Patient Discomfort Scores Research Articles

Virtual reality tools for training in gastrointestinal endoscopy: A systematic review

BACKGROUND Virtual reality (VR) has emerged as an innovative technology in endoscopy training, providing a simulated environment that closely resembles real-life scenarios and offering trainees a valuable platform to acquire and enhance their endoscopic skills. This systematic review will critically evaluate the effectiveness and feasibility of VR-based training compared to traditional methods. AIM To evaluate the effectiveness and feasibility of VR-based training compared to traditional methods. By examining the current state of the field, this review seeks to identify gaps, challenges, and opportunities for further research and implementation of VR in endoscopic training. METHODS The study is a systematic review, following the guidelines for reporting systematic reviews set out by the PRISMA statement. A comprehensive search command was designed and implemented and run in September 2023 to identify relevant studies available, from electronic databases such as PubMed, Scopus, Cochrane, and Google Scholar. The results were systematically reviewed. RESULTS Sixteen articles were included in the final analysis. The total number of participants was 523. Five studies focused on both upper endoscopy and colonoscopy training, two on upper endoscopy training only, eight on colonoscopy training only, and one on sigmoidoscopy training only. Gastrointestinal Mentor virtual endoscopy simulator was commonly used. Fifteen reported positive results, indicating that VR-based training was feasible and acceptable for endoscopy learners. VR technology helped the trainees enhance their skills in manipulating the endoscope, reducing the procedure time or increasing the technical accuracy, in VR scenarios and real patients. Some studies show that the patient discomfort level decreased significantly. However, some studies show there were no significant differences in patient discomfort and pain scores between VR group and other groups. CONCLUSION VR training is effective for endoscopy training. There are several well-designed randomized controlled trials with large sample sizes, proving the potential of this innovative tool. Thus, VR should be more widely adopted in endoscopy training. Furthermore, combining VR training with conventional methods could be a promising approach that should be implemented in training.

Spray nozzle for topical anaesthesia during flexible bronchoscopy: a randomised controlled trial.

The effectiveness of using a spray nozzle to deliver lidocaine for superior topical airway anaesthesia during non-sedation flexible bronchoscopy (FB) remains a topic of uncertainty when compared with conventional methods. Patients referred for FB were randomly assigned to receive topical lidocaine anaesthesia via the bronchoscope's working channel (classical spray (CS) group) or through a washing pipe equipped with a spray nozzle (SN group). The primary outcome was cough rate, defined as the total number of coughs per minute. Secondary outcomes included subjective perceptions of both the patient and operator regarding the FB process. These perceptions were rated on a visual analogue scale, with numerical ratings ranging from 0 to 10. Our study enrolled a total of 126 (61 CS group; 65 SN group) patients. The SN group exhibited a significantly lower median cough rate compared with the CS group (4.5 versus 7.1 counts·min-1; p=0.021). Patients in the SN group also reported less oropharyngeal discomfort (4.5±2.7 versus 5.6±2.9; p=0.039), better tolerance of the procedure (6.8±2.2 versus 5.7±2.7; p=0.011) and a greater willingness to undergo a repeat FB procedure (7.2±2.7 versus 5.8±3.4; p=0.015) compared with those in the CS group. From the operator's perspective, patient discomfort (2.7±1.7 versus 3.4±2.3; p=0.040) and cough scores (2.3±1.5 versus 3.2±2.4; p=0.013) were lower in the SN group compared with the CS group, with less disruption due to coughing observed among those in the SN group (1.6±1.4 versus 2.3±2.3; p=0.029). This study illustrates that employing a spray nozzle for the delivery of lidocaine provides superior topical airway anaesthesia during non-sedation FB compared with the traditional method.

Efficacy of intertruncal and corner-pocket approaches of ultrasound-guided supraclavicular block in terms of ulnar nerve blockade: A randomised controlled study.

The incidence of ulnar nerve sparing has declined with the corner-pocket approach of the supraclavicular block (SCB), however, it continues to persist. A recent technique of SCB, the intertruncal approach, separately blocks each trunk of the brachial plexus. Thus, we hypothesised that the intertruncal approach results in a complete ulnar nerve blockade. Eighty-eight patients were randomised to undergo SCB using an ultrasound (USG)-guided corner-pocket or intertruncal approach and were compared primarily regarding the complete sensory and motor blockade of the ulnar nerve and all four nerves (ulnar, radial, median and musculocutaneous nerves) at 15 min. Secondary objectives included time required for block performance, patient discomfort score, time to readiness for surgery and duration of sensory blockade of the ulnar nerve. Continous data were compared using an independent t-test, and categorical data were compared using the Chi-square test. The proportion of participants with complete sensory (30/44 vs. 14/44, P < 0.001) and complete motor (22/44 vs. 7/44, P < 0.001) blocks in the ulnar nerve and all four nerves at 15 min was significantly higher in the intertruncal group. Block performance time and patient discomfort score were higher in the intertruncal group (P < 0.001). The total duration of sensory blockade in the ulnar nerve was more in the corner-pocket group (P < 0.001). USG-guided intertruncal approach is superior to the corner-pocket approach of SCB regarding a complete ulnar nerve blockade.

An algorithm for cognitive fusion targeted tumor puncture based on 3-D mathematical modelling

BackgroundPercutaneous puncture is an important means of tumor diagnosis and treatment. At present, most puncture operations are still based on imaging location and clinical experience, and quantitative and accurate targeted puncture cannot be achieved. How to improve the accuracy of percutaneous tumor puncture, avoid errors to the greatest extent, reduce the occurrence of complications, and improve the overall clinical diagnosis and treatment quality and curative effect, are scientific problems worthy of further study. MethodIn the present study, mathematical modeling was first used to construct the tumor puncture path, determine the needle entry angle, and define the relevant limited parameters and the substitution formula. Secondly, relevant parameters were extracted from CT and other imaging data and substituted into formulas, the deviation angle and puncture path were determined, and the personalized tumor puncture scheme was carried out. Third, targeted puncture was precisely implemented under the guidance of B-ultrasound. Compared with the traditional empirical puncture, our model improved the accuracy, decreased the puncture time, and reduced the pain of diagnosis and treatment for patients. ResultsA tumor-targeted puncture model was established based on mathematical theory and imaging data. By extracting clinical data, such as tumor radius, projection distance of tumor center and projection distance from puncture point to body surface, the optimal puncture deviation angle was modeled and calculated and a personalized puncture scheme was established. Compared with the conventional method, our model markedly increased the puncture accuracy rate by ∼30%. The puncture number was decreased by ∼50% using our model. Furthermore, our model shortened the operation time by 20% to ease pain of patients and guarantee greater security for patients. Doctor satisfaction and patient discomfort scores were examined. Our model improved doctor satisfaction by ∼20% and reduced subjective discomfort of patients by ∼25%. These data revealed that the model could markedly improve the accuracy and efficiency of puncture, clinical efficacy and accuracy of tumor diagnosis. Additionally, the confidence of doctors in the operation was greatly enhanced and patient discomfort was greatly reduced. ConclusionThe present study analyzed in detail how to find the best puncture path using a mathematical model. Based on the mathematical model of cognitive fusion puncture, combined with clinical personalized data and mathematical calculation analysis, accurate puncture was effectively realized. It not only greatly improved the effectiveness of puncture, but also ensured the safety of clinical patients and reduced injury, which means it may be worthy of clinical application.

Comparative study of intubating conditions and hemodynamic changes during awake fiber-optic intubation using midazolam with fentanyl versus dexmedetomidine in cases of difficult airway.

Background:The aim of the study is to compare intubating conditions and hemodynamic changes during awake fiber-optic intubation (AFOI) using midazolam and fentanyl versus dexmedetomidine in cases of difficult airway.Materials and Methods:A randomized prospective study was conducted in the department of oral and maxillofacial surgery, with a total of 60 patients, 18–55 years of age, ASA class I–II, of either sex with anticipated difficult airway planned for elective surgery. They were divided into two groups; group I patients received 1 μg/kg of dexmedetomidine and then an infusion of 0.5 to 0.7 μg/kg/hr of dexmedetomidine, whereas group II patients received 1 μg/kg of intra-venous (iv) fentanyl and 0.05 mg/kg of iv midazolam with additional doses of 0.02 mg/kg to achieve a Ramsay Sedation Scale score of ≥2. The ease of placement of the fiber-optic scope and the endotracheal tube and the patient's reaction to placement of the fiber-optic scope were assessed on a scale of 1–4 and were recorded as endoscopist satisfaction score and patient discomfort score, respectively.Results:The endoscopy time ranged from 2.66 ± 1.00 (group I) to 3.90 ± 0.96 (group II) minutes and was found to be statistically significant (p < 0.05). Also, the patient discomfort score was recorded during endoscopy (1–4) and ranged from 1.3 ± 0.53 (group I) and 2.33 ± 0.66 (group II) and was found to be statistically significant (p value < 0.05). Patients undergoing the procedure who received dexmedetomidine were thus more comfortable than those who received fentanyl and midazolam combination.Conclusion:Dexmedetomidine provided better intubating conditions, patient tolerance, higher endoscopist satisfaction, and reduced hemodynamic responses compared to fentanyl and midazolam combinations. Also, the major advantage of dexmeditomidine for preservation of airway with a lesser degree of respiratory depression allows for safer use of AFOI in cases of difficult airway.

Intubating conditions and hemodynamic changes during awake fiberoptic intubation using fentanyl with ketamine versus dexmedetomidine for anticipated difficult airway: a randomized clinical trial

Background and objectivesAwake fiberoptic intubation (AFOI) is usually performed in patients with an anticipated difficult airway. Various sedation regimens are used during AFOI, however, most of them cause respiratory depression. The present study aims to compare the effectiveness of fentanyl with ketamine versus dexmedetomidine in search of a better sedation regimen which would achieve desirable intubating conditions and hemodynamic stability without causing respiratory depression. MethodsThis is a single centered randomized, double-blind clinical trial. Patients of both sexes between age 18–55 years and ASA (American Society of Anesthesiologists) physical status I–II with an anticipated difficult airway were randomly divided into two groups of thirty each. Group FK patients received intravenous fentanyl and ketamine, and group DX patients received dexmedetomidine, until Ramsay sedation scale ≥ 2. Heart rate (HR), mean blood pressure (MBP), oxygen saturation (SpO2), respiratory rate (RR), endoscopy time, intubation time, first end-tidal carbon dioxide (ETCO2) after intubation, endoscopist satisfaction score, and patient discomfort score were recorded during the study period. The level of recall was assessed on the next postoperative day. ResultsEndoscopist satisfaction score was better in group DX patients (p < 0.05). There was a smaller variation in HR and MBP from baseline with dexmedetomidine compared to fentanyl with ketamine. First ETCO2 after intubation was higher in group FK patients (p < 0.05). No significant difference was found in patient discomfort score, intubation time, RR, SpO2 and level of recall of the event. ConclusionsThe use of dexmedetomidine in AFOI provides better intubating conditions and hemodynamic stability compared to fentanyl with ketamine.

Merits of conjunctival frill incision in reducing trabeculectomy-induced astigmatism and patient discomfort.

Purpose:To compare results of a novel “conjunctival frill/smile incision” on surgically induced astigmatism (SIA) and patient discomfort vs conventional trabeculectomy in the initial postoperative period.Methods:Sixty trabeculectomy cases were subjected to either conjunctival frill incision, performed 1.5–2.0 mm from the limbus (study group) or conventional fornix-based conjunctival flap (control group). Corneal astigmatism and suture-induced discomfort were assessed by keratometry and a self-devised patient questionnaire, respectively.Results:Both groups generated a “with the rule” SIA, which was 1.77 vs 2.42 at 1 week and reduced to 1.27 vs 1.8 in the study vs control group, after removal of sutures – both scleral flap releasable and conjunctival at 1 month. Patient discomfort score revealed enhanced comfort in 37% of patients (study group) vs 17% (control group) during the early postoperative period. After 1 month of surgery, good comfort was regained in all cases.Conclusion:This novel suturing technique results in reduced SIA, patient discomfort during the 1st month after trabeculectomy.

Transradial access by cardiology catheter lab nurses

Abstract Introduction Nurse led radial arterial access (RAA) is emerging as an attractive alternative to traditional physician-led access.[1] Methods A multidisciplinary program was developed by the nursing and medical teams in a busy tertiary cardiac centre performing over 3000 interventional cardiology procedures of which 90% of cases are done radially. Phase 1 of the training programme consisted of 50 procedures per nurse performed under direct consultant operator supervision. Phase 2 consisted of routine nurse led radial artery cannulation on unselected patients. In addition 2 sub-studies were performed an audit of patient experience comparing the two nurse practitioners with cardiology trainees. An audit of the time to sheath insertion was carried out. Results Technical success was defined as access within two puncture attempts. In phase 1 of the training two nurses were successful in 84% of cases. In this case cohort there were no identified vascular complications. One patient needed an alternate access route. In Phase 2 311 cases were performed independently on unselected patients. The technical success rate was 86.5% for both nurses in total in this cohort. This included a mixture of both right radial (249 cases) and left radial (25 cases) access. 8 of these were also PPCI cases. No major vascular complications were identified. In cases where no access after two attempts was secured access was gained by a consultant. In 6 cases ultrasound guidance was used by the consultant. A patient discomfort score was recorded immediately via a questionnaire post access procedure. Results were compared with cardiology trainees performing RAA in parallel, demonstrating excellent outcomes. Similarly when comparing difference between patient on table to sheath insertion times between trainees and nurses performing the radial access, nurse radial access had competitive outcomes. Discussion Nurse led RAA procedure is an advanced practice skill which can be adopted by appropriately trained and experienced senior members of the nursing team. The advantages include facilitating flow through the catheter lab, greater advocacy of patients through their clinical pathway and high levels of patient satisfaction. Median Time Funding Acknowledgement Type of funding source: None

Comparison of Intravenous Dexmedetomidine-Propofol Versus Ketofol for Sedation During Awake Fiberoptic Intubation: A Prospective, Randomized Study.

BackgroundManagement of difficult airway due to laryngeal mass is a major challenge to the anesthesiologists, and awake fiberoptic intubation (AFOI) would be the technique of choice.ObjectivesThe current study aimed at comparing the effects of administration of dexmedetomidine-propofol or ketofol for sedation during AFOI in terms of intubation conditions, hemodynamic stability, and patients and anesthesiologist’s satisfaction.MethodsEighty adult patients, 18 - 60 years old, ASA (the American Society of Anesthesiologists) physical status I-III, with difficult airway due to laryngeal mass and planned for AFOI were enrolled. Sedation was randomly given to the patients according to their assigned group by either dexmedetomidine-propofol (group D; n = 40) or ketofol (group K; n = 40). Outcome variables included time to reach Ramsay sedation scale (RSS) ≥ 3, intubation time, number of patients in need of rescue propofol, patient’s discomfort score, tolerance to endoscopy and intubation, hemodynamic parameters, patients and anesthesiologist’s satisfaction, and occurrence of side effects.ResultsTime to reach RSS ≥ 3 and intubation time were significantly shorter, and fewer patients required rescue propofol in the K group as compared to the D group (P = 0.000*, and 0.035*, respectively). Higher discomfort score and better tolerance to endoscopy and intubation were noticed in group K than group D, but with no statistical significance (P = 0.132, 0.137, and 0.211, respectively). Patients in group D had significantly lower mean arterial pressure (MAP) and heart rate (HR) after the loading dose till five minutes after intubation (P = 0.000*). There was no significant difference in patients’ satisfaction between the two groups (P = 0.687), while anesthesiologist’s satisfaction was higher in group K compared with that of group D (P = 0.013*). Cough score as well as incidence of unfavorable respiratory outcomes were not significantly different between the two groups (P = 0.611, 0.348, respectively).ConclusionsKetofol and dexmedetomidine-propofol combination were suitable and satisfactory for AFOI. However, ketofol was more advantageous in offering faster onset of sedation, shorter intubation time, stable hemodynamic profile, as well as higher anesthesiologist’s satisfaction when compared to dexmedetomidine-propofol.

Meperidine for patients expected to have poor tolerance to esophagogastroduodenoscopy: A double‐blind, randomized, controlled study

Anxious patients and those with poor tolerance to previous esophagogastroduodenoscopy (EGD) usually have poor tolerance for EGD. To investigate the effect of meperidine on these patients during EGD. A total of 110 patients undergoing diagnostic EGD were randomized to receive either meperidine (n = 55) or placebo (n = 55) before EGD. The primary outcome was patient discomfort scores during esophageal intubation. Patients in the meperidine group reported less discomfort during esophageal intubation (median score of 5.0 and interquartile range (IQR) 1.5-7.0) compared with the control (median score of 6.0, IQR 5.0-8.5, P = .003). Patients in the meperidine group had better tolerance during the procedure (median score of 2 (IQR 1.0-3.0) versus 3 (IQR 1.0-4.0), P = .048), and the endoscopists reported higher overall satisfaction scores (median score of 9 (IQR 7.0-9.0) versus 8 (IQR 7.0-9.0), P = .043). There was significantly less increase in heart rate and blood pressure during the procedure in the meperidine group than in the placebo group (23 bpm (IQR 9-32) versus 30 bpm (IQR 18-52); P = .006); (7 mmHg (IQR 1-14) versus 18 mmHg (IQR 2-30); P = .008). Connect-the-numbers test showed comparable results before and after EGD between the two groups. For patients expected to have poor tolerance during EGD, meperidine reduced discomfort, decreased cardiovascular distress, and improved endoscopist satisfaction, without adverse effects on their psychomotor function after the procedure.

Impact of a new distal attachment on colonoscopy performance in an academic screening center

Distal attachments placed on the colonoscope tip may positively affect performance by assisting insertion and polyp detection. The original Endocuff (ARC Medical Design, Leeds, United Kingdom) appears to improve adenoma detection rate (ADR), but no data assess the performance of the second-generation Endocuff Vision. A pilot service evaluation study (April 2013 to September 2014) was conducted on patients with positive fecal occult blood tests within the National Bowel Cancer Programme during 3 consecutive periods: precuff/no device used, during-cuff/device used, and postcuff/no device used. During the middle period theuse of the Endocuff Vision by the 4 screening-accredited colonoscopists was discretional (nonrandomized design). Data were analyzed using pairwise comparisons during the 3 designated periods to examine key performance indicators: adenoma detection, procedural time, sedation requirements, and patient comfort. Four hundred ten complete colonoscopies were performed (137 precuff, 136 cuff, and 137 postcuff period). Overall, there was a notable increase in the mean ADR of 16% (P< .03) and in the mean number adenoma per procedure (MAP) of 83% (P= .007) from precuff to cuff period. The mean cecal intubation time was statistically lower during the cuff period (7 minutes) in relation to the precuff period (8 minutes; reduction of12.5%, P= .002) and the postcuff period (9 minutes; increase of 28.6%, P= .002). The mean negative colonoscopy withdrawal time was also significantly lowerduring the cuff period (8 minutes, 30 seconds) when compared with the precuff (12 minutes) or postcuff period (9 minutes, 45 seconds; P≤ .001). Multivariate regression analysis showed that the use of the Endocuff Vision was not associated with sedation requirements or patient discomfort scores. No adverse events were reported from the use of the Endocuff Vision, although it was electively removed in 6 patients where severe sigmoid colon diverticulosis was encountered and 2 patients because of discomfort during anal insertion. In this pilot service evaluation study, the use of the Endocuff Vision appears to be associated with an improvement in overall colonoscopy operator performance. We found increased ADR and MAP as well as decreased time for colonoscope insertion and withdrawal time with no increase in sedation requirements or patient discomfort.

PTH-020 Too Old to Push? A Prospective Comparison Study on The Safety of Double Balloon Enteroscopy with Propofol Versus Standard Sedation in The Elderly

Introduction Propofol sedation is increasingly being used for complex endoscopy. Double balloon enteroscopy (DBE) has been shown to be poorly tolerated using standard sedation. We investigated the feasibility and safety of DBE in the elderly compared to the young, using propofol versus standard sedation in our routine small bowel service. Methods Between March 2013 and December 2015, all patients undergoing DBE were prospectively recruited. Standard sedation with fentanyl and midazolam or anaesthetist-assisted propofol sedation was decided based on patient history and the expected complexity of procedure. Patients were categorised by age into elderly: ≥70 years and young: Results A total of 183 patients underwent DBE. Ten elderly patients (50% male, 80% oral) and 72 young patients (43% male, 79% oral) received propofol respectively whilst 25 elderly patients (44% male, 80% oral) and 76 young patients (51% male, 83% oral) received standard sedation. Background demographics, comorbidities and HADS were comparable. There was no difference in the mean dose of propofol used in elderly or young patients (mean 1032 mg vs 1097 mg, p = 0.651) or the procedure time in any group (p = 0.081). The most common indications for DBE were iron deficiency anaemia (57.1%), overt gastrointestinal bleeding (20%) and suspected Crohn’s disease (11.4%) in elderly patients; akin to that in young patients (31.8%, 7.4%, 23.6% respectively). The most common findings at DBE (elderly vs young) were angioectasias (37.1% vs 18.9%, p = 0.025), tumours/masses (17.1% vs 17.6%, p = 1), ulcers (17.1% vs 13.5%, p = 0.593) and a normal examination (22.9% vs 39.2%, p = 0.080). Diagnostic and therapeutic yields were also comparable in all groups (range 60–90%, p = 0.205 and 24–50%, p = 0.054 respectively). There were no complications in elderly patients receiving propofol. One elderly patient receiving standard sedation had a significant troponin rise. Propofol gave lower patient pain, discomfort and distress scores compared to sedation (p Conclusion This is the first study to compare sedation types for DBE in the elderly. Our data suggests that not only is safety comparable in the elderly receiving propofol compared to standard sedation during DBE but tolerability is significantly better. This would support the use of propofol sedation for DBE in elderly patients. Disclosure of Interest None Declared

What can we learn from publishing endoscopy trial protocols?

What can we learn from publishing endoscopy trial protocols?

A low-cost alternative for nasolaryngoscopy simulation training equipment: a randomised controlled trial.

Flexible nasolaryngoscopy is a key diagnostic procedure used in many specialities. Simulation-based teaching is beneficial for endoscopy training, but it is expensive. This study assessed whether an inexpensive simulation model is an effective training method for flexible nasolaryngoscopy. A three-armed, randomised, controlled trial was performed. One group received no simulation training, while two others were trained with either a high-cost or a low-cost model. All candidates then performed flexible nasolaryngoscopy on a volunteer. Their ability to perform this task was assessed by the patient discomfort score and time taken by a blinded expert. Simulation-based teaching reduced patient discomfort and improved candidate skill level. Low-cost model training did not have a negative effect when compared with high-cost model training. Simulated flexible nasolaryngoscopy training may be more accessible with the use of an effective low-cost model.

A Comparative Study of the Efficacy of IV Dexketoprofen, Lornoxicam, and Diclophenac Sodium on Postoperative Analgesia and Tramadol Consumption in Patients Receiving Patient-Controlled Tramadol.

This study was designed to compare the effects of dexketoprofen, lornoxicam, and diclophenac sodium on postoperative analgesia and tramadol consumption in patients receiving postoperative patient-controlled tramadol after a major abdominal surgery. Eighty patients were randomized to receive one of the four study drugs. Patients in group dexketoprofen (DT) received IV 50 mg dexketoprofen, group lornoxicam (LR) received IV 8 mg lornoxicam, group diclophenac sodium (DS) received 75 mg IV diclophenac sodium and group saline (S) received 0.9% saline in 2 mL syringes, 20 min before the end of anaesthesia. A standardized (1 mg kg(-1)) dose of tramadol was routinely administered to all patients as the loading dose at the end of surgery. Postoperatively, whenever patients requested, they were allowed to use a tramadol patient-controlled analgesia device giving a bolus dose (0.2 mg kg(-1)) of tramadol. Pain, discomfort, and sedation scores, cumulative tramadol consumption, supplemental meperidine requirement, and side effects were recorded. Visual rating scale and patient discomfort scores were significantly lower in DT, LR and DS groups compared to those in in group S (p<0.001). Cumulative tramadol consumption was significantly lower in non-steroidal anti-inflammatory drug (NSAID)-treated groups at each study period after the second postoperative hour than in group S (p<0.001). Supplemental meperidine requirement was significantly higher in group S at each study period after postoperative 30 min than in NSAID-treated groups (p<0.01). After major abdominal surgery, adding IV diclophenac, lornoxicam or dexketoprofen to patient-controlled tramadol resulted in lower pain scores, smaller tramadol consumption, less rescue supplemental analgesic requirement, and fewer side effects compared with the tramadol alone group.

Remifentanil, ketamine, and propofol in awake nasotracheal fiberoptic intubation in temporomandibular joint ankylosis surgery.

Nasotracheal intubation of patients with temporomandibular joint (TMJ) ankylosis is a challenge for anesthesiologists. Awake fiberoptic intubation (AFOI) is the safest technique in patients with difficult airway. This study compares 3 different techniques of conscious sedation during AFOI in patients with TMJ ankylosis. This study comprised 54 patients, American Society of Anesthesiologists physical status 1, scheduled for TMJ surgery. The patients were randomly allocated to remifentanil group (n = 18, 0.75 μg/kg over 30 seconds), ketamine group (n = 18, 0.25 mg/kg over 30 seconds), or propofol group (n = 18, 0.5 mg/kg over 30 seconds) for conscious sedation. The main determinants affecting the patient's outcome included intubation time, intubation conditions, and patient discomfort, which were determined by scoring system. In addition, postoperative patient dissatisfaction, hemodynamic stability, and respiratory impairment were measured. Intubation times were significantly different between groups (P < 0.001), where remifentanil had the shortest time (30.28 seconds). Intubation conditions (scores 0-3) were significantly different between groups (P < 0.001).In this context, remifentanil had score 3 (2-3), which was higher compared with 2 (1-3) for ketamine and 2 (1-2) for propofol. Patient discomfort score was lowest in the remifentanil group. Hemodynamic stability was maintained within groups, and its changes were not significant (P > 0.05). Postoperative patient's dissatisfaction was observed in 2, 3, and 5 patients in remifentanil, ketamine, and propofol groups, respectively. Respiratory impairment (apnea) recorded lowest in the remifentanil group. Remifentanil was the best agent for AFOI, because it provided shorter intubation time, better intubation conditions, and least patient's complaint.Iranian registry no.: IRCT 201208061674N4 (www.irct.ir).

A comparative study of intravenous dexmedetomidine-versus propofol-based sedation for awake fiberoptic intubation along with airway blocks in cervical discectomy patients

Background: In unstable cervical spine, optimal intubation positioning of the patient may be unsafe. Awake intubation is indicated, which is rendered more comfortable by light sedation. Aims and Objectives: This study compared intravenous dexmedetomidine versus propofol-based sedation for awake fiberoptic intubation along with airway blocks. Materials and Methods: 100 ASA I and II patients with cervical PIVD are recruited for this study. Vital parameters such as heart rate, systolic BP (SBP), diastolic BP (DBP), mean arterial pressure (MAP), and SPO2 were monitored at regular intervals. Patient sedation score, endoscopy score, intubation score, post-intubation conditions, and discomfort score were also recorded. Results: There was no statistically significant difference between the two groups with respect to SBP, DBP, mean blood pressure (MBP), heart rate (HR), and SPO2. Conclusions: Dexmedetomidine appeared to offer better patient tolerance, better preservation of a patent airway, and spontaneous ventilation.

Predictors for cecal insertion time: the impact of abdominal visceral fat measured by computed tomography.

Several factors affect the risk for longer cecal insertion time. The aim of this study was to identify the predictors of longer insertion time and to evaluate the effect of visceral fat measured by CT. This is a retrospective observational study. Outpatients for colorectal cancer screening who underwent colonoscopies and CT were enrolled. Computed tomography was performed in individuals who requested cancer screening and in those with GI bleeding. Information on obesity indices (BMI, visceral adipose tissue, and subcutaneous adipose tissue area), constipation score, history of abdominal surgery, poor preparation, fellow involvement, diverticulosis, patient discomfort, and the amount of sedation used was collected. The cecal insertion rate was 95.2% (899/944), and 899 patients were analyzed. Multiple regression analysis showed that female sex, lower BMI, lower visceral adipose tissue area, lower subcutaneous adipose tissue area, higher constipation score, history of surgery, poor bowel preparation, and fellow involvement were independently associated with longer insertion time. When obesity indices were considered simultaneously, smaller subcutaneous adipose tissue area (p = 0.038), but not lower BMI (p = 0.802) or smaller visceral adipose tissue area (p = 0.856), was associated with longer insertion time; the other aforementioned factors remained associated with longer insertion time. In the subanalysis of normal-weight patients (BMI <25 kg/m), a smaller subcutaneous adipose tissue area (p = 0.002), but not a lower BMI (p = 0.782), was independently associated with a longer insertion time. Longer insertion time had a positive correlation with a higher patient discomfort score (ρ = 0.51, p < 0.001) and a greater amount of midazolam use (ρ = 0.32, p < 0.001). This single-center retrospective study includes a potential selection bias. In addition to BMI and intra-abdominal fat, female sex, constipation, history of abdominal surgery, poor preparation, and fellow involvement were predictors of longer cecal insertion time. Among the obesity indices, high subcutaneous fat accumulation was the best predictive factor for easier passage of the colonoscope, even when body weight was normal.

Comparison of the safety and effectiveness of endoscopic biliary decompression by nasobiliary catheter and plastic stent placement in acute obstructive cholangitis

Endoscopic retrograde biliary drainage (ERBD) using a plastic stent is suggested to be as effective as endoscopic nasobiliary drainage (ENBD) with a nasobiliary catheter for temporary biliary drainage in acute obstructive cholangitis. However, there are few studies that have compared the two methods. We therefore compared the safety and effectiveness of endoscopic biliary decompression by nasobiliary catheter versus plastic stent placement in these patients. A total of 94 screened patients with acute obstructive cholangitis were randomised to undergo emergency endoscopic biliary drainage with ENBD (n = 47) or ERBD (n = 47). Clinical outcomes and adverse events were compared. Patient backgrounds were similar in the two groups. Endoscopic biliary drainage was successfully achieved in all patients. Eleven patients underwent unscheduled endoscopic retrograde cholangiopancreatography (ERCP) to replace the nasobiliary catheter, 10 due to a catheter (1 in the ENBD group) or stent (9 in the ERBD group) blockage and 1 due to catheter migration. Clinical manifestations were similar, however, there was a significantly lower patient discomfort score in the ERBD group (p <0.05). The mean serum gamma-glutamyltransferase and total bilirubin concentrations after ERCP were significantly higher in the ERBD than ENBD group (p <0.001). Complication rates were similar in the ENBD and ERBD groups. However, the incidence rate of blockage in ERBD was statistically higher than ENBD (p = 0.015). Endoscopic biliary decompression is an effective treatment for patients with acute obstructive cholangitis. In contrast to other studies, we found an increased rate of blockage in the ERBD group and a greater decrease in liver enzyme levels in the ENBD group.

Meperidine as the single sedative agent during esophagogastroduodenoscopy, a double‐blind, randomized, controlled study

In Taiwan, unsedated esophagogastroduodenoscopy (EGD) is widely used, but it is uncomfortable for some patients. While meperidine has been adopted in colonoscopy, its use in EGD has not received extensive attention. This was a prospective study to investigate the use of meperidine as a single sedative agent during EGD. One hundred and forty patients were randomized to receive either 25-mg meperidine (n = 70) or placebo (n = 70) by intramuscular injection before EGD. The primary outcome was patient discomfort scores. The secondary outcomes included patient, endoscopist, and EGD-related variables. Patients in the meperidine group reported less discomfort during esophageal intubation (median score of 2.0 and interquartile range [IQR] of 0-4.0 vs median score of 4.8 and IQR of 1.7-7.0, respectively; P < 0.001) and during the procedure (median score of 1.0 [IQR 0-3.1] vs 3.5 [IQR 0-5.6], P = 0.001) than patients in the placebo group. The endoscopist found patients in the meperidine group had better tolerance during esophageal intubation (median score of 1.0 [IQR 0-2.0] vs 2.0 [IQR 1.0-3.0], P = 0.021) and during the procedure (median score of 0 [IQR 0-1.0] vs 1.0 [IQR 0-3.0], P < 0.001). After the procedure more patients in the meperidine group (71.4% vs 35.7%, P < 0.001) experienced self-limited dizziness that prolonged recovery by ∼3.7 min. After receiving meperidine injection, patients had better tolerance and less discomfort during diagnostic EGD (NCT01547520).