Moderate Conscious Sedation Research Articles

Sedation of Pediatric Patients during Dermatosurgery

Executing dermatosurgical procedures can be a challenging task in the pediatric population due to their hyperreactive and hypermobile behavioral responses to discomfort posed by these procedures. Thus, most of the dermatological procedures are to be performed in minimal or moderate (conscious) sedation. The objective of this review is to compare the different sedative drugs used in pediatric patients to achieve cooperation during a standard dermatological procedure. Other traditional methods of ensuring compliance by feeding and distracting the patient will be discussed briefly to help or add on to current knowledge in sedation of children during dermatosurgery. While sedatives can be effective in managing anxiety and pain in pediatric dermatosurgery, their use should be carefully considered given the potential adverse effects and risks involved in indiscriminate use and the decision to use sedatives should be individually tailored, considering factors such as the child’s age, medical history, and the nature of procedure being performed.

Effectiveness and Safety of Same-Day Discharge After Left Atrial Appendage Closure Using Moderate Conscious Sedation: One-Year Follow-Up Outcomes

Effectiveness and Safety of Same-Day Discharge After Left Atrial Appendage Closure Using Moderate Conscious Sedation: One-Year Follow-Up Outcomes

Pilot Study: Personalized Medicine in Endoscopy, Can Pharmacogenomics Predict Response to Conscious Sedation?

Adequate response to moderate (conscious) sedation varies significantly between individuals. Polymorphisms in genes encoding drug metabolizing enzymes can lead to inter-individual variability in drug efficacy, potentially influencing sedation requirements during endoscopic procedures. The aim of this study was to assess the potential role of inter-individual variation in inherited polymorphisms of drug-metabolizing enzymes, cytochrome P450 (CYP450), specifically CYP3A4 and CYP3A5, in sedation requirements for outpatient endoscopic procedures. A retrospective analysis of sedation requirements and pharmacogenomics data in 106 unique patients who received outpatient esophagogastroduodenoscopy (EGD), colonoscopy, or both between December 2011 and February 2019 was conducted. Patients were divided into two groups based on their sedation requirements during endoscopy (high vs. normal sedation). Patients with reduced a CYP2C19 metabolism (poor + intermediate metabolizers) (odds ratio [OR] = 0.38, 95% confidence interval [CI]: 0.16-0.91, p = 0.03), poor CYP3A5 metabolism (OR = 0.25, 95% CI: 0.095-0.65, p = 0.0046), and poor UGT1A1 (OR = 2.76, 95% CI: 1.07-7.13, p = 0.08) had higher odds of requiring normal sedation compared to those with CYP2C19 increased metabolism, CYP3A5 intermediate metabolism, and UGT1A1 intermediate metabolism. Information about inter-individual variation in (CYP450) genes may be useful for determining the sedation requirements for outpatient endoscopic procedures. We found that patients with reduced CYP2C19 metabolism, poor CYP3A5 metabolism, and poor UGT1A1 metabolism were more likely to require normal sedation requirements during outpatient endoscopic procedures.

Dexmedetomidine infusion in the management of acute ischemic stroke undergoing endovascular recanalization: a retrospective observational study

Background and purposeStroke is defined as a sudden onset of a neurological deficit caused by an acute focal injury to the central nervous system due to a vascular cause. It represents the second leading cause of death, the third leading cause of disability worldwide and the primary cause of disability in the elderly. Ischemic strokes are the most common (≈85%), the rest (≈15%) are hemorrhagic strokes, that include cerebral and subarachnoid. One of the commonly procedure used in patients with large-vessel occlusion is intra-arterial (IA) recanalization. Moderate conscious sedation (CS) and general anesthesia (GA) with intubation are the most used anesthesia techniques for patients with acute ischemic stroke undergoing endovascular recanalization.MethodsIn this retrospective observational study, we analyzed data of registry before and after we have changed our sedation protocol from remifentanil/propofol (P/R group) infusion in total intravenous anesthesia (TIVA) to intravenous infusion of dexmedetomidine alone (D group). The primary endpoint was to determine the rate of conversion from CS to GA for each group. The secondary outcomes were the incidence of complications (bradycardia, hypotension, tachycardia, hypertension).Results and conclusion12 patients in P/R group need the conversion from CS to GA while only 5 patients in D group. There weren't significant differences between the 2 groups respect to heart rate (HR), peripheral oxygen saturation (SpO2) during the procedure, for the good neurological outcome (mRS score < 3, p > .05) and NIHSS score after 48 h (p > .05). There were several organizational and economic advantages with the conscious sedation procedure, such as reduction of occupation time in the operating room and reduction of postoperative Intensive Care Unit (ICU) stay.

CRT-700.31 Effectiveness and Safety of Same-Day Discharge After Left Atrial Appendage Closure Using Moderate Conscious Sedation: One-Year Follow-Up Outcomes

CRT-700.31 Effectiveness and Safety of Same-Day Discharge After Left Atrial Appendage Closure Using Moderate Conscious Sedation: One-Year Follow-Up Outcomes

Awareness of usage of fentanyl in dental applications among dental students.

Opioids like fentanyl are used both alone and in combination with other drugs to induce anesthesia and treat pain. It is also combined with heroin or cocaine when used recreationally. It starts acting quickly, and its effects usually wear off within 2 h. A typical pharmaceutical strategy for controlling the physical pain and psychological discomfort related to dental treatments, including surgery, is moderate (conscious) sedation. This study aimed to assess knowledge and awareness about dental applications of fentanyl among dental students. A 15-question survey was sent through an online platform to about 150 dental students in Tamil Nadu. Data were collected over a 6-month period and compared using SPSS software by IBM. The results were statistically analyzed and graphically interpreted. From the results obtained, we can observe that from the respondents of the current survey, 52% were undergraduates and 48% were postgraduate dental students. About 93% of them were aware of the fact that fentanyl comes under opioid analgesics, and 82% were aware that it is mostly used in case of pediatric patients. About 81% of the participants were aware that apart from benzodiazepines, fentanyl can also be used in combination with general anesthesia in dentistry. This study revealed that most of the participants are aware of the commonly used anesthesia and analgesia such as fentanyl in dental practices. However, more continuing dental education programs and seminars must be conducted to further enhance the knowledge and understanding of dental students about drugs such as fentanyl in dental practice.

Drugs used for sedation in gastrointestinal endoscopy

Background: Sedation, defined as the depressed level of consciousness induced by the administration of drugs, is used widely for gastrointestinal endoscopy to relieve the patient’s anxiety and discomfort. In addition, a successful procedure can be anticipated with the control of unintended movements. Therefore, sedation has become an essential element of gastrointestinal endoscopy.Current Concepts: Sedation is classified into the following four stages according to the level of consciousness: minimal sedation or anxiolysis, moderate sedation or conscious sedation, deep sedation, and general anesthesia. The degree of response to sedation varies from person to person, depending on the age, underlying diseases, alcohol or medication intake, anxiety level, sensitivity to pain, and pharmacogenetic characteristics. In particular, certain situations require special attention not only during preoperative evaluation but also during the procedure and recovery, such as old age, obesity, pregnancy, lactation, and liver cirrhosis. Therefore, the same procedure may require different levels of sedation in different patients, and some patients may even experience changing levels of sedation during a single procedure.Discussion and Conclusion: Although most patients undergoing gastrointestinal endoscopy under sedation recover without any problem, various types of adverse events related to sedation may occur occasionally. In rare cases, serious complications may occur that threaten the patient’s life. Therefore, basic principles governing the facilities and equipment as well as performance of sedation itself should be followed to prevent unfavorable accidents. Moreover, every medical personnel should be familiar with the pharmacological properties of the drugs used for sedation and trained for emergencies.

Moderate (conscious) sedation in abortion care

Moderate (conscious) sedation in abortion care

696 Moderate sedation for transesophageal echocardiography guidance of percutaneous left atrial appendage closure: the MID-DEX protocol

Abstract Aims Left atrial appendage closure (LAAC) is usually performed under general anesthesia to allow prolonged transesophageal echocardiography (TEE) guidance. There is scarce knowledge about the feasibility and safety of moderate conscious sedation (MCS) in LAAC. We aimed to assess the feasibility, effectiveness and safety of an innovative MCS protocol of dexmedetomidine plus midazolam (MID-DEX), in a retrospective population of LAAC patients. Methods and results A total of 100 patients underwent LAAC with MCS using the MID-DEX protocol between May 2019 and January 2021 in a single centre. Clinical and procedural outcomes of these patients have been collected in the context of a retrospective registry on LAAC with the Watchman FLX device. All patients were treated preoperative with Dex, administered with initial bolus infusion (1.0 mcg/kg) in 10 min, then i.v. infusion was maintained throughout the LAAC procedure (0.2–1.0 μg/kg/h), tailored on patient’s frailty (advanced age, low body mass index) and haemodynamic status (BP, HR). Midazolam was administered to patients after Dex bolus, to induce sedation and to ease probe insertion, according to patient age and respiratory status (from 2.5 to max 10 mg). The ease of insertion of the TEE probe (one very easy—five impossible), and the duration of the TEE (m′) were recorded. Additional variables were: total amount of each drug given, time to recovery from sedation. After procedure a verbal survey about the quality of sedation, level of comfort, recall of the procedure, and future acceptance of this type of sedation was administered. The operators also rated the procedural conditions on a scale of 1–5 (5 = excellent). Mean patient age was 78.5 ± 6.96 years and 34% were women. The mean LVEF was 62.9 ± 8.9%. All patients underwent LAAC under MID-DEX MCS protocol with an acute procedural success rate of 100%. Ninety patients (90%) successfully underwent TEE under MCS; in 10 patients ICE guidance was required. Fluoroscopic time was 31 ± 21.7 min. The median required dosage of Dex infusion was 0.08–0.09 μg/kg/h and midazolam was 6.2 ± 2.4 mg. No complications were observed from MCS. There was no need for conversion to GA during the procedure. We observed five cases of bradycardia (solved by reducing to half Dex infusion) and three of hypotension (only two requiring Ringer’s solution infusion). Echocardiographist rated procedural conditions as perfect (5) in 85% of cases and good (4) in 6%. Interventionalist rated procedural comfort with 5 (excellent) in 90% of cases and 4 (good) in 3%. Patients satisfaction was high with best rate (5) in 80% with 5% of 4 (good); 12% described the procedure as fair, without memory of discomfort. Conclusions LAAC is safe and effective when performed under MCS. Thus, applying MCS may simplify the LAAC procedure, as well as reduce procedural time and procedural costs, while increasing overall patient and physician satisfaction.

Intracranial Stenting: Angioplasty Basic Technique, Indications, and Sizing: 2-Dimensional Operative Video.

Intracranial atherosclerotic disease (ICAD) is a common cause of stroke. Antiplatelet therapy is the mainstay for symptomatic ICAD treatment. Endovascular management with submaximal angioplasty and/or intracranial stenting is reserved for patients with repeated ischemic events despite optimal medical therapy. We demonstrate intracranial angioplasty and stenting technique, technique indications, and sizing of stent and target vessel diameter. Stenting and angioplasty have been described in the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis and Wingspan Stent System Post Market Surveillance trials.1,2 Submaximal angioplasty has also been described.3 This patient, who had been on dual antiplatelet therapy for several months, initially presented with occlusion of the left middle cerebral artery M2 inferior division and underwent mechanical thrombectomy with successful reperfusion. Postoperatively, the patient's symptoms did not improve. Medical management was optimized with heparin infusion. However, repeat stroke study demonstrated M2 inferior division reocclusion. A decision was made to proceed with intracranial angioplasty and stenting. P2Y12 levels were therapeutic. Under moderate conscious sedation, submaximal angioplasty of up to 80% of the normal M2 caliber was attempted. However, we observed persistent high-grade stenosis of the M2 inferior division. The major risk of crossing the lesion for angioplasty is vessel perforation. To safely perform this maneuver, we used a J-configured Synchro-2 microwire (Stryker). Because of the patient's recent thrombectomy, we also had prior tactile feedback about how much resistance was encountered while crossing the occlusion. We then deployed a balloon-mounted intracranial stent for optimal radial force across the stenotic area to restore perfusion. Postoperative computed tomography perfusion showed resolution of the previously noticed perfusion deficit. The patient gave informed consent for the procedures and video recording. Institutional review board approval was deemed unnecessary. Video. ©University at Buffalo Neurosurgery, September 2020. With permission.

Prospective Comparison of Moderate Conscious Sedation and Anesthesia Assistance for the Performance of Endoscopic Retrograde Cholangiopancreatography (ERCP).

Objectives Recent trends have favored the use of anesthesia personnel more frequently for advanced endoscopic procedures. We hypothesize a selective sedation approach based on patient and procedural factors using either moderate conscious sedation (MCS) or general anesthesia (GA) will result in similar outcomes and safety with significant cost savings. Methods A 12-month prospective study of all adult endoscopic retrograde cholangiopancreatography (ERCPs) performed at a tertiary medical center was enrolled. Technical success, cannulation rates, procedural related complications, procedure time, and cost were compared between MCS and GA. Results A total of 876 ERCPs were included in the study with 74% performed with MCS versus 26% with GA. The intended intervention was completed successfully in 95% of cases with MCS versus 96% cases with GA (p = 0.59). Cannulation success rates with MCS were 97.5 versus 97.8% with GA (p = 0.81). Overall, adverse event rates were similar in both groups (MCS: 6.6% vs. GA: 9.2%, p = 0.21). Mean procedure time was less for MCS versus GA, 18.3 and 26 minutes, respectively (p < 0.0001). Selective use of MCS vs. universal sedation with GA resulted in estimated savings of $8,190 per case and $4,735,202 per annum. Conclusions Preselection of ERCP sedation of moderate conscious sedation versus general anesthesia based upon patient risk factors and planned therapeutic intervention allows for the majority of ERCPs to be completed with MCS with similar rates of technical success and improvement in resource utilization and cost savings compared to performing ERCPs universally with anesthesia assistance.

Effectiveness and safety of same day discharge after left atrial appendage closure under moderate conscious sedation.

Left atrial appendage occlusion (LAAO) using Watchman device has become a world-wide, well-established therapeutic alternative to chronic systemic oral anticoagulation in patient who are at high-risk of bleeding with paroxysmal (PAF) or chronic atrial fibrillation (Afib). Currently, LAAO procedures are performed under general anesthesia (GA) and patients stay overnight post procedure in the United States. We aimed to present the effectiveness and safety of same day discharge following LAAO under moderate conscious sedation (MCS) in patients without procedural complications. A total of 112 patients between August 2019 and May 2020 with elevated CHA2 DS2 VASc (median score of 3) underwent transesophageal echocardiography (TEE)-guided LAAO with FDA approved Watchman (Boston Scientific, MN) under MCS and discharged home on the same day 6 hr following their post procedural transthoracic echocardiogram (TTE) evaluations. All patients had next day TTE and follow up at the cardiology clinic. We prospectively evaluated clinical and procedural outcomes using medical records of these patients. Among all the patients, the mean age was 83.5 ± 8.5 years, 45 (40%) were women. Procedural duration, device implant time and fluoroscopic times were 45 ± 8.6, 14.5 ± 7.8 and 10.2 ± 1.2 min, respectively. The median required dosage of propofol was 105 ± 2.8 mg. No complications arose from MCS. There was no need for conversion to GA in any of the patients during the procedure. All patients were able to be discharged 6 hr following their TTE evaluation post procedure. There were no procedural complications. Same day discharge following LAAO closure seems to be safe and effective in patients without procedural complications. LAAO can also be performed safely and effectively under moderate conscious sedation. Applying moderate conscious sedation may simplify the LAAO procedure, reduce procedural time, procedural costs and hospital stay while increasing overall patient satisfaction.

Dexmedetomidine reduces the amount of benzodiazepines and opioids administered during moderate conscious sedation for dental treatment

To assess the efficacy of dexmedetomidine (DEX) on the intravenous moderate sedation (IVMS) regimen, while treating patients of the special patient care (SPC) population. This study aims to incorporate DEX into the typical IVMS drug regimen in order to reduce the amount of benzodiazepines (BZD) and opioids administered and as a result reduce the amount of unwanted side effects. A retrospective study was performed in the University of California Los Angeles (UCLA) SPC Clinic, where 42 patients were seen with and without DEX for dental treatment under IVMS. Medications administered, vital signs, and complications were recorded at 5 minute intervals over the first hour. All BZDs and opioids were converted to their IV midazolam and IV fentanyl equivalents, respectively. An opioid conversion equation was developed to summate the total amount of anesthetic agents administered. Data were analyzed by t-test. The amount of BZDs administered was reduced, however the decrease was not statistically significant (P=.066). There was a significant reduction in opioids (P<.05) and total anesthetic agents (P<.05) administered. The addition of DEX to the anesthetic regimen results in a reduction of overall medications administered.

Evaluation of Effectiveness and Safety of Transcatheter Mitral Valve Repair Under Moderate Conscious Sedation.

Transcatheter mitral valve repair (TMVR) using the MitraClip system (Abbott Vascular) has become a world-wide, well-established therapeutic alternative to symptomatic patients with severe mitral regurgitation (MR) and prohibitive surgical risk. Currently, TMVRs are performed under general anesthesia. Herein, we aimed to present the effectiveness and safety of TMVR under moderate conscious sedation (MCS). A total of 102 patients with severe MR (49 primary MRs and 53 secondary MRs) who underwent TMVR with MCS between December 2018 and December 2019 were included. We prospectively evaluated clinical and procedural outcomes using medical records of these patients. Among all the patients, the mean age was 81.6 ± 3.5 years, 60 (59%) were women, and 72.7% had coronary artery disease. The mean left ventricular ejection fraction was 47.9 ± 12.7%, while the MR grade was 3+ in 18.2% of the patients and 4+ in 81.8%. A mean of 1.2 ± 0.4 clips (range, 1-2 clips) were implanted per patient. Postprocedural MR grade was 1+ or lower in 64 patients (63.6%) and 2+ in 38 patients (36.4%). Procedural duration, clip implant time, and fluoroscopy times were 60 ± 10.5 minutes, 19.5 ± 8.0 minutes, and 10.1 ± 2.1 minutes, respectively. The median required dosage of propofol was 140 mg (interquartile range, 84-156 mg). No complications arose from MCS. There was no need for conversion to general anesthesia in any of these patients during the procedure. TMVR can be performed safely and effectively under moderate conscious sedation. Applying moderate conscious sedation may simplify the TMVR procedure and reduce procedural time and costs, while increasing overall patient satisfaction.

P1050General anesthesia improved rate of first-pass pulmonary vein isolation by radiofrequency ablation in patients with atrial fibrillation

Abstract Background Pulmonary vein isolation (PVI) with radiofrequency ablation (RFA) is one of the important procedures for atrial fibrillation (AF). Attaining the stability of RFA, respiratory management and pain control during the procedure are required. Purpose We compared the characteristic parameters and procedural outcomes between general anesthesia and moderate (conscious) sedation in patients with AF performed RFA. Methods We performed a retrospective, 2-center observational study to compare the general anesthesia with moderate sedation during RFA on AF from January 2018 until December 2018. In general anesthesia group, we administrated propofol and muscle relaxants under mechanical ventilation. In moderate sedation group, we administrated dexmedetomidine and/or propofol with analgesic drug. Procedural time of AF ablation, first-pass PVI (pulmonary vein isolation after completing the right or left circle) were assessed. Results A total of 98 patients with mean age 66 ± 11 years were enrolled (80 males, 81%). Of these, 19 patients were performed RFA under general anesthesia and 79 patients were performed under moderate sedation. Age, gender, BMI, medications before admission and CHADs2 score (general anesthesia:1.9 ± 1.2 vs moderate sedation:1.5 ± 1.1, p = 0.14), left atrium diameter (40.2 ± 6.2 vs 40.6 ± 6.8 mm, p = 0.81) and proportion of paroxysmal AF (47.4 vs 54.4%, p = 0.61) were similar between two groups. Our study found catheter RFA with general anesthesia to be associated with reduced procedural time (161 ± 29 vs 241 ± 58 minutes, p &amp;lt; 0.01) and improved the rate of first-pass PVI (left pulmonary vein: 84.2 vs 59.5%, p = 0.06 and right pulmonary vein: 84.2 vs 58.2%, p =0.04). Conclusions RFA under general anesthesia improved first-pass PVI (quality of PVI) and shortened procedural time. General anesthesia may attribute to attaining the catheter and patient stability during RFA for PVI.

NOVEL CRYOBIOPSY TECHNIQUE USING A LONG ENDOBRONCHIAL TUBE TO PREVENT BLEEDING COMPLICATIONS

SESSION TITLE: Emerging Techniques for Interventional Pulmonary SESSION TYPE: Original Investigations PRESENTED ON: 10/20/2019 2:15 PM - 3:15 PM PURPOSE: Prophylactic balloon blockers are placed to prevent blood flooding into the large central airway during cryobiopsy. However, the blocker may interfere with, and increase the difficulty of, the cryobiopsy procedure. This study evaluated a novel and simple technique using a long silicone endobronchial tube as a drain for bleeding during cryobiopsy. METHODS: Under local anesthesia and moderate conscious sedation, a customized silicone tube (5.0 mm inner diameter, 40 or 48 cm in length) was advanced through the nose and trachea to the target bronchus under bronchoscopic control using a 4.0- or 4.2-mm thin bronchoscope and firmly wedged into the target bronchus to prevent blood leakage from the tube during the cryobiopsy. A forceps biopsy was performed followed by a cryobiopsy using a 1.9-mm cryoprobe through the wedged tube. Patients who underwent cryobiopsies using the tube-wedging method for diagnosing peripheral lung lesions from April 2018 to January 2019 were reviewed retrospectively. RESULTS: Twenty-four patients (diffuse lesions in 13 and localized lesions in 11) underwent cryobiopsies using the tube-wedging method during the study period. A median of three specimens (range; one to six specimens) were obtained by cryobiopsy. Cryobiopsy and forceps biopsy provided diagnostic material in 17 patients (71%) and 12 patients (50%), respectively. Median bronchoscopy time was 33.5 min (range; 16−56 min). Bleeding was controlled easily in all patients by bronchoscopic blood suctioning within the wedged tube, and there was no blood flooding out of the tube. CONCLUSIONS: The tube-wedging method is simple and safe, and may be a promising alternative to the balloon occlusion method for cryobiopsy. CLINICAL IMPLICATIONS: The tube-wedging method is a valuable option for safely performing a cryobiopsy. DISCLOSURES: No relevant relationships by Masahide Oki, source=Web Response No relevant relationships by HIDEO SAKA, source=Web Response

A novel technique for retrieval of a broken biopsy needle

A broken needle is a rare complication of bone biopsy. We describe an easily applied technique of retrieval of a retained biopsy needle fragment using a cannulated drill typically used for internal fixation of femoral neck fractures. This approach allows for removal under moderate conscious sedation and can be performed by a radiologist using fluoroscopic or CT-fluoroscopic guidance in the radiology suite.

Cryoprobe transbronchial lung biopsy with flexible bronchoscope using Arndt endobronchial blocker.

Cryoprobe transbronchial lung biopsy (TBLB)/transbronchial lung cryobiopsy (TBLC) is increasingly being described as an alternative to surgical lung biopsy and provides larger lung biopsy samples as compared with conventional TBLB in patients with diffuse parenchymal lung diseases. The technique for cryoprobe TBLB procedure has not yet been standardized, and various authors describe different modalities. However, the use of an artificial airway (rigid bronchoscope or endotracheal tube) is preferred for airway protection. In addition, the use of an occlusion balloon provides safety to prevent excessive bleeding. The exclusive use of rigid bronchoscopy may limit the widespread adoption of this diagnostic modality. We describe a method to perform cryoprobe TBLB with exclusive use of a flexible bronchoscope and utilization of Arndt endobronchial blocker as an occlusion balloon. The procedure was performed in two patients under moderate conscious sedation. Adequate lung biopsies were obtained in both the cases without any complications. This modality may allow safe performance of cryoprobe TBLB with a flexible bronchoscope. Herein, we describe the technical and procedural considerations of this modality.

Abstract 17022: Pericardial Decompression Syndrome: Incidence in a Large Consecutive Series of Echocardiographic-Guided Pericardiocentesis Procedures

Introduction: Pericardial decompression syndrome (PDS) has been reported as a spectrum of cardiac decompensation following pericardiocentesis including ventricular failure, cardiogenic shock and pulmonary edema. PDS has been reported in patients undergoing drainage ≥450 mL of pericardial fluid. Hence judicious drainage of large volume effusions to avoid complication has been recommended Hypothesis: PDS complicating undergoing transthoracic echocardiography (TTE) guided pericardiocentesis is uncommen Methods: Consecutive patients undergoing TTE guided pericardiocentesis at our center from 1/2007 to 12/2016 were reviewed. Procedures were performed in a standard fashion under moderate conscious sedation with TTE determining the location of aspiration and determining adequate resolution of pericardial fluid post procedure. All fluid was removed at time of centesis regardless of the size of effusion, except for patients with severe pulmonary hypertension (n=9), who had staged removal of 100cc every 10 minutes. Post procedure, a pigtail catheter was left in the pericardial space for ongoing intermittent drainage and removed after the total net output was &lt;50 mL/24 hours. Patients were monitored in an intermediate level care unit. All patients underwent repeat TTE at the time of catheter removal. Large volume was defined as ≥450 mL of fluid. Patients in whom pericardiocentesis was technically unsuccessful were excluded Results: Over a 10-year period a total of 1067 patients (57% male, mean age 62±16 years) underwent 1164 technically successful pericardiocentesis procedures. Of these, 561 patients had large volume (≥450 mL) aspirated (mean 750±345 mL aspirated, range 450 - 4300 mL). Patients had a pericardial catheter in place for a mean 2.9±2 days. One patient with pre-existing severe biventricular dysfunction after aspiration of 400cc developed hypotension that improved with reversal of sedation, but proceeded to have PEA arrest and die. No other patient developed clinical events of acute left or right heart failure, ventricular dysfunction, unexplained hypotension, cardiogenic shock or other clinical events that could relate to PDS Conclusions: At most one episode of PDS was observed after technically successful percutaneous pericardiocentesis in 1164 cases (561 were large volume), although whether this case was PDS is unclear. PDS appears to be very rare, and staging pericardial decompression over time may be unnecessary, other than, perhaps, in patients with severe ventricular dysfunction or severe pulmonary hypertension

939 GENERAL ANESTHESIA VERSUS MODERATE CONSCIOUS SEDATION: A PROSPECTIVE STUDY ON OUTCOMES WITH SELECTIVE SEDATION IN ERCP

Endoscopic retrograde cholangiopancreatography (ERCP) requires adequate sedation for successful completion. The sedation type may affect rates of cannulation, success of intended intervention, and utilization of resources. Recent trends have favored the use of general anesthesia (GA) more frequently for advanced endoscopic procedures. We hypothesize that a selective sedation approach based on patient and procedural factors using either moderate conscious sedation (MCS) or GA will result in similar rates of successful interventions and complications, while offering more favorable utilization of resources compared to performing all ERCPs with GA. This is a prospective study evaluating the success rates, complications, and resource utilization in patients undergoing ERCP in an ambulatory procedure center. The study assessed 502 consecutive ERCPs from January 2017 to July 2017. Indications for GA included chronic opiates, benzodiazepines, or alcohol abuse; severity of patient illness; morbid obesity; complexity or difficulty of intervention as characterized by Modified Schutz Score; prior failed procedure or poor tolerance with MCS, or prior GA use. The outcomes of success of the intended intervention, cannulation rates, complications, total operating room (OR) and procedure time, and recovery time were compared. Of the 502 ERCPs, 366 (72.9%) were performed with MCS vs. 136 (27.1%) performed with GA. Successful intended interventions were completed in 350 / 366 cases with MCS vs. 129 / 136 cases with GA (95.6% versus 94.9% respectively, p=0.712). Cannulation success rates with MCS were 357 / 366 vs. 132 / 136 with GA (97.5% versus 97.1%, p=0.762). Of the 16 / 366 cases with MCS which failed, 9 / 366 (2.5%) were attributed to sedation complications such as hypoxia, hypotension, or patient restlessness preventing the intended intervention. Overall adverse event rates were significantly lower in MCS vs. GA (p=0.04). The rates of post-ERCP pancreatitis were not significantly different between the two groups (p=0.18). Mean procedure time for MCS vs. GA was 17.4 +/- 12.5 minutes versus 24.7 +/- 20.9 minutes (p<0.00001). Mean OR time for MCS vs. GA was 49.1 +/- 18.0 minutes vs. 52.4 +/- 22.5 minutes (p=0.087). Mean recovery time for MCS vs. GA was 82.6 +/- 42.2 minutes vs. 92.1 +/- 40.5 minutes (p=0.024). ERCP can be accomplished with comparable rates of success with MCS compared with GA with use of a selective sedation protocol which accounts for patient and procedure related factors. Further studies to assess the cost benefit with selective sedation would be beneficial.