Post-procedure Recovery Time Research Articles

Sa1143 Monitored Anesthesia Care Versus Conscious Sedation for Common Endoscopic Procedures. A Prospective Patient Satisfaction and Procedure Outcome Study

Background Sedation for endoscopic procedures induced with opioid and benzodiazepine combination is called conscious sedation (CS) and defined by The American Society of Anesthesiology (ASA) to be moderate sedation.Sedation for endoscopic procedures induced with propofol as the main anesthetic is called Monitored Anesthesia Care (MAC) and defined by the ASA to be deep sedation. This is generally administered by an anesthesiologist.In this prospective study we collected data directly from patients undergoing endoscopic procedures.We compared patient satisfaction and overall procedural outcome in two different modes of sedation. Methods:473 patients were enrolled in this prospective study at two community hospitals. Inclusion criteria were adult patients undergoing EGD or colonoscopy and able to complete the survey form. Patients with ASA score above 3 and undergoing other GI procedures were excluded. Hospital A exclusively used MAC and hospital B exclusively used CS. Group A at Hospital A enrolled 259 patients who received deep sedation with propofol as the main anesthetic, which was administered and monitored by an anesthesiologist. Group B at Hospital B enrolled 214 patients who received conscious sedation (CS) using a combination of midazolam and fentanyl administered by the endoscopist. Patient satisfaction surveys were completed once patients were out of sedation and prior to discharge. Results : Pain at drug administration site in group A was 22% as compared to 7% in group B. However, abdominal discomfort and pain was 20.46% in group A which was higher in group B at 32.71%. Interestingly, there was no difference in gagging/choking sensation during EGD in both groups with incidence of 22%. In Group A, 98.06% patient reported adequate pain control in contrast to 89.71% in comparison group B. It was noted that post procedure recovery time from the conscious sedation group was 13.80 minutes as compared to 23.15 minutes in MAC group. Overall patient satisfaction rate was 96.91% in group A and 97.66% in group B. Regarding revisit, 94.59% and 97.66% patients in group A and B respectively, would consider coming back for the next visit. In terms of periprocedural complications, only one patient showed transient respiratory depression in the CS group and was reversed with IV naloxone and flumazenil. Conclusion:This study compares patient satisfaction and periprocedural complications for the use of CS and MAC for common endoscopic procedures. We did not find any statistical differences between the two groups except for less recovery time in the CS group. In the MAC group there is less incidence of abdominal pain or discomfort while CS group has shown less pain at site of drug administration. Overall patient satisfaction and revisit consideration were the same in both groups.

Anesthetic management for oocyte retrieval: An exploratory analysis comparing outcome in in vitro fertilization cycles with and without pre-implantation genetic diagnosis

PURPOSE:To date, there has been no comparison of outcomes in women undergoing anesthesia for in vitro fertilization (IVF) oocyte retrieval for the purpose of pre-implantation genetic diagnosis (PGD) because of their or their partner's genetic disease relative to the outcome in women requiring IVF because of fertility issues.MATERIALS AND METHODS:A prospective observational study, wherein all demographic and anesthetic management data were collected from IVF and PGD units' records for a 6-month period. Descriptive analyses and parametric tests were employed.RESULTS:There were 307 cases IVF and 76 cases PGD: most (97.4% and 99.7%, respectively) received general anesthesia with propofol and fentanyl ± dipyrone (90.5% and 93.3%, respectively) with no adverse effects. The only statistically significant difference between IVF and PGD groups that was potentially clinically significant was post-procedure recovery time (23.0 ± 20.4 vs. 29.4 ± 35.8 min, respectively; P < 0.0001), but is explainable as greater caution by Anesthesiologists for higher-risk PGD cases having autosomal dominant diseases that may impact anesthesia management (myotonic dystrophy, neurofibromatosis, Marfan's); two of these cases also recovered in the general post-anesthesia care unit, as a precaution for early diagnosis and treatment of potential post-procedural complication.CONCLUSIONS:Results of this first-ever survey of anesthesia for PGD compared with IVF cases imply that propofol-and-fentanyl-based anesthesia is safe and can be recommended, bearing in mind that with patients who have autosomal dominant diseases impacting anesthetic management it is prudent to be more cautious post-recovery.

Safety Profile of Endoscopist-Directed Sedation with Propofol in a Community Setting

Purpose: Most endoscopic procedures in the United States(US) are performed using endoscopist- directed benzodiazepines and opioid administration. More recently, deep sedation with Propofol has been used in the US but is generally managed by anaesthesiologists. Compared to conscious sedation, deep sedation with Propofol is associated with lower or comparable rates of adverse events, higher post-procedure patient satisfaction, faster sedation and recovery time. Professional societies have released position statements endorsing the administration of Propofol by non-anesthesiologists. Methods: This is a multicenter retrospective study evaluating data from a total of 5 sites in the community setting in the United States from 01/1999 to 04/2012. All the procedures were elective cases performed by gastroenterologists in an ambulatory surgery unit. All personnel (endoscopist, RN and LPN) involved in the procedure were ACLS certified and educated on Propofol administration, airway management annually by a board certified anesthesiologist. Results: A total of 102,143 procedures (39,450 EGDs and 62,693 colonoscopies) were performed at 5 sites. Most of the patients were ASA class I or II with few being ASA class III. There were no deaths or permanent neurological injuries. There was 1 (0.0009%) cardiac complication. The overall number of cases needing Ambu bag assists were 8 (0.0079%) and transfer for acute care were 4 (0.0039%).Table: [1452] Adverse eventsConclusion: Endoscopist-directed deep sedation with Propofol during elective procedures in a community setting is safe. In ASA I & II patients, Propofol can be safely administered by trained endoscopists and nurses without the presence of an anesthesiologist, which would lead to substantial cost saving.

Nurse-Administered Propofol Sedation for Upper Endoscopic Ultrasonography

Limited data exist regarding the safety of nurse-administered propofol sedation (NAPS) for advanced endoscopy. To evaluate the frequency of and the risk factors for complications associated with NAPS for upper endoscopic ultrasound (EUS). Consecutive upper EUS examinations using NAPS were retrospectively identified. Clinical data and adverse events were recorded. Univariate and multivariable repeated measures logistic regression models were used to identify independent risk factors for complications. Among 806 EUS procedures, the mean procedure duration, time for sedation induction, and postprocedure recovery time were: 34 +/- 20 min, 3.6 +/- 1.4 min, and 27 +/- 23 min, respectively. A decline in systolic blood pressure (SBP) to <90 mm Hg occurred in 104 patients (13%). Six patients (0.7%) had a decline in oxygen saturation (SpO(2)) to <90%. Four patients (0.5%; 95% confidence interval [CI] 0.14-1.27) required assisted positive pressure ventilation. There were no major complications. The minor complication rate from sedation was 21% (95% CI 17.2-25.3). All of the complications were clinically insignificant. Overall complication risk was not related to age, dose, or procedure time. Sedation-related complication rates for advanced experience-level (> or =100 NAPS procedures) nurses were lower compared to the least-experienced (< or =30 NAPS procedures) nurses (17.2%vs 25.4%, odds ratio [OR] 0.61, 95% CI 0.41-0.92). NAPS for upper EUS is safe and may be performed without major complications. Four patients (0.5%) required assisted ventilation. Minor complications occurred in 21% of patients, but were not associated with patient age, propofol dose, or procedure time.

Embolization as first-line therapy for diverticular massive lower gastrointestinal bleeding: Evidence from a meta-analysis

Objective. To determine which etiologies of lower gastrointestinal bleeding (LGIB) may best be treated with super-selective embolization. Methods. A meta-analysis was undertaken of all 25 identified publications reporting the use of embolization and 12 consecutive cases of LGIB from the authors’ institution. Seven series met selection criteria for further analysis. Results. Multiple regression analysis demonstrated no significant difference in pooled outcomes when varying the included study, age, or embolization method on the outcome of rebleeding. The pooled odds ratio for rebleeding up to 30 days postlocalization and embolization for arteriovenous malformations (AVM) and other diseases was 3.53 compared to re-bleeding after localization and embolization for diverticular disease [95% Confidence Interval OR (1.33, 9.41), P < 0.01]. Embolization for diverticular bleeding demonstrated was successful in 85% of cases. Moreover, the vast majority of cases that rebled did so within 48 h. In contrast, rebleeding after embolization for nondiverticular bleeding occurred in greater than 40% of cases and over a more protracted period. Conclusion. Embolization for LGIB is most effective for the treatment of diverticular bleeding. Given the low observed complication rate, minimal post-procedure recovery time, and low failure rate, super-selective embolization may be considered first-line therapy for severe diverticular LGIB regardless of age. Caution should be used when applying embolization therapy for non-diverticular causes due to the considerably higher associated failure rate.

PGI3: A PROSPECTIVE, RANDOMIZED COST ANALYSIS OF MEPERIDINE AND MIDAZOLAM VERSUS PROPOFOL FOR COMPLEX UPPER ENDOSCOPY PROCEDURES

OBJECTIVES: Meperidine/midazolam (M/M) and propofol (P) are clinically effective alternatives for sedation during endoscopic procedures. Propofol has a higher acquisition cost, but may be associated with cost savings due to shorter duration of post-procedure care. The objective of this project was to compare the costs associated with complex upper endoscopic procedures (ERCP/EUS) in subjects who received either M/M or propofol. METHODS: Subjects scheduled for ERCP/EUS were randomized to receive M/M or P during the procedure. A blinded observer assessed time to recovery using a standard 10-point postanesthesia recovery score (PARS) every 15 minutes. Once a PARS score of 10 was reached, the study terminated and the subject was discharged from the recovery ward. The cost of drug (source: Redbook), an anesthetist for the propofol group (source: Bureau of Labor Statistics), recovery room personnel costs (source: Bureau of Labor Statistics), and overhead costs were compared from the institutional perspective. A sensitivity analysis was performed by assuming generic drug, a nurse anesthetist, and licensed practical nurse (LPN) care in the recovery ward. RESULTS: 33 and 31 subjects were randomized to receive M/M and P, respectively. There were no significant differences detected between the groups in age, gender, case severity, or procedure duration. P group subjects had a significantly shorter post-procedure recovery time (19 minutes) compared with M/M group subjects (71 minutes, p < 0.001). Subjects in the M/M group cost an average of $65 per case, while P group subjects cost an average of $144 per case (p < 0.001). The sensitivity analysis resulted in an average cost of $77 per case in the P group and $34 in the M/M group (p < 0.001). CONCLUSIONS: Subjects in the P group had a significantly shorter post-procedure recovery time but this did not result in cost savings compared with subjects treated with M/M.