Endoscopist Satisfaction Research Articles

Tu1380 Multicenter Preliminary Experience With the SEDASYS Propofol Infusion Pump for Colonoscopy in Routine Clinical Practice: Safety and Endoscopist Satisfaction

Tu1380 Multicenter Preliminary Experience With the SEDASYS Propofol Infusion Pump for Colonoscopy in Routine Clinical Practice: Safety and Endoscopist Satisfaction Anand Sahai*, John C. Wong, Michael Gould, Michael F. Byrne CHUM-Hopital Saint Luc, Montreal, QC, Canada; Vancouver General Hospital/University of British Columbia, Vancouver, BC, Canada; Vaughan Endoscopy Clinic, Vaughan, ON, Canada Background: When the endoscopy team includes only 1 nurse and 1 physician, the Sedasys propofol infusion pump, which is operated by the nurse, uses patient BMI to calculate the estimated infusion rate required to maintain light to moderate sedation for colonoscopy in ASA 1-2 patients that have been premedicated with a single 100 g dose of fentanyl. It then continuously monitors O2 saturation, capnography, respiratory rate, and patient responsiveness and lowers or stops the infusion as needed. If the physician wishes to increase the rate or give a PRN dose, the system will only allow so if the system’s algorithm deems the patient’s sedation level is not too deep. Aim: To report our early experience with Sedasys in routine clinical practice. Methods: Consecutive available case records and any available Sedasys case summary printouts from 3 centres (2 hospitals, 1 ASC) currently using Sedasys were reviewed for all available pertinent information. Results: As per product instructions, Sedasys was used only for colonoscopy patients, 70 yrs old, ASA 1-2, BMI 30, and with no history of sleep apnea. Since 2011, Sedasys was used in over 500 patients in 3 Canadian centers. Data for study purposes were available for 311 patients: 50% female, mean age 54 11, mean BMI 26 4. Primary indications were: screening 50%, bleeding 21%, other symptoms 17%, IBD 12%. All colonosocopies were completed to the cecum. Mean procedure length was 18 7 min. Mean propofol dose: 87 41mg [median 79mg]. O2 SAT%: mean -3.1 3.9, mean minimum: 95 4.1. Desaturation episodes: 92%: 17%, 85%: 2%. BPmmHg: mean : -24 18, mean minimum: 107 16. Hypotension: 90mmHg: 14%, 80mmHg: 3%. Endoscopist satisfaction: Of 14 users surveyed anonymously: 86% liked Sedasys, 86% found it more effective than endoscopistadministered non-propofol sedation, 100% found it convenient to use, and 93% would recommend it at least slightly strongly. Conclusions: Early clinical experience suggests that Sedasys is as safe as regular sedation, but is preferred by endoscopists to conventional, endoscopist-administered non-propofol sedation.

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and endoscopist satisfaction were significantly higher in the ‘subcutaneous ketamine in conjunction with opioid’ group. Recovery time was comparable in three groups and all patients experienced an uneventful recovery. Conclusion Subcutaneous dissociative conscious sedation, a recently reported method of conscious sedation, provides more safety and patient satisfaction in comparison with conventional methods. Subcutaneous ketamine in conjunction with opioid could be considered as a safe and efficient method of conscious sedation in remote location anaesthesia.

Usefulness of applying lidocaine in esophagogastroduodenoscopy performed under sedation with propofol

To determine whether topical lidocaine benefits esophagogastroduoduenoscopy (EGD) by decreasing propofol dose necessary for sedation or procedure-related complications. The study was designed as a prospective, single centre, double blind, randomised clinical trial and was conducted in 2012 between January and May (NCT01489891). Consecutive patients undergoing EGD were randomly assigned to receive supplemental topical lidocaine (L; 50 mg in an excipient solution which was applied as a spray to the oropharynx) or placebo (P; taste excipients solution without active substance, similarly delivered) prior to the standard propofol sedation procedure. The propofol was administered as a bolus intravenous (iv) dose, with patients in the L and P groups receiving initial doses based on the patient's American Society of Anaesthesiologists (ASA) classification (ASA I-II: 0.50-0.60 mg/kg; ASA III-IV: 0.25-0.35 mg/kg), followed by 10-20 mg iv dose every 30-60 s at the anaesthetist's discretion. Vital signs, anthropometric measurements, amount of propofol administered, sedation level reached, examination time, and the subjective assessments of the endoscopist's and anaesthetist's satisfaction (based upon a four point Likert scale) were recorded. All statistical tests were performed by the Stata statistical software suite (Release 11, 2009; StataCorp, LP, College Station, TX, United States). No significant differences were found between the groups treated with lidocaine or placebo in terms of total propofol dose (310.7 ± 139.2 mg/kg per minute vs 280.1 ± 87.7 mg/kg per minute, P = 0.15) or intraprocedural propofol dose (135.3 ± 151.7 mg/kg per minute vs 122.7 ± 96.5 mg/kg per minute, P = 0.58). Only when the L and P groups were analysed with the particular subgroups of female, < 65-year-old, and lower anaesthetic risk level (ASA I-II) was a statistically significant difference found (L: 336.5 ± 141.2 mg/kg per minute vs P: 284.6 ± 91.2 mg/kg per minute, P = 0.03) for greater total propofol requirements). The total incidence of complications was also similar between the two groups, with the L group showing a complication rate of 32.2% (95%CI: 21.6-45.0) and the P group showing a complication rate of 26.7% (95%CI: 17.0-39.0). In addition, the use of lidocaine had no effect on the anaesthetist's or endoscopist's satisfaction with the procedure. Thus, the endoscopist's satisfaction Likert assessments were equally distributed among the L and P groups: unsatisfactory, [L: 6.8% (95%CI: 2.2-15.5) vs P: 0% (95%CI: 0-4.8); neutral, L: 10.1% (95%CI: 4.2-19.9) vs P: 15% (95%CI: 7.6-25.7)]; satisfactory, [L: 25.4% (95%CI: 10-29.6) vs P: 18.3% (95%CI: 15.5-37.6); and very satisfactory, L: 57.6% (95%CI: 54-77.7) vs P: 66.6% (95%CI: 44.8-69.7)]. Likewise, the anaesthetist's satisfaction Likert assessments regarding the ease of maintaining a patient at an optimum sedation level without agitation or modification of the projected sedation protocol were not affected by the application of lidocaine, as evidenced by the lack of significant differences between the scores for the placebo group: unsatisfactory, L: 5.8% (95%CI: 1.3-13.2) vs P: 0% (95%CI: 0-4.8); neutral, L: 16.9% (95%CI: 8.9-28.4) vs P: 16.7% (95%CI: 8.8-27.7); satisfactory, L: 15.2% (95%CI: 7.7-26.1) vs P: 20.3% (95%CI: 11.3-31.6); and very satisfactory, L: 62.7% (95%CI: 49.9-74.3) vs P: 63.3% (95%CI: 50.6-74.7). Topical pharyngeal anaesthesia is safe in EGD but does not reduce the necessary dose of propofol or improve the anaesthetist's or endoscopist's satisfaction with the procedure.

Sedation in gastrointestinal endoscopy: current issues.

Diagnostic and therapeutic endoscopy can successfully be performed by applying moderate (conscious) sedation. Moderate sedation, using midazolam and an opioid, is the standard method of sedation, although propofol is increasingly being used in many countries because the satisfaction of endoscopists with propofol sedation is greater compared with their satisfaction with conventional sedation. Moreover, the use of propofol is currently preferred for the endoscopic sedation of patients with advanced liver disease due to its short biologic half-life and, consequently, its low risk of inducing hepatic encephalopathy. In the future, propofol could become the preferred sedation agent, especially for routine colonoscopy. Midazolam is the benzodiazepine of choice because of its shorter duration of action and better pharmacokinetic profile compared with diazepam. Among opioids, pethidine and fentanyl are the most popular. A number of other substances have been tested in several clinical trials with promising results. Among them, newer opioids, such as remifentanil, enable a faster recovery. The controversy regarding the administration of sedation by an endoscopist or an experienced nurse, as well as the optimal staffing of endoscopy units, continues to be a matter of discussion. Safe sedation in special clinical circumstances, such as in the cases of obese, pregnant, and elderly individuals, as well as patients with chronic lung, renal or liver disease, requires modification of the dose of the drugs used for sedation. In the great majority of patients, sedation under the supervision of a properly trained endoscopist remains the standard practice worldwide. In this review, an overview of the current knowledge concerning sedation during digestive endoscopy will be provided based on the data in the current literature.

The Efficacy and Tolerability of Sugared Polyethylene Glycol for Colonoscopy

Although polyethylene glycol (PEG) solution is commonly used for colonoscopic bowel preparation because of its safety and effectiveness, its salty taste decreases patient's compliance. The aim of this study was to compare the sugared PEG solution with the standard PEG solution in regard to the quality of bowel preparation and patient's compliance. From January through June in 2012, 100 patients who underwent colonoscopy in Gangneung Asan Hospital were prospectively enrolled. They were randomly assigned to receive either standard PEG solution or sugared PEG solution. The quality of bowel preparation was assessed by a doctor's questionnaire and the patient's compliance was assessed by a patient's questionnaire. There was no significant difference in the quality of bowel preparation (4.2±2.0 vs. 4.1±1.5, p=0.783), and endoscopist's satisfaction score (8.2±1.8 vs. 8.5±1.3, p=0.253) between two groups. However, The degree of disgust was lower in the sugared PEG group than the standard PEG group (6.4±2.3 vs. 3.9±2.9, p=0.000). The willingness to repeat same regimen was higher in the sugared PEG group than the standard PEG group (2.0±0.6 vs. 2.3±0.7, p=0.004). There was no difference in side effects between two groups. The sugared PEG solution as a bowel preparation method revealed a higher patient's compliance and was effective as the standard PEG solution. When the patient dislike the taste and saltness of the standard PEG solution, the sugared PEG solution will be good alternative method.

Patient Satisfaction with the Endoscopy Experience and Willingness to Return in a Central Canadian Health Region

Patient experiences with endoscopy visits within a large central Canadian health region were evaluated to determine the relationship between the visit experience and the patients' willingness to return for future endoscopy, and to identify the factors associated with patients' willingness to return. A self-report survey was distributed to 1200 consecutive individuals undergoing an upper and⁄or lower gastrointestinal endoscopy at any one of the six hospital-based endoscopy facilities in the region. The Spearman correlation coefficient was used to assess the association between the patients' overall rating of the visits and willingness to return for repeat procedures under similar medical circumstances. Logistic regression analyses were performed to identify the factors associated with willingness to return for repeat endoscopy and overall satisfaction (rating) of the visit. A total of 529 (44%) individuals returned the questionnaire, with 45% rating the visit as excellent and 56% indicating they were extremely likely to return for repeat endoscopy. There was a low moderate correlation between overall rating of the visit and patients' willingness to return for repeat endoscopy (r=0.30). The factors independently associated with patient willingness to return for repeat endoscopy included perceived technical skills of the endoscopists (OR 2.7 [95% CI 1.3 to 5.5]), absence of pain during the procedure (OR 2.2 [95% CI 1.3 to 3.6]) and history of previous endoscopy (OR 2.4 [95% CI 1.4 to 4.1]). In contrast, the independent factors associated with the overall rating of the visit included information provided pre- and postprocedure, wait time before and on the day of the visit, and the physical environment. To facilitate patient return for needed endoscopy, it is important to assess patients' willingness to return because positive behavioural intent is not simply a function of satisfaction with the visit.

Two dosages of remifentanil for patient-controlled analgesia vs. meperidine during colonoscopy: A prospective randomized controlled trial

Background and studyCombined use of opiates and benzodiazepines often results in delayed discharge after colonoscopy. AimsTo compare sedation quality of two dosages of patient controlled analgesia remifentanil with one another and with that of a midazolam-meperidine association during colonoscopy. MethodsNinety patients undergoing colonoscopy were randomly assigned to three groups. Group M received a meperidine bolus (0.7mg/kg) and sham patient controlled analgesia. Group R1 received remifentanil 0.5μg/kg and group R2 remifentanil 0.8μg/kg together with a patient-controlled analgesia pump injecting further boluses (2-min lock-out). Technical difficulties of the examination, gastroenterologist's and patient's satisfaction with sedoanalgesia were evaluated after colonoscopy on a 100mm Visual Analogue Scale. Patient's satisfaction was assessed 24h later. ResultsGroup M had more adverse events (p=0.044), required more rescue boluses (p=0.0010), had lower Observer's Assessment of Alertness and Sedation Scale score at the end of the procedure (p=0.0016) and longer discharge time (p=0.0001). Groups R1 and R2 did not differ with respect to these variables. Patient's degree of pain and satisfaction with sedo-analgesia, endoscopist's technical difficulty and satisfaction were not different among groups. ConclusionsRemifentanil patient controlled analgesia is a safe approach to sedation for colonoscopy.

Unsedated transnasal upper gastrointestinal endoscopy has favorable diagnostic effectiveness, cardiopulmonary safety, and patient satisfaction compared with conventional or sedated endoscopy

To assess the diagnostic effectiveness, cardiopulmonary safety, and patient comfort of transnasal endoscopy (TNE), compared with conventional endoscopy (CES) and sedated endoscopy (SES), and to compare procedural risks and patient satisfaction/preference. In this prospective, randomized, and controlled protocol, eligible patients (n = 397) in an outpatient clinic were randomized to CES (n = 133), SES (n = 134), or unsedated TNE (n = 130) due to upper gastrointestinal (GI) complaints. Patients were continuously monitored for systolic/diastolic blood pressure (SBP/DBP), pulse rate (PR), and SpO(2) throughout the endoscopy. All subjects (n = 392) completing their assigned endoscopy were asked to evaluate endoscopy satisfaction, pain, and nausea/vomiting on visual analog scales. Patient preference for the assigned endoscopy was assessed against previous endoscopy experience or by willingness to repeat the assigned endoscopy. Endoscopic outcomes for the esophagus, stomach, and duodenum were comparable among the three groups. SBP/DBP and PR were more stable in patients undergoing TNE than in those undergoing CES or SES, while SpO(2) remained stable and above 95% among all three groups. Patients were more satisfied with TNE than with CES and experienced less pain and nausea/vomiting. Patients exhibited a high preference for SES, whereas 67.6% of patients who previously underwent SES and were randomly assigned to TNE were willing to undergo TNE again. TNE has comparable diagnostic effectiveness to CES and SES, but is less stressful on cardiopulmonary function, indicating that TNE is a more comfortable, preferred, and cost-effective endoscopic technique than CES and SES.

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

IntroductionParecoxib 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.MethodsEighty-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 NarcotrendTM monitor, maintaining stage D0–E0 during ERCP. All patients were oxygenated with 100% O2 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.ResultsThere 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.ConclusionPreprocedure 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.

Comparison of Meperidine Versus Hyoscine During Colonoscopy in the Elderly: A Prospective Randomized Study

Colonoscopy is the gold standard in diagnosis of diseases of the colon. Sedation and antispasmodic agents are recommended during colonoscopy. Age is a limiting factor when the surgeon is deciding whether to use these medications or not. One hundred twenty patients older than 65 years of age were randomized into two groups. The first group (n=60) received 2 mg of midazolam and 25 mg of meperidine intravenously. The second group (n=60) received 2 mg of midazolam and 20 mg of hyoscine N-butylbromide intravenously. The data collected were colonoscopy procedure time, time to cecum, visual analog pain scale, systolic blood pressure before and after the procedure, pulse, partial oxygen pressure, comfort of the endoscopist, the modified observer's assessment of alertness/sedation scale, and morbidity. Total colonoscopy and cecal reach times were shorter in Group 2 (19.58±4.82 minutes and 10.57±2.54 minutes, respectively) than in Group 1 (25.05±5.93 minutes and 13.78±3.37 minutes, respectively) (P<.001). The sedation score of Group 2 (4.52±0.50) was better than that of Group 1 (3.45±0.75) (P<.001). Nine patients (15%) in Group 1 experienced diaphoresis, temporary memory loss, or lip smacking. Three patients in Group 1 and 1 patient in Group 2 had hypoxia. Three patients in Group 1 had hypotension; this was seen in 1 patient in Group 2. One patient had perforation in Group 1. The visual analog scale score was 4.37±1.38, and the endoscopist satisfaction was 6.72±0.99 in Group 1, while these values were 3.95±0.81 and 7.75±0.89, respectively, in Group 2 (P>.05). Use of midazolam and hyoscine N-butylbromide during colonoscopy is safe in the elderly and significantly reduces procedure time while increasing comfort for the endoscopist.

PWE-105 Clinical efficacy of the combination of propofol and ketamine (ketofol) for deep sedation for colonoscopy

IntroductionA combination of propofol and ketamine is usually used to achieve sedation and analgesia during colonoscopy. Few studies have compared their efficacy. The aim of this study was to compare...

Nonanesthesiologist-Administered Propofol Versus Midazolam and Propofol, Titrated to Moderate Sedation, for Colonoscopy: A Randomized Controlled Trial

Nonanesthesiologist-administered propofol (NAAP) is controversial due to deep sedation concerns. The purpose of this study was to evaluate the feasibility of moderate sedation with two different NAAP regimens for colonoscopy. This was a double-blinded, randomised, placebo-controlled trial allocating 135 consecutive outpatients to placebo (group P) or midazolam 2 mg (group M+P) before NAAP targeted to moderate sedation. Depth of sedation every 2 min throughout the procedure, propofol doses, recovery times, complications and patient and endoscopist satisfaction were measured. A total of 84 % of assessments of the depth of sedation were moderate. Mean induction (76 [40-150] vs. 53 [30-90]) and total propofol doses (mg) (136 [60-270] vs. 104 [50-190]) were significantly higher for group P (p < 0.001). However, deep sedation was significantly more prevalent in group M+P in minutes 4 (16 vs. 1 %, p = 0.05), 6 (20 vs. 3.5 %, p = 0.046) and 8 (17 vs. 1.8 %, p = 0.06) of the procedure, coinciding with midazolam peak action. From minute 8 on, moderate sedation was significantly deeper for M+P (p = 0.002). Early recovery time (6.8 min vs. 5.2, p = 0.007), but not discharge time (10.4 min vs. 9.8, p = 0.5), was longer for M+P. Pain perception (P 1.03 vs. M+P 0.3, p = 0.009) and patient satisfaction scores (P 9.4 vs. M+P 9.8, p = 0.047) were better for M+P. No major complications occurred. Moderate sedation was feasible with both NAAP regimens. Drug synergy in the midazolam plus propofol sedation regimen promotes a deeper and longer moderate sedation, improving patient satisfaction rates but prolonging early recovery time (Clinical Trials gov NCT01428882).

Gastroenterologist-guided sedation with propofol for endoscopic ultrasonography in average-risk and high-risk patients

Only a few reports have addressed non-anesthesiologist-administered propofol for endoscopic ultrasonography (EUS), but none specifically in high-risk patients. Our aim was to study the application of a propofol sedation protocol for EUS in average-risk and high-risk patients. This was a prospective observational study including 446 patients referred for EUS. We analyzed the induction time, procedure duration, recovery times, and patients' comfort and safety. Sedation was administered by a trained nurse, under the guidance of the endoscopist. We continuously monitored vital signs as well as patient cooperation and tolerance. Complications, patient, and endoscopist satisfaction were analyzed. No major complications occurred. The rate of minor complications was 9%, the most frequent being hypoxemia (8%). One hundred and thirty-eight high-risk patients were included [American Society of Anesthesiologists (ASA) III-IV]. Average-risk patients received higher propofol doses (202.9 ± 84.8 vs. 164.8 ± 84.3; P=0.003). No differences were found in the rate of complications or procedure-related variables. Overall patient and endoscopist satisfaction was excellent. The logistic regression model identified propofol doses (P=0.02) as a risk factor and ASA-I classification (P=0.03) as a protective factor for the appearance of complications. Non-anesthesiologist-administered propofol for upper EUS in high-risk and average-risk patients is safe and could be routinely offered to high-risk and elderly patients.

Patient-controlled sedation for ERCP: a randomized double-blind comparison of alfentanil and remifentanil

Self-administration of a propofol and opioid mixture by patients (patient-controlled sedation, PCS) could offer a practical alternative for individual sedation during endoscopic retrograde cholangiopancreatography (ERCP). However, what would be the most suitable sedative mixture for PCS is unknown. The aim of this study was to compare remifentanil and alfentanil in the PCS during ERCP. Eighty-one patients undergoing elective ERCP received PCS with propofol and opioid in three different regimens. The concentrations of opioids in the sedative mixture were 0.02 mg/mL in the remifentanil group (R) and 0.04 mg/mL and 0.08 mg/mL in the alfentanil 1 (A1) and alfentanil 2 (A2) groups, respectively. The infusion pump was adjusted to deliver a 1 mL single dose with zero lockout time. We considered PCS as successful if no procedure interruption due to sedation-related complications occurred or if additional propofol was not needed. The consumption of propofol was registered, and sedation levels and vital signs were monitored. Endoscopist and patient satisfaction with sedation were assessed using structured questionnaires. The consumption (SD) of propofol was 177 (105)mg in group R, 197 (88) mg in group A1 and 162 (70)mg in group A2. PCS was successful in 74 /81 (91 %) of sedations, without differences between the groups in terms of propofol consumption, sedation success rate, sedation levels, vital signs, postprocedural pain, and endoscopist and patient satisfaction. Respiratory depression and nausea were observed more frequently with remifentanil than with alfentanil (P < 0.05). PCS is an acceptable method of sedation for ERCP. The combination of propofol and alfentanil should be recommended because a remifentanil - propofol mixture depresses spontaneous respiration more and produces nausea more frequently.

Midazolam‐Ketamine Combination for Moderate Sedation in Upper GI Endoscopy

The aim of the study was to compare the quality of sedation with 3 different sedation regimens in upper gastrointestinal endoscopy (UGIE) in pediatric patients. One hundred fifty consecutive children who underwent UGIE were randomly assigned to 1 of the 3 medication regimens. Patients in group A (n = 49) received placebo. Forty-five minutes after the placebo was given, repeated intravenous (IV) doses of 0.1 mg/kg midazolam were administered titrated to achieve a level of deep sedation. Patients in group B (n = 51) received oral ketamine instead of placebo, and patients in group C (n = 50) received oral fentanyl instead of placebo with the same methodology and sedation endpoint. The mean dose of midazolam administered in group B patients was remarkably lower compared with that of groups A and C. Patients in group B showed less distress in IV line placement and separation from parents, higher comfort level, more endoscopist satisfaction, and higher sedation depth compared with groups A and C. The recovery time was significantly shorter in group B. All of the 3 regimens were safe. All of the complications were managed successfully. Our data suggest that synergistic sedation with oral ketamine and IV midazolam for UGIE in children is a suitable and safe sedation. The higher rate of vomiting in group B in contrast to previous studies must be caused mainly by the oral route of ketamine administration.

Bispectral index monitoring of midazolam and propofol sedation during endoscopic retrograde cholangiopancreatography: a randomized clinical trial (the EndoBIS study)

Bispectral index (BIS) monitoring provides a non-invasive measure of the level of sedation. The purpose of this randomized, single-blind clinical trial was to evaluate whether BIS monitoring of sedation would lead to improved oxygenation and a reduced rate of cardiopulmonary complications during endoscopy. Patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) under procedural sedation with a combination of low dose midazolam and propofol were randomly assigned to either standard monitoring of sedation only (BIS-blinded arm) or an open arm in which additional BIS monitoring was available (BIS-open arm). In the BIS-open arm, propofol administration was to be withheld if BIS values were <55. The primary study end point was the mean oxygen saturation per patient. Secondary end points were the rates of cardiopulmonary complications, propofol dose, quality of sedation (patient cooperation as rated by the endoscopist and patient satisfaction), and recovery. A total of 144 patients were enrolled and included in the intention-to-treat analysis. Mean oxygen saturation per patient was 97.7% in the BIS-open arm and 97.6% in the BIS-blinded arm (P=0.71). Total rates of cardiopulmonary complications, single numbers of hypoxemic, bradycardic, and hypotensive events, mean propofol doses, and quality of sedation also showed no statistically significant differences between the groups. However, BIS monitoring did result in faster recovery of patients as reflected by shorter times to eye opening (P=0.001), first verbal response (P=0.02), and leaving the procedure room (P<0.001). The use of additional BIS monitoring did not lead to improved oxygenation or a reduced rate of cardiopulmonary complications. Recovery times after the procedure were shorter than with standard monitoring alone, but the clinical benefit for daily practice may be limited.

A Survey of the Practice of After-Hours and Emergency Endoscopy in Canada

To determine staffing and practice patterns for after-hours endoscopy service in Canada. A link to a web-based survey was sent by e-mail to all clinical members of the Canadian Association of Gastroenterology in February 2011. A priori, it was planned to compare variations in practice among gastroenterologists (GIs) performing endoscopy in different regions of Canada, between pediatric and adult GIs, and between university and community hospitals. Of 422 potential respondents, 168 (40%) responded. Of the 139 adult GIs, 61% performed after-hours endoscopy in the endoscopy suite where daytime procedures were performed, 62% had a trained endoscopy nurse available for all procedures, 38% had access to propofol sedation, 12% reprocessed the endoscopes themselves or with the help of a resident, 4% had out-of-hospital patients come directly to their endoscopy suite and 53% were highly satisfied. The adult endoscopists practising at community hospitals were more likely to have an anesthetist attend the procedure. Regional differences were noted, with more involvement of anesthetists (13%) and availability of propofol (50%) in Ontario, more frequent reprocessing of endoscopes in the central reprocessing units in British Columbia (78%) and almost universal availability of a trained endoscopy nurse (96%) with concomitant higher endoscopist satisfaction (84% highly satisfied) in Alberta. More than one-third of surveyed endoscopists across the country do not have a trained endoscopy nurse to assist in after-hours endoscopy - the time period when urgent patients often present and typically require therapeutic endoscopic interventions. There are significant regional differences in the practice of after-hours endoscopy in Canada.

Impact of anesthesia on patient and endoscopist satisfaction after colonoscopy — A pilot study

Abstract Introduction Colonoscopy is a standard diagnostic tool for the investigation and surveillance of diseases affecting the colon. The procedure can be uncomfortable and sometimes very painful, resulting in increased cecal intubation time and lower completion rate. However, it seems to be apparent that anesthesia for this procedure increases patient satisfaction; data are lacking about the impact of anesthesia on the technical performance of colonoscopic examination. Aim In our observational survey, we studied patients undergoing colonoscopy with or without anesthesia. We compared patient satisfaction, difficulties in endoscopy, and the impact of anesthesia on the examination room occupancy. Methods We enrolled 60 patients undergoing elective, outpatient colonoscopy because of various reasons. The patients were able to choose between anesthesia and sedation. Difficulties in colonoscopy were evaluated by the endoscopist's rating and by the time to cecal intubation. We assessed patient satisfaction by a numeric rating scale. Results We observed that neither the duration of colonoscopy nor the time spent in the examination room was different in the two groups (p 0.825, 0.998). There was a significant improvement in both patient and endoscopist satisfaction scores in patients undergoing anesthesia (p 0.0007). Conclusion We found that during colonoscopy, compared to sedation, anesthesia increases both endoscopist and patient satisfaction without prolonged occupation of the examination room.

Propofol, the preferred sedation for screening colonoscopy, is underused. Results of an international survey

BackgroundThe use of propofol during colonoscopy has become more widespread. To increase availability while maintaining quality and decreasing costs, European Guidelines have been issued for non-anesthesiologist administration of propofol (NAAP). We aimed to assess the current use of propofol during screening colonoscopy. MethodsInternational survey. ResultsEighty-four questionnaires were collected from endoscopists practicing in 29 countries. Practices were most often located in high-volume community hospitals (Italy, Belgium, Spain, Netherlands in half cases). An anesthesiologist was regularly present in the Endoscopy Unit of 69.0% survey respondents. In low-risk (ASA classification, 1–2) patients, propofol, benzodiazepine+opioids and benzodiazepine alone were used in 45%, 31% and 14% of screening colonoscopies, respectively. Propofol was associated with the highest endoscopist satisfaction (score on a 10-point visual analogue scale, 9.2±1.2 vs. 5.5±1.9 and 4.7±2.0 for benzodiazepine+opioids and benzodiazepine alone, respectively; P<0.0001). NAAP was used by 29.9% of respondents in 9 countries and approximately two-thirds of other endoscopists would consider implementing NAAP. Main reasons for not considering NAAP implementation were medico-legal issues and cost. ConclusionPropofol provides the highest endoscopist satisfaction but it is used in less than half of screening colonoscopies. Propofol is administered by non-anesthesiologists in one-third of settings; its implementation is foreseen by a majority of endoscopists who do not currently use it.

Propofol sedation alone or in combination with pharyngeal lidocaine anesthesia for routine upper GI endoscopy: a randomized, double-blind, placebo-controlled, non-inferiority trial

In patients undergoing routine upper EGD, propofol is increasingly used without pharyngeal anesthesia because of its excellent sedative properties. It is unclear whether this practice is non-inferior in regard to ease of endoscopic intubation and patient comfort. To assess the relevance of local pharyngeal anesthesia regarding the ease of EGD performance in patients sedated with propofol as monotherapy. Randomized, double-blind, placebo-controlled, non-inferiority trial. One community hospital and one university hospital in Switzerland. We enrolled 300 consecutive adult patients undergoing elective EGD. Pharyngeal anesthesia with 4 squirts of lidocaine spray versus placebo spray immediately before propofol sedation. Number of gag reflexes (primary endpoint), number of intubation attempts, and degree of salivation during intubation (secondary endpoints) assessed by the endoscopists and staff. In the lidocaine group, 122 patients (82%) had no gag events, and 25 patients had a total of 39 gag events, whereas in the placebo group 104 patients (71%) had no gag events, and 43 patients had a total of 111 gag events. The rate ratio of gagging with quasi-likelihood estimation of placebo compared with lidocaine was 2.85 (95% confidence interval [CI], 1.42-6.19; P = .005). In adjusted logistic regression analysis, the odds ratio for gagging for placebo pharyngeal anesthesia compared with lidocaine was 1.9 (95% CI, 1.03-3.54). The number of intubation attempts and the degree of salivation were similar in both groups. Two patients in the placebo group experienced oxygen desaturation and needed short-term mask ventilation. The level of sedation and possible long-term side effects of pharyngeal anesthesia were not assessed. Topical pharyngeal anesthesia reduces the gag reflex in patients sedated with propofol even though it does not seem to have an influence on the ease of the procedure and on patient or endoscopist satisfaction in adequately sedated patients.