Conscious Sedation Group Research Articles

Comparison of General Anesthesia and Conscious Sedation During Computed Tomography–Guided Radiofrequency Ablation of T1a Renal Cell Carcinoma

PurposePercutaneous radiofrequency ablation is so painful that this treatment requires pain control such as conscious sedation or general anesthesia. It is still unclear which type of anesthesia is better for treatment outcomes of renal cell carcinoma. This study aimed to compare general anesthesia and conscious sedation in treating patients with renal cell carcinoma with radiofrequency ablation. MethodsBetween 2010 and 2015, 51 patients with biopsy-proven renal cell carcinomas (<4 cm) were treated with computed tomography–guided radiofrequency ablation. General anesthesia was performed in 41 and conscious sedation was performed in 10 patients. Tumour size, local tumour progression, metastasis, major complication, effective dose, glomerular filtration rate difference, and recurrence-free survival rate were compared between these groups. ResultsThe mean tumour size was 2.1 cm in both groups (P = .673). Local tumour progression occurred in 0% (0 of 41) of the general anesthesia group, but in 40% (4 of 10) of the conscious sedation group (P = .001). Metastases in these groups occurred in 2.4% (1 of 41) of the general anesthesia group and 20% (2 of 10) of the conscious sedation group (P = .094). No major complications developed in either group after the first radiofrequency ablation session. The mean effective doses in these groups were 21.7 mSv and 21.2 mSv, respectively (P = .868). The mean glomerular filtration rate differences in the general anesthesia and conscious sedation groups were -13.5 mL/min/1.73 m2 and -19.1 mL/min/1.73 m2, respectively (P = .575). Three-year recurrence-free survival rates in these groups were 97.6% and 60.0%, respectively (P = .001). ConclusionsGeneral anesthesia may provide better intermediate outcomes than conscious sedation in treating small renal cell carcinomas with radiofrequency ablation.

Can liver cirrhosis patients benefit from target controlled infusion of propofol for conscious sedation during endoscopic variceal ligation?

Background: The aim of the present study was to evaluate the feasibility of conscious sedation using target controlled infusion of propofol combined with a single dose of fentanyl during endoscopic variceal ligation in patients with liver cirrhosis.Methods: Forty-eight patients with liver cirrhosis scheduled for endoscopic variceal ligation were randomly assigned to deep sedation group (DS group) with intravenous bolus of propofol and conscious sedation group (CS group) with target controlled infusion of propofol, 1 μg/kg fentanyl was intravenously injected in each patient before administration of propofol. Cardiorespiratory parameters were monitored, and the side-effects were recorded. The depth of sedation was assessed by both of the sale of observer′s assessment of alertness/sedation (OAA/S) and the bispectral index (BIS). The quality of sedation/analgesia was evaluated by the endoscopist and patients using Visual Analog Scores (VAS). The recovery level was evaluated with the Aldrete scales.Results: No significant differences were found on demographic data and initial parameters in the two groups. Compared with the CS group, the changes of mean arterial pressure (MAP) and heart rate (HR) and the signs of respiratory depression were significant in the DS group (p&lt;0.05). The recovery time in DS group (16.7±2.7 minutes) was much longer than that in the CS group (9.3±3.0 minutes, p&lt;0.01). There was no difference in Visual Analogue Scale scores for endoscopist’s satisfaction between the two groups (9.2±0.6 versus 9.0±0.6, p&gt;0.05), but a higher degree of satisfaction for patient was found in the DS group (9.3±0.6 versus 7.9±0.7, p&lt;0.01).Conclusions: Conscious sedation with target controlled infusion of propofol combined with a single bolus of fentanyl for endoscopic variceal ligation in patients with liver cirrhosis had better hemodynamic stability, less respiratory depression and shorter recovery time.

Response by Löwhagen Hendén and Rentzos to Letter Regarding Article, “General Anesthesia Versus Conscious Sedation for Endovascular Treatment of Acute Ischemic Stroke: The Anstroke Trial (Anesthesia During Stroke)”

We appreciate the comments from Tang et al. The authors have mixed the time intervals in their comment. We have taken that into account in our answer. Tang et al are concerned that the time interval from stroke onset to computed tomography (CT) was longer in the general anesthesia (GA) group compared with the conscious sedation (CS) group, diluting the difference in the total time interval from stroke onset to recanalization between the groups. They state that the no difference in neurological outcome found might be attributed to this fact. First, time interval from stroke onset to CT did not differ statistically (GA 97 minutes versus CS 72 minutes; P =0.2523). Neither was the time interval from stroke onset to recanalization statistically different between the groups (GA 254 minutes …

Improved costs and outcomes with conscious sedation vs general anesthesia in TAVR patients: Time to wake up?

BackgroundTranscatheter aortic valve replacement (TAVR) has become a commonplace procedure for the treatment of aortic stenosis in higher risk surgical patients. With the high cost and steadily increasing number of patients receiving TAVR, emphasis has been placed on optimizing outcomes as well as resource utilization. Recently, studies have demonstrated the feasibility of conscious sedation in lieu of general anesthesia for TAVR. This study aimed to investigate the clinical as well as cost outcomes associated with conscious sedation in comparison to general anesthesia in TAVR.MethodsRecords for all adult patients undergoing TAVR at our institution between August 2012 and June 2016 were included using our institutional Society of Thoracic Surgeons (STS) and American College of Cardiology (ACC) registries. Cost data was gathered using the BIOME database. Patients were stratified into two groups according to whether they received general anesthesia (GA) or conscious sedation (CS) during the procedure. No-replacement propensity score matching was done using the validated STS predicted risk of mortality (PROM) as a propensity score. Primary outcome measure with survival to discharge and several secondary outcome measures were also included in analysis. According to our institution's data reporting guidelines, all cost data is presented as a percentage of the general anesthesia control group cost.ResultsOf the 231 patients initially identified, 225 (157 GA, 68 CS) were included for analysis. After no-replacement propensity score matching, 196 patients (147 GA, 49 CS) remained. Overall mortality was 1.5% in the matched population with a trend towards lower mortality in the CS group. Conscious sedation was associated with significantly fewer ICU hours (30 vs 96 hours, p = <0.001) and total hospital days (4.9 vs 10.4, p<0.001). Additionally, there was a 28% decrease in direct cost (p<0.001) as well as significant decreases in all individual all cost categories associated with the use of conscious sedation. There was no difference in composite major adverse events between groups. These trends remained on all subsequent subgroup analyses.ConclusionConscious sedation is emerging as a safe and viable option for anesthesia in patients undergoing transcatheter aortic valve replacement. The use of conscious sedation was not only associated with similar rates of adverse events, but also shortened ICU and overall hospital stays. Finally, there were significant decreases in all cost categories when compared to a propensity matched cohort receiving general anesthesia.

General anesthesia improves contact force and reduces gap formation in pulmonary vein isolation: a comparison with conscious sedation.

Compared to conscious sedation (CS), the use of general anesthesia (GA) in pulmonary vein isolation (PVI) is associated with a lower recurrence rate of atrial fibrillation (AF). GA may improve catheter stability and mapping system accuracy compared to CS, but its influence on contact force (CF) parameters during ipsilateral PVI has not previously been investigated. The study population comprised 176 consecutive patients (107 in GA group and 69 in CS group) with AF who underwent their first PVI procedure. We retrospectively assessed CF parameters, force-time integral (FTI), FTI/wall thickness during anatomical ipsilateral PVI and long-term outcome after ablation. Complete PVI with single continuous circular lesions around the ipsilateral PVs was achieved in 54 patients (50.5%) in the GA group but only 24 patients (34.8%) in the CS group (P = 0.04). The distribution of gaps did not differ between the groups. All CF parameters were significantly higher in the GA group than in the CS group (average CF: 19.4 ± 8.7 vs. 16.7 ± 7.7g, P < 0.0001; FTI: 399.0 ± 262.5 vs. 293.9 ± 193.4gs, P < 0.0001; FTI/wall thickness: 155.5 ± 106.1 vs. 115.7 ± 85.5gs, P < 0.0001). GA was associated with lower AF recurrence rate in patients with paroxysmal AF but not with persistent AF. Compared with CS, GA improves CF parameters, FTI and FTI/wall thickness, and reduced gap formation after ipsilateral PVI.

Comparing the effects of haematoma block and conscious sedation in adults with distal radius fractures

Background: Distal radius fractures present frequently to the orthopaedic surgeon following high velocity injuries in the young or low velocity injuries in the elderly. Haematoma block or conscious sedation can be applied to provide anaesthesia during reduction. Comparing the effects of both anaesthetic methods is yet to be fully evaluated.Objective: To compare the pain level and quality of reduction using haematoma block and conscious sedation following reduction of distal radius fractures.Design: Prospective comparative cross-sectional study.Patients and Methods: Seventy patients with distal radius fractures were grouped for closed reduction; in one group conscious sedation was used and the other, haematoma block. All patients had pain measured with Visual Analogue Scale and quality of reduction by measuring palmar tilt on plain radiograph.Main Outcome Measures: Severity of pain and palmar tilt on radiograph measured before and after reduction.Results: The modal age group was 60 years (40%) with a slightly higher female preponderance (57.1%). Majority, 54.3% had injuries following fall on outstretched hand. The mean Visual Analogue Score for pain following conscious sedation and haematoma block post reduction was 3.5 and 2.4 respectively. The mean palmar tilt of radius for conscious sedation and haematoma groups were 10.1 and 10.9 degrees respectively. There was no statistically significant difference in the efficacy of both anaesthetic methods.Conclusion: The choice anaesthesia for reduction of distal radius fracture on should be based on surgeon’s preference, patient’s wish and history of drug reactions.Keywords: Distal Radius Fractures, Haematoma Block, Conscious Sedation

Assisted reproduction technology: Comparison of anesthetic techniques for oocyte retrieval in a tertiary health facility in Ilorin, Nigeria

Background: Transvaginal ultrasound-guided oocyte retrieval (TUGOR) technique is minimally invasive and requires shorter time compared to previous techniques. Yet, it is a potentially stressful and painful procedure and thus requires some form of analgesia with or without sedation. The effects of various anesthetic techniques used for TUGOR on reproductive outcomes remain controversial. Aims and Objectives: This study aimed at comparing the efficacy of paracervical block (PCB) and conscious sedation for pain relief and pregnancy outcomes during TUGOR. Materials and Methods: This is a cross-sectional comparative study of 137 eligible clients that underwent assisted reproduction program in our facility. All clients were treated with antagonist protocol for controlled ovarian hyperstimulation. The choice of analgesia for TUGOR was influenced by clients' and/or clinicians' preference. PCB and conscious sedation were administered for TUGOR in 66 and 71 clients, respectively. Pain was assessed using a 10-cm Visual Analog Scale (VAS), while clients' overall satisfaction was rated using Likert scoring system. Results: There was no statistically significant difference in the clinical pregnancy, miscarriage, and live birth rates between the two groups. The mean VAS 10-point scores at 1, 6, and 24 h postretrieval and on the day of embryo transfer were significantly higher for paracervical group. The mean Likert score for conscious sedation group was significantly higher than that of paracervical group. Conclusion: Conscious sedation is superior to PCB as anesthetic/analgesic agent for pain relief and clients' satisfaction for TUGOR. However, a multimodal approach to anesthesia/analgesia for TUGOR is suggested to further improve overall clients' satisfaction.

Effect of Conscious Sedation vs General Anesthesia on Early Neurological Improvement Among Patients With Ischemic Stroke Undergoing Endovascular Thrombectomy

Optimal management of sedation and airway during thrombectomy for acute ischemic stroke is controversial due to lack of evidence from randomized trials. To assess whether conscious sedation is superior to general anesthesia for early neurological improvement among patients receiving stroke thrombectomy. SIESTA (Sedation vs Intubation for Endovascular Stroke Treatment), a single-center, randomized, parallel-group, open-label treatment trial with blinded outcome evaluation conducted at Heidelberg University Hospital in Germany (April 2014-February 2016) included 150 patients with acute ischemic stroke in the anterior circulation, higher National Institutes of Health Stroke Scale (NIHSS) score (>10), and isolated/combined occlusion at any level of the internal carotid or middle cerebral artery. Patients were randomly assigned to an intubated general anesthesia group (n = 73) or a nonintubated conscious sedation group (n = 77) during stroke thrombectomy. Primary outcome was early neurological improvement on the NIHSS after 24 hours (0-42 [none to most severe neurological deficits; a 4-point difference considered clinically relevant]). Secondary outcomes were functional outcome by modified Rankin Scale (mRS) after 3 months (0-6 [symptom free to dead]), mortality, and peri-interventional parameters of feasibility and safety. Among 150 patients (60 women [40%]; mean age, 71.5 years; median NIHSS score, 17), primary outcome was not significantly different between the general anesthesia group (mean NIHSS score, 16.8 at admission vs 13.6 after 24 hours; difference, -3.2 points [95% CI, -5.6 to -0.8]) vs the conscious sedation group (mean NIHSS score, 17.2 at admission vs 13.6 after 24 hour; difference, -3.6 points [95% CI, -5.5 to -1.7]); mean difference between groups, -0.4 (95% CI, -3.4 to 2.7; P = .82). Of 47 prespecified secondary outcomes analyzed, 41 showed no significant differences. In the general anesthesia vs the conscious sedation group, substantial patient movement was less frequent (0% vs 9.1%; difference, 9.1%; P = .008), but postinterventional complications were more frequent for hypothermia (32.9% vs 9.1%; P < .001), delayed extubation (49.3% vs 6.5%; P < .001), and pneumonia (13.7% vs 3.9%; P = .03). More patients were functionally independent (unadjusted mRS score, 0 to 2 after 3 months [37.0% in the general anesthesia group vs 18.2% in the conscious sedation group P = .01]). There were no differences in mortality at 3 months (24.7% in both groups). Among patients with acute ischemic stroke in the anterior circulation undergoing thrombectomy, conscious sedation vs general anesthesia did not result in greater improvement in neurological status at 24 hours. The study findings do not support an advantage for the use of conscious sedation. clinicaltrials.gov Identifier: NCT02126085.

Comparison of Conscious Sedation and Asleep-Awake-Asleep Techniques for Awake Craniotomy

Since awake craniotomy (AC) has become a standard of care for supratentorial tumour resection, especially in the motor and language cortex, determining the most appropriate anaesthetic protocol is very important. The aim of this retrospective study is to compare the effectiveness of conscious sedation (CS) to “awake-asleep-awake” (AAA) techniques for supratentorial tumour resection. Forty-two patients undergoing CS and 22 patients undergoing AAA were included in the study. The primary endpoint was to compare the CS and AAA techniques with respect to intraoperative pain and agitation in patients undergoing supratentorial tumour resection. The secondary endpoint was comparison of the other intraoperative complications. This study results show that the incidence of intraoperative agitation and seizure were lower in the AAA group than in the CS group. Intraoperative blood pressures were significantly higher in the CS group than in the AAA group during the pinning and incision, but the level of blood pressures did not need antihypertensive treatment. Otherwise, blood pressures were significantly higher in the AAA group than in the CS group during the neurological examination and the severity of hypertension needed statistically significant more antihypertensive treatment in the AAA group. As a result of hypertension, the amount of intraoperative bleeding was higher in the AAA group than in the CS group. In conclusion, the AAA technique may provide better results with respect to agitation and seizure, but intraoperative hypertension needed a vigilant follow-up especially in the wake-up period.

11 Conscious sedation as the default anaesthetic approach for transcatheter aortic valve insertion (TAVI)

Aim TAVI has traditionally been performed under general anaesthetic (GA), as there is no consensus on anaesthetic management. Our default has been to perform TAVI under conscious sedation (CS) for non-surgical access, since the inception of our program. We sought to determine the efficacy, safety and cost savings of this approach. Methods We reviewed our program at St James’s Hospital and Blackrock Clinic, Dublin from commencement in September 2008 to December 2014. Mean EURO II score, 30 day and one year mortality; cerebrovascular complications, vascular and major bleeding complications (drop in Hb > 2 g/dl), acute kidney injury (AKI) and length of stay were compared between GA and CS groups. Results TAVI was undertaken on 145 patients. 13 patients had a primary surgical access and were excluded from our analysis. 132 patients underwent TAVI implantation via a non-surgical approach; 27/132 (20%) under GA and 105/132 (80%) under CS. Table 1 highlights the demographic data and procedural outcomes. CS was associated with a significantly shorter length of stay and incidence of acute kidney injury. The estimated hospital cost of 1000 euro per night per patient means that the shorter length of stay for CS generated significant cost savings compared to GA. Conclusion TAVI using conscious sedation is associated with a much shorter post procedural hospital stay, significant cost savings and similar procedural success. Conscious sedation should be the default anaesthetic approach for non-surgical access.

Outcomes of General Anesthesia and Conscious Sedation in Endovascular Treatment for Stroke.

Background Recent studies have strongly indicated the benefits of endovascular therapy for acute ischemic stroke, but what remains a continued debate is the role for general anaesthesia versus conscious sedation (CS) for such procedures. Retrospective studies have found poorer neurological outcomes in patients who underwent general anesthesia (GA); however, some have revealed worse baseline stroke severity in these patients. Methods This study is a retrospective cohort study aimed at comparing mortality and morbidity of GA versus CS in patients treated with endovascular intervention in acute ischemic stroke. Chi-square and t-test analyses were used. Results Patients in the GA (n=42) group were more likely to be deceased than those in the CS (n=67) group at hospital discharge, 3 months, and 6 months poststroke onset. Morbidity, as defined by modified Rankin Score, was significantly greater in the GA group at hospital discharge, and a similar trend was seen in morbidity at 3 months postdischarge. Conclusion General anesthesia for endovascular intervention in acute ischemic stroke was associated with increased mortality and poorer neurological incomes compared with conscious sedation. In our study, age, gender, history of hypertension, history of diabetes, and baseline National Institute of Health Stroke Scale were not significantly different between the groups. Although the need for a randomized, prospective study on this topic is clear, our study represents further corroboration of the safety and efficacy of conscious sedation in these procedures.

Subcutaneous Dissociative Conscious Sedation (sDCS) an Alternative Method of Anesthesia for Fiberoptic Bronchoscopy

Objective: Current randomized clinical trial was conducted to compare the efficacy and side effects of dissociative conscious sedation and conscious sedation in patients under bronchoscopy. Methods: In this randomized clinical trial, 110 patients scheduled for Fiberoptic Bronchoscopy in a training hospital in 2012 were enrolled and randomly assigned to receive either SC ketamine plus IV fentanyl (dissociative conscious sedation) or placebo plus IV fentanyl (conscious sedation) and the efficacy and side effects were assessed and compared. Results: There was significant difference between systolic and diastolic blood pressure and heart rate in two groups and more stability was shown in dissociative conscious sedation group (P < 0.05). Also the incidence of cough, the need to extra dose of fentanyl and recall showed less frequency in dissociative conscious sedation group (P < 0.05). Conclusions: Totally, according to the obtained results, it may be concluded that Subcutaneous Dissociative Conscious Sedation (sDCS) in comparison to Conscious Sedation is significantly more efficient accompanied by less side effects in fiberoptic bronchoscopy and using this method is recommended. Implication of the Manuscript: The study was designed in order to evaluate the efficacy of subcutaneous Dissociative Conscious Sedation (sDCS) Method in fiberoptic bronchoscopy.

Impact of Anesthesia on Mortality During Endovascular Clot Removal for Acute Ischemic Stroke

Endovascular clot retrieval is a technique available for removing intracranial arterial occlusions in acute ischemic stroke (AIS). This rescue therapy can be performed with moderate conscious sedation (CS) or general anesthesia (GA). The effect of GA on clinical outcome in AIS remains controversial. Therefore, we retrospectively investigated whether the use of CS or GA during endovascular intervention for AIS influenced outcomes. Patients who underwent emergent endovascular intervention for intracranial arterial occlusion during the years 2006 to 2012 were included in this study. Statistical analysis using the Spearman ρ was performed to examine demographic data and clinical outcomes between patients in the GA and CS groups. Binary logistic regression was used to determine the predictors of mortality. A total of 109 patients fit the inclusion criteria. Among them, 35 patients had GA and 74 patients had CS. Patients needing intubation upon admission for airway protection were more likely to receive GA (P<0.001). The duration of the procedure and the time-to-revascularization from symptom onset were significantly longer in the GA group. Mortality was higher in the GA group compared with the CS group (40% vs. 22%, P=0.045). Multivariate analysis, controlled for confounding variables, identified GA and elevated postprocedure glucose level to be significant predictors of mortality. Larger prospectively randomized multicenter trials evaluating the effects of GA and CS on clinical and radiographic outcomes seems warranted.

Comparison of Bier's Block and Systemic Analgesia for Upper Extremity Procedures: a Randomized Clinical Trial

Background: There are three methods for procedural sedation in upper extremity traumas; systemic, regional and local anesthesia. There is controversy in the literature regarding the method of choice for this purpose. Objectives: The aim of this study was to compare conscious sedation and Bier’s block methods for pain reduction in upper extremity trauma patients. Patients and Methods: This was a non-blinded randomized clinical trial. Patients were randomly allocated to either the Bier’s block or the conscious sedation group. Pain reduction was assessed by a numerical rating scale; patients, surgeons and physicians responsible for analgesia satisfaction were assessed using a five-point Likert scale. Results: There were no significant differences between the two groups regarding basic characteristics. Pain reduction was significantly more in Bier’s block group (P = 0.09). The most common complication in patients of the Bier group was pain in the tourniquet site (6 cases; 17.65%) and in the conscious sedation group this was nausea (11cases; 31.43%). The total number of cases with complications did not significantly differ between the two groups (P = 0.35). Surgeons' satisfaction was similar between the two groups yet satisfaction of patients and physicians, responsible for analgesia, was more in Bier’s block group (P = 0.1 and P = 0.05, respectively). Although the amount of time needed for inducing sedation was more in the Bier group yet total duration of procedure in the Bier group was significantly lower than the conscious sedation group (P < 0.01). Decline in pulse rate and mean arterial pressure was more intense in the conscious sedation group indicating more hemodynamic instability (P < 0.01). Conclusions: Regarding our results, it seems that Bier’s block works better for procedural sedation in upper extremity traumas compared to conscious sedation, when used appropriately for selected cases.

The feasibility of delivering a duodenal–jejunal bypass liner (endobarrier) endoscopically with patients under conscious sedation

The endoscopically placed duodenal-jejunal bypass liner (DJBL) or EndoBarrier gastrointestinal liner has been designed for the treatment of type 2 diabetes mellitus and simultaneous achievement of weight loss by obese patients. This study was performed to determine the safety, efficacy, and feasibility of delivering the DJBL with the patient under conscious sedation (CS). The primary end points of the study were safety and complications. The secondary end points were delivery time (min), amount of propofol (mg) used, and the total hospital stay (h). This prospective study compared placement of the DJBL with the patient under propofol sedation and placement with the patient under general anesthesia (GA). The study included 56 patients, with 28 patients in each group. Both groups were comparable in terms of age, gender, and body mass index. All the devices were placed successfully, and no complications occurred in either group. Comparison of the CS group with the GA group respectively showed a mean total operation time of 29 versus 56 min, a mean propofol use of 170 versus 258 mg, and a mean hospital stay of 11 versus 22 h. Delivery of the DJBL to patients under CS is feasible, safe, and efficient in terms of time and cost. Because of possible complications during the procedure, the authors recommend placement of the DJBL with the patient under CS in proximity to the operating room.

Does General Anesthesia Increase the Diagnostic Yield of Endoscopic Ultrasound-Guided Fine Needle Aspiration of Pancreatic Masses?

Ootaki, Chiyo*; Stevens, Tyler†; Vargo, John†; You, Jing‡; Shiba, Ayako*; Foss, Joseph*; Borkowski, Raymond*; Maurer, Walter* Author Information

Sa1143 Monitored Anesthesia Care Versus Conscious Sedation for Common Endoscopic Procedures. A Prospective Patient Satisfaction and Procedure Outcome Study

Background Sedation for endoscopic procedures induced with opioid and benzodiazepine combination is called conscious sedation (CS) and defined by The American Society of Anesthesiology (ASA) to be moderate sedation.Sedation for endoscopic procedures induced with propofol as the main anesthetic is called Monitored Anesthesia Care (MAC) and defined by the ASA to be deep sedation. This is generally administered by an anesthesiologist.In this prospective study we collected data directly from patients undergoing endoscopic procedures.We compared patient satisfaction and overall procedural outcome in two different modes of sedation. Methods:473 patients were enrolled in this prospective study at two community hospitals. Inclusion criteria were adult patients undergoing EGD or colonoscopy and able to complete the survey form. Patients with ASA score above 3 and undergoing other GI procedures were excluded. Hospital A exclusively used MAC and hospital B exclusively used CS. Group A at Hospital A enrolled 259 patients who received deep sedation with propofol as the main anesthetic, which was administered and monitored by an anesthesiologist. Group B at Hospital B enrolled 214 patients who received conscious sedation (CS) using a combination of midazolam and fentanyl administered by the endoscopist. Patient satisfaction surveys were completed once patients were out of sedation and prior to discharge. Results : Pain at drug administration site in group A was 22% as compared to 7% in group B. However, abdominal discomfort and pain was 20.46% in group A which was higher in group B at 32.71%. Interestingly, there was no difference in gagging/choking sensation during EGD in both groups with incidence of 22%. In Group A, 98.06% patient reported adequate pain control in contrast to 89.71% in comparison group B. It was noted that post procedure recovery time from the conscious sedation group was 13.80 minutes as compared to 23.15 minutes in MAC group. Overall patient satisfaction rate was 96.91% in group A and 97.66% in group B. Regarding revisit, 94.59% and 97.66% patients in group A and B respectively, would consider coming back for the next visit. In terms of periprocedural complications, only one patient showed transient respiratory depression in the CS group and was reversed with IV naloxone and flumazenil. Conclusion:This study compares patient satisfaction and periprocedural complications for the use of CS and MAC for common endoscopic procedures. We did not find any statistical differences between the two groups except for less recovery time in the CS group. In the MAC group there is less incidence of abdominal pain or discomfort while CS group has shown less pain at site of drug administration. Overall patient satisfaction and revisit consideration were the same in both groups.

Feasibility, Safety, and Periprocedural Complications Associated With Endovascular Treatment of Selected Ruptured Aneurysms Under Conscious Sedation and Local Anesthesia

Endovascular coil embolization of ruptured aneurysms is performed under general anesthesia at most centers for perceived improved image quality and patient safety. To report the feasibility of and outcomes associated with endovascular treatment of subarachnoid hemorrhage (SAH) patients with ruptured cerebral aneurysms performed under conscious sedation with local anesthetics. Between January 2005 and December 2009, 187 patients with aneurysmal SAH were treated with coil embolization at the authors' hospital. For each patient, procedural details, mode of anesthesia, and clinical and radiographic outcomes were reviewed retrospectively (retrospective case series). A total of 197 coil embolizations were performed: 112 under general anesthesia, 78 under conscious sedation with local anesthetics, and 7 converted from conscious sedation to general anesthesia. None of the patients who presented with Hunt & Hess grade IV or V were treated under conscious sedation. For patients who presented with Hunt & Hess grades I, II, and III, 79.2%, 66.7%, and 32.6% of patients, respectively, underwent successful completion of treatment under conscious sedation. The symptomatic procedural complication rate was 2.5% overall and 2.4% for the conscious sedation group alone. Among the 14 interventions with intraprocedural perforation, 11 were performed under general anesthesia and 3 were performed under conscious sedation. In the authors' experience, conscious sedation with local anesthetics for endovascular treatment of ruptured intracranial aneurysms is feasible and safe in most patients with low-grade SAH. It may allow direct evaluation of the patient's neurological status, potentially leading to earlier detection and response to intraprocedural complications.

Does General Anesthesia Increase the Diagnostic Yield of Endoscopic Ultrasound-guided Fine Needle Aspiration of Pancreatic Masses?

: Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) of the pancreas has become the preferred method for tissue diagnosis for pancreatic solid masses. The yield of EUS-FNA in this setting is influenced by multiple factors. We hypothesized that general anesthesia (GA) may improve EUS-FNA yield by improving patient cooperation and stillness during the procedure. Our objective was to assess the association between the sedation method employed and the diagnostic yield of EUS-FNA. : A retrospective cohort study was conducted involving consecutive patients who received EUS-FNA for diagnosis of a solid pancreatic mass at the Cleveland Clinic (Cleveland, OH) gastrointestinal endoscopy units from 2007 to 2009. We compared the diagnostic yield of EUS-FNA between patients receiving GA provided by an anesthesiologist (GA group) and patients receiving conscious sedation (CS) provided by a qualified registered nurse (CS group). : Of 371 patients, a cytological diagnosis was obtained in 73/88 patients (83%) in the GA group and 206/283 patients (73%) in the CS group. Anesthesiologist-delivered GA was associated with an increased odds of having a successful diagnosis as compared with CS (adjusted odds ratio [95% CI]: 2.56 [1.27-5.17], P = 0.01). However, the incidence of complication during or after the procedure was not different between the groups (P > 0.99). : Anesthesiologist-delivered GA was associated with a significantly higher diagnostic yield of EUS-FNA. GA should be considered a preferred sedation method for EUS-FNA of a solid pancreatic mass.

Adverse events of conscious sedation in ambulatory spine procedures

Interventional spine procedures are commonly performed in the ambulatory surgical setting, often using conscious sedation. The rate of adverse events with conscious sedation has not been previously assessed in the interventional spine procedure setting. The goal of this study was to determine the rate of adverse events when using conscious sedation in the ambulatory interventional spine setting. A retrospective cohort chart review analysis was performed on all interventional spine procedures performed during one calendar year at a university-affiliated ambulatory surgery center by six nonanesthesia-trained spine interventionalists. Of the 3,342 procedures performed that year, 2,494 charts (74.6%) were available for review. Adverse events were documented immediately after the procedure and at a maximum 3-day follow-up phone call. The rate and type of adverse events were analyzed and compared between those who received conscious sedation with local anesthesia and those who received local anesthesia alone. Of the 2,494 cases reviewed, 1,228 spine procedures were performed with local anesthesia and conscious sedation, and 1,266 procedures were performed with local anesthesia alone. Of these cases, 66 immediate adverse events (5.12%) were documented in the conscious sedation group, and 61 immediate adverse events (4.82%) were documented in the local anesthesia alone group. At maximum 3-day follow-up, 670 patients of the conscious sedation group were available for contact, and 699 patients were available from the local anesthesia group. Thirty-two adverse events (4.77%) were noted in the conscious sedation group, and 28 adverse events (4.00%) were noted in the local anesthesia group. Comparison of these rates found no significant statistical difference. However, patients in the local anesthesia group had a significantly higher rate of postoperative hypertension. Adverse events reported both immediately and at follow-up were determined to be mild, with no serious adverse events reported. The findings of this study suggest that mild to moderate conscious sedation in interventional spine procedures is associated with low rates of adverse events when established protocols are followed.