complications were assessed.

RESULTS

One hundred and forty-four patients underwent this procedure during the study period. The mean age of the patients was 57.6 ± 17.2 years, and most were American Society of Anesthesiologists (ASA) class II (53.2%). Indications for this procedure were gastrointestinal bleeding (59.7%), chronic diarrhea (14.3%), protein losing enteropathy (2.6%) and others (23.4%). Hematologic disease, hypertension, heart disease and electrolyte imbalance were the most common pre-anesthetic problems. General anesthesia with endotracheal tube was the anesthetic technique mainly employed (50.6%). The main anesthetic agents administered were fentanyl, propofol and midazolam. The mean anesthetic time was 94.0 ± 50.5 min. Single balloon and oral (antegrade) intubation was the most common type and route of enteroscopy. The anesthesia-related complication rate was relatively high. The overall and cardiovascular-related complication rates including hypotension in the older patient group (aged ≥ 60 years old) were significantly higher than those in the younger group.

CONCLUSION

During anesthetic management for small bowel enteroscopy, special techniques and drugs are not routinely required. However, for safety reasons anesthetic personnel need to optimize the patient's condition.

A randomized controlled trial of preprocedure administration of parecoxib for therapeutic endoscopic retrograde cholangiopancreatography

INTRODUCTION

Parecoxib is occasionally used for analgesia in postprocedural patients. The clinical efficacy of parecoxib used for endoscopic retrograde cholangiopancreatography (ERCP) is controversial. The aim of the study was to determine the clinical efficacy of preprocedure administration of parecoxib for therapeutic ERCP patients.

METHODS

Eighty-five patients who underwent therapeutic ERCP in a single year were randomly assigned to normal saline group (C, n = 43) and parecoxib group (P, n = 42). Patients in group C received normal saline and those in group P received 40 mg of parecoxib intravenously in equivalent volume. Patients in both groups received the saline or parecoxib 60 seconds before administration of the sedative agents. All patients were monitored for the depth of sedation by using the Narcotrend(TM) monitor, maintaining stage D0-E0 during ERCP. All patients were oxygenated with 100% O(2) via nasal cannula and sedated with 0.03 mg/kg of intravenous midazolam and 1 μg/kg of intravenous fentanyl as well as the titration of intravenous propofol. After the ERCP procedure, pethidine in an intramuscular dose of 0.5-1.0 mg/kg was used as rescue medication. The pain scores (visual analog scale [VAS], 0-10) at 2, 12, and 24 hours post-ERCP, the total number of doses of pethidine used, the dose volume of pethidine used, patient satisfaction, endoscopist satisfaction, and complications were recorded.

RESULTS

There were no significant differences in sedative and analgesic agents used during the procedure, pain at 24 hours post-ERCP, endoscopist satisfaction, and complications in both groups. The total number of doses of pethidine used post-ERCP in group C was significantly higher than in group P. Additionally, the mean pain score at 2 and 12 hours post-ERCP in group C was significantly greater than in group P. Patient satisfaction in group P was higher than in group C.

CONCLUSION

Preprocedure administration of parecoxib for therapeutic ERCP patients was clinically effective. The analgesic efficacy of a standard dose of parecoxib was clearly demonstrated during the first 12 hours postprocedure. Additionally, patient satisfaction in the parecoxib group was also higher than in the control group.

Age-dependent safety analysis of propofol-based deep sedation for ERCP and EUS procedures at an endoscopy training center in a developing country

INTRODUCTION

Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasonography (EUS) procedures in elderly patients are on the rise, and they play an important role in the diagnosis and management of various gastrointestinal diseases. The use of deep sedation in these patients has been established as a safe and effective technique in Western countries; however, it is uncertain if the situation holds true among Asians. The present study aimed to evaluate the age-dependent safety analysis and clinical efficacy of propofol-based deep sedation (PBDS) for ERCP and EUS procedures in adult patients at a World Gastroenterology Organization (WGO) Endoscopy Training Center in Thailand.

METHODS

We undertook a retrospective review of anesthesia or sedation service records of patients who underwent ERCP and EUS procedures. All procedures were performed by staff endoscopists, and all sedations were administered by anesthesia personnel in the endoscopy room.

RESULTS

PBDS was provided for 491 ERCP and EUS procedures. Of these, 252 patients (mean age, 45.1 + 11.1 years, range 17-65 years) were in the <65 age group, 209 patients (mean age, 71.7 + 4.3 years, range 65-80 years) were in the 65-80 year-old group, and 30 patients (mean age, 84.6 + 4.2 years, range 81-97 years) were in the >80 age group. Common indications for the procedures were pancreatic tumor, cholelithiasis, and gastric tumor. Fentanyl, propofol, and midazolam were the most common sedative drugs used in all three groups. The mean doses of propofol and midazolam in the very old patients were relatively lower than in the other groups. The combination of propofol, midazolam, and fentanyl, as well as propofol and fentanyl, were frequently used in all patients. Sedation-related adverse events and procedure-related complications were not statistically significantly different among the three groups. Hypotension was the most common complication.

CONCLUSION

In the setting of the WGO Endoscopy Training Center in a developing country, PBDS for ERCP and EUS procedures in elderly patients by trained anesthesia personnel with appropriate monitoring is relatively safe and effective. Although adverse cardiovascular events, including hypotension, in this aged group is common, all adverse events were usually transient, mild, and easily treated, with no sequelae.

Dose requirement and complications of diluted and undiluted propofol for deep sedation in endoscopic retrograde cholangiopancreatography

BACKGROUND

In general, the dose requirement and complications of propofol are lower when used in the diluted form than in the undiluted form. The aim of this study was to determine the dose requirement and complications of diluted and undiluted propofol for deep sedation in endoscopic retrograde cholangiopancreatography.

METHODS

Eighty-six patients were randomly assigned to either group D (diluted propofol) or U (undiluted propofol). All patients were sedated with 0.02-0.03 mg/kg midazolam (total dose ≤2 mg for age <70 years and 1 mg for age ≥70) and 0.5-1 μg/kg fentanyl (total dose ≤75 μg for age <70 and ≤50 μg for age ≥70). Patients in group U (42) were sedated with standard undiluted propofol (10 mg/mL). Patients in group D (44) were sedated with diluted propofol (5 mg/mL). All patients in both groups were monitored for the depth of sedation using the Narcotrend system. The primary outcome variable was the total dose of propofol used during the procedure. The secondary outcome variables were complications during and immediately after the procedure, and recovery time.

RESULTS

All endoscopies were completed successfully. Mean propofol doses per body weight and per body weight per hour in groups D and U were 3.0 mg/kg, 6.2 mg/kg per hour and 4.7 mg/kg, 8.0 mg/kg per hour, respectively. The mean dose of propofol, expressed as total dose, dose/kg or dose/kg per hour and the recovery time were not significantly different between the two groups. Sedation-related adverse events during and immediately after the procedure were higher in group U (42.9%) than in group D (18.2%) (P=0.013).

CONCLUSIONS

Propofol requirement and recovery time in the diluted and undiluted propofol groups were comparable. However, the sedation-related hypotension was significantly lower in the diluted group than the undiluted group.

Deep sedation for endoscopic retrograde cholangiopancreatography: a comparison between clinical assessment and Narcotrend(TM) monitoring

INTRODUCTION

Moderate to deep sedation is generally used for endoscopic retrograde cholangiopancreatography (ERCP). The depth of sedation is usually judged by clinical assessment and electroencephalography-guided monitoring. The aim of this study was to compare the clinical efficacy of clinical assessment and Narcotrend(TM) monitoring during deep-sedated ERCP.

METHODS

One hundred patients who underwent ERCP in a single year were randomly assigned to either group C or group N. Patients in group C (52) were sedated using the Modified Observer's Assessment of Alertness/Sedation (MOAA/S) scale. Patients in group N (48) were sedated using the Narcotrend(TM) system. The MOAA/S scale 1 or 2 and the Narcotrend(TM) index 47-56 to 57-64 were maintained during the procedure. The primary outcome variable of the study was the successful completion of the endoscopic procedure. The secondary outcome variables were the total dose of propofol used during the procedure, complications during and immediately after procedure, and recovery time.

RESULTS

All endoscopies were completed successfully. The mean total dose of propofol in group C was significantly lower than that in group N. However, the mean dose of propofol, expressed as dose/kg or dose/kg/h in both groups, was not significantly different (P = 0.497, 0.136). Recovery time, patient tolerance and satisfaction, and endoscopist satisfaction were comparable between the two groups. All sedation-related adverse events during and immediately after the procedure, such as hypotension, hypertension, tachycardia, bradycardia, transient hypoxia, and upper airway obstruction, in group C (62.2%) were significantly higher than in group N (37.5%) (P = 0.028).

CONCLUSION

Clinical assessment and Narcotrend(TM)-guided sedation using propofol for deep sedation demonstrated comparable propofol dose and recovery time. Both monitoring systems were equally safe and effective. However, the Narcotrend(TM)-guided sedation showed lower hemodynamic changes and fewer complications compared with the clinical assessment-guided sedation.

Propofol-based deep sedation for endoscopic retrograde cholangiopancreatography procedure in sick elderly patients in a developing country

INTRODUCTION

The aim of this study was to evaluate and compare the clinical efficacy of propofol-based deep sedation (PBDS) for endoscopic retrograde cholangiopancreatography (ERCP) procedure in sick (American Society of Anesthesiologists [ASA] physical status III-IV) and nonsick (ASA physical status I-II) elderly patients in a teaching hospital in Thailand.

METHODS

We undertook a retrospective review of the anesthesia or sedation service records of elderly patients who underwent ERCP procedures from October 2007 to September 2008. All patients were classified into two groups according to the ASA physical status. In group A, the patients had ASA physical status I-II, while in group B, the patients had ASA physical status III-IV. The primary outcome variable of the study was the successful completion of the procedure. The secondary outcome variables were sedation-related adverse events during and immediately after the procedure.

RESULTS

There were 158 elderly patients who underwent ERCP procedure by using PBDS during the study period. Of these, 109 patients were in group A and 49 patients were in group B. There were no significant differences in age, gender, weight, duration of ERCP, indication of procedure, and the mean dose of fentanyl, propofol, and midazolam between the two groups. All patients in both groups successfully completed the procedure except eight patients in group A and three patients in group B (P = 0.781). Overall, respiratory and cardiovascular adverse events in both groups were not significantly different. All adverse events were easily treated, with no adverse sequelae.

CONCLUSION

In the setting of a developing country, PBDS for ERCP procedure in sick elderly patients by trained anesthetic personnel with appropriate monitoring was safe and effective. The clinical efficacy of this technique in sick elderly patients was not different or worse than in nonsick elderly patients. Serious adverse events were rare in our population.

Propofol-Based Sedation Does Not Increase Rate of Complication during Percutaneous Endoscopic Gastrostomy Procedure

Objectives. To evaluate and compare the complication rate of sedation with or without propofol regimen for percutaneous endoscopic gastrostomy (PEG) in a hospital in Thailand. Subjects and Methods. A total of 198 patients underwent PEG procedures by using intravenous sedation (IVS) from Siriraj Hospital, Thailand from August 2006 to January 2009. The primary outcome variable was the overall complication rate. The secondary outcome variables were sedation and procedure related complications, and mortality rate. Results. After matching ASA physical status and indications of procedure, there were 92 PEG procedures in propofol based sedation group (A) and 20 PEG procedures in non-propofol based sedation group (B). All sedation was given by residents or anesthetic nurses directly supervised by staff anesthesiologist in the endoscopy room. There were no significant differences in patients' characteristics, sedation time, indication, complications, anesthetic personnel and mortality rate between the two groups. All complications were easily treated, with no adverse sequelae. Mean dose of fentanyl and midazolam in group A was significantly lower than in group B. Conclusion. Propofol-based sedation does not increase rate of complication during PEG procedure. Additionally, IVS of PEG procedure is relatively safe and effective when performed by physicians in training. Serious complications are none.

Comparison of the clinical use of macintosh and miller laryngoscopes for orotracheal intubation by second-month nurse students in anesthesiology

Aim. The aim of this study is to compare the clinical feasibility of Macintosh and Miller laryngoscopes for tracheal intubation in non-experienced users in anesthetized patients. Patients and Methods. 119 patients were randomized into the Macintosh group (59) and the Miller group (60). The primary outcome variable was successful tracheal intubation. The secondary outcome variables were number of insertion attempt, intubation time needed, total time to intubation, hemodynamic change and complications. Results. All patients were successfully intubated using the Macintosh, whereas 13 patients (21.6%) were failed with the Miller (P < .001). The Macintosh significantly reduced the mean total time to intubation (P < .001). There were significant differences in the mean blood pressure at 2 minutes after laryngoscope insertion, immediately, and 2 minutes after tracheal intubation and in the mean heart rate at the laryngoscope insertion, immediately, and at 2 minutes after tracheal intubation between the two groups. Overall complications in both were not significantly different. Conclusion. Orotracheal intubation using the Macintosh is an effective and safe technique in non-experienced hands with significantly increased success rate as well as decreased mean total time to intubation as compare to the Miller. However, these intubations only apply to selected patients deemed to have normal airways.

Clinical effectiveness of an anesthesiologist-administered intravenous sedation outside of the main operating room for pediatric upper gastrointestinal endoscopy in Thailand

Objectives. To review our sedation practice and to evaluate the clinical effectiveness of an anesthesiologist-administered intravenous sedation outside of the main operating room for pediatric upper gastrointestinal endoscopy (UGIE) in Thailand. Subjects and Methods. We undertook a retrospective review of the sedation service records of pediatric patients who underwent UGIE. All endoscopies were performed by a pediatric gastroenterologist. All sedation was administered by staff anesthesiologist or anesthetic personnel. Results. A total of 168 patients (94 boys and 74 girls), with age from 4 months to 12 years, underwent 176 UGIE procedures. Of these, 142 UGIE procedures were performed with intravenous sedation (IVS). The mean sedation time was 23.2 +/- 10.0 minutes. Propofol was the most common sedative drugs used. Mean dose of propofol, midazolam and fentanyl was 10.0 +/- 7.5 mg/kg/hr, 0.2 +/- 0.2 mg/kg/hr, and 2.5 +/- 1.2 mcg/kg/hr, respectively. Complications relatively occurred frequently. All sedations were successful. However, two patients became more deeply than intended and required unplanned endotracheal intubation. Conclusion. The study shows the clinical effectiveness of an anesthesiologist-administered IVS outside of the main operating room for pediatric UGIE in Thailand. All complications are relatively high. We recommend the use of more sensitive equipments such as end tidal CO(2) and carefully select more appropriate patients.

Experience of intravenous sedation for pediatric gastrointestinal endoscopy in a large tertiary referral center in a developing country

BACKGROUND

The aim of this study was to evaluate the clinical efficacy of intravenous sedation for pediatric gastrointestinal endoscopy (GIE) at a tertiary care teaching hospital in a developing country.

METHODS

We undertook a retrospective review of the sedation service records of pediatric patients who underwent GIE. All endoscopies were performed by a pediatric gastroenterologist. All of the sedation was administered by staff anesthesiologist or anesthetic personnel in the gastroenterology procedure room.

RESULTS

Sedation was provided for 222 procedures in 214 patients ranged in age from younger than 1 to 17 years and in weight from 2.7 to 80.0 kg. Intravenous sedation was provided in 176 patients (82.2%). Of these patients, 185 procedures were performed and reviewed, with 152 (82.2%) procedures were esophagogastroduodenoscopy (EGD) alone, 14 (7.6%) procedures were colonoscopy alone, 18 (9.7%) procedures were EGD and colonoscopy, and one procedure was endoscopic ultrasonography (EUS). Most common indications of the procedure were screening for esophageal varices (25.2%), abdominal pain (15.9%), history of upper gastrointestinal hemorrhage (13.6%), and unexplained anemia (10.3%). The majority of preanesthetic problems were hematologic disease, anemia (38.2%); liver disease, cirrhosis (13.5%); and electrolyte imbalance (13.5%). Propofol (94.0%), fentanyl (87.0%), and midazolam (67.8%) were frequently used. The mean dose of propofol was 7.8 +/- 4.1 mg.kg(-1).h(-1), fentanyl 2.3 +/- 1.1 mcg.kg(-1).h(-1), and midazolam 0.1 +/- 0.1 mg.kg(-1).h(-1). Most of them were used in combination. The combination of propofol, fentanyl, and midazolam was commonly employed (46.4%). The mean sedation time of all procedures was 28.2 min and was different according to procedure type. Complications occurred infrequently (13.5%) and were medication or airway related. All complications were easily treated, with no adverse sequelae. Intravenous sedation was successful except for one patient who required general anesthesia. However, all procedures were completed successfully.

CONCLUSIONS

In the setting of the developing country, intravenous sedation for pediatric GIE by trained anesthetic personnel with appropriate monitoring was safe and effective. Serious adverse events were rare in our population.

Topical viscous lidocaine solution versus lidocaine spray for pharyngeal anesthesia in unsedated esophagogastroduodenoscopy

BACKGROUND AND STUDY AIMS

Pharyngeal anesthesia using topical lidocaine is generally used as pretreatment for unsedated esophagogastroduodenoscopy (UEGD). The aim of this study was to compare and evaluate the clinical efficacy of topical viscous lidocaine solution and lidocaine spray when each is used as a single agent for UEGD.

PATIENTS AND METHODS

Patients were randomized into the viscous lidocaine (V) group (n = 930) or the lidocaine spray (S) group (n = 934). The total dose of lidocaine was not higher than 5 mg/kg. The primary objective was to measure the successful completion rate of the endoscopy. The secondary objectives were to assess patient and endoscopist satisfaction, procedural pain, patient tolerance, ease of intubation, and adverse events.

RESULTS

The procedure was successfully completed in 868 patients from group V (93.3 %) and 931 patients from group S (99.7 %; P < 0.001). Patients and endoscopists reported a higher degree of satisfaction in group S than group V ( P < 0.0001). Procedural pain score in group S was significantly lower than in group V ( P < 0.0001). The endoscopist rated patients in group S as having better tolerance and ease of intubation than those in group V ( P = 0.0004 and P = 0.002, respectively). Adverse events occurred in 370 patients in group V and 316 patients in group S ( P = 0.002). These were mainly transient changes in vital signs including hypertension, tachycardia, and bradycardia.

CONCLUSIONS

The use of lidocaine spray in UEGD was shown to result in a higher procedural completion rate, greater ease of intubation, and greater patient and endoscopist satisfaction. Topical lidocaine spray may be a better form of pharyngeal anesthesia than viscous lidocaine solution in UEGD.

Recovery pattern and home-readiness after ambulatory gastrointestinal endoscopy

BACKGROUND

Despite increased use of ambulatory gastrointestinal endoscopy, few data exist regarding patient recovery patterns and home-readiness.

OBJECTIVE

The authors prospectively identified the pattern of home-readiness, the persistent symptoms after procedure and the factors that delay discharge after home-readiness criteria are satisfied.

MATERIAL AND METHOD

Three hundred and sixty nine patients were scored by the investigator using the Modified Post-Anesthetic Discharge Scoring System (PADSS) every 30 min, commencing 30 min after procedure, until the PADSS score was > or =9. The same investigator telephoned each patient 24 hr after discharge to administer a standardized questionnaire so that postoperative symptoms could be identified.

RESULTS

The number of patients who satisfied the PADSS home-readiness criteria was 81.6%, 97.9%, and 100% at 30, 60, and 90 min, respectively. All patients were promptly discharged before two hours. After home-readiness criteria were satisfied, 36% of patients had delayed discharge because of the unavailability of immediate escorts or other non-medical reasons. No patient had persistent symptoms and all patients could achieve a PADSS score > or =9 three hours after anesthesia. The patients undergoing shorter endoscopic procedures, such as EGD or dilated esophagus were discharged faster than patients undergoing colonoscopy or duodenal stent. The 24 hr postoperative symptoms were mainly sore throat, pain, weakness, and abdominal distension. There was no incidence of unanticipated admission.

CONCLUSION

Periodic objective evaluation of home-readiness revealed that the majority of patients would achieve a satisfactory score on or before 1 hr after procedure. The time to home-readiness by objective evaluation correlated with the type of procedure. Most delays after satisfactory home-readiness scores were reached, were due to non-medical reasons.

The effectiveness of intravenous sedation in diagnostic upper gastrointestinal endoscopy

BACKGROUND

Topical pharyngeal anesthesia is required to perform a technically adequate esophago-gastroduodenoscopy (EGD), but does not improve patient satisfaction, comfort, and willingness to repeat, particularly in the elderly and those with increased pharyngeal sensitivity. The comparative effectiveness of intravenous sedation versus no sedation remains poorly characterized.

OBJECTIVE

To compare the effectiveness of diagnostic EGD with and without intravenous sedation in an adult Thai population.

MATERIAL AND METHOD

A randomized controlled trial assigned patients into two groups, group C (topical pharyngeal anesthesia alone) and group I (intravenous sedation and topical pharyngeal anesthesia). All patients were topicalized with lidocaine viscous and spray. The patients in group I were sedated with midazolam 0.035 mg x kg(-1) and maintained with continuous propofol infusion. The ease of procedure and patient tolerance were evaluated. Secondary outcomes included patient and endoscoptist satisfaction, total time to awake, and willingness to repeat the procedure.

RESULTS

One hundred and seventy patients (mean age 50.5, 41.2% male) were randomized (group C = 85 and group I = 85; intervention) into two groups. Among patients of the two groups, 100% of the procedures were "successful". In group C, 98.8% were satisfied with their level of tolerance (comfort) while the group I had 100%. The willingness to repeat was 6.2 +/- 1.6 in group C while group I had 9.4 +/- 0.8. Patient and endoscopist satisfaction in group I was more satisfied than in group C (90.6% vs 35.3% and 81.2% vs 40.0% respectively) (p < 0.001). In group I, total amount of propofol was 91.6 +/- 45.5 mg and total time to awake was 8.2 +/- 4.2 min. The use of sedation was the major determinant of patient satisfaction, but contributed to an increased recovery room time. Hypertension and tachycardia were the most complications in group C, and hypotension was the most complication in group I.

CONCLUSION

In the average Thai adult population, sedated diagnostic EGD is a good strategy to increase endoscopist satisfaction and willingness to repeat.

Anesthesia for endoscopic retrograde cholangiopancreatography (ERCP) from 1999--2003 in Siriraj Hospital: a retrospective study

BACKGROUND

Endoscopic retrograde cholangio-pancreatography (ERCP) is another treatment option for hepato-biliary tract abnormalities. The authors studied anesthetic data as a basis for further research.

METHOD

Retrospectively analyzed the patients on whom ERCP had been performed during the period of January, 1999 to November, 2003 in Siriraj Hospital. The patients' characteristics, preanesthetic problems, anesthetic techniques, anesthetic agents, anesthetic time, ERCP procedure and complications were assessed.

RESULTS

There were 2,144 patients who received the procedure during study period The age group of 50-69 years was the highest one (46.9%). Most patients had ASA class 11 (54.7%). The diagnosis were stone (40.3%), tumor (34.0%), hepato-biliary tract infection (8.1%) and others (17.6%). Hypertension, diabetes mellitus and hematologic diseases were the most common preanesthetic problems. Total intravenous anesthesia (TIVA) was the anesthetic technique mainly employed (96.4%). Anesthetic agents were mainly administered with propofol, midazolam and fentanyl. The mean anesthetic time was 40.0+/-18.5 minutes. The indications for ERCP procedures were diagnostic (18.9%), stone removal (37.1%), stent removal and/or insertion (35.3%) and others (8.7%). The most frequent anesthetic complication was hypotension.

CONCLUSION

During anesthetic management for ERCP, special techniques or drugs in anesthesia are not routinely required, however, the anesthetic personnel had to optimize the patient's condition for safety and there should be an awareness of complications.