Prevalence and clinical significance of left atrial spontaneous echo contrast detected by transesophageal echocardiography

The prevalence and clinical significance of left atrial spontaneous echo contrast (SEC) were studied in patients undergoing transesophageal echocardiography (TEE). The study group included 290 consecutive patients (186 male and 104 female, aged 17-86 years, mean age 56.1 +/- 12.8 years). Left atrial SEC was found in 50 (17.2%) patients, and was significantly associated with atrial fibrillation, mitral stenosis, absence of mitral regurgitation, and left atrial dimension. Atrial fibrillation was recorded in 44 (88%) patients, mitral stenosis or mitral valve replacement in 21 (42%) patients, and left atrial thrombus or previous embolism in 23 (46%) patients with SEC. Univariate analysis showed a significant association between the presence of SEC and atrial fibrillation, mitral stenosis or mitral valve replacement, and left atrial size. Multivariate analysis showed the presence of left atrial SEC and atrial fibrillation to be independent factors for thrombus formation and/or thromboembolism. Since left atrial SEC associated with atrial fibrillation, left atrial enlargement, mitral stenosis, or mitral valve prosthesis was found in 17.2% of patients undergoing TEE, it might be considered a marker of left atrial thrombus or previous thromboembolism.     

Midazolam versus diazepam for combined esophogastroduodenoscopy and colonoscopy

This study compares the effects of two different benzodiazepines used for conscious sedation during combined upper gastrointestinal endoscopy (EGD) and colonoscopy. Subjects were assessed for their degree of analgesia and amnesia for the procedure, prior experience with endoscopy, and willingness to undergo another similar procedure should such be necessary. The patients were randomized single blind to receive either midazolam or diazepam for their preprocedure sedation. The amount of preprocedure sedation utilized was determined by titration of the dose to achieve slurring of speech. Prior to receiving either agent, the subjects were shown a standard card containing pictures of 10 common objects, were asked to name and remember them, and were told they would be quizzed (at 30 min and 24 hr) after being sedated for their recollection as to the objects pictured on the card. Each subject filled out a questionnaire addressing their perceived discomfort during the endoscopic procedure and their memory of the procedure 24 hr after the procedure. Sixty-three percent of the midazolam-sedated subjects reported total amnesia for their colonoscopy vs 20% of diazepam-sedated patients (P<0.001). Fifty-three percent of midazolam-sedated patients reported total amnesia of their upper gastrointestinal endoscopy vs only 23% of diazepam-sedated subjects (P<0.05). The midazolam-sedated subjects reported experiencing less pain with both upper gastrointestinal endoscopy (P<0.05) and colonoscopy (P<0.001) than did the diazepam-sedated group. Most importantly, the midazolam group was more willing to undergo another similar endoscopic procedure should they be asked to do so by their physician (P<0.05). Subjects greater than 60 years of age required significantly less midazolam for sedation than did the younger subjects (P<0.001). This difference in dosing based upon age was not observed in the diazepam-sedated group. Based upon these data we conclude that midazolam is superior to diazepam in producing conscious sedation for combined upper gastrointestinal endoscopy and colonoscopy with regard to: (1) amnesia for the procedures, (2) discomfort experienced at the time of the procedure, and (3) better patient acceptance of future gastrointestinal endoscopic procedures.This work was supported in part by a grant from the Gastroenterology Medical Research Foundation of Southwestern Pennsylvania.     

Conscious Sedation: For a TEE,Is It Always Required?

Conscious sedation is an anesthesia technique frequently used to facilitate transesophageal echocardiography, but it is not really necessary for performing routine adult cases. Children and complicated circumstances generally do warrant sedation. Using such anesthesia does increase complication rates and financial costs, therefore, omitting it should be considered when appropriate. Conscious sedation does diminish pain and anxiety, but results in patients being temporarily not decisional; without sedation they remain at full decisional capacity and can resume routine activities immediately after the procedure. (Echocardiography 2010;27:74-76)     

咪达唑仑清醒镇静在支气管镜检查中的作用及其对肺功能的影响

目的 探讨在支气管镜检查中应用静脉注射咪达唑仑清醒镇静的作用及其对肺功能的影响.方法 40例患者分为A、B两组,各20例,分别采用丁卡因、利多卡因局部麻醉和局部麻醉加咪达唑仑静脉注射镇静;对比患者术中麻醉效果,观察其各时点的生命体征和肺功能指标.结果B组在麻醉效果四个方面均优于A组;两组肺功能指标FVC、FEV1.0及PEF在术后10 min均比术前下降,其中B组FVC下降程度较A组更显著(P<0.05);两组术后4h的肺功能可回到基线水平;A组生命体征指标在术中及术后均较麻醉前有明显波动;B组内仅术中HR、MAP较麻醉前有差异,且A组进声门时HR的升高程度大于B组.结论 静脉应用咪达唑仑清醒镇静安全、有效、便捷,对患者术后4 h肺功能没有影响.     

Gastrointestinal and non-gastrointestinal complication rates associated with diagnostic esophagogastroduodenoscopy under sedation

Esophagogastroduodenoscopy (EGD) under sedation may result in gastrointestinal (GI) and non-GI complications. However, no previous studies have reported 30-day GI and non-GI complications after diagnostic EGD under sedation.We conducted a retrospective, observational study of 30-day GI and non-GI complication rates after outpatient diagnostic EGD under sedation in subjects ≥18 years between January 2012 and December 2017 based on a common data model database. Thirty-day complication rates were compared with EGD under sedation or not, type of sedation drugs (midazolam only vs midazolam/propofol) and age groups (18-64 year vs ≥65 year) for GI (bleeding and perforation) and non-GI complications (pneumonia, acute myocardial infarction, congestive heart failure and cerebral stroke).In total, 39,910 were performed with sedation (midazolam only, n = 16,033 and midazolam/propofol, n = 23,864) and 22,894 were performed without sedation. Elderly patients significantly favored EGD without sedation (P < .01). GI and non-GI complication rates were similar between EGD under sedation and without sedation (all P > .1) except for acute myocardial infarction rate, which was significantly higher in EGD without sedation than EGD under sedation (1.7/10,000 vs 0.3/10,000 persons, P = .043). All GI and non-GI complications were also similar between the midazolam/propofol and midazolam only groups as well as between young and old patients (all P > .1).Outpatient diagnostic EGD under sedation has an excellent safety profile. In addition, it can be safely performed with midazolam only or midazolam/propofol and in young and old patients.     

Sedation during endoscopic retrograde cholangiopancreatography: a randomized controlled study of patient-controlled propofol sedation and that given by a nurse anesthetist

Abstract

Objective. Different regimens are used for sedation during endoscopic retrograde cholangiopancreatography (ERCP). Our objectives were to compare safety, ease of treatment, recovery, and patients’ experiences using patient-controlled sedation (PCS) with propofol, nurse anesthetist-controlled sedation (ACS), or the department’s standard of care, midazolam given by the procedure team (control group). Material and methods. The study included 281 adults in 301 procedures. The PCS group (n = 101) delivered bolus doses of 5 mg of propofol according to their need for sedation. The ACS group (n = 100) had 2–8 mg/kg/h of propofol infused, with the target for sedation being level 3 of the Observer’s Assessment of Alertness/Sedation (OAA/S) scale. The control group was given 2–3 mg of midazolam for induction and additional 1 mg if required. Results. PCS and ACS increased the ease of the procedure and reduced the number of sedation failures compared to midazolam sedation (ACS n = 0; PCS n = 4; midazolam n = 20). The ACS group had more deeply sedated patients (OAA/S level 2), desaturation, and obstructed airways than the PCS and midazolam groups. Time to full recovery (Aldrete score ≥9) was shortest following PCS. PCS resulted in the least fatigue and pain after the procedure. Patients’ preference for PCS and ACS was the same. Conclusion. PCS with propofol is superior to midazolam and comparable to ACS. PCS resulted in a rapid recovery, fewer respiratory events, and was almost as effective as ACS in ensuring a successful examination.     

不同剂量舒芬太尼联合咪达唑仑对先天性心脏病术后镇痛镇静及血清皮质醇的影响

目的 本研究旨在探讨不同剂量舒芬太尼对先天性心脏病（先心病）术后早期应激反应的影响，以找到更为合适的镇痛药物剂量，既能达到良好镇痛效果，又对血流动力学影响最小。方法 采用前瞻性研究方法选择44例在我科接受先天性心脏病手术的患儿，术后常规进行镇痛镇静治疗。患儿被随机分成低剂量组（A组，枸橼酸舒芬太尼0.1 μg·kg-1·h-1）和高剂量组（B组，枸橼酸舒芬太尼0.2 μg·kg-1·h-1），两组患儿同时接受咪达唑仑100 μg·kg-1·h-1作为镇静治疗。在术前麻醉完成后（T1）、返回监护室即刻（T2）、术后4 h（T3）、术后8 h（T4）、术后12 h（T5）、术后24 h（T6）时间点抽血检测血清皮质醇水平；在T2~T6各时间点评估镇痛镇静评分；在T2~T6各时间点记录心率、收缩压、心排血量指数（cardiac index，CI）、体循环血管阻力指数（systemic vascular resistance index，SVRI）。采用t检验比较同一时间点两组之间各项指标的差异及同一组内术后各时间点的差异。结果 A组26例，其中男性14例、女性12例，年龄（8.3±6.7）个月，体重（6.5±2.4）kg。B组18例，其中男性8例、女性10例，年龄（5.8±7.9）个月，体重（5.7±1.7）kg。两组患儿性别（p=0.540）、年龄（t=1.112，p=0.273）、体质量（t=1.330，p=0.191）、体外循环时间（t=-0.484，p=0.631）及主动脉阻断时间（t=-0.202，p=0.841）比较均未见统计学差异。两组患儿组内比较不同时间点血清皮质醇水平存在统计学差异（F=18.252，p=0.000）。两组患儿组间对比各时间点血清皮质醇水平无统计学差异（F=1.725，p=0.199）。两组间各时间点对比FLACC镇痛评分、RAMSAY镇静评分、心率、收缩压、CI、SVRI组间比较均未见统计学差异（P>0.05）。结论 对于复杂或危重先心病术后气管插管预计大于24 h的患儿，早期联合应用舒芬太尼联合咪达唑仑可以达到良好的镇痛镇静效果、抑制应激反应，使血流动力学平稳恢复，使用舒芬太尼剂量0.1 μg·kg-1·h-1与0.2 μg·kg-1·h-1相比无差异，因此建议可以选择0.1 μg·kg-1·h-1舒芬太尼持续输注以防止发生不良反应。     

A comparison of ketamine-midazolam and ketamine-propofol combinations used for sedation in the endobronchial ultrasound-guided transbronchial needle aspiration: a prospective,single-blind,randomized study

Objective

We aimed to compare the effectiveness and safety of ketamine-midazolam and ketamine-propofol combinations for procedural sedation in endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA).

Methods

Sixty patients who were undergoing EBUS-TBNA were included in this study. Patients were randomly divided into two groups. Group 1 was given 0.25 mg/kg intravenous (iv) ketamine, 2 min later than 0.05 mg/kg iv midazolam. Group 2 received 0.125 mg/kg ketamine-propofol mixture (ketofol), 2 min subsequent to injection of 0.25 mg/kg each. Sedation was maintained with additional doses of ketamine 0.25 mg/kg, and ketofol 0.125 mg/kg each in Group 1 and Group 2, respectively. Blood pressure, heart rate (HR), peripheral oxygen saturation, respiratory rate (RR), Ramsay Sedation Score (RSS), and severity of cough were recorded prior to and after administration of sedation agent in the beginning of fiberoptic bronchoscopy (FOB) and every 5 min of the procedure. The consumption of the agents, the satisfactions of the bronchoscopist and the patients, and the recovery time were also recorded.

Results

HR in the 10^th min and RSS value in the 35^th min of induction in Group 1 were higher than the other group (P<0.05). The recovery time in Group 1 was statistically longer than Group 2 (P<0.05). There was no statistically significant difference between groups with respect to other parameters (P>0.05).

Conclusions

It was concluded that both ketamine-midazolam and ketamine-propofol combinations for sedation during EBUS-TBNA were similarly effective and safe without remarkable side effects.     

Aortic dissection with fistula to right atrium after heart transplantation: diagnosis by transthoracic and transesophageal echocardiography

Aortic dissection with rupture into the right atrium is an extremely rare and rapidly fatal condition that may occur after cardiac surgery. We report the case of a 59-year-old woman with a 6-year history of heart transplantation who presented with subacute illness characterized by chest pain and severe cardiac decompensation accompanied by a continuous murmur in the precordium. The diagnosis of aortic dissection complicated by right atrial fistula was made by the combination of transthoracic and transesophageal echocardiographic examination.     

Clinical and echocardiographic characteristics of left atrial spontaneous echo contrast in sinus rhythm

OBJECTIVES

In this study we attempt to define the clinical and echocardiographic characteristics of patients with left atrial spontaneous echo contrast (LASEC) in sinus rhythm (NSR).

BACKGROUND

Left atrial spontaneous echo contrast in atrial fibrillation (AF) is associated with increased risk of thromboembolism. Little is known about its significance in NSR.

METHODS

We reviewed reports of 1,288 transesophageal echocardiogram (TEE) studies done with a 5 MHz probe. Patients with swirling LASEC who were in NSR during TEE were analyzed. We compared them with a control group of 45 age matched patients selected to have NSR, left atrium (LA) >4.0 cm but no SEC.

RESULTS

Spontaneous echo contrast in NSR was noted in 24 patients (2%) and formed our study group. All patients with SEC had enlarged LA, mean 5.6 cm ± 0.6 cm. There was a higher prevalence of cerebrovascular accident (CVA) in patients with SEC when compared with controls with no SEC, 83% versus 56%, p = 0.02. Patients with SEC had larger LA, 5.6 versus 4.9 cm, p < 0.0001 and lower mean peak left atrial appendage emptying velocity (LAAEV), 38 versus 56 cm/s, p = 0.001. Thirteen percent of patients with SEC had LA thrombus as compared with none in the control group, p = 0.02. By multivariate analysis, SEC in NSR was found to be associated with CVA, larger LA size and decreased mean LAAEV. Even after adjusting for LA size, patients with SEC had a higher prevalence of CVA than controls, p = 0.03.

CONCLUSIONS

Spontaneous echo contrast in NSR occurs in patients with significantly dilated LA and depressed atrial function. Left atrial thrombus is noted in 13% of such patients despite NSR. Spontaneous echo contrast in NSR is associated with a higher prevalence of CVA. Further, SEC is found to be an independent and more powerful correlate of CVA than reduced LAAEV or atrial size. These data indicate that LASEC in NSR is a prothombotic condition.