Intravenous sedation for gastrointestinal endoscopy in very elderly patients of Thailand.

Background: The use of sedation for gastrointestinal endoscopy (GIE) procedures in elderly patients has been established as a safe and effective technique. However, it is still uncertain whether the situation is valid for Asians. Objective: Evaluate the outcome of intravenous sedation (IVS) for GIE procedures in very elderly patients (>86 years old) in Thailand and compare the clinical efficacy of IVS between very elderly and those younger (<86 years old) Methods: We undertook a retrospective review of the sedation service records of patients who underwent GIE procedures between 2007 and 2008 at Siriraj Hospital, Thailand. All sedations were administered by anesthetic personnel in the endoscopy room. The cohort was divided into three groups, <65 years old (group 1), 65-85 years old (group 2), and >86 years old (group 3). Results: Sedation was provided for 1,779 patients (965, 687, and 127 patients in group 1, 2, and 3, respectively) in 2,061 GIE procedures. Fentanyl, midazolam and propofol were the most common IVS drugs used in all three groups. Patients in group 3 required lower mean doses of these intravenous sedatives than those in group 1 or 2 (p <0.001). Mean procedure time in group 3 was longer than in group 1 or 2 (p=0.010). Adverse events in group 3 occurred more frequently when compared to group 1 or 2 (p <0.001). Transient hypotension was the main complication across all aged groups. Conclusion: IVS for GIE procedure in very elderly patients was associated with higher minor advance events but relatively safe and effective when carried out by trained anesthetic personnel with appropriate monitoring and dose adjustment.

Recovery pattern and home-readiness after ambulatory gastrointestinal endoscopy.

BACKGROUND: Despite increased use of ambulatory gastrointestinal endoscopy, few data exist regarding patient recovery patterns and home-readiness. OBJECTIVE: The authors prospectively identified the pattern of home-readiness, the persistent symptoms after procedure and the factors that delay discharge after home-readiness criteria are satisfied. MATERIAL AND METHOD: Three hundred and sixty nine patients were scored by the investigator using the Modified Post-Anesthetic Discharge Scoring System (PADSS) every 30 min, commencing 30 min after procedure, until the PADSS score was > or =9. The same investigator telephoned each patient 24 hr after discharge to administer a standardized questionnaire so that postoperative symptoms could be identified. RESULTS: The number of patients who satisfied the PADSS home-readiness criteria was 81.6%, 97.9%, and 100% at 30, 60, and 90 min, respectively. All patients were promptly discharged before two hours. After home-readiness criteria were satisfied, 36% of patients had delayed discharge because of the unavailability of immediate escorts or other non-medical reasons. No patient had persistent symptoms and all patients could achieve a PADSS score > or =9 three hours after anesthesia. The patients undergoing shorter endoscopic procedures, such as EGD or dilated esophagus were discharged faster than patients undergoing colonoscopy or duodenal stent. The 24 hr postoperative symptoms were mainly sore throat, pain, weakness, and abdominal distension. There was no incidence of unanticipated admission. CONCLUSION: Periodic objective evaluation of home-readiness revealed that the majority of patients would achieve a satisfactory score on or before 1 hr after procedure. The time to home-readiness by objective evaluation correlated with the type of procedure. Most delays after satisfactory home-readiness scores were reached, were due to non-medical reasons.

Anesthesia for embolization from 2003-2004 in Siriraj Hospital: A retrospective study.

Objective: To report and evaluate the choices and techniques of anesthesia, drug usage and complications at Siriraj Hospital. Methods: Retrospectively analyzed the patients on whom embolization had been performed during the period of January, 2003 to October, 2004 in Siriraj Hospital.The patients’ characteristics, preanesthetic problems, anesthetic techniques, anesthetic agents, embolization agents and complications were assessed. Results: There were 292 cases and 476 procedures.The age group of 20-29 years was the highest one (27.9%).Most patients had American Society of Anesthesiologist (ASA) class I (60.3%). The diagnoses were brain arteriovenous malformation (30.3%), carotid cavernous sinus fistula (23.5%), other arteriovenous malformations (11.8%), hemangioma (7.8%), venous malformation (3.6%), arteriovenous fistula (2.3%), angiofibroma (2.3%), hemoptysis (2.1%), brain aneurysm (1.7%), gastrointestinal bleeding (1.3%) and others (13.3%).Hematologic disease, hypertension and neurological disease were the most common preanesthetic problems.General anesthesia with endotracheal tube was the anesthetic technique mainly employed (71.0%). Anesthetic agents were mainly administered with propofol, fentanyl and succinylcholine. The mean anesthetic time was 132.5+63.0 minutes.The embolization agents were glue (42.0%), balloon (20.6%), alcohol (13.2%), ivolon (7.1%), coil (6.9%) and gel foam (0.4%).The most frequent anesthetic complication was hypotension. Conclusion:During anesthetic management for embolization, special techniques or drugs in anesthesia are not routinely required, although the anesthetic personnel had to optimize the patient’s condition for safety and there should be an awareness of complications.

The effectiveness of intravenous sedation in diagnostic upper gastrointestinal endoscopy.

BACKGROUND: Topical pharyngeal anesthesia is required to perform a technically adequate esophago-gastroduodenoscopy (EGD), but does not improve patient satisfaction, comfort, and willingness to repeat, particularly in the elderly and those with increased pharyngeal sensitivity. The comparative effectiveness of intravenous sedation versus no sedation remains poorly characterized. OBJECTIVE: To compare the effectiveness of diagnostic EGD with and without intravenous sedation in an adult Thai population. MATERIAL AND METHOD: A randomized controlled trial assigned patients into two groups, group C (topical pharyngeal anesthesia alone) and group I (intravenous sedation and topical pharyngeal anesthesia). All patients were topicalized with lidocaine viscous and spray. The patients in group I were sedated with midazolam 0.035 mg x kg(-1) and maintained with continuous propofol infusion. The ease of procedure and patient tolerance were evaluated. Secondary outcomes included patient and endoscoptist satisfaction, total time to awake, and willingness to repeat the procedure. RESULTS: One hundred and seventy patients (mean age 50.5, 41.2% male) were randomized (group C = 85 and group I = 85; intervention) into two groups. Among patients of the two groups, 100% of the procedures were "successful". In group C, 98.8% were satisfied with their level of tolerance (comfort) while the group I had 100%. The willingness to repeat was 6.2 +/- 1.6 in group C while group I had 9.4 +/- 0.8. Patient and endoscopist satisfaction in group I was more satisfied than in group C (90.6% vs 35.3% and 81.2% vs 40.0% respectively) (p < 0.001). In group I, total amount of propofol was 91.6 +/- 45.5 mg and total time to awake was 8.2 +/- 4.2 min. The use of sedation was the major determinant of patient satisfaction, but contributed to an increased recovery room time. Hypertension and tachycardia were the most complications in group C, and hypotension was the most complication in group I. CONCLUSION: In the average Thai adult population, sedated diagnostic EGD is a good strategy to increase endoscopist satisfaction and willingness to repeat.

Anesthesia for endoscopic retrograde cholangiopancreatography (ERCP) from 1999--2003 in Siriraj Hospital: a retrospective study.

BACKGROUND: Endoscopic retrograde cholangio-pancreatography (ERCP) is another treatment option for hepato-biliary tract abnormalities. The authors studied anesthetic data as a basis for further research. METHOD: Retrospectively analyzed the patients on whom ERCP had been performed during the period of January, 1999 to November, 2003 in Siriraj Hospital. The patients' characteristics, preanesthetic problems, anesthetic techniques, anesthetic agents, anesthetic time, ERCP procedure and complications were assessed. RESULTS: There were 2,144 patients who received the procedure during study period The age group of 50-69 years was the highest one (46.9%). Most patients had ASA class 11 (54.7%). The diagnosis were stone (40.3%), tumor (34.0%), hepato-biliary tract infection (8.1%) and others (17.6%). Hypertension, diabetes mellitus and hematologic diseases were the most common preanesthetic problems. Total intravenous anesthesia (TIVA) was the anesthetic technique mainly employed (96.4%). Anesthetic agents were mainly administered with propofol, midazolam and fentanyl. The mean anesthetic time was 40.0+/-18.5 minutes. The indications for ERCP procedures were diagnostic (18.9%), stone removal (37.1%), stent removal and/or insertion (35.3%) and others (8.7%). The most frequent anesthetic complication was hypotension. CONCLUSION: During anesthetic management for ERCP, special techniques or drugs in anesthesia are not routinely required, however, the anesthetic personnel had to optimize the patient's condition for safety and there should be an awareness of complications.

Effectiveness of lightwand (Trachlight) intubation by 1st year anesthesia residents.

Transillumination of the soft tissue of the neck using a lighted stylet (lightwand) is an effective and safe intubating technique in experienced hands. The goal of this study was to determine the effectiveness and safety of this device in intubating the trachea of elective surgical patients by non-experienced hands. One hundred and fifty, paralysed, anesthetized, adult patients (ASA I-II, no known or potential problems with intubation) were studied. Failure to intubate was defined as lack of successful intubation after three attempts. The duration of each attempt was recorded as the time from insertion of the device into the oropharynx to the time of its removal. The total time to intubation (TTI) was defined as the sum of the durations of all (as many as three) intubation attempts. Complications, such as mucosal bleeding, lacerations, dental injury and sore throat were recorded. The mean TTI was 42.0 +/- 34.3 seconds. The overall intubation success rate was 92 per cent. Of all the successful intubations, 87.68 per cent were successful after one attempt. There were significantly fewer traumatic events (5.33%). Most of the trauma consisted of minor mucosal bleeding or mucosal laceration. We conclude that lightwand intubation is an effective and safe technique in non-experienced hands.

Can lidocaine reduce succinylcholine induced postoperative myalgia?

This study was undertaken to determine the effect of lidocaine pretreatment on reduction of succinylcholine-induced myalgia in patients undergoing general anesthesia for gynecological surgery. One hundred and thirty-five patients were assigned to one of three groups in a prospective, double blind, randomized manner. Group PS, the control group, received normal saline and succinylcholine 1.5 mg x kg(-1); Group LS, lidocaine 1.5 mg x kg(-1) and succinylcholine 1.5 mg x kg(-1); Group PR, normal saline and rocuronium 0.6 mg x kg(-1). Morphine 0.1 mg x kg(-1) iv was given for premedication and all patients were monitored with a noninvasive blood pressure monitor, ECG and pulse oximetry. Anesthesia was induced with 5 mg.kg(-1) thiopental iv. followed by succinylcholine (Group PS, LS) or rocuronium (Group PR) for tracheal intubation. Following administration of these agents, the presence, and degree of fasciculation were assessed visually on a four point scale by one investigator who was blinded to the drug administered. The blood pressure and heart rate of each patient were monitored on nine occasions. Twenty-four hours later, any myalgia experienced was assessed according to a structured questionaire and graded by a four point scale by one investigator blinded to the intraoperative management. The results indicate that muscle fasciculation was not found in Group PR while the patients in Group LS had a lower incidence of muscle fasciculation than those in Group PS (p < 0.001). At 24 h, the incidence of myalgia was higher in Group PS than in Group LS and PR (p < 0.05). A correlation was not found between the incidence of myalgia and the occurrence of muscle fasciculation. The changes in systolic and diastolic blood pressure and heart rate were not significant among the three groups. In conclusion, where succinylcholine is used, lidocaine is proven to be the useful pretreatment agent for the reduction of postoperative myalgia.