Sedation For Endoscopy Research Articles

The effect of pre-procedure anxiety on sedative requirements for sedation during upper gastrointestinal endoscopy.

Sedation for upper gastrointestinal endoscopy, commonly used for diagnosis and treatment of gastrointestinal diseases, has been increasing widespread. Sedative agent requirements during sedation or anesthesia can be affected by many factors such as age and sex. In the present study, we aimed to evaluate the effects of pre-procedural anxiety levels on sedative requirements during upper gastrointestinal endoscopy. 300 patients between the ages of 18-70 years were studied. Baseline anxiety levels were measured before the procedure using Spielberger's State-Trait Anxiety Inventory (STAI) form X1. Propofol was administered to have BIS values between 65-85 during sedation. Doses of propofol, total procedure time, satisfaction of the patients and endoscopists and BIS values were recorded. Pre-procedural anxiety was 44 (40-48 [20-70]). We found significant correlations between pre-procedure anxiety and the usage of propofol (mg, mg/kg, mg/kg/dk) at BIS values between 65-85, [respectively, (p= 0.451, p <0.001), (p= 0.455, p <0.001), (p= 0.428, p <0.001)]. No correlation was found between pre-procedure anxiety and procedural or sedation complications (respectively p= 0.111, p= 0.424 and p= 0.408, p= 0.363). We found significant negative correlations between pre-procedure anxiety and the satisfaction of the patients/endoscopist [respectively, (p= -0.477, p <0.001), (p= -0.495, p <0.001)]. Based on the results of this study, we suggest that there is a significant association between the pre-procedural anxiety levels and use of sedative drugs in patients undergoing upper gastrointestinal endoscopy.

Clinical decision support system, using expert consensus-derived logic and natural language processing, decreased sedation-type order errors for patients undergoing endoscopy.

Determination of appropriate endoscopy sedation strategy is an important preprocedural consideration. To address manual workflow gaps that lead to sedation-type order errors at our institution, we designed and implemented a clinical decision support system (CDSS) to review orders for patients undergoing outpatient endoscopy. The CDSS was developed and implemented by an expert panel using an agile approach. The CDSS queried patient-specific historical endoscopy records and applied expert consensus-derived logic and natural language processing to identify possible sedation order errors for human review. A retrospective analysis was conducted to evaluate impact, comparing 4-month pre-pilot and 12-month pilot periods. 22755 endoscopy cases were included (pre-pilot 6434 cases, pilot 16321 cases). The CDSS decreased the sedation-type order error rate on day of endoscopy (pre-pilot 0.39%, pilot 0.037%, Odds Ratio = 0.094, P-value < 1e-8). There was no difference in background prevalence of erroneous orders (pre-pilot 0.39%, pilot 0.34%, P = .54). At our institution, low prevalence and high volume of cases prevented routine manual review to verify sedation order appropriateness. Using a cohort-enrichment strategy, a CDSS was able to reduce number of chart reviews needed per sedation-order error from 296.7 to 3.5, allowing for integration into the existing workflow to intercept rare but important ordering errors. A workflow-integrated CDSS with expert consensus-derived logic rules and natural language processing significantly reduced endoscopy sedation-type order errors on day of endoscopy at our institution.

Implementing Sleep Apnea Screening Prior to Conscious Sedation Procedures in a Rural Hospital: A Quality Improvement Project.

Screening patients for obstructive sleep apnea (OSA) risk factors is an effective method for helping reduce adverse outcomes in conscious sedation. Patients receiving conscious sedation for endoscopy were not being screened for OSA at a rural hospital. The purpose of this quality improvement project was to implement a nurse education program to improve OSA screening of endoscopy patients, using an evidence-based screening tool, and to increase nurse OSA knowledge and patient education. This study was conducted in the outpatient perioperative section of a small rural hospital in northern Michigan. Data were obtained from pre/post chart review and nurse knowledge assessment. Twenty-eight nurses participated in an educational session that included OSA education and instructions on using the STOP-Bang questionnaire for OSA screening. Nurse OSA knowledge increased from 75% preeducation program to 89% posteducation program. Use of the STOP-Bang Questionnaire for patients presenting for outpatient endoscopy procedures requiring conscious sedation and patient OSA education increased from 43.5% to 81.2% pre- to posteducation program. This study's educational session was successful in promoting use of the STOP-Bang questionnaire among perioperative nurses and increasing education for patients screened positive for OSA. Training nurses to use a brief OSA screening tool effectively improved the OSA screening of patients presenting for outpatient conscious sedation involving endoscopy.

A focused ethnography of how endoscopy practitioners utilize capnography in sedated patients

The literature shows that respiratory complications are common with sedation. Given the inherent risk, capnography monitoring is recommended whenever sedation is administered. We aimed to explore sedation practitioners’ behavior patterns and perceptions regarding capnography monitoring during endoscopy sedation and examine how capnography influenced clinical decision making when assessing respiration. We conducted a focused ethnography with triangulated observations and semi-structured interviews, and we purposively sampled and recruited five sedation practitioners as participants at a hospital in Saudi Arabia. Through data analysis, we identified representative themes and found cultural differences between anesthesia practitioners and nurses when using capnography during sedation. Anesthesia practitioners linked safety and the use of capnography to maintain adequate respiration, while nurses believed capnography was a secondary supportive monitor to patient observation and assessment. Findings also captured the unique cultures and values of each professional group to be associated with the varying perceptions. We also identified several factors facilitating and barring adequate utilization of capnography. In conclusion, professional culture, hospital policy, knowledge and previous experience with capnography guided the monitoring practice of endoscopy practitioners when assessing respiration during sedation.

Outcomes of a Swallowable Intragastric Balloon (Elipse™) on 96 Overweight and Obese Patients.

The traditional gastric balloons have been used for several years to reduce weight in overweight and obese patients, but the need for sedation and upper endoscopy leading to several limitations. The current series is the first study that evaluates the safety and effectiveness of the swallowable gastric (Elipse™) balloon in our population on the national level. Ninety-six patients (mean BMI was 33.6 ± 4.3kg/m2) participated in this study. All patients swallowed one Elipse™ balloon intended to remain in the stomach for 4months, self-empty, and then pass. Each balloon was filled with 550mL of filling fluid. Anti-emetics and anti-spasmodic drugs were prescribed for 2-3days after insertion; proton pump inhibitor was prescribed twice daily 1week before the procedure and continued until the end of residence time (16-20weeks). In the current series, at end of the procedure (after 4months), the overall mean weight loss (WL) was 11.2 ± 5.1kg, mean waist circumference reduction was 10.9 ± 2.1cm, and a mean BMI reduction was 4.9 ± 2.0kg/m2. The percentage of total body weight loss (TBWL%) was 12.1 ± 5.2%. The Elipse™ therapy reported improvements in the metabolic parameters investigated. This swallowable gastric balloon (Elipse™) can be safely and successfully swallowed, filled, imaged, and passed with accepted weight loss and clinical improvement in factors related to the metabolic syndrome.

Safety of balanced propofol and midazolam in upper gastrointestinal endoscopy for sedation in cirrhotic patients.

Sedation for upper gastrointestinal endoscopy (UGIE) in patients with cirrhosis is theoretically associated with high incidence of adverse events due to low levels of binding proteins and decreased hepatic clearance of drugs. The objective of the study was to assess the safety of combined propofol and midazolam sedation in cirrhotic patients undergoing UGIE. A total of 500 patients undergoing UGIE were divided in to two groups in a prospective observational study from Jan 1st 2018 to June 30th 2018. Group (I) consisted of cirrhotic patients who underwent the procedure with sedation and Group (II) consisted of non-cirrhotic patients who opted for sedation. The main outcome measurements included vitals monitoring before, during and after procedure, total sedation dose, time to initial and deep sedation, recovery time and complications. There was no significant difference between sedation safety and rate of complications for the cirrhotic and non-cirrhotic patients except for the recovery period during initial 10 minutes. The Modified Aldrete score for the cirrhotic patients was 9.5±0.5 min as compared to 9.8±0.4 min for non-cirrhotic patients (p<0.001) at 10 minutes. Grade 2 hepatic encephalopathy was seen in 0.8% of the cirrhotic patients who required hospitalization for 24 hours. Also balanced sedation was acceptable by the patients and the endoscopists equally with statistically significant scores on endoscopist's assessment of co-operation and assessment of patient's satisfaction scores. Balanced propofol and midazolam sedation has a good index of safety for both cirrhotic and non-cirrhotic patients and is acceptable by the patients and endoscopists equally.

Oxygenation before Endoscopic Sedation Reduces the Hypoxic Event during Endoscopy in Elderly Patients: A Randomized Controlled Trial.

Background: Sedation endoscopy increases patient and examiner satisfaction but involves complications. The most serious complication is hypoxia, the risk factors for which are old age, obesity, and American Society of Anesthesiologists physical status of 3 or greater. However, clear evidence of oxygenation during sedation endoscopy for elderly people is lacking in US, European, and Korean guidelines. Method: This study was conducted for 1 year starting in August 2018 to evaluate whether pre-oxygenation use 1 min before sedation endoscopy could reduce the incidence of hypoxia in patients older than 65 years of age. A total of 70 patients were divided into the non-oxygenated group (n = 35; control group) and oxygen-treated group (n = 35; experimental group) during endoscopy. Result: The incidence of hypoxia was 28 (80%) in the control group versus 0 (0%) in the pre-oxygenated group. Factors related to hypoxia in the non-oxygenated group were a relatively high dose of midazolam and concomitant injection with narcotic analgesics such as pethidine. Conclusion: The incidence of hypoxia during sedation endoscopy is high in patients over 65 years, but oxygenation during endoscopic sedation in elderly people can significantly reduce the incidence of intraprocedural hypoxic events.

Impact of endoscopic sedation on gastric polyp detection: A one-center retrospective observational study.

Sedation esophagogastroduodenoscopy (EGD) has become more prevalent in many countries. However, owing to the limitation of health insurance payment for sedation EGD in Taiwan, non-sedation EGD still accounts for the majority of cases. This study was aimed to explore the differences between the sedation and non-sedation groups in terms of endoscopic findings, such as detection rate of gastric polyp of any size, number of detected gastric polyps, and location of the gastric polyps detected.We enrolled 10,940 patients who underwent EGD between January 1, 2016 and December 31, 2016 at the Tri-Service General Hospital; among the patients, 1900 received intravenous sedation (IVS) and 9040 did not. The data reviewed included demographics, parameters of the polyp (number, size, and location), and pathology.Compared with the non-sedation group, the sedation group had a higher overall polyp detection rate (P < .001); a greater number of detected polyps (Odds ratio 1.50, P = .007); and a higher detection rate of smaller polyps, such as fundic gland polyp, and hyperplastic polyp (P < .001). Among the pathological findings, gastric neuroendocrine tumor (NET) was detected using EGD in 2 cases and manifested as small polyps (<0.05 cm), and it showed significantly better detection rates in the sedation EGD group than in the non-sedation EGD group (P = .002).Sedation EGD could enhance a patients willingness and cooperation during EGD. Furthermore, sedation EGD increased the detection rates of small gastric polyps and was more likely to enable identification of unusual findings, such as gastric NET.

Nurse-Administered Propofol Continuous Infusion Sedation: A New Paradigm for Gastrointestinal Procedural Sedation.

Nurse-Administered Propofol Continuous Infusion Sedation (NAPCIS) is a new nonanesthesia propofol delivery method for gastrointestinal endoscopy. NAPCIS is adopted from the computer-assisted propofol sedation (CAPS) protocol. We evaluated the effectiveness, efficiency, and safety of NAPCIS in low-risk subjects. Between December 2016 and July 2017, patients who underwent esophagogastroduodenoscopy or colonoscopy with NAPCIS at our center were compared against 2 historical control groups of similar patients who had undergone procedures with CAPS or midazolam and fentanyl (MF) sedation. The mean age of the NAPCIS cohort (N = 3,331) was 55.2 years (45.8% male) for 945 esophagogastroduodenoscopies and 57.8 years (48.7% male) for 2,386 colonoscopies. The procedural success rates with NAPCIS were high (99.1%-99.2%) and similar to those seen in 3,603 CAPS (98.8%-99.0%) and 3,809 MF (99.0%-99.3%) controls. NAPCIS recovery times were shorter than both CAPS and MF (24.8 vs 31.7 and 52.4 minutes, respectively; P < 0.001). On arrival at the recovery unit, 86.6% of NAPCIS subjects were recorded as "Awake" compared with 82.8% of CAPS and 40.8% of MF controls (P < 0.001). Validated clinician and patient satisfaction scores were generally higher for NAPCIS compared with CAPS and MF subjects. For NAPCIS, there were only 4 cases of oxygen desaturation requiring transient mask ventilation and no serious sedation-related complications. These low complication rates were similar to those seen with CAPS (8 cases of mask ventilation) and MF (3 cases). NAPCIS seems to be a safe, effective, and efficient means of providing moderate sedation for upper endoscopy and colonoscopy in low-risk patients.

S0524 Safety Profile of Endoscopist-Directed Balanced Propofol Sedation for Procedural Sedation: An Experience at a Hospital-Based Endoscopy Unit

INTRODUCTION: Nurse administered propofol sedation was widely used for endoscopic procedures until 2009 when its use was restricted to anesthesiologists per CMS guidelines, a practice that has led to increases in healthcare costs. Aim was to evaluate the safety of endoscopist-directed balanced propofol sedation (EDBPS) for endoscopy. METHODS: We identified patients who underwent endoscopic procedures with EDBPS from Jan to Jun 2017. Medical records were abstracted for data on procedure indication, medication doses, time to induction of sedation, duration of procedure and recovery time. Adverse events (AEs) included: Hypoxia - oxygen saturation (SPO₂) 50 mm Hg, c) Drop in mean arterial pressure (MAP) > 30%; Bradycardia (heart rate < 40 beats/minute). Major complications include death, neurologic sequelae (CVA, permanent cognitive impairment), and need for hospitalization or endotracheal intubation. RESULTS: A total of 1897 patients received EDBPS during the study period. Mean age was 55 (SD 11.4) years and 43.6% were men. Patients received median doses of 50 mcg fentanyl and 2 mg of midazolam and a mean propofol dose of 160 ± 99 mg (range 20–960). Mean time for sedation induction was 3.4 (SD 1.9) and mean recovery was 14 (SD 10.2) min. There were no major complications (0%; 95% CI, 0–0.19%). Three hundred thirty-four patients (17.6%) experienced an AE, all of which were managed with simple measures (chin-lift, jaw thrust and increasing flow of O₂ and IV fluids): 65 (3.4%) had transient hypoxia, 277 (14.6%) had hypotension. In bivariate analysis, a 5-yr increase in patient age was associated with in increased risk of hypotension. A 50 mg increase in propofol dose was associated with a statistically significant risk of transient hypoxia. A 10-min increase in procedure duration was associated with statistically significant risk of both transient hypoxia and hypotension (Table 1). Age, weight, BMI, propofol dose and procedure length were associated with AEs (Table 2). Gender had no association with AEs. In multivariate analysis, only procedure length was independently associated with AEs. CONCLUSION: EDBPS is safe for endoscopic procedural sedation, as AEs occurred infrequently. Given the much higher cost of anesthesia-administered propofol for routine endoscopic procedures, endoscopists should re-instate EDBPS by revising institutional sedation policies.Table 1Table 2

S3175 Gastrointestinal Bleeding and Endoscopic Evaluation Within 90 Days of Acute Cardiac Event

INTRODUCTION: Patients are at increased risk of gastrointestinal bleeding (GIB) after acute coronary syndrome (ACS). The diagnosis and management of GIB in this setting is challenging as the risk of endoscopic intervention and sedation increases after ACS. The risk of sedation increases multifold with increasing ASA status. Re-vascularization of coronary lesions via stenting or CABG should theoretically decrease this risk by restoring blood flow to the ischemic myocardium. Data regarding safety of endoscopic evaluation before and after a myocardial infarction remains sparse in the literature. METHODS: We reviewed the chart of a sample of 119 patients admitted for GIB within 90 days before and after an ACS event between 2008 and 2019. Patients were identified through ICD billing codes for myocardial infarction, angina, and GIB. We collected data on 61 of these patients who met the inclusion criteria for this study. Descriptive statistics was used to tabulate the findings. RESULTS: Our cohort included 41 men (67%) with an average age of 71 +/- 23.2 years. 32 patients (52%) were receiving dual anti-platelet therapy at the time of GIB and 16 (26%) were receiving anticoagulation at the time of bleeding. Majority of these patients, 49 (80%) underwent endoscopic evaluation within 3 months after cardiac event, while 8 patients (13%), underwent endoscopic evaluation within 3 months prior to ACS. A source of bleeding could be identified in 36 (59%) of patients with 16 (26%) exhibiting signs of active bleeding or stigmata of recent bleeding at the time of evaluation. 22 (37%) patients were diagnosed with peptic ulcer disease, while angioectasias were the second most common finding. Rebleeding was observed in 9 (15%) of patients with all but one occurring in the first month after the incident bleed. At least 4 patients did not undergo evaluation for GIB given cardiac arrest, refractory cardiogenic shock and anticipated imminent death. All-cause mortality was 18% at 1 year, however, none of the deaths occurred during or within 24 hrs of endoscopic evaluation and all were attributed to non-GI causes. CONCLUSION: GIB occurs commonly in patients after ACS often in a setting of anti-platelet, anti-coagulant therapy. While endoscopic evaluation is high risk after ACS, it remains safe in most patients following appropriate revascularization. However, mortality in patients with ACS and GIB is high within 1 year of the events, mostly attributed to non-GI etiology.Table 1Table 2

Nurse-Administered Propofol Continuous Infusion Sedation for Gastrointestinal Endoscopy in Patients Who Are Difficult to Sedate

Patients who chronically use alcohol, marijuana, or opioids, or suffer from post-traumatic stress disorder (PTSD), can be difficult to sedate with midazolam and fentanyl, and often are referred for monitored anesthesia care during endoscopy. Nurse-administered propofol continuous infusion sedation (NAPCIS), which confers the benefit of propofol-based sedation without the added expense of anesthesia, is effective and safe for sedation of healthy patients. We investigated whether NAPCIS also is effective for patients who are difficult to sedate. We performed a retrospective study of patients who underwent upper endoscopy or colonoscopy with NAPCIS at a single center from January 2018 through April 2018. We reviewed records from patients who were heavy users of alcohol (n= 105), daily users of marijuana (n= 267) or opioids (n= 178), had a diagnosis of PTSD (n= 91), or were none of these (controls, n= 786). We compared mean fentanyl and propofol doses (adjusted for body weight), procedure and recovery times, procedure success rates, and adverse events. Compared with the controls, the marijuana group required higher mean adjusted sedative doses for colonoscopies (0.6 vs 0.4 mcg/kg fentanyl and 5.0 vs 4.7 mg/kg propofol; P ≤ .025 for both) and upper endoscopies (0.8 vs 0.3 mcg/kg fentanyl and 3.7 vs 3.2 mg/kg propofol; P ≤ .021 for both), the PTSD group required a higher dose of fentanyl for colonoscopies (0.6 vs 0.4 mcg/kg; P= .009), and the alcohol group required a higher dose of fentanyl for upper endoscopies (0.7 vs 0.3 mcg/kg; P < .001). Procedure success rates were high (95.1%-100%) and did not differ significantly between the difficult-to-sedate groups and controls; mean procedure times (7.0-9.0 minutes for upper endoscopies, 21.1-22.9 minutes for colonoscopies) and recovery times (22.5-29.6 minutes) also were similar among groups. Upper endoscopies were associated with lower sedative doses and shorter procedure and recovery times than colonoscopies. Sedation-related adverse events were rare in all groups (only 26 cases total), and there were no serious complications or deaths. NAPCIS seems to be a safe and effective means of providing sedation for endoscopy to patients who may be difficult to sedate owing to alcohol, marijuana, or opioid use, or PTSD.

Endoscopist-directed propofol is more efficient than anesthesiologist-administered propofol in patients at low-intermediate anesthetic risk.

Endoscopist-directed propofol (EDP) sedation is becoming more popular, with a reported safety and efficacy similar to anesthesiologist-administered propofol (AAP). The aim of this study is to compare the efficiency of EDP and AAP in patients of low-intermediate anesthetic risk. A prospective cost-effectiveness comparison study was conducted. The costs of the endoscopic procedures in the EDP and AAP group were calculated using the full cost methodology after breaking down the endoscopic activity into relative value units to allocate costs in an equitable way. To determine the effectiveness, adverse events related to endoscopic sedation and the number of incomplete procedures were registered for the EDP group and compared with those published by anesthesiologists for AAP. A total of 1165 and 18 919 endoscopic procedures were, respectively, included in the EDP and AAP groups. The average costs of EDP vs. AAP for gastroscopy, colonoscopy and endoscopic ultrasound were &OV0556; 182.81 vs. &OV0556; 332.93, &OV0556; 297.07 vs. &OV0556; 459.76, and &OV0556; 319.92 vs. &OV0556; 485.12, respectively. No significant differences were detected regarding the rate of overall adverse events (4.43 vs. 4.46%) or serious adverse events (0 vs. 0.17%); the rate of arterial hypotension was significantly lower in the EDP group: 0.34 vs. 1.78% [odds ratio (OR), 0.19; 95% confidence interval (CI), 0.08-0.46] and the desaturation rate was significantly lower in the AAP group: 3.26 vs. 1.29% (OR, 2.58; 95% CI, 1.85-3.60). No significant differences were found in terms of incomplete examinations (0.17 vs. 0.14%). In patients with low-intermediate anesthetic risk referred for an endoscopic examination, EDP appears to be more efficient than AAP.

Depth of sedation during drug induced sedation endoscopy monitored by BiSpectral Index® and Cerebral State Index®.

Drug induced sedation endoscopy (DISE) is performed to investigate patterns and sites of obstruction in patients with sleep-disordered breathing (SDB). During DISE the patients are sedated to obtain a muscular relaxation of the upper airway which mimics the relaxation during natural sleep. Different sleep stages are intended to be simulated by drug induced sedation, and it is helpful to measure the depth of sedation. The BiSpectral Index® (BIS) is often used for this procedure. Besides the BIS, other means of sedation depth monitoring exist in anaesthesiology but have not yet been investigated with respect to DISE. Monitoring of the Cerebral State Index® (CSI) is one of these methods. The aim of the study was to compare the BIS and CSI for sedation depth monitoring during DISE. Sixty patients underwent DISE monitored by the BIS and CSI in parallel. The BIS and CSI values were compared using the Bland-Altman analysis. The BIS and CSI values differed during the course of sedation during DISE by a mean of - 6.07. At light sedation (BIS 60-80), lower values by 10 scale points of CSI compared with BIS were detectable. At deeper sedation levels (BIS 40-50), the CSI turned to present equal and even higher values compared with the BIS. Sedation depth measurement during DISE can be performed by the BIS or CSI, but the differences should be interpreted carefully as comparable data for sleep stages in natural sleep are available only for BIS.

A novel algorithm to predict oxygen desaturation in sedated patients with obstructive sleep apnea utilizing polysomnography: A STROBE-compliant article.

This retrospective study aimed at identifying the predictors of oxygen desaturation (OD) (i.e., SpO2 < 95%) in patients with obstructive sleep apnea (OSA) requiring deep sedation and developing an algorithm to predict OD.We studied 66 OSA patients undergoing propofol-induced deep sedation for drug-induced sleep endoscopy (DISE). The patients were divided into prediction (n = 35) and validation (n = 31) groups. Patient characteristics and polysomnographic parameters were analyzed with receiver operating characteristic curve and Chi-squared test to identify significant predictors of OD for developing an algorithm in the prediction group. The predictive accuracy, sensitivity, positive predictive value, and negative predictive value of the algorithm were determined in the validation group.Six polysomnographic predictors of OD were identified, including Apnea-Hypopnea Index of total sleep time (AHI-TST), AHI at the stage of rapid eye movement (AHI-REM), percentage of time with oxygen saturation <90% (mO2 < 90%), average SpO2, lowest SpO2, and desaturation index. Stepwise multiple logistic regression analysis demonstrated that low average SpO2 (<95.05%) and high AHI-REM (>16.5 events/h) were independent predictors of OD. The algorithm thus developed showed that patients with an average SpO2 < 95.05% and those with an average SpO2 ≥ 95.05% together with an AHI-REM > 16.5 events/h would be at risk of OD under sedation. The predictive accuracy, sensitivity, positive predictive value, and negative predictive value were 84%, 100%, 83%, 100%, respectively.For patients with OSA, average SpO2 and AHI-REM may enable clinicians to predict the occurrence of oxygen desaturation under deep sedation. Future large-scale studies are needed to validate the findings.

Prospective audit of the safety of endoscopist-directed nurse-administered propofol sedation in an Australian referral hospital.

Endoscopist directed nurse administered propofol sedation (EDNAPS) is widely considered to be safe and efficient, but there are limited data from the Australian health-care setting, and Australian sedation guidelines do not support the practice. Thus, we report data from a prospective audit of EDNAPS over a 6.5-year period in an Australian referral hospital. Consecutive endoscopic procedures performed between January 2013 and June 2019. Sedation protocol was an initial dose of midazolam 1-3mg intravenously (i.v.) and propofol 10-50mg i.v.. Further aliquots of propofol 10-30mg i.v. were given as required. ProvationMD® endoscopic reporting system was used to prospectively record patient demographics, medication and dose, American Society of Anesthesiologist's (ASA) class, and sedation-related complications. During the 78-month period, 28051 eligible procedures were performed; 3093 procedures performed with anesthetic support or without EDNAPS were excluded. In total, 24958 procedures with EDNAPS were analyzed including 7563 gastroscopies, 12941 colonoscopies, 2932 gastroscopy and colonoscopy, 1440 flexible sigmoidoscopies, and 82 combined gastroscopy and flexible sigmoidoscopy. Of these, 9539 were ASA 1 (38.2%), 13680 were ASA 2 (54.8%), 1733 were ASA 3 (6.9%), and 4 were ASA 4 (0.02%). Sedation-related complications occurred in 66 patients (0.26%), predominantly transient hypoxic episodes. No patient required intubation for an airway emergency, and there was no sedation-related mortality. Sedation-related complications increased with ASA class and were significantly more common with gastroscopy. Endoscopist directed nurse administered propofol sedation is a safe way of performing endoscopic sedation in low-risk patients in the hospital setting.

Improving safety and reducing error in endoscopy (ISREE): a survey of UK services

BackgroundThe Joint Advisory Group on Gastrointestinal Endoscopy (JAG) ‘Improving Safety and Reducing Error in Endoscopy’ (ISREE) strategy was developed in 2018. In line with the strategy, a survey was conducted...

Propofol vs midazolam sedation for elective endoscopy in patients with cirrhosis: A systematic review and meta-analysis of randomized controlled trials

BACKGROUNDPatients with cirrhosis frequently require sedation for elective endoscopic procedures. Several sedation protocols are available, but choosing an appropriate sedative in patients with cirrhosis is challenging.AIMTo conduct a systematic review and meta-analysis to compare propofol and midazolam for sedation in patients with cirrhosis during elective endoscopic procedures in an attempt to understand the best approach.METHODSThis systematic review and meta-analysis was conducted using the PRISMA guidelines. Electronic searches were performed using MEDLINE, EMBASE, Central Cochrane, LILACS databases. Only randomized control trials (RCTs) were included. The outcomes studied were procedure time, recovery time, discharge time, and adverse events (bradycardia, hypotension, and hypoxemia). The risk of bias assessment was performed using the Revised Cochrane Risk-of-Bias tool for randomized trials (RoB-2). Quality of evidence was evaluated by GRADEpro. The meta-analysis was performed using Review Manager.RESULTSThe search yielded 3,576 records. Out of these, 8 RCTs with a total of 596 patients (302 in the propofol group and 294 in the midazolam group) were included for the final analysis. Procedure time was similar between midazolam and propofol groups (MD: 0.25, 95%CI: -0.64 to 1.13, P = 0.59). Recovery time (MD: -8.19, 95%CI: -10.59 to -5.79, P < 0.00001). and discharge time were significantly less in the propofol group (MD: -12.98, 95%CI: -18.46 to -7.50, P < 0.00001). Adverse events were similar in both groups (RD: 0.02, 95%CI: 0-0.04, P = 0.58). Moreover, no significant difference was found for bradycardia (RD: 0.03, 95%CI: -0.01 to 0.07, P = 0.16), hypotension (RD: 0.03, 95%CI: -0.01 to 0.07, P = 0.17), and hypoxemia (RD: 0.00, 95%CI: -0.04 to 0.04, P = 0.93). Five studies had low risk of bias, two demonstrated some concerns, and one presented high risk. The quality of the evidence was very low for procedure time, recovery time, and adverse events; while low for discharge time.CONCLUSIONThis systematic review and meta-analysis based on RCTs show that propofol has shorter recovery and patient discharge time as compared to midazolam with a similar rate of adverse events. These results suggest that propofol should be the preferred agent for sedation in patients with cirrhosis.

High-flow nasal cannula vs standard respiratory care in pediatric procedural sedation: A randomized controlled pilot trial.

Respiratory instability is frequently observed during pediatric procedural sedation. The aim of this trial was to estimate the impact of high-flow nasal cannula (HFNC) therapy on respiratory stability during sedation for upper gastrointestinal tract endoscopy in children. Prospective randomized controlled non-blinded single-center pilot trial. Children were randomly allocated to receive either HFNC (2 L/kg/min) or low-flow nasal oxygen cannula (LFNC, standard care). FiO2 was titrated to maintain SpO2 94% to 98% in both groups. Primary outcome was the number of events of respiratory instability defined by prespecified criteria (hypoxia, hypercapnia, apnea). Secondary outcomes included type and duration of events, number of interventions to regain respiratory stability and cumulative doses of medication. Fifty children (mean age, 12.3 ± 3.1 years) were enrolled and treated with HFNC (n = 25) or LFNC (n = 25). Patient and intervention characteristics were not different in the two study groups, including total oxygen flow rate. Mean (SD) number of respiratory events in the HFNC group was 2.0 ± 1.9 events compared to 2.0 ± 1.4 events in the LFNC group (P = .65; 95% CI of difference, -1.0 to 1.0). There was no difference for any secondary outcome criteria, percentage of patients for any outcome criteria and no difference in the number of respiratory events or airway management maneuvers per patient between treatment groups. HFNC did not increase respiratory stability in sedated children undergoing upper gastrointestinal tract endoscopy compared to LFNC.

Neurologic Safety of Etomidate-Based Sedation during Upper Endoscopy in Patients with Liver Cirrhosis Compared with Propofol: A Double-Blind, Randomized Controlled Trial.

(1) Background: Although etomidate-based sedation is an effective and safe protocol in endoscopic procedures, there is a lack of evidence regarding the safety of etomidate in patients with liver cirrhosis (LC). This study aimed to compare the neurologic safety and efficacy of etomidate and propofol for endoscopic sedation in patients with LC. (2) Methods: From December 2017 to December 2019, consecutive cirrhotic patients who underwent sedative endoscopy using either etomidate or propofol were randomly recruited. The primary endpoint was the number connection test (NCT), and the secondary endpoints included factors for the safety of sedatives during endoscopy. (3) Results: 63 patients were enrolled in each of the etomidate and propofol groups. The NCT times were significantly lower in the etomidate group than in the propofol group. Furthermore, severe or very severe degree of encephalopathy was higher in the propofol group but was not significantly different. Pharmacological properties and the overall incidence of respiratory and cardiovascular events did not differ significantly between the groups. (4) Conclusion: Etomidate-based sedation exacerbates neither subclinical nor overt hepatic encephalopathy. It guarantees efficacies similar to those of propofol regarding rapid sedation, fast recovery, and early discharge, with no increased risk of adverse respiratory or cardiovascular events in patients with LC.