Non-anesthesia Providers Research Articles

Improving the Safety and Convenience of Emergency Anesthesia Codes by Implementing a Portable Glidescope Bag

Anesthesia providers such as residents, CRNAs, fellows, and attendings are responsible to quickly arrive to anesthesia STATs, code blues and trauma pages and are responsible for securing the airway if needed. In emergent situations like these the providers are expected to provide efficient and safe care Almost always we come with no information on patient history, airway, age, etc. Multiple studies have shown higher intubation success rates in adults and children by using a glidescope on the first attempt (1). Currently at Childrens Hospital of Michigan in Detroit Michigan, in such scenarios many providers take the glide-scope on wheels with them to emergency overhead calls while some choose not to take it mostly due to the cumbersome task of wheeling the glide-scope and being forced to take the elevator which delays the arrival to the patient. This quality initiative project highlights improvements made by a plan do study act which implements a small bag with a portable handheld glide-scope device inside that attaches to the trauma backpack. This will eliminate the cumbersome task of wheeling the glidescope to emergencies, decrease the time to get to the patient, increase first time intubation success rate by having a glidescope available when needed and decreasing attempts by non-anesthesia providers before the anesthesia provider gets to the scene. In the preintervention survey most attendings stated that they do not take the glides-cope to emergencies due to the transportation issue mostly and those attendings did also state that they would consider taking it if its easier to transport. Most residents do take the large glidescope on wheels to emergencies but they did admit that they feel like it takes them longer to get to codes/traumas and anesthesia STATs due them having to wait for the elevator. By adding this glide-scope portable bag to our existing code bags I believe it will take less time to get to the anesthesia emergency, increase the intubation success rate & decrease attempts to intubation hence will reduce trauma to the airway, prolonged hypoxia and morbidity.

What we can learn from nonoperating room anesthesia registries: analysis of clinical outcomes and closed claims data.

The prevalence of procedures performed outside of the operating room is steadily growing around the world, especially in the United States. This review aims to discuss the risks and safety of anesthesia performed in remote locations based on an up-to-date literature review, with a focus on the results from closed claims and other database analyses. The published literature in the last decade shows that there is an increase in nonoperating room anesthesia cases and that the highest number of these cases are in gastroenterology endoscopy suites. There are safety concerns in nonoperating room cases that involve both anesthesia and nonanesthesia providers. Specific complications found in closed claims analyses include airway compromise, aspiration pneumonia, and dental injuries. The current literature demonstrates that procedures performed in the endoscopy suite make up the largest number of nonoperating room closed claims anesthesia cases. Oversedation and subsequent inadequate oxygenation/ventilation account for the majority of malpractice claims. Conclusions from the current literature emphasize the importance of complying with monitoring standards and having well prepared providers to improve patient outcomes in nonoperating room locations.

Addressing Inter-Rater Variability in the ASA-PS Classification System.

The American Society of Anesthesiologists' Physical Status (ASA-PS) Classification System was established to grade a patient's physical status prior to surgery. The literature shows inconsistencies in the application of the ASA-PS classification among providers. The many uses of the ASA-PS class require reliable ASA-PS class designations between providers. While much literature illustrates the inconsistency, there is limited research on how to improve inter-rater agreement. Following an educational intervention targeted at medicine providers, a retrospective chart review was completed to determine the long-term impact of an educational intervention on ASA-PS class agreement among providers of different specialties. To assess the overall agreement between the data sets following the intervention, kappa statistics were calculated for the medicine and anesthesia data sets. These values were compared to the kappa statistics from a similar study completed prior to the educational intervention. Overall, the kappa score, or agreement, between medicine and anesthesia providers improved from the range generally accepted to indicate slight agreement to the range indicating moderate agreement. While there was improvement in agreement following an education intervention, the agreement seen was not statistically significant. More research needs to be done to determine how to improve inter-rater reliability of the ASA-PS classification system with a focus on non-anesthesia providers.

CE: Original Research: Errors in Postoperative Administration of Intravenous Patient-Controlled Analgesia: A Retrospective Study.

Relevant data were collected from the medical records of all patients who received IV PCA at a large academic medical center in South Korea during a three-year period. The study sample comprised 45,104 patients who used one of four types of IV PCA delivery devices. Errors occurred in 406 cases (0.9%). Operator error was the most common type of error (54.7%), followed by device malfunction (32.3%), prescription error (12.3%), and patient error (0.7%). Of the 222 operator errors, the most frequent type was failure to begin IV PCA drug administration (28.8%), followed by programming errors by non-anesthesia providers who weren't authorized to program the device (24.8%) and wrong infusion rates set by anesthesia providers who were so authorized (24.8%). The findings provide valuable information that can aid in the development of policy and procedures for safer, more effective postoperative administration of IV PCA. They also suggest that it's necessary not only to improve the operation of acute pain services teams, but also to ensure ongoing provider and patient education specific to IV PCA use.

The Evolving Role of Intranasal Dexmedetomidine for Pediatric Procedural Sedation.

For decades, chloral hydrate (CH) was the standard agent used to provide sedation for noninvasive pediatric procedures.1 The drug had a long history of safe administration by nonanesthesia providers, which in many institutions included registered nurses.2,3 Despite reasonably high reported rates of success, CH had a number of disadvantages: a variable half-life in young children, clinical resedation, and a potential role as a neuroapoptotic agent in the developing brain.4,5 Perhaps the greatest disadvantage was the loss of the oral formulation in the US market, limiting its availability. After the loss of oral CH, many institutions evolved to an intravenous (IV) sedation regimen with propofol.6 Propofol was an attractive agent because of its high success rate, rapid onset, and short recovery. However, this change in practice presented new challenges because propofol is typically administered only by pediatric providers with advanced training in deep sedation or anesthesiologists. These deep sedation systems often require more intensive resource utilization (IV catheter placement, advanced monitoring systems, postanesthesia care, etc), which may have economic consequences for both the patient and the health care system. For many years, IV dexmedetomidine has been used for sedation in the critical care setting.7 In 2008, Mason et al8 took …

Anesthesiologists' Preferences regarding Visitor Presence during Placement of Neuraxial Labor Analgesia.

Introduction Neuraxial labor analgesia has become an integral part of modern obstetric anesthetic practice. Presence of a familiar person during its placement may be beneficial to the patient. A survey was sent to anesthesiologists practicing obstetric anesthesia in the USA to determine their views. Methods The survey queried the following: existence of a written policy; would they allow a visitor; visitor's view, sitting or standing; reasons to allow or not allow a visitor; and influence by other staff on the decision. The responses were analyzed using multiple chi-square analyses. Results Most practitioners supported allowing a visitor during placement. Reduction of patient anxiety and fulfillment of patient request were the major reasons for allowing a visitor. Sitting position and no view of the workspace were preferred. Visitor interference and safety were cited as the major reasons for precluding a visitor. Nonanesthesia providers rarely influenced the decision. Epidural analgesia was the preferred technique. Essentially no bias was found in the responses; there was statistical uniformity regardless of procedures done per week, years in practice, professional certification, geographic region (rural, urban, or suburban), or academic, private, or government responders. Conclusion The practice of visitor presence during the placement of neuraxial labor analgesia is gaining acceptance.

The relationship between minute ventilation and end tidal CO2 in intubated and spontaneously breathing patients undergoing procedural sedation.

BackgroundMonitoring respiratory status using end tidal CO2 (EtCO2), which reliably reflects arterial PaCO2 in intubated patients under general anesthesia, has often proven both inaccurate and inadequate when monitoring non-intubated and spontaneously breathing patients. This is particularly important in patients undergoing procedural sedation (e.g., endoscopy, colonoscopy). This can be undertaken in the operating theater, but is also often delivered outside the operating room by non-anesthesia providers. In this study we evaluated the ability for conventional EtCO2 monitoring to reflect changes in ventilation in non-intubated surgical patients undergoing monitored anesthesia care and compared and contrasted these findings to both intubated patients under general anesthesia and spontaneously breathing volunteers.MethodsMinute Ventilation (MV), tidal volume (TV), and respiratory rate (RR) were continuously collected from an impedance-based Respiratory Volume Monitor (RVM) simultaneously with capnography data in 160 patients from three patient groups: non-intubated surgical patients managed using spinal anesthesia and Procedural Sedation (n = 58); intubated surgical patients under General Anesthesia (n = 54); and spontaneously breathing Awake Volunteers (n = 48). EtCO2 instrument sensitivity was calculated for each patient as the slope of a Deming regression between corresponding measurements of EtCO2 and MV and expressed as angle from the x-axis (θ). All data are presented as mean ± SD unless otherwise indicated.ResultsWhile, as expected, EtCO2 and MV measurements were negatively correlated in most patients, we found gross systematic differences across the three cohorts. In the General Anesthesia patients, small changes in MV resulted in large changes in EtCO2 (high sensitivity, θ = -83.6 ± 9.9°). In contrast, in the Awake Volunteers patients, large changes in MV resulted in insignificant changes in EtCO2 (low sensitivity, θ = -24.7 ± 19.7°, p < 0.0001 vs General Anesthesia). In the Procedural Sedation patients, EtCO2 sensitivity showed a bimodal distribution, with an approximately even split between patients showing high EtCO2 instrument sensitivity, similar to those under General Anesthesia, and patients with low EtCO2 instrument sensitivity, similar to the Awake Volunteers.ConclusionsWhen monitoring non-intubated patients undergoing procedural sedation, EtCO2 often provides inadequate instrument sensitivity when detecting changes in ventilation. This suggests that augmenting standard patient care with EtCO2 monitoring is a less than optimal solution for detecting changes in respiratory status in non-intubated patients. Instead, adding direct monitoring of MV with an RVM may be preferable for continuous assessment of adequacy of ventilation in non-intubated patients.

Pharmacologic Considerations for Pediatric Sedation and Anesthesia Outside the Operating Room: A Review for Anesthesia and Non-Anesthesia Providers.

Understanding the pharmacologic options for pediatric sedation outside the operating room will allow practitioners to formulate an ideal anesthetic plan, allaying anxiety and achieving optimal immobilization while ensuring rapid and efficient recovery. The authors identified relevant medical literature by searching PubMed, MEDLINE, Embase, Scopus, Web of Science, and Google Scholar databases for English language publications covering a period from 1984 to 2017. Search terms included pediatric anesthesia, pediatric sedation, non-operating room sedation, sedation safety, and pharmacology. As a narrative review of common sedation/anesthesia options, the authors elected to focus on studies, reviews, and case reports that show clinical relevance to modern day sedation/anesthesia practice. A variety of pharmacologic agents are available for sedation/anesthesia in pediatrics, including midazolam, fentanyl, ketamine, dexmedetomidine, etomidate, and propofol. Dosing ranges reported are a combination of what is discussed in the reviewed literature and text books along with personal recommendations based on our own practice. Several reports reveal that ketofol (a combination of ketamine and propofol) is quite popular for short, painful procedures. Fospropofol is a newer-generation propofol that may confer advantages over regular propofol. Remimazolam combines the pharmacologic effects of remifentanil and midazolam. A variety of etomidate derivatives such as methoxycarbonyl-etomidate, carboetomidate, methoxycarbonyl-carboetomidate, and cyclopropyl-methoxycarbonyl metomidate are in development stages. The use of nitrous oxide as a mild sedative, analgesic, and amnestic agent is gaining popularity, especially in the ambulatory setting. Utilizing a dedicated and experienced team to provide sedation enhances safety. Furthermore, limiting sedation plans to single-agent pharmacy appears to be safer than using multi-agent plans.

ASA physical status assignment by non-anesthesia providers: Do surgeons consistently downgrade the ASA score preoperatively?

ObjectiveThe American Society of Anesthesiologists physical status (ASA-PS) is associated with increased morbidity and mortality in the perioperative period. When surgeries are scheduled by surgeons and their staff at our large institution a presumed ASA-PS is chosen. This is because our institution (and, anecdotally, others in our hospital system and elsewhere), recognizing the relationship between higher ASA-PS and poorer postoperative outcomes, requires all patients with higher ASA-PS levels (≥3) to undergo enhanced preoperative workup. The patients may not, however, necessarily be seen in the anesthesia clinic prior to surgery. As a result, patients are assigned a presumed ASA-PS by a non-anesthesia provider (e.g., surgeons and physician extenders) that may not reflect the ASA-PS chosen by the anesthesiologist on the day of surgery. Errors in the accuracy of the ASA-PS prior to surgery lead to unnecessary and costly preoperative testing, delays in operative procedures, and potential case cancellations. Our study aimed to determine whether there are significant differences in the assignment of ASA-PS by non-anesthesia providers when compared to anesthesia providers. DesignWe administered an IRB-approved survey asking the ASA-PS of 20 hypothetical case vignettes to 229 clinicians in various departments. Responses by non-anesthesia providers were compared to the consensus of the department of anesthesiology. SettingFaculty office spaces and conferences. PatientsNo patients, physicians only. InterventionsSurvey administration. MeasurementsASA-PS scores acquired from surveys. Main resultsResidents and faculty in the department of anesthesiology demonstrated no statistical difference in the median ASA score in 19/20 case scenarios. All other departments were statistically different when compared to the department of anesthesiology (p<0.05). The probability of a department either over- or under-rating the ASA-PS was calculated, and is summarized in Fig. 3. All departments, except anesthesiology, had a 30–40% chance of under-rating the ASA-PS of the patients in the clinical vignettes. ConclusionsNon-anesthesia providers assign ASA-PS with significantly less accuracy than do anesthesia providers, even when adjusted for multiple comparisons. Surgical and procedural departments were found to consistently under-rate the ASA-PS of patients in our clinical vignettes.

The challenges of implementing electronic health records for anesthesia use outside the operating room.

The nonoperating room environment presents a number of distinct challenges for anesthesiologists in the implementation of electronic health records (EHRs). These include documentation compliance, billing, and room design. EHRs offer multiple opportunities for improved continuity of care, expedited preoperative evaluation, and seamless transitions between anesthesia and nonanesthesia providers. Additionally, data gathered through adoption of EHRs provide the promise of future analysis and research, allowing for data-driven improvements in quality of care and value optimization. Institutions adopting a new EHR in areas where anesthesia is provided outside of the operating room should plan wisely to address these matters. The needs of anesthesiology practice should be carefully incorporated into future EHR builds as demands for anesthesia care outside of the operating room expand.

Education and training for nonanesthesia providers performing deep sedation.

There has been a significant increase in the number and types of procedures performed outside of the operating room with nonanesthesia providers administering sedation. This review describes current recommendations for training nonanesthesiologists involved in administering deep sedation, summarizes best practices and highlights select patient outcomes. There are numerous guidelines and standards related to the administration of deep sedation. However, there are no universally accepted guidelines regarding the necessary educational and skill competencies needed for nonanesthesiologists to provide deep sedation. The American Society of Anesthesiologists has published a position statement and guidelines on these educational requirements, yet the extent to which these are adhered to remains unknown. As evidence-based guidelines continue to evolve, more research is needed to describe how current practices affect patient outcomes. The American Society of Anesthesiologists publishes recommendations regarding the essential educational components for nonanesthesiologist providers who administer deep sedation. The available data support the need for formal educational programmes to prevent adverse events associated with deep sedation. Competencies should include preprocedural evaluation, understanding sedation levels, airway management, documentation, emergency life support skills, teamwork and quality improvement.

Neurotoxicity, general anesthesia in young children, and a survey of current pediatric anesthesia practice at US teaching institutions.

Recent articles in both scholarly journals and the lay press about the topic of anesthetic related neurotoxicity have increased the awareness and discussion of this topic with parents and other pediatric medical specialties (i.e., surgeons, radiologists, and pediatricians). The purpose of the present study was to survey how a subset of pediatric anesthesia departments in the US have responded to the issue of anesthetic related neurotoxicity in terms of clinical practice, training and communication with other medical specialties, and the frequency and timing of discussions with families. A survey consisting of 22 questions was sent to PALC (Pediatric Anesthesia Leadership Council) & PAPDA (Pediatric Anesthesia Program Directors Association) via SurveyMonkey. The survey was divided into sections on Anesthesia Faculty/Trainees, Parents and Non-Anesthesia Providers. Responses to the survey were solicited via email to PALC and PAPDA, and then followed up with reminders to individual emails using the mailing lists of both organizations. The results of this survey demonstrate that pediatric anesthesia programs around the US do not have a consistent approach in managing the topic of anesthesia-related neurotoxicity with pediatric anesthesiologists, anesthesiology residents, pediatric anesthesiology fellows and their non-anesthesia medical and surgical colleagues, as well as the discussion of this topic with parents. A significant need exists to provide information to other pediatric professionals and parents. A consistent message from all providers that includes what is known, and indeed more importantly what is not known may be a useful approach.

Videolaryngoscopy: should it replace direct laryngoscopy? a pro-con debate

Although it is universally recognized that the advent of videolaryngoscopy has revolutionized airway management, there is considerable disagreement over the future role of direct laryngoscopy and whether direct laryngoscopy should be relegated to a legacy technique. Arguments against the continued relevance of traditional intubation methods include increased success and decreased complications when videolaryngoscopy is utilized, as well as the fact that videolaryngoscopy enhances the performance of nonanesthesia providers. However, proponents of direct laryngoscopy cite technical issues, as well as instances in which intubation by videolaryngoscopy fails despite successful visualization. This argument serves as the rationale for the continued use of direct laryngoscopy, particularly for airway management experts.

Administration of propofol for sedation of non-mechanically ventilated patients in non-critical care areas by anesthesia providers and non-anesthesia trained healthcare providers: a systematic review.

The use of propofol as a sedative in various outpatient settings is controversial. At the heart of this controversy is the use of propofol by non-anesthesia trained healthcare providers. To synthesize the best available evidence on the administration of propofol for sedation by anesthesia and non-anesthesia providers in spontaneous breathing patients in non-critical care settings. This review considered non-anesthesia trained and anesthesia trained healthcare providers administering propofol as the agent for sedation in patients of all ages who were not mechanically ventilated and were undergoing procedures for gastrointestinal endoscopy, cardiac catheterization, and procedural sedation for emergency room and radiology procedures.This review included studies where propofol was the sole sedative agent used by non-anesthesia trained, and formally trained anesthesia healthcare providers.This review considered as outcomes procedure time, return to baseline functioning, postoperative recovery time, mean amount of propofol administered, patient satisfaction, incidence of adverse hemodynamic and respiratory events, unplanned admission to hospital, and death.This review considered randomized controlled trials, cohort studies, case-control studies, and case series/report studies. The search strategy aimed to find both published and unpublished studies in English language beginning with the commercial use of propofol in 1989 through 2011. Search was performed across: CINAHL, MEDLINE, Nursing@Ovid, EMBASE, Elsevier Science Direct, Mednar, and Proquest. Studies were critically appraised by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute. Data was extracted using the standardized data extraction tool from the Joanna Briggs Institute. Due to the heterogeneous nature of the interventions and outcome measurements, a meta-analysis was not possible; results are presented in a narrative summary. 9 studies were included in the review: 1 randomized controlled trial, 2 cohort studies, and 6 descriptive studies. In seven of the studies, non-anesthesia providers administered propofol, while two studies had anesthesia providers providing propofol sedation. Five studies reported procedure time. None of the studies reported a return to baseline functioning. Four studies reported postoperative recovery time. One study reported mean propofol dosage according to the two phases of the study, while another study in addition to reporting total and mean propofol dosages, differentiated propofol dosage according to ASA classification. Six of the studies reported average or mean propofol dosage, with one study also reporting the propofol induction dosage. Reporting of adverse hemodynamic and respiratory events varied in the studies. None of the studies reported unplanned admission to the hospital or death. The evidence suggests that anesthesia healthcare providers have the experience and training to safely administer propofol in non-critical care settings involving procedures in non-mechanically ventilated patients. The evidence also suggests that non-anesthesia trained healthcare providers can safely administer propofol sedation in low-risk patients who are not mechanically ventilated if they have received specialized training in the use of propofol sedation, are experienced in its administration, and follow a defined dosage protocol. The administration of propofol sedation by anesthesia providers can be safely administered in patients of all risk categories and depth of sedation.The administration of propofol sedation by non-anesthesia providers can be safely administered to low risk patients for moderate sedation providing the non-anesthesia provider is specially trained and experienced in the administration of propofol sedation while using a defined dosage protocol. Randomized controlled trials are needed to examine the propofol sedation by non-anesthesia healthcare providers in spontaneous breathing patients in non-critical care settings. The type of training required for safe administration of propofol in the outpatient settings should be explored.

A systematic review contrasting the administration of propofol for sedation of non-mechanically ventilated patients in non-critical care areas by anesthesia providers to that of non-anesthesia trained healthcare providers

Review Questions/Objectives This systematic review seeks to synthesize the best available evidence on the administration of propofol for sedation by anesthesia providers and non-anesthesia trained providers of non-mechanically ventilated patients in non-critical care settings. Inclusion Criteria Types of participants This systematic review will consider non-anesthesia trained health care providers, and anesthesia providers administering propofol for sedation in non-critical care situations on (all adult and paediatric) patients who are not mechanically ventilated while undergoing gastrointestinal endoscopy, cardiac catheterization, and procedural sedation for emergency room and radiology procedures. Types of interventions The intervention of interest is the use of propofol sedation administered by non-anesthesia trained health care providers, and formally trained anesthesia providers for patients in non-critical care environments who were not mechanically ventilated while undergoing gastrointestinal endoscopies, cardiac catheterization, and procedural sedation for emergency room and radiology procedures. Types of outcome measures This systematic review will consider as outcomes: procedure time, return to baseline functioning, postoperative recovery time, mean amount of propofol administered, patient satisfaction, incidence of adverse hemodynamic and respiratory events, unplanned admission to hospital, and death of patients undergoing gastrointestinal endoscopy, cardiac catheterization, or procedural sedation for emergency room and radiology procedures while administering propofol for sedation. Adverse hemodynamic and respiratory events that will be considered are respiratory arrest, airway obstruction, hypoxia requiring intervention, hypotension, bradycardia, and arrhythmias.

Basic Requirements for Monitoring Sedated Patients: Blood Pressure, Pulse Oximetry, and EKG

The American Society of Anesthesiologists published monitoring requirements for non-anesthesia providers performing sedation and analgesia in 2002. This manuscript covered not only the monitoring of patients under sedation and analgesia but pre-procedure evaluation and preparation, personnel availability and training, emergency equipment availability, use of supplemental oxygen, sedative-analgesic agents, and discharge criteria. Current recommendations for monitoring include patient responsiveness, blood pressure, respiratory rate, heart rate, and oxygen saturation. Oxygen saturation is a critical vital sign, but there can be a significant delay between inadequate ventilation and desaturation. Supplemental oxygen can dangerously increase this disconnect. Thus, one must monitor adequacy of ventilation by direct observation, auscultation, and/or end-tidal CO₂ monitoring. The most important admonition is that ‘ventilation’ and ‘oxygenation’ are not the same.

New Insights about an Old Foe

New Insights about an Old Foe

Perioperative Patient Safety and Procedural Sedation

The use of sedation administered by nonanesthesia providers has increased exponentially over the past decade. Moderate sedation is safe but has potential adverse reactions such as hypoxemia, apnea, hypotension, airway obstruction, and cardiopulmonary arrest. Patient safety is the responsibility of every person on the perioperative team and relies on an effective sedation delivery system to keep the patient from harm. Performing safe and effective sedation involves several aspects of sedation, including the persons administering the sedation, the educational processes involved, the environment in which the sedation is conducted, patient-specific information processes, and guidelines and protocols of the institution. Future areas of research in clinical studies include safety and efficacy studies, applications of new technology, and procedural sedation and analgesia adjuncts.

SAFETY OF USING REMIFENTANIL FOR MONITORED ANESTHESIA CARE (MAC) IN OLDER PATIENTS UNDERGOING AMBULATORY COLONOSCOPY*

S33 INTRODUCTION: Remifentanil is an FDA-approved synthetic opioid whose application in outpatient procedures requiring brief analgesia is being explored. [1] Outpatient colonoscopy in the elderly is particularly challenging given the brief but intense pain associated with this procedure. In view of its ultra-short half-life, remifentanil may be ideal in this setting. This study was designed to determine the safety of using remifentanil and meperidine in outpatients undergoing colonoscopy. METHODS: Following IRB approval and informed consent, eighty-nine patients were randomized in this double-blind study to receive MAC with either remifentanil (RemiMAC) or meperidine for outpatient colonoscopy. One group received a 1 mg/kg (<or=to 65 yrs) or 0.5 mg/kg (>65 yrs) bolus of meperidine with a placebo infusion. Remifentanil was infused for 5 minutes in the other group at 0.05 [micro sign]g/kg/min (<or=to 65 yrs) or 0.025 [micro sign]g/kg/min (> 65 yrs) prior to beginning the procedure. The remifentanil group also received a placebo bolus. Further adjustments in infusions or aliquots were based on patient response. Age, weight, ASA status, duration of colonscopy and total dose of medications were recorded. Measurements included the incidence of hypertension ([up arrow] SBP >20% of baseline), tachycardia (HR >110 / >20% of baseline), hypotension (SBP <or=to 80 mmHg / >20% of baseline), bradycardia (HR <40 / >20% of baseline], nausea, vomiting, and pruritus. Patient and operator satisfaction were surveyed on a 4 point scale (1=poor, 2=satistfactory, 3=good, 4=excellent). Ventilatory drive (minute ventilation [MV]) and time-to-home readiness were used to assess speed of recovery. Data were analyzed using either t-test (t) Fisher's Exact test (FET) or Mann-Whitney U (MWU). P-value of < 0.05 was considered significant. RESULTS: The two groups were similar with regards to demographics and patient/operator satisfaction. Demographic, side effects, and recovery data are shown in Table 1. Data are expressed as mean +/- SD.Table 1DISCUSSION: This study demonstrates that remifentanil can be safely administered to older patients undergoing colonoscopy as part of a MAC with fewer side effects than meperidine. Although patient and operator satisfaction did not differ, patients receiving RemiMAC had faster recovery of respiratory effort and home readiness than patients receiving an optimally titrated meperidine MAC. Future studies are needed to establish the most efficacious dosing for RemiMAC and compare it to meperidine as used by non-anesthesia providers. This study was supported, in part, by a grant from Glaxo Wellcome Inc.