Fellows' Journal Club: Rate and Prognosis of Patients under Conscious Sedation Requiring Emergent Intubation during Neuroendovascular Procedures

BACKGROUND AND PURPOSE:Neuroendovascular procedures are performed with the patient under conscious sedation (local anesthesia) in varying numbers of patients in different institutions, though the risk of unplanned conversion to general anesthesia is poorly characterized. Our aim was to ascertain the rate of failure of conscious sedation in patients undergoing neuroendovascular procedures and compare the in-hospital outcomes of patients who were converted from conscious sedation to general anesthesia with those whose procedures were initiated with general anesthesia.MATERIALS AND METHODS:All patients who had an endovascular procedure initiated under general anesthesia or conscious sedation were identified through a prospective data base maintained at 2 comprehensive stroke centers. Patient clinical and procedural characteristics, in-hospital deaths, and favorable outcomes (modified Rankin Scale score, 0–2) at discharge were ascertained.RESULTS:Nine hundred seven endovascular procedures were identified, of which 387 were performed with the patient under general anesthesia, while 520 procedures were initiated with conscious sedation. Among procedures initiated with intent to be performed under conscious sedation, 9 (1.7%) procedures required emergent conversion to general anesthesia. Favorable clinical outcome and in-hospital mortality in patients requiring emergent conversion from conscious sedation to general anesthesia and in those with procedures initiated with general anesthesia were not statistically different (42% versus 50%, P = .73 and 17% versus 13%, P = 1.00, respectively).CONCLUSIONS:In our study, there was a very low rate of conscious sedation failure and associated adverse outcomes among patients undergoing neuroendovascular procedures. Proper patient selection is important if procedures are to be performed with the patient under conscious sedation. Limitations of the methodology used in our study preclude us from offering specific recommendations regarding when to use a specific anesthetic protocol.

Controversy exists regarding the type of anesthesia required in patients undergoing neuroendovascular procedures. Some operators advocate the use of local anesthesia and intravenous sedation known as conscious sedation, while others argue that these interventions are best performed with the patient under general anesthesia. One study showed that initiation of an intervention for anterior circulation stroke with the patient under general anesthesia varied widely among centers, ranging from 0% to 100%, with the average being 44%.¹ A recent survey reported that a large majority of neurointerventionalists prefer general anesthesia as the intraprocedural technique of choice.²Although such decisions depend on personal preference, experience, and institutional protocols, some studies suggest that certain modalities of sedation may prolong the hospital stay and worsen outcome. Concern for increased risk of aspiration and potential airway injury with emergent intubation³ in a procedure initiated with conscious sedation, especially if thrombolytic therapy or anticoagulation has been used, may bias operators toward general anesthesia at the onset of the procedure. However, there is insufficient evidence to suggest that such conversion is a common occurrence or that it is detrimental to the patient. We sought to determine the frequency and prognosis of patients converted from conscious sedation to general anesthesia during neurointerventional procedures at 2 academic comprehensive stroke centers.     

Sedation procedures in MR imaging: safety, effectiveness, and nursing effect on examinations

PURPOSE: To measure the safety and effectiveness of conscious sedation in order to assess utilization and the effect on magnetic resonance (MR) imaging examinations. MATERIALS AND METHODS: A database of conscious sedation records for MR imaging at the Johns Hopkins Hospital, Baltimore, Md, from 1991 to 1998 was searched. Safety data according to medication and procedure duration for each nurse were tabulated for 6,093 patient records. Data were analyzed by using quality control statistical measures to determine time utilization and effectiveness. Break-even costs for the procedure were determined. RESULTS: Of 6,093 patients scheduled for examination, 4,761 patients (78.1%) received conscious sedation by the MR conscious sedation service. Complications were observed in 20 of the 4,761 patients (0.42%). No deaths occurred. The most common complication was oxygen desaturation (n = 8). Diagnostic and complete MR examinations were performed in 4,453 of the 4,761 patients (93.5%). The mean time to sedate the patient (+/- SD) was 23.6 minutes +/- 15.2 for specialized MR sedation nurses and 26.8 minutes +/- 20.1 for general radiology nurses (P: <.001). For inpatient nurses from the inpatient hospital units, the sedation time was considerably longer (47.3 minutes +/- 36.6, P: <.001) and more variable. Break-even costs were 37% ($11 vs $8 for MR room time) more for general radiology nurses than for specialized MR sedation nurses performing the procedure. CONCLUSION: Conscious sedation is safe and has a high effectiveness rate. A highly specialized nursing staff reduces procedure variability and cost.     

Patients Requiring Conversion to General Anesthesia during Endovascular Therapy Have Worse Outcomes: A Post Hoc Analysis of Data from the SAGA Collaboration

BACKGROUND AND PURPOSE:Endovascular therapy for acute ischemic stroke is often performed with the patient under conscious sedation. Emergent conversion from conscious sedation to general anesthesia is sometimes necessary. The aim of this study was to assess the functional outcome in converted patients compared with patients who remained in conscious sedation and to identify predictors associated with the risk of conversion.MATERIALS AND METHODS:Data from 368 patients, included in 3 trials randomizing between conscious sedation and general anesthesia before endovascular therapy (SIESTA, ANSTROKE, and GOLIATH) constituted the study cohort. Twenty-one (11%) of 185 patients randomized to conscious sedation were emergently converted to general anesthesia.RESULTS:Absence of hyperlipidemia seemed to be the strongest predictor of conversion to general anesthesia, albeit a weak predictor (area under curve = 0.62). Sex, hypertension, diabetes, smoking status, atrial fibrillation, blood pressure, size of the infarct, and level and side of the occlusion were not significantly associated with conversion to general anesthesia. Neither age (mean age, 71.3   ± 13.8 years for conscious sedation versus 71.6  ± 12.3 years for converters, P = .58) nor severity of stroke (mean NIHSS score, 17 ± 4 versus 18 ± 4, respectively, P = .27) were significantly different between converters and those who tolerated conscious sedation. The converters had significantly worse outcome with a common odds ratio of 2.67 (P = .015) for a shift toward a higher mRS score compared with the patients remaining in the conscious sedation group.CONCLUSIONS:Patients undergoing conversion had significantly worse outcome compared with patients remaining in conscious sedation. No factor was identified that predicted conversion from conscious sedation to general anesthesia.

Five studies published in 2015 proved the efficacy of endovascular therapy (EVT) for acute ischemic stroke caused by a large-vessel occlusion.¹ However, numerous questions remain regarding how to best deliver this treatment, including evaluation of the optimal thrombectomy technique,² the most effective method of patient triage,³ or whether EVT should be performed with the patient under either general anesthesia (GA) or conscious sedation (CS).Observational studies have suggested that EVT with the patient under CS is associated with better neurologic outcome and lower mortality compared with GA.⁴ However, 3 randomized trials reported similar outcomes between CS and GA.^5-7 Proposed benefits of CS include stable hemodynamics, clinical monitoring, and a potentially shorter procedure. The disadvantages are an unprotected airway and patient movement, which sometimes may require emergent conversion to GA. Patients who need conversion might be sicker (larger strokes, more medical complications), but the conversion procedure itself may also have a potentially deleterious influence on outcome due to the emergent anesthetic induction, associated hypotension, and added time delay before reperfusion.Although most patients can be treated under the less complex CS, it is of interest to identify factors that can predict the risk of conversion and hence the requirement for GA. We undertook a detailed analysis of the patients who were converted from CS to GA in our individual patient data base from the 3 randomized trials to examine the outcome of the converted patients compared with patients who remained in CS. We also aimed to identify possible predictors associated with a need for GA with EVT.     

Comparison of General Anesthesia and Conscious Sedation During Computed Tomography–Guided Radiofrequency Ablation of T1a Renal Cell Carcinoma

Purpose

Percutaneous radiofrequency ablation is so painful that this treatment requires pain control such as conscious sedation or general anesthesia. It is still unclear which type of anesthesia is better for treatment outcomes of renal cell carcinoma. This study aimed to compare general anesthesia and conscious sedation in treating patients with renal cell carcinoma with radiofrequency ablation.

Canadian radiology residents' knowledge of sedation and analgesia: a web-based survey.

OBJECTIVE: An increasing number of procedures in the radiology department require the use of conscious sedation, with the agents often administered by the radiologist. We sought to determine the level of understanding of the nature and use of such agents in Canadian radiology residents. METHODS: A Web-based questionnaire was distributed to residents from 8 Canadian radiology residency programs. The questions concerned the pharmacology of common medications for conscious sedation, their indications and appropriateness for use, and the experience and attitudes of residents toward formal training in conscious sedation. RESULTS: A total of 178 surveys were dispersed and yielded an adjusted response rate of 51%. Most residents stated that they had not received any formal training in conscious sedation (65%) and were in favour (68%) of having such training. Although the residents typically correctly prescribed appropriate dosages of lorazepam (54%), midazolam (51%), and fentanyl (58.7%), excessively high dosages of midazolam were ordered by 15.9% of the residents. Knowledge regarding the onset of action and duration of commonly used medications was poor. Residents gave the correct response with regard to duration of action for lorazepam (23.8%), midazolam (31.9%), diazepam (15.9%), and fentanyl (28.6%). The correct responses to onset of action were as follows: for fentanyl, 22.2%; for midazolam, 19.1%; for lorazepam, 6.35%; and for diazepam, 11.1%. Residents were uncertain regarding the maximum dosage of local anesthetics that a patient could receive, with 1.5% and 20.6% correct responses regarding bupivacaine and lidocaine, respectively. CONCLUSION: Despite the recent publication of conscious sedation guidelines for nonanesthesiologists, this survey suggests that Canadian radiology residents are not receiving adequate training in the use of medications required for conscious sedation.     

Conscious Sedation versus General Anesthesia during Endovascular Acute Ischemic Stroke Treatment: A Systematic Review and Meta-Analysis

BACKGROUND AND PURPOSE:A number of studies have suggested that anesthesia type (conscious sedation versus general anesthesia) during intra-arterial treatment for acute ischemic stroke has implications for patient outcomes. We performed a systematic review and meta-analysis of studies comparing the clinical and angiographic outcomes of the 2 anesthesia types.MATERIALS AND METHODS:In March 2014, we conducted a computerized search of MEDLINE and EMBASE for reports on anesthesia and endovascular treatment of acute ischemic stroke. Using random-effects meta-analysis, we evaluated the following outcomes: recanalization rate, good functional outcome (mRS ≤ 2), asymptomatic and symptomatic intracranial hemorrhage, death, vascular complications, respiratory complications, procedure time, time to groin, and time from symptom onset to recanalization.RESULTS:Nine studies enrolling 1956 patients (814 with general anesthesia and 1142 with conscious sedation) were included. Compared with patients treated by using conscious sedation during stroke intervention, patients undergoing general anesthesia had higher odds of death (OR = 2.59; 95% CI, 1.87–3.58) and respiratory complications (OR = 2.09; 95% CI, 1.36–3.23) and lower odds of good functional outcome (OR = 0.43; 95% CI, 0.35–0.53) and successful angiographic outcome (OR = 0.54; 95% CI, 0.37–0.80). No difference in procedure time (P = .28) was seen between the groups. Preintervention NIHSS scores were available from 6 studies; in those, patients receiving general anesthesia had a higher average NIHSS score.CONCLUSIONS:Patients with acute ischemic stroke undergoing intra-arterial therapy may have worse outcomes with general anesthesia compared with conscious sedation. However, the difference in stroke severity at the onset may confound the comparison in the available studies; thus, a randomized trial is necessary to confirm this association.

Intra-arterial recanalization for acute ischemic stroke is commonly used in patients with large-vessel occlusion.¹ Timely recanalization of the occluded vessel with either IV-tPA or intra-arterial therapy is essential in preventing neuronal death and improving patient outcome.² A number of factors affect patient outcomes following endovascular recanalization, possibly including choice of anesthetic agent during the procedure. Moderate conscious sedation and general anesthesia with intubation are the 2 most commonly used anesthesia techniques for patients with acute ischemic stroke undergoing endovascular recanalization.³ General anesthesia is often the preferred method due to the perceptions of improved procedural safety and efficacy.³ However, conscious sedation and local anesthesia allow operators to monitor neurologic status during the procedure and avoid delays in procedure initiation.⁴ Furthermore, conscious sedation may be associated with improved hemodynamic stability compared with general anesthesia. Due to the continuing debate regarding anesthesia choices during intra-arterial treatment of acute ischemic stroke, we performed a meta-analysis of studies comparing outcomes of patients with stroke receiving general anesthesia and conscious sedation during the procedures.^5,6     

Comparison of angiographic CT and spiral CT to assess cement distribution after vertebral augmentation

PURPOSE: To compare angiographic computed tomographic (CT) imaging with standard spiral CT imaging for the depiction of extraosseous cement after vertebral augmentation. MATERIALS AND METHODS: Retrospective analysis of 28 consecutive patients treated with vertebral augmentation for compression fracture was conducted. Intraprocedural angiographic CT and postprocedural spiral CT images were acquired in all patients. Angiographic CT and spiral CT images were evaluated independently by two experienced radiologists. RESULTS: All vertebral augmentation procedures were performed successfully. All observed cement leaks were small, and no patient underwent additional treatment for cement leak. One level was excluded as a result of severe motion artifacts that rendered angiographic CT nondiagnostic. Further analysis was performed in the remaining 27 patients (12 men; mean age, 62 years; age range, 31-87 y) corresponding to 48 vertebral levels. Seventeen patients were treated under general anesthesia (33 levels) and 11 were treated under conscious sedation (15 levels). To detect the presence of extraosseous cement, angiographic CT achieved sensitivity of 0.70 and 0.57 for reader 1 and reader 2, respectively, and specificity of 0.93 and 0.92, respectively. Stratified analyses by anesthesia type showed sensitivity of 0.73 and 0.50, respectively, for conscious sedation versus 0.67 and 0.62, respectively, for general anesthesia. Specificity was 1.00 and 1.00, respectively, versus 0.92 and 0.90, respectively. CONCLUSIONS: Cement leaks were detected with a high specificity and a moderate sensitivity with angiographic CT. No difference was found between treatments with general anesthesia versus intravenous conscious sedation.     

Cost analysis of adjunct hypnosis with sedation during outpatient interventional radiologic procedures

PURPOSE: To compare the cost of standard intravenous conscious sedation with that of sedation with adjunct self-hypnotic relaxation during outpatient interventional radiologic procedures. MATERIALS AND METHODS: Data were reviewed from a prospective randomized study in which patients undergoing vascular and renal interventional procedures underwent either standard sedation (n = 79) or sedation with adjunct hypnosis (n = 82). These data were used to construct a decision analysis model to compare the cost of standard sedation with the cost of sedation with adjunct hypnosis. Multiple sensitivity analyses were performed to assess the applicability of these results to other institutions with different cost structures with respect to the following variables: cost of the hypnosis provider, cost of room time for interventional radiologic procedure, hours of observation after the procedure, and frequency and cost of complications associated with over- or undersedation. RESULTS: According to data from this experience, the cost associated with standard sedation during a procedure was $638, compared with $300 for sedation with adjunct hypnosis, which resulted in a savings of $338 per case with hypnosis. Although hypnosis was known to reduce room time, hypnosis remained more cost-effective even if it added an additional 58.2 minutes to the room time. CONCLUSION: Use of adjunct hypnosis with sedation reduces cost during interventional radiologic procedures.     

Conscious sedation for endoscopic and non-endoscopic interventional gastrointestinal procedures: meeting patients' expectations, missing the standard

AIM: To assess the level of sedation, patient satisfaction and frequency of unplanned events with conscious sedation for interventional procedures. MATERIALS AND METHODS: One hundred and seventeen patients were assessed prospectively before, during and after procedures. Blood pressure, pulse, oxygen saturation and sedation level were monitored and patients followed up after 24 h. Sedation was scored after drugs were given in accordance with an established protocol. Doses were recorded, as were patients' weight, age and ASA grade and any unplanned events and their management. RESULTS: Seventy-six of the 117 patients (65%) had no unplanned event, 20 (17.1%) became agitated, 15 (12.8%) hypotensive, three (2.6%) hypoxic and three (2.6%) had more than one response. Twelve patients required active management. Fifty-two (44.4%) had a sedation level of 相似文献   

镇静-镇痛策略与机械通气患者ICU不适经历关系的多中心调查研究

目的 了解我国ICU机械通气患者镇静、镇痛治疗的现状,以进一步探讨镇静-镇痛策略对该类患者ICU不适住院经历的影响.方法 2006年6月15日-2006年8月15日,对全国31家三级甲等教学医院所有转出ICU的清醒机械通气患者进行调查,内容包括患者一般情况,疾病分类,机械通气时间,所接受的镇静-镇痛治疗,以及包括紧张害怕、情绪低落、睡眠不良、疲劳感、口渴、疼痛等6项内容的ICU不适经历情况.结果 163例接受机械通气的ICU清醒患者中,出现ICU不适经历的比例高达96.9%,其中83例(50.9%)出现严重不适.机械通气时间≥48h的患者严重不适经历发生率为59.7%,与机械通气时间＞48h的患者(44.8%)比较无统计学差异.61例未给予任何镇静、镇痛治疗,其严重不适经历发生率(73.8%)显著高于接受镇静、镇痛治疗的患者(37.3%,P＜0.01).以镇痛为基础的镇静治疗方案对严重不适经历的发生具有显著的保护作用(OR＝0.125;95%CI:0.052～0.298;P＜0.01),单独应用镇静剂或镇痛药保护作用差.结论 恰当的镇静-镇痛治疗可有效降低ICU严重不适经历的发生率.我国ICU机械通气患者接受系统镇静-镇痛治疗的比例较低,对ICU医师进行系统镇静-镇痛知识和方法的培训亟待加强.     

多发伤早期诊疗中漏诊原因分析

目的分析多发伤患者漏诊的原因并探讨其预防对策,以降低漏诊的发生率。方法回顾性分析我科收治的512例多发伤患者的漏诊原因,并针对性提出预防对策。结果多发伤患者漏诊率为16.19%,漏诊原因以意识障碍、休克和镇静治疗(149例次,19.68%)、影像学检查不完善(77例次,10.17%)、患者、家属不遵从医嘱(76例次,10.04%)为主,漏诊患者的住院天数为(23.59±7.26)天,死亡率为2.93%,显著高于整体水平(P0.01)。结论多发伤患者早期诊疗中应优先抢救生命,允许出现非致命伤的漏诊,应待患者病情稳定后,再次进行检查和评估,以明确诊断,提高救治质量。     

A Medicare cost analysis of MRI- versus CT-based high-dose-rate brachytherapy of the cervix: Can MRI-based planning be less costly?

PurposeWhile some institutions deliver multiple fractions per implant for MRI-based planning, it is common for only one fraction to be delivered per implant with CT-based cervical brachytherapy. The purpose of this study was to compare physician costs, hospital costs, and overall costs for cervical cancer patients treated with either CT-based or MRI-based high-dose-rate (HDR) cervical brachytherapy to determine if MRI-based brachytherapy as described can be financially feasible.Methods and MaterialsWe identified 40 consecutive patients treated with curative intent cervical brachytherapy. Twenty patients underwent CT-based HDR brachytherapy with five fractions delivered in five implants on nonconsecutive days in an outpatient setting with the first implant placed with a Smit sleeve under general anesthesia. Twenty patients received MRI-based HDR brachytherapy with four fractions delivered in two implants, each with MRI-based planning, performed 1–2 weeks apart with an overnight hospital admission for each implant. We used Medicare reimbursements to assess physician costs, hospital costs, and overall cost.ResultsThe median cost of MRI-based brachytherapy was $14,248.75 (interquartile range [IQR]: $13,421.32–$15,539.74), making it less costly than CT-based brachytherapy with conscious sedation (i.e., $18,278.85; IQR: $17,323.13–$19,863.03, p < 0.0001) and CT-based brachytherapy with deep sedation induced by an anesthesiologist (i.e., $27,673.44; IQR: $26,935.14–$29,511.16, p < 0.0001). CT-based brachytherapy with conscious sedation was more costly than CT-based brachytherapy with deep sedation (p < 0.001).ConclusionsMRI-based brachytherapy using the described treatment course was less costly than both methods of CT-based brachytherapy. Cost does not need to be a barrier for MRI-based cervical brachytherapy, especially when delivering multiple fractions with the same application.     

Safety of Conscious Sedation In Interventional Radiology

Purpose: To identify rates of adverse events associated with the use of conscious sedation in interventional radiology. Methods: In a 5-month period, prospective data were collected on patients undergoing conscious sedation for interventional radiology procedures (n = 594). Adverse events were categorized as respiratory, sedative, or major adverse events. Respiratory adverse events were those that required oral airway placement, ambu bag, or jaw thrust. Sedation adverse events were unresponsiveness, oxygen saturation less than 90%, use of flumazenil/naloxone, or agitation. Major adverse events were hypotension, intubation, CPR, or cardiac arrest. The frequency of adverse events for the five most common radiology procedures were determined. Results: The five most common procedures (total n = 541) were biliary tube placement/exchange (n = 182), tunneled catheter placement (n = 135), diagnostic arteriography (n = 125), vascular interventions (n = 52), and other catheter insertions (n = 46). Rates for respiratory, sedation, and major adverse events were 4.7%, 4.2%, and 2.0%, respectively. The most frequent major adverse event was hypotension (2.0%). Biliary procedures had the highest rate of total adverse events (p < .05) and respiratory adverse events (p < .05). Conclusion: The frequency of adverse events is low with the use of conscious sedation during interventional procedures. The highest rates occurred during biliary interventions.     

Bispectral index monitoring for conscious sedation in intervention: better, safer, faster

AIM: The aim of this study was to compare subjective (Ramsay sedation score, RSS) with objective electroencephalogram-based bispectral index (BIS) assessment, and to validate the appropriate BIS range for measurement of conscious sedation in interventional procedures. MATERIALS AND METHODS: One hundred patients undergoing sedo-analgesia (midazolam and fentanyl) for interventional gastrointestinal procedures were divided into two groups. In group A (n=30) sedation was guided by the RSS with the operator blinded to the BIS recording. In group B (n=70) the operator titrated intravenous sedation to maintain an optimal BIS, predetermined from the results in group A. Recovery time, procedure duration, physiological parameters and unplanned events were recorded in both groups. RESULTS: There was a significant correlation between the BIS and RSS (p<0.001). BIS values of 87.2 and 80.9 corresponded to an RSS of 3 and 4, respectively. The optimal BIS level was defined as 80-85. Fifty-seven point five percent of readings were within this range in group B compared with 26.5% in group A (p<0.001). Sedation approaching general anaesthesia (BIS<60) occurred in 5.5% of patients in group A but not in group B. Mean recovery time, duration of procedure, midazolam and fentanyl doses were significantly reduced in group B. Unplanned events were reduced from 27 to 17%, but this was not statistically significant (p=0.29). CONCLUSION: BIS monitoring enables more effective titration of sedatives to maintain a suitable level of consciousness, whilst reducing procedure time. The BIS offers an objective, safe and reliable measure of sedation, without disturbing either patient or operator. BIS monitoring raises the standard of patient care, and in our view, should be used to augment standard assessment.     

瑞芬太尼用于高龄患者内镜逆行胰管造影术的镇静效果和安全性

目的研究单独持续输注瑞芬太尼用于高龄患者内镜逆行胰管造影术（endoscopicretrogradecholangiopancreat—ic，ERCP）患者清醒镇静的临床效果和安全性。方法选择89例ASAI～Ⅲ级、年龄70～89岁拟在清醒镇静下实施ERCP的患者，首先以0．2μg/（kg·nlin）速率持续输注瑞芬太尼5rain，手术开始后减为0．15μg（kg·min），未复合其他麻醉药物。观察患者麻醉前（T0）、手术开始即刻（T1）、手术开始后5min（T1）、和10min（T3）以及术毕（rr4）时血压、心率、呼吸频率、、血氧饱和度（SpO2）、脑电双频指数（BIS）以及术后改良Aldrete镇静评分、操作者满意度评分和不良反应发生情况，并记录手术操作时间和麻醉时间。结果与麻醉诱导前基础值相比较，患者在T2时的血压明显升高，心率在T1、T2、T3、T4时升高显著，SpO2值T4时降低明显，BIS值彳FT1、T2、T3和T4时均明显降低。所有患者均顺利完成操作，操作过程中5例患者血氧饱和度降至90％以下，无1例需要面罩辅助通气或气管插管发生。插入十二指肠镜时发生恶心5例，取石操作中引起轻微疼痛但能忍受的6例，疼痛评分小于3分。8例对镜干入口和取石操作无记忆，19例对镜干入口有记忆，62例对镜干入口和取石操作都存在记忆。术毕取出镜干时9例处于睡眠状态，其他患者均清醒；术后恶心、呕吐的25例，操作者满意度评分为97．1±2．8。结论单独持续输注瑞芬太尼用于高龄ERCP患者清醒镇静可获得满意的麻醉效果，且安全性好。     

Improving gynecologic brachytherapy patient experience by optimizing MRI,anesthesia, and scheduling to decrease the length of time tandem and ovoid applicators are in place

PurposeBrachytherapy requires multiple different steps and plays a critical role in treatment for gynecological cancer. In an effort to improve gynecologic patient experience, we investigated how different aspects of the procedure influence how long the patient has the brachytherapy applicator in place.Methods and MaterialsWe prospectively recorded 145 consecutive tandem and ovoid treatments for 33 patients and determined how anesthesia vs. conscious sedation, MRI or not, and the number of procedures in the day impact applicator in time. The data were analyzed in a mixed effects linear regression model to account for the within-patient correlation.ResultsWe found average applicator in place time was 179 minutes (range: 87–311 minutes). Patients who received anesthesia had a significant increase in length of applicator in patient time by an average of 42 minutes compared with those who received conscious sedation. Undergoing an MRI increased length of applicator in time by an average of 66 minutes, although the actual MRI performed generally took less than 30 minutes. Having three or more procedures scheduled for 1 day increased the length of time the tandem and ovoid was inserted by an average of 35 minutes.ConclusionThe use of anesthesia vs. conscious sedation, MRI scans for treatment planning, and number of procedures scheduled per day have significant influence on the duration of brachytherapy treatments. This information can help us work to optimize scheduling and thereby improve patient brachytherapy experience.     

Percutaneous endoscopy for biliary radiologic interventions

Biliary endoscopy is an adjunct to percutaneous biliary interventions. Although there are technical and cost considerations, the interventional radiologist may apply this useful tool to patients with a wide range of biliary diseases (eg, patients with retained intrahepatic stones, patients with suspected lesions requiring biopsy, etc). Discussed in this article are advantages, disadvantages, patient preparation, technical advice, complications, and a review of the literature. Percutaneous biliary endoscopy, applied through a transhepatic tube tract or a mature T tube tract, reduces radiation exposure to the patient and health care personnel in the room. The procedure is generally performed on an outpatient basis under conscious sedation. Given access to a choledochofiberscope and familiarity with its use, percutaneous endoscopy for biliary radiologic interventions is a valuable technique and may be used to manage patients with complex biliary disease.     

Even Small Decreases in Blood Pressure during Conscious Sedation Affect Clinical Outcome after Stroke Thrombectomy: An Analysis of Hemodynamic Thresholds

BACKGROUND AND PURPOSE:The adverse effects of general anesthesia in stroke thrombectomy have been attributed to intraprocedural hypotension, yet optimal hemodynamic targets remain elusive. Identifying hemodynamic thresholds from patients without exposure to general anesthesia may help separate the effect of hypotension from the effect of anesthesia in thrombectomy outcomes. Therefore, we investigated which hemodynamic parameters and targets best correlate with outcome in patients treated under sedation with monitored anesthesia care.MATERIALS AND METHODS:We performed a retrospective analysis of a prospectively collected data base of patients with anterior circulation stroke who were successfully reperfused (modified TICI ≥ 2b) under monitored anesthesia care sedation from 2010 to 2015. Receiver operating characteristic curves were generated for the lowest mean arterial pressure before reperfusion, both as absolute values and relative changes from baseline. Cutoffs were tested in binary logistic regression models of poor outcome (90-day mRS > 2).RESULTS:Two-hundred fifty-six of 714 patients met the inclusion criteria. In a multivariable model, a ≥10% mean arterial pressure decrease from baseline had an OR for poor outcome of 4.38 (95% CI, 1.53–12.56; P < .01). Other models revealed that any mean pressure of <85 mm Hg before reperfusion had an OR for poor outcome of 2.22 (95% CI, 1.09–4.55; P = .03) and that every 10-mm Hg drop in mean arterial pressure below 100 mm Hg had an OR of 1.28 (95% CI, 1.01–1.62; P = .04).CONCLUSIONS:A ≥10% mean arterial pressure drop from baseline is a strong risk factor for poor outcome in a homogeneous population of patients with stroke undergoing thrombectomy under sedation. This threshold could guide hemodynamic management of patients during sedation and general anesthesia.

Retrospective studies have found that performing thrombectomies with the patient under general anesthesia may be associated with worse outcomes,^1,2 possibly because of the increased incidence and severity of hypotension compared with the use of conscious sedation.³ Hypotension before reperfusion may compromise collateral blood flow and negatively impact outcomes in acute ischemic stroke. Previous investigations demonstrated that a lowest recorded systolic blood pressure of >140 mm Hg during endovascular therapy for acute ischemic stroke is associated with good neurologic outcome.³ Our group subsequently showed that a lowest mean arterial pressure (MAP) of ≥70 mm Hg is an independent predictor of favorable neurologic outcome.⁴These studies were limited because they included a mix of patients receiving conscious sedation and general anesthesia. In this setting, the association between general anesthesia and hypotension may make it difficult to discern the independent effects of blood pressure regardless of anesthesia type. We hypothesized that hypotension influences outcome even in those patients not exposed to general anesthesia. Our aim was to determine optimal hemodynamic parameters and thresholds for patients with acute stroke undergoing thrombectomy under conscious sedation with monitored anesthesia care (MAC). Such parameters could be used in future studies of outcome and anesthesia type to determine whether general anesthesia has deleterious effects independent of hypotension.     

Virtual reality distraction during uterovaginal brachytherapy applicators’ removal: A pilot comparative study

PURPOSETo assess the relevance of virtual reality distraction (VR) during uterovaginal brachytherapy applicators’ removal, as an alternative to nitrous oxide (N₂O) conscious sedation, to decrease anxiety and pain perception.METHODS AND MATERIALSWe prospectively evaluated 35 patients treated with cervical brachytherapy for locally or locally advanced cervical cancer. Brachytherapy applicators were removed in the patient's room at the end of the treatment. Patients were assigned to N₂O conscious sedation (reference group) or VR (experimental group). Anxiety and pain were evaluated with the STAI-E score and with Visual Analogical Scales (VAS).RESULTSFourteen patients were treated with VR and 21 with N₂O. STAI-E baselines scores were 35 in the VR group and 38 in the reference group and declined to 30 and 28, respectively after procedure. The mean VAS-anxiety was 2.9 before and 2.7 at the peak in the VR group versus 4.1 and 1.6, respectively in the reference group. The mean VAS-pain was 1.0 before, 3.1 at the peak and 0.4 after the procedure in the experimental group, versus 1.8, 2.0, and 0.6 respectively in the N₂O group. Four patients in the VR group experienced mild nausea/vomiting or dizziness during the procedure. The preparation duration was higher in the VR group, with a similar duration for the removal itself.CONCLUSIONSReplacing a medical gas by a virtual reality device was feasible and led to acceptable levels of pain and anxiety. Prospective randomized trials are needed to confirm efficacy and to determine which patients could benefit the most from this approach.     

Impact of Anesthesia on the Outcome of Acute Ischemic Stroke after Endovascular Treatment with the Solitaire Stent Retriever

BACKGROUND AND PURPOSE:General anesthesia during endovascular treatment of acute ischemic stroke may have an adverse effect on outcome compared with conscious sedation. The aim of this study was to examine the impact of the type of anesthesia on the outcome of patients with acute ischemic stroke treated with the Solitaire stent retriever, accounting for confounding factors.MATERIALS AND METHODS:Four-hundred one patients with consecutive acute anterior circulation stroke treated with a Solitaire stent retriever were included in this prospective analysis. Outcome was assessed after 3 months by the modified Rankin Scale.RESULTS:One-hundred thirty-five patients (31%) underwent endovascular treatment with conscious sedation, and 266 patients (69%), with general anesthesia. Patients under general anesthesia had higher NIHSS scores on admission (17 versus 13, P < .001) and more internal carotid artery occlusions (44.6% versus 14.8%, P < .001) than patients under conscious sedation. Other baseline characteristics such as time from symptom onset to the start of endovascular treatment did not differ. Favorable outcome (mRS 0–2) was more frequent with conscious sedation (47.4% versus 32%; OR, 0.773; 95% CI, 0.646–0.925; P = .002) in univariable but not multivariable logistic regression analysis (P = .629). Mortality did not differ (P = .077). Independent predictors of outcome were age (OR, 0.95; 95% CI, 0.933–0.969; P < .001), NIHSS score (OR, 0.894; 95% CI, 0.855–0.933; P < .001), time from symptom onset to the start of endovascular treatment (OR, 0.998; 95% CI, 0.996–0.999; P = .011), diabetes mellitus (OR, 0.544; 95% CI, 0.305–0.927; P = .04), and symptomatic intracerebral hemorrhage (OR, 0.109; 95% CI, 0.028–0.428; P = .002).CONCLUSIONS:In this single-center study, the anesthetic management during stent retriever thrombectomy with general anesthesia or conscious sedation had no impact on the outcome of patients with large-vessel occlusion in the anterior circulation.

Endovascular treatment of acute ischemic stroke due to large-vessel occlusion in the anterior circulation is safe and effective for improving functional outcome.¹ However, there is an ongoing debate about the type of anesthesia to be used, general anesthesia (GA) or conscious sedation (CS). No patient movements, better airway control, and perceived procedural safety and efficacy are regarded as potential advantages of GA, but more recent data of nonrandomized studies including 1 meta-analysis of 9 studies suggest that CS during endovascular stroke treatment might improve outcome.^2–5 This finding might be explained by a shorter time to start the intervention, less blood pressure dip, and easier neurologic monitoring during and after CS. However, many confounding factors such as stroke severity, occlusion site, pretreatment with IV rtPA, age, endovascular treatment techniques, and recanalization rates, might influence outcome.^3,6–11 Recently, the results of the first randomized study, Sedation versus Intubation for Endovascular Stroke TreAtment (SIESTA), were published, which showed no differences between GA and CS for the primary end point defined as early neurologic improvement on the NIHSS after 24 hours.¹²The aim of this study was to examine the impact of the type of anesthesia (GA versus CS) on the outcome of patients with acute ischemic stroke with large-vessel occlusion in the anterior circulation who were treated with the Solitaire stent retriever (Covidien, Irvine, California), while accounting for confounding factors.