Effect of music on procedure time and sedation during colonoscopy：A meta-analysis

AIM：To integrate results from different studies in examining the effectiveness of music in reducing the procedure time and the amount of sedation used during colonoscopic procedure. METHODS： An electronic search in various databases was performed to identify related articles. Study quality was evaluated by the Jadad’s scale. The random effect model was used to pool the effect from individual trials and the Cohen Q-statistic was used to determine heterogeneity. Egger’s regression was used to detect publication bias. RESULTS： Eight studies with 722 subjects were included in this meta-analysis. The combined mean difference for the time taken for the colonoscopy procedure between the music and control groups was -2.84 with 95% CI （-5.61 to -0.08）, implying a short time for the music group. The combined mean difference for the use of sedation was -0.46 with 95%CI （-0.91 to -0.01）, showing a significant reduction in the use of sedation in the music group. Heterogeneity was observed in both analyses but no publication bias was detected. CONCLUSION： Listening to music is effective in reducing procedure time and amount of sedation during colonoscopy and should be promoted.     

How to improve patient satisfaction during midazolam sedation for gastrointestinal endoscopy?

AIM To determine the procedure-related factors that affect sedation satisfaction and to make a suggestion to improve it.METHODS We prospectively enrolled a total of 456 patients who underwent outpatient endoscopy procedures with midazolam sedation between March 2014 and August 2014. All patients completed both pre- and postendoscopy questionnaires about sedation expectations and satisfaction. RESULTS The study cohort included 167 (36.6%) patients whounderwent esophagogastroduodenoscopy (EGD), 167 (36.6%) who underwent colonoscopy, and 122(26.8%) who underwent a combined procedure (EGD and colonoscopy). Over 80% of all patients were satisfied with sedation using midazolam. In univariate and multivariate analyses, total procedure time in the EGD group, younger age (≤ 50 years), and longer colonoscopy withdrawal time in the colonoscopy group were related to decreased satisfaction with sedation. However, in active monitoring and intervention group, there was no decrease in grade of satisfaction despite longer procedure time due to more procedures during colonoscopy. Younger age (≤ 50 years), longer interprocedure time gap, and colonoscopy withdrawal time were related to decreased satisfaction in the combined EGD and colonoscopy group. CONCLUSION Midazolam is still a safe and effective sedative for gastrointestinal endoscopy. Satisfaction with sedation depends on several factors including age(≤ 50 years) and procedure time duration. To improve patient satisfaction with sedation, active monitoring of sedation status by the endoscopist should be considered for patients who require long procedure time.     

Deep sedation for endoscopic retrograde cholangiopacreatography

Sedation and analgesia comprise an important element of unpleasant and often prolonged endoscopic retrograde cholangiopacreatography (ERCP), contributing, however, to better patient tolerance and compliance and to the reduction of injuries during the procedure due to inappropriate co-operation. Although most of the studies used a moderate level of sedation, the literature has revealed the superiority of deep sedation and general anesthesia in performing ERCP. The anes- the siol ogist’s presence is mandatory in these cases. A mod erate sedation level for ERCP seems to be adeq uate for octogenarians. The sedative agent of choice for sedation in ERCP seems to be propofol due to its fast distribution and fast elimination time without a cumulative effect after infusion, resulting in shorter recovery time. Its therapeutic spectrum, however, is much narrower and therefore careful monitoring is much more de manding in order to differentiate between moder ate, deep sedation and general anesthesia. Apart from conventional monitoring, capnography and Bispectral index or Narcot rend monitoring of the level of sedation seem to be useful in titrating sedatives in ERCP.     

Effectiveness of outpatient percutaneous endoscopic gastrostomy replacement using esophagogastroduodenoscopy and propofol sedation

AIM: To evaluate the effectiveness of outpatient percutaneous endoscopic gastrostomy (PEG) replacement using esophagogastroduodenoscopy (EGD) and propofol sedation. METHODS: We retrospectively assessed the outcome and complications of consecutive patients referred for PEG replacement which was performed using EGD under propofol sedation in the outpatient setting. The success rate, the mean dose of propofol, procedure time, EGD findings, discharge time from endoscopy unit, respiratory depression, and complications within 72 h of the procedure were evaluated. In a subset of these patients, the blood concentrations of propofol were measured.RESULTS: All 221 patients underwent successful PEG replacement. The mean dose of propofol was 34 mg (range, 20-60 mg) with a mean procedure time of 5.9 min (range, 3-8 min). Reflux esophagitis (12 patients), gastric ulcer (5), gastric neoplasm (2), and duodenal ulcer (1) were newly diagnosed at replacement. Discharge from endoscopy unit was possible in 100% of patients 45 min after the procedure. Only 3.6% (8) required transient supplemental oxygen. No complications occurred within 72 h of the procedure. During EGD the level of sedation and propofol blood concentrations after administration of propofol (30 mg) in these PEG patients corresponded to those of propofol (60 mg) in middle aged subjects (control).     

Identification of factors associated with sedation tolerance in 5000 patients undergoing outpatient colonoscopy:Canadian tertiary center experience

AIM To develop a prediction model aimed at identifying patients that may require higher than usual sedation doses during colonoscopy.METHODS A retrospective chart review on 5000 patients who underwent an outpatient colonoscopy at St.Paul's Hospital from 2009 to 2010 was conducted in order to develop a model for identifying patients who will require increased doses of sedatives.Potential predictor variables including age,gender,endoscopy indication,high sedation requirements during previous endoscopies,difficulty of the procedure,bowel preparation quality,interventions,findings as well as current use of benzodiazepines,opioids and alcohol were analyzed.The outcome of study was the use ofhigh dose of sedation agents for the procedure.In particular,the high dose of sedation was defined as fentanyl greater than 50 mcg and midazolam greater than 3 mg.RESULTS Analysis of 5282 patients(mean age 57 ± 12,49% female) was performed.Most common indication for the procedure was screening colonoscopy(57%).Almost half of our patients received doses exceeding Fentanyl 50 mcg and Midazolam 3 mg.Logistic regression models identified the following variables associated with high sedation:Younger age(OR=0.95 95%CI:0.94-0.95;P 0.0001);abdominal pain(OR=1.45,95%CI:1.08-1.96);P=0.01) and Inflammatory Bowel Disease(OR=1.45,95%CI:1.04-2.03;P=0.02) as indications for the procedure;difficult procedure as defined by gastroenterologist(OR=1.73,95%CI:1.48-2.03;P 0.0001);past history of abdominal surgery(OR=1.33,95%CI:1.17-1.52;P 0.0001) and previous colonoscopy(OR=1.39,95%CI:1.21-1.60;P=0.0001) and alcohol use(OR=1.26,95%CI:1.03-1.54;P=0.02).Age and gender adjusted analysis yielded inflammatory bowel disease as an indication(OR=3.17,95%CI:1.58-6.37;P=0.002);difficult procedure as defined by an endoscopist(OR=5.13 95%CI:2.97-8.85;P=0.0001) and current use of opioids,benzodiazepines or antidepressants(OR=2.88,95%CI:1.74-4.77;P=0.001) having the highest predictive value of high sedation requirements.Our prediction model using the following pre-procedural variables including age,indication for the procedure,medication/substance use,previous surgeries yielded an area under the curve of 0.76 for Fentanyl ≥ 100 mcg and Midazolam ≥ 3 mg.CONCLUSION Pre-procedural planning is the key in conducting successful,efficient colonoscopy.Logistic regression analysis of 5000 patients who underwent out-patient colonoscopy revealed the following factors associated with increased sedation requirement:Younger age,female gender,difficult endoscopy,specific indications as well as cardiopulmonary complications and current use of opioids/benzodiazepines.Age and gender adjusted analysis yielded similar results.These patients are more likely to need a longer recovery periods post-endoscopy,which could result in additional time and personnel requirements.The final predictive model has good predictive ability for Fentanyl ≥ 100 mcg and Midazolam ≥ 3 mg and fair predictive ability for Fentanyl ≥ 50 mcg and Midazolam ≥ 2 mg.The external validity of this model is planned to be tested in another center.     

Sedation and analgesia in gastrointestinal endoscopy: What’s new?

Various types of sedation and analgesia technique have been used during gastrointestinal endoscopy procedures.The best methods for analgesia and sedation during gastrointestinal endoscopy are still debated.Providing an adequate regimen of sedation/analgesia might be considered an art,influencing several aspects of endoscopic procedures: the quality of the examination,the patient’s cooperation and the patient’s and physician’s satisfaction with the sedation.The properties of a model sedative agent for endosc...     

Endoscopic retrograde cholangiopancreatography under moderate sedation and factors predicting need for anesthesiologist directed sedation: A county hospital experience

AIM: To evaluate variables associated with failure of gastroenterologist directed moderate sedation (GDS) during endoscopic retrograde cholangiopancreatography (ERCP) and derive a predictive model for use of anesthesiologist directed sedation (ADS) in selected patients. METHODS: With institutional review board approval, we retrospectively analyzed consecutive records of all patients who underwent ERCPs between July 1, 2009 to October 1, 2011 to identify patient related and procedure related factors which could predict failure of GDS. For patient related factors, we abstracted and analyzeddata regarding the age, gender, ethnicity, alcohol and illicit drug use habits. For procedure related factors, we abstracted data regarding initial or repeat procedures, indication for performing ERCP, the interventions performed during ERCP, and the grade d difficulty of cannulation as defined in the American Society for Gastrointestinal Endoscopy guidelines. Our outcome of interest was procedural success. If the procedure was not successful, the reasons for failure of procedures were recorded along with immediate post procedure complications. Multivariate analysis was then performed to define factors associated with failure of GDS and a model constructed to predict requirement of ADS. RESULTS: Fourteen percent of patients undergoing GDS could not complete the procedure due to intolerance and 2% due to cardiovascular complications. Substance abuse, male gender, black race and alcohol use were significant predictors of failure of GDS on univariate analysis and substance abuse and higher grade of procedure remained significant on multivariate analysis. Using our predictive model where the presence of substance abuse was given 1 point and planned grade of intervention was scored from 1-3, only 12% patients with a score of 1 would require ADS due to failure of GDS, compared to 50% with a score of 3 or higher. CONCLUSION: We conclude that ERCP under GDS is safe and effective for low grade procedures, and ADS should be judiciously reserved for procedures which have a higher risk of failure with moderate sedation.     

Sedation and monitoring for gastrointestinal endoscopy

The safe sedation of patients for diagnostic or therapeutic procedures requires a combination of properly trained physicians and suitable facilities.Additionally,appropriate selection and preparation of patients,suitable sedative technique,application of drugs,adequate monitoring,and proper recovery of patients is essential.The goal of procedural sedation is the safe and effective control of pain and anxiety as well as to provide an appropriate degree of memory loss or decreased awareness.Sedation practices for gastrointestinal endoscopy(GIE) vary widely.The majority of GIE patients are ambulatory cases.Most of this procedure requires a short time.So,short acting,rapid onset drugs with little adverse effects and improved safety profiles are commonly used.The present review focuses on commonly used regimens and monitoring practices in GIE sedation.This article is to discuss the decision making process used to determine appropriate pre-sedation assessment,monitoring,drug selection,dose of sedative agents,sedation endpoint and post-sedation care.It also reviews the current status of sedation and monitoring for GIE procedures in Thailand.     

Bispectral index monitoring as an adjunct to nurse-administered combined sedation during endoscopic retrograde cholangiopancreatography

AIM:To determine whether bispectral index (BIS) monitoring is useful for propofol administration for deep sedation during endoscopic retrograde cholangiopancreatography (ERCP). METHODS:Fifty-nine consecutive patients with a variety of reasons for ERCP who underwent the procedure at least twice between 1 July 2010 and 30 November 2010. This was a randomized cross-over study, in which each patient underwent ERCP twice, once with BIS monitoring and once with control monitoring. Whether BIS monitoring was done during the first or second ERCP procedure was random. Patients were intermittently administered a mixed regimen including midazolam, pethidine, and propofol by trained nurses. The nurse used a routine practice to monitor sedation using the Modified Observer's Assessment of Alertness/Sedation (MOAA/S) scale or the BIS monitoring. The total amount of midazolam and propofol used and serious side effects were compared between the BIS and control groups. RESULTS:The mean total propofol dose administered was 53.1 ± 32.2 mg in the BIS group and 54.9 ± 30.8 mg in the control group (P = 0.673). The individual propofol dose received per minute during the ERCP procedure was 2.90 ± 1.83 mg/min in the BIS group and 3.44 ± 2.04 mg in the control group (P = 0.103). The median value of the MOAA/S score during the maintenance phase of sedation was comparable for the two groups. The mean BIS values throughout the procedure (from insertion to removal of the endoscope) were 76.5 ± 8.7 for all 59 patients in using the BIS monitor. No significant differences in the frequency of 80% oxygen saturation, hypotension ( 80 mmHg), or bradycardia ( 50 beats/min) were observed between the two study groups. Four cases of poor cooperation occurred, in which the procedure should be stopped to add the propofol dose. After adding the propofol, the procedure could be conducted successfully (one case in the BIS group, three cases in the control group). The endoscopist rated patient sedation as excellent for all patients in both groups. All patients in both groups rated their level of satisfaction as high (no discomfort). During the post-procedural follow-up in the recovery area, no cases of clinically significant hypoxic episodes were recorded in either group. No other postoperative side effects related to sedation were observed in either group. CONCLUSION:BIS monitoring trend to slighlty reduce the mean propofol dose. Nurse-administered propofol sedation under the supervision of a gastroenterologist may be considered an alternative under anesthesiologist.     

High-flow nasal oxygen availability for sedation decreases the use of general anesthesia during endoscopic retrograde cholangiopancreatography and endoscopic ultrasound

AIM To examine whether high-flow nasal oxygen(HFNO) availability influences the use of general anesthesia(GA) in patients undergoing endoscopic retrograde cholangiopancreatography(ERCP) and endoscopic ultrasound(EUS) and associated outcomes.METHODS In this retrospective study, patients were stratified into 3 eras between October 1, 2013 and June 30, 2014 based on HFNO availability for deep sedation at the time of their endoscopy. During the first and last 3-mo eras(era 1 and 3), no HFNO was available, whereas it was an option during the second 3-mo era(era 2). The primary outcome was the percent utilization of GA vs deep sedation in each period. Secondary outcomes included oxygen saturation nadir during sedation between periods, as well as procedure duration, and anesthesia-only time between periods and for GA vs sedation cases respectively.RESULTS During the study period 238 ERCP or EUS cases were identified for analysis. Statistical testing was employed and a P 0.050 was significant unless the Bonferroni correction for multiple comparisons was used. General anesthesia use was significantly lower in era 2 compared to era 1 with the same trend between era 2 and 3(P = 0.012 and 0.045 respectively). The oxygen saturation nadir during sedation was significantly higher in era 2 compared to era 3(P 0.001) but not between eras 1 and 2(P = 0.028) or 1 and 3(P = 0.069). The procedure time within each era was significantly longer under GA compared to deep sedation(P ≤ 0.007) as was the anesthesia-only time(P ≤ 0.001).CONCLUSION High-flow nasal oxygen availability was associated with decreased GA utilization and improved oxygenation for ERCP and EUS during sedation.     

Frequently overlooked and rarely listened to： Music therapy in gastrointestinal endoscopic procedures

To elucidate the role of music therapy in gastrointestinal endoscopic procedures following the conflicting outcomes reported in two recent studies. The findings of our recent meta-analysis that examined this matter were discussed in the context of later studies. Our meta-analysis illustrated the beneficial effects of music therapy on patient anxiety levels when used as a single measure of relaxation and analgesia. Beneficial effects were also shown on analgesia and sedation requirements and procedure duration times when used as an adjunct to pharmacotherapy. These findings are in agreement with those of both studies excluded from analysis and those that followed it. Music therapy is an effective tool for stress relief and analgesia in patients undergoing gastrointestinal endoscopic procedures.     

Carbon dioxide accumulation during analgosedated colonoscopy: Comparison of propofol and midazolam

AIM: To characterize the profiles of alveolar hypoventilation during colonoscopies performed under sedoanalgesia with a combination of alfentanil and either midazolam or propofol. METHODS: Consecutive patients undergoing routine colonoscopy were randomly assigned to sedation with either propofol or midazolam in an open-labeled design using a titration scheme. All patients received 4 μg/kg per body weight alfentanil for analgesia and 3 L of supplemental oxygen. Oxygen saturation (SpO 2 ) was measured by pulse oximetry (POX), and capnography (PcCO 2 ) was continuously measured using a combined dedicated sensor at the ear lobe. Instances of apnea resulting in measures such as stimulation of the patient, a chin lift, a mask maneuver, or withholding of sedation were recorded. PcCO 2 values (as a parameter of sedation-induced hypoventilation) were compared between groups at the following distinct time points: baseline, maximal rise, termination of the procedure and 5 min after termination of the procedure. The number of patients in both study groups who regained baseline PcCO 2 values (± 1.5 mmHg) five minutes after the procedure was determined.RESULTS: A total of 97 patients entered this study. The data from 14 patients were subsequently excluded for clinical procedure-related reasons or for technical problems. Therefore, 83 patients (mean age 62 ± 13 years) were successfully randomized to receive propofol (n = 42) or midazolam (n = 41) for sedation. Most of the patients were classified as American Society of Anesthesiologists (ASA) Ⅱ [16 (38%) in the midazolam group and 15 (32%) in the propofol group] and ASA Ⅲ [14 (33%) and 13 (32%) in the midazolam and propofol groups, respectively]. A mean dose of 5 (4-7) mg of Ⅳ midazolam and 131 (70-260) mg of Ⅳ propofol was used during the procedure in the corresponding study arms. The mean SpO 2 at baseline (%) was 99 ± 1 for the midazolam group and 99 ± 1 for the propofol group. No cases of hypoxemia (SpO 2 85%) or apnea were recorded. However, an increase in PcCO 2 that indicated alveolar hypoventilation occurred in both groups after administration of the first drug and was not detected with pulse oximetry alone. The mean interval between the initiation of sedation and the time when the PcCO 2 value increased to more than 2 mmHg was 2.8 ± 1.3 min for midazolam and 2.8 ± 1.1 min for propofol. The mean maximal rise was similar for both drugs: 8.6 ± 3.7 mmHg for midazolam and 7.4 ± 3.2 mmHg for propofol. Five minutes after the end of the procedure, the mean difference from the baseline values was significantly lower for the propofol treatment compared with midazolam (0.9 ± 3.0 mmHg vs 4.3 ± 3.7 mmHg, P = 0.0000169), and significantly more patients in the propofol group had regained their baseline value ± 1.5 mmHg (32 of 41vs 12 of 42,P = 0.0004). CONCLUSION: A significantly higher number of patients sedated with propofol had normalized PcCO 2 values five minutes after sedation when compared with patients sedated with midazolam.     

Reducing risk of transjugular intrahepatic portosystemic shunt using ultrasound guided single needle pass

Delayed liver laceration following transjugular intrahepatic portosystemic shunt (TIPS) is a serious and likely underdiagnosed complication. It is however an important complication following TIPS, which remains one of the most technically challenging interventional procedures performed. In addition to laceration, a number of complications regarding bleeding and perforation are well described following TIPS procedures. We feel the adoption of techniques such as ours and that of other authors described in the literature using an ultrasoundguided percutaneous transhepatic approach with a small caliber needle provides a safer and less traumatic procedure and should reduce complications of bleeding and almost completely eliminate the risk of liver laceration. Our procedure was successfully performed under conscious sedation rather than general anaesthesia further reducing the overall procedural risk to the patient.     

Advanced endoscopic technologies for colorectal cancer screening

Colorectal cancer is the third most common cancer in men and the second most common cancer in women worldwide. Diagnosing colorectal has been increasingly successful due to advances in technology. Flexible endoscopy is considered to be an effective method for early diagnosis and treatment of gastrointestinal cancer, making it a popular choice for screening programs. However, millions of people who may benefit from endoscopic colorectal cancer screening fail to have the procedure performed. Main reasons include psychological barriers due to the indignity of the procedure, fear of procedure related pain, bowel preparation discomfort, and potential need for sedation. Therefore, an urgent need for new technologies addressing these issues clearly exists. In this review, we discuss a set of advanced endoscopic technologies for colorectal cancer screening that are either already available or close to clinical trial. In particular, we focus on visual-inspectiononly advanced flexible colonoscopes, interventional colonoscopes with alternative propulsion mechanisms, wireless capsule colonoscopy, and technologies for intraprocedural bowel cleansing. Many of these devices have the potential to reduce exam related patient discomfort, obviate the need for sedation, increase diagnostic yield, reduce learning curves, improve access to screening, and possibly avert the need for a bowel preparation.     

Simultaneous endoscopic ultrasound fine needle aspiration and endoscopic retrograde cholangio-pancreatography： Evaluation of safety

AIM： To investigate the rate of complications of endoscopic retrograde cholangio-pancreatography （ERCP） performed immediately after endoscopic ultrasound fine needle aspiration （EUS-FNA） in a large series of patients.
METHODS： Patients with the following conditions were considered candidates for EUS-FNA and ERCP： diagnosis of locally advanced or metastatic pancreatic lesion not eligible for surgery, and patients with pancreatic lesion of unknown nature causing jaundice. Data were prospectively collected on the following parameters： indication for FNA, EUS findings, pathological diagnosis, procedure duration of EUS-FNA and combined EUS-FNA and ERCP, and immediate and late complications.
RESULTS： From January 2004 to October 2006, 72 patients were deemed eligible for combined EUS and ERCP. In 25/72 EUS-FNA was performed to obtain a pathology diagnosis of lesions causing biliary obstruction, and ERCP sequentially performed to drain the biliary system. No immediate complications occurred except for two mild bleeding episodes post sphincterotomy. No late complications were recorded except for one patient who experienced fever, promptly recovered with antibiotic therapy.
CONCLUSION： Simultaneous approach appears to be feasible and safe. When possible, this can be considered the reference standard to avoid double sedation and reduce duration of the procedure and hospital stay.     

Identifying who best tolerates moderate sedation:Results from a national database of gastrointestinal endoscopic outcomes

BACKGROUND With increasing volume and cost of gastrointestinal endoscopic procedures, the proper selection of patients for moderate sedation becomes increasingly relevant. The current literature lacks consistent findings that allow for appropriate selection of patients for moderate sedation.AIM To analyze a nationwide registry of patients to identify patient and procedural factors associated with lower sedation requirements for endoscopy.METHODS The Clinical Outcomes Research Initiative National Endoscopic Database was queried to assess adult patients undergoing moderate sedation for esophagogastroduodenoscopy(EGD) and colonoscopy from 2008 to 2014. Patients were stratified into two groups [low dose(LD) and high dose sedation] based on sedation requirements. Anthropometric, procedural, and anesthesia data were compared, and multivariable analysis was performed to identify factors associated with LD sedation.RESULTS Of the 371102 patients included in the study, 63137 where stratified into the LD sedation group and 307965 were in the high dose group. Moderate sedation was managed primarily by endoscopists(50%) and anesthesia providers(47%). Patients undergoing EGDs and procedures performed in the inpatient setting, in ambulatory surgery centers, intensive care units or hospital wards, required less sedation than colonoscopies, outpatient procedures and procedures done in endoscopy suites, respectively(P 0.0001 for all). On multivariable analysis, factors predictive of tolerance with lower sedation requirements for EGDs and colonoscopies were female gender, age ≥ 50, non-White race, Hispanic descent, body mass index ≤ 25 kg/m~2, and higher American Society of Anesthesia Class(P 0.0001 for all).CONCLUSION Clinicians should consider these patient profiles in determining which patients will better tolerate moderate sedation vs those better suited for alternative sedation methods.     

Sedation in gastrointestinal endoscopy:Current issues

Diagnostic and therapeutic endoscopy can successfully be performed by applying moderate(conscious) sedation.Moderate sedation,using midazolam and an opioid,is the standard method of sedation,although propofol is increasingly being used in many countries because the satisfaction of endoscopists with propofol sedation is greater compared with their satisfaction with conventional sedation.Moreover,the use of propofol is currently preferred for the endoscopic sedation of patients with advanced liver disease due to its short biologic half-life and,consequently,its low risk of inducing hepatic encephalopathy.In the future,propofol could become the preferred sedation agent,especially for routine colonoscopy.Midazolam is the benzodiazepine of choice because of its shorter duration of action and better pharmacokinetic profile compared with diazepam.Among opioids,pethidine and fentanyl are the most popular.A number of other substances have been tested in several clinical trials with promising results.Among them,newer opioids,such as remifentanil,enable a faster recovery.The controversy regarding the administration of sedation by an endoscopist or an experienced nurse,as well as the optimal staffing of en-doscopy units,continues to be a matter of discussion.Safe sedation in special clinical circumstances,such as in the cases of obese,pregnant,and elderly individuals,as well as patients with chronic lung,renal or liver disease,requires modification of the dose of the drugs used for sedation.In the great majority of patients,sedation under the supervision of a properly trained endoscopist remains the standard practice worldwide.In this review,an overview of the current knowledge concerning sedation during digestive endoscopy will be provided based on the data in the current literature.     

Efficiency and patient experience with propofol vs conventional sedation: A prospective study

AIM: To determine whether anaesthesiologistadministered sedation with propofol(AAP) or endoscopist-administered conscious sedation(EAC) with fentanyl/midazolam shortens colonoscopy duration/total room time. METHODS: This is a prospective, non-randomized, comparative study that enrolled patients greater than 18 years of age undergoing colonoscopy in a single Canadian academic outpatient endoscopy unit over a three-month consecutive period. Colonoscopies in this unit are performed both with AAP and EAC. Patient demographics, procedure-related data and adverse events were documented. Additionally, the level of procedure difficulty, and whether a staff endoscopist, trainee with assistance, or independent trainee, performed the procedure were documented. A validated modified 4-question, 5-point Likert scale telephone survey was used to assess patient satisfaction with colonoscopy. The telephone patient satisfaction survey was conducted 24-72 h following the procedure.RESULTS: Two hundred and thirty patients were enrolled during the study period with 126 patients in the AAP group and 104 patients in the EAC group. Mean procedure time was 18.3 ± 10.1 min in the AAP group and 14.7 ± 7.1 min in the EAC group(P = 0.002). Mean total room time was 36.8 ± 13.7 with AAP and 30.1 ± 11 min with EAC(P 0.001). Multivariate analysis revealed the use of AAP(P = 0.002), resident participation(P 0.001), diagnostic interventions(P = 0.033), therapeutic interventions(P 0.001), lower body mass index(P = 0.008) and American Society of Anaesthesiologist class(P = 0.016), to be predictors of longer total room time. Patient age and gender were not significant predictors. After excluding cases in which trainees were involved, there was no significant difference in procedure time between the two groups(P = 0.941), however total room time was still prolonged in the AAP group(P = 0.019). The amount of pain experienced was lower with AAP(P = 0.02), with a trend toward overall higher patient satisfaction(P = 0.074). There were 2 sedation-related adverse events, both in the AAP group involving a patient with aspiration requiring hospitalization and a patient with hypoxia managed with bronchodilators.CONCLUSION: EAC results in reduced total room time compared to AAP. Resident participation doubles procedure time regardless of sedation type.     

Effects of oral premedication on cognitive status of elderly patients undergoing cardiac catheterization

Background Sedatives and analgesics are often administered to achieve conscious sedation for diagnostic and therapeutic procedures. Appropriate concerns have been raised regarding post procedure delirium related to peri-procedural medication in the elderly. The objective of this study was to investigate the effect of premedication on new onset delirium and procedural care in elderly patients. Methods Patients ≥ 70 years old and scheduled for elective cardiac catheterization were randomly assigned to receive either oral diphenhydramine and diazepam (25 mg/5 mg) or no premedication. All patients underwent a mini mental state exam and delirium assessment using confusion assessment method prior to the procedure and repeated at 4 h after the procedure and prior to discharge. Patients’ cooperation during the procedure and ease of post-procedure were measured using Visual Analog Scale (VAS). The degree of alertness was assessed immediately on arrival to the floor, and twice hourly afterwards using Observer’s Assessment of Alertness/Sedation Scale (OAA/S). Results A total of 93 patients were enrolled. The mean age was 77 years, and 47 patients received premedication prior to the procedure. None of the patients in either group developed delirium. Patients’ cooperation and the ease of procedure was greater and pain medication requirement less both during and after the procedure in the pre-medicated group (P < 0.05 for both). Nurses reported an improvement with patient management in the pre-medicated group (P = 0.08). Conclusions In conclusion, premedication did not cause delirium in elderly patients undergoing cardiac catheterization. The reduced pain medication requirement, perceived procedural ease and post procedure management favors premedication in elderly patients undergoing cardiac catheterization.     

Conscious sedation: A dying practice?

Sedation practices vary according to countries with different health system regulations, the procedures done, and local circumstances. Interestingly, differences in the setting in which the practice of gastroenterology and endoscopy takes place (university-based vs academic practice) as well as other systematic practice differences influence the attitude of endoscopists concerning sedation practices. Conscious sedation using midazolam and opioids is the current standard method of sedation in diagnostic and therapeutic endoscopy. Interestingly, propofol is a commonly preferred sedation method by endoscopists due to higher satisfaction rates along with its short half-life and thus lower risk of hepatic encephalopathy. On the other hand, midazolam is the benzodiazepine of choice because of its shorter duration of action and better pharmacokinetic profile compared with diazepam. The administration of sedation under the supervision of a properly trained endoscopist could become the standard practice and the urgent development of an updated international consensus regarding the use of sedative agents like propofol is needed.