Conventional Sedation Research Articles

Endoscopic Sedation in the United States in 2004: Results From a Postal Survey of 5000 Gastroenterologists

Background: The introduction of new sedative agents and a desire for greater efficiency during endoscopy have contributed to changes in the practice of endoscopic sedation in the United States (US). However, sedation practices have not been surveyed since 1990 (Gastrointest Endosc 1990;36:S13-S18). The aim of this study was to define current practice patterns of endoscopic sedation within the US. Methods: A 23-question survey pertaining to endoscopic sedation was created, refined by a consultant, and then mailed during 07/04 to 5,000 randomly-selected ACG physician members. A follow-up “reminder” was sent 6 weeks later. Proportional geographic representation of the ACG membership was preserved by dividing the US into 6 regions for mailings. Results: 1353 questionnaires (27%) were returned. 60% of respondents were between the ages of 30 and 49. 33% were in practice 0-9 years, 33% 10-19 years, and 33% > 19 years. 21% were in academic practice, 19% in solo practice, and 60% in group practice. 55% of endoscopies were performed in a hospital (range 0-100%), 36% in an ambulatory center (0-100%) and 9% in an office (0-100%). Respondents performed an average of 12 EGDs and 22 colonoscopies (CL) per week, and 99% of all endoscopies were performed with sedation. Supplemental O2 was routinely administered by 66% and 89% of respondents using conventional and propofol sedation, respectively. Monitoring of vital signs (99%) and pulse oximetry (99%) was standard, but only 3% of respondents used capnography. 75% of respondents used narcotic/benzodiazepine sedation exclusively, while 25% used propofol for some or all exams. The use of propofol varied by geographic region, ranging from 2% (northeastern states) to 43% (mid-Atlantic states) of providers. 38% of gastroenterologists utilized an anesthesiologist to administer propofol, 16% a CRNA, 33% a combination of the two, and 8% administered propofol themselves. Endoscopist satisfaction was greater with propofol than conventional sedation (9.0/10 vs. 8.2/10, p < 0.0001). 48% of endoscopists would choose propofol for their own CL, 39% conventional sedation, and 12% no sedation. Conclusions: 1. Propofol is used by about one-quarter of all endoscopists nationwide although this rate varies by region of the country. 2. Physician satisfaction scores for sedation are higher among users of propofol than conventional sedation drugs, and 3. More endoscopists would choose propofol than conventional sedation for their own exam. Background: The introduction of new sedative agents and a desire for greater efficiency during endoscopy have contributed to changes in the practice of endoscopic sedation in the United States (US). However, sedation practices have not been surveyed since 1990 (Gastrointest Endosc 1990;36:S13-S18). The aim of this study was to define current practice patterns of endoscopic sedation within the US. Methods: A 23-question survey pertaining to endoscopic sedation was created, refined by a consultant, and then mailed during 07/04 to 5,000 randomly-selected ACG physician members. A follow-up “reminder” was sent 6 weeks later. Proportional geographic representation of the ACG membership was preserved by dividing the US into 6 regions for mailings. Results: 1353 questionnaires (27%) were returned. 60% of respondents were between the ages of 30 and 49. 33% were in practice 0-9 years, 33% 10-19 years, and 33% > 19 years. 21% were in academic practice, 19% in solo practice, and 60% in group practice. 55% of endoscopies were performed in a hospital (range 0-100%), 36% in an ambulatory center (0-100%) and 9% in an office (0-100%). Respondents performed an average of 12 EGDs and 22 colonoscopies (CL) per week, and 99% of all endoscopies were performed with sedation. Supplemental O2 was routinely administered by 66% and 89% of respondents using conventional and propofol sedation, respectively. Monitoring of vital signs (99%) and pulse oximetry (99%) was standard, but only 3% of respondents used capnography. 75% of respondents used narcotic/benzodiazepine sedation exclusively, while 25% used propofol for some or all exams. The use of propofol varied by geographic region, ranging from 2% (northeastern states) to 43% (mid-Atlantic states) of providers. 38% of gastroenterologists utilized an anesthesiologist to administer propofol, 16% a CRNA, 33% a combination of the two, and 8% administered propofol themselves. Endoscopist satisfaction was greater with propofol than conventional sedation (9.0/10 vs. 8.2/10, p < 0.0001). 48% of endoscopists would choose propofol for their own CL, 39% conventional sedation, and 12% no sedation. Conclusions: 1. Propofol is used by about one-quarter of all endoscopists nationwide although this rate varies by region of the country. 2. Physician satisfaction scores for sedation are higher among users of propofol than conventional sedation drugs, and 3. More endoscopists would choose propofol than conventional sedation for their own exam.

Does the Use of Propofol Sedation Increase the Incidence of Post-ERCP Pancreatitis?

Background: Propofol is a short-acting sedative-hypnotic drug used for induction of anesthesia and maintenance of sedation in mechanically ventilated patients. In the last 10 years several case reports have linked propofol to episodes of acute pancreatitis. If propofol-induced pancreatitis is a true entity, it is quite rare, so that randomized controlled trials would require large number of patients to detect a statistically significant difference. Since propofol is now routinely used in endoscopic procedures such as ERCP, and patients undergoing ERCP are at higher risk for developing pancreatitis, we theorized that post-ERCP pancreatitis could serve as a model to evaluate whether propofol is indeed associated with acute pancreatitis. A recent literature search confirmed that this is the first study to systematically test the hypothesis that pancreatitis is a complication of propofol administration in humans. Methods: We reviewed charts of patients who had ERCP performed in 2002 and 2003 at our institution. Data extracted included patient's initials, sex, age, date of procedure, indication for procedure, attending physician's initials, medications being taken at the time of procedure, smoking and alcohol use, type of sedation used, whether a sphincterotomy was performed, and if pancreatitis was observed following the procedure. Sedation used was classified as either propofol or a combination of midazolam, diazepam and fentanyl. Pancreatitis was defined as abdominal pain or nausea/vomiting accompanied by an elevation of serum amylase and/or lipase three times the upper limit of normal. Results: In the group of patients receiving propofol sedation 10 out of 93 patients developed post-ERCP pancreatitis (10.7%), whereas in the group receiving non-propofol sedation the incidence was 5.7% (5/88); this difference was not statistically significant (p=0.2162). Multivariate analysis showed that the two groups were similar with respect to age (mean 63 years) and sex (64% female), but the propofol group had a lower rate of sphincterotomy (56 vs. 68%) which was not statistically significant (p=0.1202). Conclusion: Our study showed a trend towards an increased incidence of post-ERCP pancreatitis in patients receiving propofol sedation versus conventional sedation; the difference between the two groups was not statistically significant. Studies with larger sample sizes need to be performed to further test this association.

EFFICACY AND SAFETY OF NURSE-ADMINISTERED PROPOFOL AS AN ADJUNCTIVE AGENT OF CONSCIOUS SEDATION IN PRIVATE NON-ACEDEMIC GASTROENTEROLOGY PRACTICE SETTING

Purpose: This study evaluates the safety and efficacy of propofol (P) in a private non-academic setting. Special interest was paid in a subset of patients who take chronic psychotropic/pain medications (cpm) (i.e. antidepressants, anxiolytics, pain meds, etc.) and who generally tend to need higher doses of conventional medication. Methods: All endoscopy nurses were given educational material designed by our ambulatory endoscopy center and were required to take a self-evaluation test. P was used as an adjunct to conventional sedation, namely midazolam (M), meperidine (MP), and fentanyl (F) and was administered by a R.N. supervised by board certified gastroenterologist. The endpoints measured were: 1) was there adequate sedation that led to a successful procedure? 2) what were the major (i.e. endotracheal intubation, bag-mask ventilation) versus minor (i.e. rash) complications? 3) can P be safely administered without an anesthesia specialist present in a private non-academic setting? 4) was a higher dose of P needed for adequate sedation in patients who are on cpm? Results: P was used in combination with conventional agents in 254 patients who underwent endoscopy. All patients in this study were ASA I-III classification. The range of P, M, MP, and F used in all patients was 5 mg-90 mg, 1 mg-5 mg, 12.5 mg-75 mg, and 25 mcg-100 mcg, respectively. The patients were divided into two groups, those on cpm (123 patients) and those who are not (131 patients). The results for those patients on cpm are as follows: the average dose of P, M, MP, and F is 22.28 mg, 3.35 mg, 45.25 mg, and 88.9mcg, respectively. The results for patients not on cpm are as follows: the average dose of P, M, MP, and F is 22.67 mg, 3.64 mg, 47.67 mg, and 70.0mcg, respectively. There were no major complications and 1 minor complication (rash). No patients required special airway intervention such as endotracheal intubation or bag-mask ventilation. Five patients had a temporary Sa02 of <90% after administration of P with spontaneous resolution. Conclusions: Propofol sedation in conjunction with conventional agents is overall safe and effective when used in a private non-academic setting. This held true even in patients who are on cpm. In our study, patients who are on cpm tended towards lower dosage of conventional medications and do not need higher doses of P compared to the other group. This indicates that P has the potential of reducing the dose of conventional medications in patients who are known to require higher doses in general.

Daily interruption of sedative infusions and complications of critical illness in mechanically ventilated patients.

In critically ill patients receiving mechanical ventilation, daily interruption of sedative infusions decreases duration of mechanical ventilation and intensive care unit length of stay. Whether this sedation strategy reduces the incidence of complications commonly associated with critical illness is not known. Blinded, retrospective chart review. University-based hospital in Chicago, IL. One hundred twenty-eight patients receiving mechanical ventilation and continuous infusions of sedative drugs in a medical intensive care unit. None. We performed a blinded, retrospective evaluation of the database from our previous trial of 128 patients randomized to daily interruption of sedative infusions vs. sedation as directed by the medical intensive care unit team without this strategy. Seven distinct complications associated with mechanical ventilation and critical illness were identified: a) ventilator-associated pneumonia; b) upper gastrointestinal hemorrhage; c) bacteremia; d) barotrauma; e) venous thromboembolic disease; and f) cholestasis or g) sinusitis requiring surgical intervention. The incidence of complications was evaluated for each patient's hospital course. One hundred twenty-six of 128 charts were available for review. Patients undergoing daily interruption of sedative infusions experienced 13 complications (2.8%) vs. 26 (6.2%) in those subjected to conventional sedation techniques (p =.04). Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation reduces intensive care unit length of stay and, in turn, decreases the incidence of complications of critical illness associated with prolonged intubation and mechanical ventilation.

Treatment Efficacy and Safety Related to the Use of Propofol vs. Conventional Sedation in the Performance of Colonoscopy: A Meta-Analysis of Published Randomized Controlled Trials

Background: Assessment of sedation levels in endoscopy is crucial for patient safety. Sedation assessment is currently guided by indirect measures: vital signs, direct observation, and subjective sedation assessment like the MOAA/S scale. BIS monitoring is a mathematical evaluation of frontal cortex EEG activity used to improve general anesthetic titration andpatient recovery. Current BIS algorithms do not differentiate various levels of MS. Aim: To compare the new BIS monitoring algorithm (BIS Revision 4.1) to MOAA/S scale for MS during elective endoscopy. Methods: 80 pts (43M/37F,mean age 61 yrs)were studied using a balanced cohort of procedures (20-EGD; 20-Colon; 20-ERCP; 20-EUS). IV MS (meperidine/midazolam) was administered. BIS levels and MOAA/S scores were recorded q 3 min. BIS level (0-100; 0=flatline EEG to 100=fully awake) and MOAA/S score (1-5; 1=unresponsive to shaking to5=coherent). ThemeanBIS level andMOAA/S score were compared. Results: Levels of sedation achieved: 54 pts (67.5%) deep sedation and 26 pts (32.5%) mild to moderate sedation. The correlation coefficient between BIS level and MOAA/S score was 0.66 (p < 0.01; Graph). The new BIS algorithm had excellent correlation tomild/moderate sedation levels (MOAA/S 2-5; p<0.001) but failed to discriminate betweenmoderate/deep sedation levels (MOAA/S 1-2; p= 0.75). Conclusions: (1)Deep sedation occurs frequently during elective endoscopy. (2)The new BIS algorithm is successful in discriminating levels of mild/moderate sedation, but is no more effective than direct observation (MOAA/S score) at distinguishing between moderate/deep levels of sedation. Clinical implication: Since a largepercentageofpatients experiencedeep sedationduringelective endoscopy, the new BIS algorithm needs to be refined to differentiate deeper levels of sedation. Treatment Efficacy and Safety Related to the Use of Propofol vs. Conventional Sedation in the Performance of Colonoscopy: A Meta-Analysis of Published Randomized Controlled Trials Neena S. Abraham, Maitreyi Raman, Kara Thompson Background and Aim: There is increasing interest in the use of propofol during the performance of colonoscopy. Our aim was to quantitatively evaluate the efficacy and safety of propofol as compared to conventional sedation in theperformance of routine colonoscopy. Methods: All randomized controlled trials evaluating propofol in colonoscopy, publishedas fullmanuscripts,were identifiedusing a standardized search and data abstraction policy. Comparisons between propofol and conventional sedationweremade in the areas of efficacy (pain control, patient satisfaction, recovery time) and risks (hypoxia, hypotension). A single combined estimate of treatment efficacy (ORwith 95%CI) was generated using a fixed effect model or random effects model if appropriate. When estimates could not be aggregated mathematically, a narrative systematic review was performed. Results: Eight studies were identified, however, twowere excluded for lack of control comparator. Aggregation of outcomes was impossible in all six studies due to lack of comparable outcome, failure to report a measure of variability or inability to dichotomize results. Recovery time post colonoscopy was substantially reduced using propofol when compared with conventional sedation (OR 18.25; 95% CI: 12.37 to 24.13). Hypoxic events occurred less frequently in the propofol arm, although this was not statistically significant (OR= 0.72; 95%CI: 0.72 to 2.37). Hypotension occurred less frequently using propofol, however, the heterogeneity in examination of this variablewas toogreat, rendering the result inconclusive. Pain and satisfaction were qualitatively reviewed due to heterogeneity in outcomes assessment andwere found equivalent or superior using propofol. Conclusions: There are a limited number of randomised controlled trials reporting on efficacy and safety of propofol during colonoscopy. Among the six published placebo controlled studies, there is a suggestion that propofol is superior to conventional sedationwith respect to recovery time, hypoxia, hypotension, pain control and patient satisfaction. The evidence for improved patient pain control and satisfaction is qualitative. Future studies require standardized assessment of these outcomes to allow quantitative aggregation of results. As more centers utilize propofol for routine colonoscopy, the cost-efficacy of reduced recovery time may become apparent.

Non-anesthetist Administered Propofol for ERCP; Efficacy, Safety Profile and Side Effect: A Prospective Randomized Trial

Introduction: Traditionally ERCP is performed under conscious sedation. Sedative agents are mainly intravenous midazolam and meperidine. These agents have many disadvantages because of difficulty on titrating the dose and delayed recovery effect. Propofol has become a popular agent for upper and lower gastrointestinal endoscopy due to its rapid recovery profile. This study is undertaken to evaluate the safety and recovery period of patients who undergo ERCP with propofol compared to conventional sedative agents. Methods : From July 2003 - November 2003, patients who required ERCP (n=75) were prospectively randomized to be sedated with intravenous midazolam/meperidine (n=34) and continuous intravenous propofol(n=41). These agents were administered by gastroenterology fellows. Vital sign and oxygen saturation were monitored with automated equipment. Oxygen supplement was provided intermittently only when the oxygen saturation dropped below 90%. Results: Baseline demographic datas were similar : age, sex, BMI, time before insertion of endoscope, procedural time, baseline blood pressure, oxygen saturation and HR. Six and thirteen patients in propofol and pethidine/midazolam group had at least one episode of oxygen saturation less than 90% (p = 0.019), respectively. But other physiological outcomes were not statistically different. At 30 minutes post sedation, more than 95% of propofol group had complete recovery compared to only 55.5% in meperidine/midazolam group. Conclusion : Continuous IV drip propofol is safe for patient undergoing ERCP. The incidence of hypoxemia is less, the recovery time is shorter significantly compared to conventional sedation. It could be used under gastroenterologist's supervision without significant adverse event compared with conservative meperidine/midazolam sedation for ERCP.

Propofol: a gastroenterologist's perspective.

The use of propofol for GI endoscopy has left the realm of experimentation and is now a viable alternative to standard sedation and analgesia. In the hands of appropriately trained gastroenterologists and registered nurses, propofol has been shown to be superior to standard sedation and analgesia in terms of patient satisfaction and comfort and shorter recovery parameters. Comparative studies have found it to be as safe as the regimens that are used for standard sedation and analgesia. Its narrow therapeutic window demands that specially trained personnel who are not directly involved in the endoscopic procedure administer it. Cost-effectiveness data suggest that propofol is superior to conventional sedation and analgesia, even with the use of added personnel.The importance of pre-procedural assessment and appropriate monitoring cannot be overemphasized. The endoscopist must have a thorough knowledge of the pharmacology of the agents used for sedation and the training necessary to recognize and manage over sedation. Numerous regulatory groups are carefully scrutinizing the practice of sedation and analgesia. It seems that ventilatory monitoring will be required for at least a subset of patients. Although hypercapnia and apnea can be reliably measured, the most important questions to be answered are if such monitoring affects patient outcomes and which patients are at risk for apnea and alveolar hypoventilation.

The Use of Melatonin as an Alternative to Sedation in Uncooperative Children Undergoing an MRI Examination

AIM: Children who are uncooperative, due either to their age or medical condition, usually require sedation or a general anaesthetic (GA) to ensure immobility during magnetic resonance imaging (MRI) examination. These procedures have a risk of respiratory compromise and loss of vital reflexes. Melatonin induces a natural sleep with no known complication or risk of respiratory compromise. We aimed to evaluate the use of melatonin in these uncooperative children. MATERIAL AND METHODS: An unselected group of 40 children, who had been referred for an MRI examination of the brain under sedation or GA, were chosen to receive melatonin instead. They all received 10mg of melatonin and 17 children additionally underwent some form of sleep deprivation. The number of children who went to sleep and had a successful MRI examination was recorded. RESULTS: Twenty-six children (65%) went to sleep and of these 22 (55%) had a successful MRI examination. In the 17 children who underwent sleep deprivation, 13 (76%) went to sleep and had a successful MRI examination. There was no complication. CONCLUSIONS: Melatonin may provide an alternative to conventional sedation regimes and GA for uncooperative children undergoing an MRI examination. The use of sleep deprivation improves the success rate and there is no risk of respiratory compromise. Johnson, K.et al. (2002). Clinical Radiology57, 502–506.

3568 Is endoscopic ultrasound useful during pediatric practice? preliminary report in venezuela.

Today Endoscopic Ultrasound (EUS) plays an important role in gastrointestinal algorithm of benign and malignant diseases. In adults, it has shown to be complementary with abdominal ultrasound, computed tomography and ERCP for gastric and pancreatobiliary pathologies. However, there is little experience published about EUS in pediatric population.AIM OF THE STUDY: To determine EUS utility in a pediatric group of patients. PATIENTS AND METHODS: Between March and November 1999, 14 children, 8 girls and 6 boys, mean age 12.5 years (range 1.5-18 years), underwent an EUS by the same operator with an Olympus UM 30 GIF 20 or 130 echoendoscope, during conventional sedation (midazolan and or meperidine) or propofol in children under 5 years old (with anestesiologist present in the room). Patients had the following initial diagnosis: 5 acute recurrent pancreatitis (ARP), 3 submucosal tumors, 3 extrahepatic cholestasis, 2 acute pancreatitis, 1 Zollinger-Ellison syndrome. All pts underwent ERCP when it was requiere as a gold standard RESULTS: EUS showed the etiology in 3/5 pts with ARP, two with changes of chronic pancreatitis (>5 criteria, 1 with normal ERCP and 1 with abnormal ERCP and anomalous biliopancreatic junction ), and one pt with a subpapilar duodenal duplication cyst confirmed by ERCP and treated endoscopically. Two pts had a normal EUS and ERCP. EUS showed in 3 pts with submucosal tumors diagnosed by gastroscopy and normal biopsies: 1 lipoma, 1 ectopic pancreas and 1 bronchogenic cyst. 3 patients with extrahepatic cholestasis (two with normal conventional US) had gallblladder minilithiasis with normal CBD. 2 patients with acute pancreatitis showed at EUS gallbladder minilithiasis with normal CBD. All five patients avoided diagnostic ERCP with a normal resolution. One patient with Zollinger-Ellison syndrome showed a normal pancreatic body and tail, without a head evaluation due to surgical history and the gastrinoma remains unlocated. CONCLUSIONS: EUS is a safe and effective complementary method for gastrointestinal pediatric pathologies. EUS can identify etiologies after rutine explorations and avoid diagnostic ERCP, and ES should be use has a therapeutic procedure. Today Endoscopic Ultrasound (EUS) plays an important role in gastrointestinal algorithm of benign and malignant diseases. In adults, it has shown to be complementary with abdominal ultrasound, computed tomography and ERCP for gastric and pancreatobiliary pathologies. However, there is little experience published about EUS in pediatric population.AIM OF THE STUDY: To determine EUS utility in a pediatric group of patients. PATIENTS AND METHODS: Between March and November 1999, 14 children, 8 girls and 6 boys, mean age 12.5 years (range 1.5-18 years), underwent an EUS by the same operator with an Olympus UM 30 GIF 20 or 130 echoendoscope, during conventional sedation (midazolan and or meperidine) or propofol in children under 5 years old (with anestesiologist present in the room). Patients had the following initial diagnosis: 5 acute recurrent pancreatitis (ARP), 3 submucosal tumors, 3 extrahepatic cholestasis, 2 acute pancreatitis, 1 Zollinger-Ellison syndrome. All pts underwent ERCP when it was requiere as a gold standard RESULTS: EUS showed the etiology in 3/5 pts with ARP, two with changes of chronic pancreatitis (>5 criteria, 1 with normal ERCP and 1 with abnormal ERCP and anomalous biliopancreatic junction ), and one pt with a subpapilar duodenal duplication cyst confirmed by ERCP and treated endoscopically. Two pts had a normal EUS and ERCP. EUS showed in 3 pts with submucosal tumors diagnosed by gastroscopy and normal biopsies: 1 lipoma, 1 ectopic pancreas and 1 bronchogenic cyst. 3 patients with extrahepatic cholestasis (two with normal conventional US) had gallblladder minilithiasis with normal CBD. 2 patients with acute pancreatitis showed at EUS gallbladder minilithiasis with normal CBD. All five patients avoided diagnostic ERCP with a normal resolution. One patient with Zollinger-Ellison syndrome showed a normal pancreatic body and tail, without a head evaluation due to surgical history and the gastrinoma remains unlocated. CONCLUSIONS: EUS is a safe and effective complementary method for gastrointestinal pediatric pathologies. EUS can identify etiologies after rutine explorations and avoid diagnostic ERCP, and ES should be use has a therapeutic procedure.

Struggling toward easier endoscopy

Struggling toward easier endoscopy

The Use of Continuous IV Sedation Is Associated With Prolongation of Mechanical Ventilation

To determine whether the use of continuous i.v. sedation is associated with prolongation of the duration of mechanical ventilation. Prospective observational cohort study. The medical ICU of Barnes-Jewish Hospital, a university-affiliated urban teaching hospital. Two hundred forty-two consecutive ICU patients requiring mechanical ventilation. Patient surveillance and data collection. The primary outcome measure was the duration of mechanical ventilation. Secondary outcome measures included ICU and hospital lengths of stay, hospital mortality, and acquired organ system derangements. A total of 93 (38.4%) mechanically ventilated patients received continuous i.v. sedation while 149 (61.6%) patients received either bolus administration of i.v. sedation (n=64) or no i.v. sedation (n=85) following intubation. The duration of mechanical ventilation was significantly longer for patients receiving continuous i.v. sedation compared with patients not receiving continuous i.v. sedation (185+/-190 h vs 55.6+/-75.6 h; p<0.001). Similarly, the lengths of intensive care (13.5+/-33.7 days vs 4.8+/-4.1 days; p<0.001) and hospitalization (21.0+/-25.1 days vs 12.8+/-14.1 days; p<0.001) were statistically longer among patients receiving continuous i.v. sedation. Multiple linear regression analysis, adjusting for age, gender, severity of illness, mortality, indication for mechanical ventilation, use of chemical paralysis, presence of a tracheostomy, and the number of acquired organ system derangements, found the adjusted duration of mechanical ventilation to be significantly longer for patients receiving continuous i.v. sedation compared with patients who did not receive continuous i.v. sedation (148 h [95% confidence interval: 121, 175 h] vs 78.7 h [95% confidence interval: 68.9, 88.6 h]; p<0.001). We conclude from these preliminary observational data that the use of continuous i.v. sedation may be associated with the prolongation of mechanical ventilation. This study suggests that strategies targeted at reducing the use of continuous i.v. sedation could shorten the duration of mechanical ventilation for some patients. Prospective randomized clinical trials, using well-designed sedation guidelines and protocols, are required to determine whether patient-specific outcomes (eg, duration of mechanical ventilation, patient comfort) can be improved compared with conventional sedation practices.

Hypnotic Technique for Sedation of Patients during Upper Gastrointestinal Endoscopy

A method of sedation of patients undergoing upper gastrointestinal endoscopy is described. This technique employs a variety of elements, including “pacing and leading,” metaphors, use of physiological reactions to deepen the relaxation, imagery, and post hypnotic suggestions. It is a simple and effective method which does not require any preparation. It spares the need for a pharmacological sedation and obviates the possible hazards of such a sedation. The author has successfully used this technique to sedate more than 200 patients undergoing upper gastrointestinal endoscopy. The duration of examinations performed this way compares with that using conventional pharmacological sedation. However, unlike the case of pharmacological sedation, no further monitoring is needed after the completion of the examination and the patients can leave the clinic immediately to resume their activities.

NITROUS OXIDE SEDATION IN PEDIATRIC PATIENTS UNDERGOING GASTROINTESTINAL ENDOSCOPY.

The ideal medication administered to children prior to gastrointestinal endoscopy procedures has not yet been found. We evaluated in this pilot study the efficacy and safety of using inhaled nitrous oxide administration during endoscopy. Subjects and methods: Thirty-seven patients were studied. Each patient received prior to endoscopy and during the procedure for some of them nitrous oxide. The pediatric endoscopist and the nurse performing the procedure were asked to rate cooperation, drowsiness and overall efficacy of the sedation. Oxygen saturation, negative behaviors and any adverse effect were recorded during all the procedure. After the endoscopy, children were asked to score their degree of pain during the procedure on a visual analogic scale (0, no pain; 100, maximal pain) and on a body outline (projective method). Results: Thirty of the patients underwent diagnostic upper gastrointestinal endoscopy while 7 underwent rectosigmoidoscopy. The mean time from nitrous oxide administration until the insertion of the endoscope was 4.6 minutes (range 3 to 8 min); 23 children continued to receive nitrous oxide inhalation using a nasal mask during endoscopy for 1 to 12 minutes (mean ± S D: 4.4 ± 2.6). Good or excellent efficacy was noted in 92% of children by the endoscopist and 89% of them by the nurses. Good or excellent cooperation was noted in 81% of the children by the nurse and 91% of them by the endoscopist. The child pain score with usual analogue scale ranged from 5 to 100 (mean ± S D: 27 ± 22) for upper gastrointestinal endoscopy and from 0 to 30 (mean ± S D: 8.3 ± 11.8) for rectosigmoidoscopy. The time of discharge following endoscopy varied from 0 to 7 minutes (mean ± S D: 1.7 ± 1.8 min). Adverse effects occurred in 10 patients and included headache (n=6), blurred vision (n=3), nausea and vomiting (n=2), paresthesia (n=2). For upper gastrointestinal endoscopy, children usually located their pain on the body outline in the cervical area (21/30), while a few of them colored the epigastric area (6/30). Conclusion: Nitrous oxide provides a rapid and effective analgesia without heavy sedation, leads to adequate relaxation and cooperation and facilitates quick and efficient endoscopy. The effect of nitrous oxide was of short duration, allowing children to leave the endoscopic unit without requirement of a long recovery period. The adverse side effects of nitrous oxide analgesia appeared to be minor and their duration was always brief. Nitrous/oxygen inhalation might provide a valuable alternative to conventional sedation regimens during gastrointestinal endoscopy in children.

A firefighter with pancreatitis

prepared in a solution similar to 10% Intralipid. The association between hypertriglyceridaemia and pancreatitis is well known among patients with primary or secondary hypertriglyceridaemia, who are prone to develop episodes of acute pancreatitis when their serum triglycerides are uncontrolled. Patients with severe hypertriglyceridaemia usually have a normal serum amylase (lipaemic serum interferes with the amylase assay), and the associated pancreatitis is often necrotising. There is conflicting evidence on the effect of short-term propofol use on serum lipids. Gottardis et al found no significant difference in serum lipid concentrations between patients in intensive care who received a continuous propofol infusion for 3 days and those who received conventional sedation. Others have found that propofol induces hypertriglyceridaemia with short-term and long-term (>7 days) use; the hypertriglyceridaemia returns to normal when the propofol is discontinued. Boyle et al found that serum lipids increased when the rate of infusion exceeded 100 μg kg 1 min 1 for prolonged periods. Propofol has many advantages over other more commonly used sedatives in intensive care, although prolonged infusions at high rates can raise serum lipid concentrations. Propofol has been implicated in a few sporadic cases of postoperative pancreatitis, but it is unlikely that intraoperative bolus doses would either raise serum lipids or induce pancreatitis, as argued by Leisure et al. Propofol-induced hypertriglyceridaemia is the most likely cause of necrotising pancreatitis in this patient. Despite high serum triglycerides, the infusion was continued to allow life-saving mechanical ventilation. Prolonged continuous propofol infusion in the intensive care unit should be discontinued, if possible, in the presence of hypertriglyceridaemia, to prevent pancreatitis.

EFFECT OF PROLONGED SEDATION WITH PROPOFOL ON SERUM TRIGLYCERIDE AND CHOLESTEROL CONCENTRATIONS

We compared changes in serum lipid concentrations in ICU patients receiving a 3-day continuous infusion of propofol with those in patients receiving conventional sedation. No adverse effects were observed and the serum lipid concentrations were not significantly influenced by propofol. It is concluded that propofol might be a suitable agent for long-term sedation in the ICU, although serum lipid concentrations should be monitored throughout its administration.

Reflex therapy in the acute period of mild closed craniocerebral trauma

We followed up 287 patients (102 men and 185 women aged 19 to 60 years) who suffered mild concussion and contusion of the brain. Of them, 112 patients were treated with acupuncture (except for drugs of psychotropic and vegetative action, analgesics and sleeping pills). The control group consisted of 175 people treated in the acute period according to conventional methods, including dehydration, desensitization and sedation therapy. Hospitalization was performed in the first hours-days after injury. Clinical, radiological, and electrophysiological examinations were performed.

Psychotherapy in obstetric practice

Psychotherapy was used by us in 52 patients: with "indomitable" vomiting - in 8, with other forms of early toxicosis - in 24 (of them in 8 with itching), threatening miscarriage - in 6, nipple hyperesthesia - in 12 and in 2 with disorder urination in the postpartum period. Psychotherapy was used in the form of suggestion in hypnotic sleep and hypnotic sleep as such. As one of the techniques, easily implemented in an obstetric clinic, they used the transformation of natural sleep into hypnotic sleep. We have repeatedly succeeded in converting natural sleep into hypnotic sleep in the first session. In some cases, we performed the first session using conventional sedation techniques, and during the second session, we proceeded to transform sleep into hypnosis.