Recent Developments in Devices Used for Gastrointestinal Endoscopy Sedation

Hypoxemia is a frequent and potentially fatal complication occurring in patients during gastrointestinal endoscopy. The administration of propofol sedation increases the risk of most complications, especially hypoxemia. Nevertheless, propofol has been increasingly used in the United States, and the trend is likely to increase in the years to come. Patient satisfaction and endoscopist satisfaction along with rapid turnover are some of the touted reasons for this trend. However, propofol sedation generally implies deep sedation or general anesthesia. As a result, hypopnea and apnea frequently occur. Inadequate sedation and presence of irritable airway often cause coughing and laryngospasm, both leading to hypoxemia and potential cardiac arrest. Hence, prevention of hypoxemia is of paramount importance. Traditionally, standard nasal cannula is used to administer supplement oxygen. However, it cannot sufficiently provide continuous positive airway pressure (CPAP) or positive pressure ventilation. Device manufacturers have stepped in to fill this void and created many types of cannulas that provide apneic insufflation of oxygen and CPAP and eliminate dead space. Such measures decrease the incidence of hypoxemia. This review aimed to provide essential information of some of these devices.

Recent Developments in Devices Used for Gastrointestinal Endoscopy Sedation

Hypoxemia is a frequent and potentially fatal complication occurring in patients during gastrointestinal endoscopy. The administration of propofol sedation increases the risk of most complications, especially hypoxemia. Nevertheless, propofol has been increasingly used in the United States, and the trend is likely to increase in the years to come. Patient satisfaction and endoscopist satisfaction along with rapid turnover are some of the touted reasons for this trend. However, propofol sedation generally implies deep sedation or general anesthesia. As a result, hypopnea and apnea frequently occur. Inadequate sedation and presence of irritable airway often cause coughing and laryngospasm, both leading to hypoxemia and potential cardiac arrest. Hence, prevention of hypoxemia is of paramount importance. Traditionally, standard nasal cannula is used to administer supplement oxygen. However, it cannot sufficiently provide continuous positive airway pressure (CPAP) or positive pressure ventilation. Device manufacturers have stepped in to fill this void and created many types of cannulas that provide apneic insufflation of oxygen and CPAP and eliminate dead space. Such measures decrease the incidence of hypoxemia. This review aimed to provide essential information of some of these devices.

Association between Type of Sedation and the Adverse Events Associated with Gastrointestinal Endoscopy: An Analysis of 5 Years’ Data from a Tertiary Center in the USA

BACKGROUND/AIMS: The landscape of sedation for gastrointestinal (GI) endoscopic procedures and the nature of the procedures themselves have changed over the last decade. In this study, an attempt is made to analyze the frequency and etiology of all major adverse events associated with GI endoscopy. METHODS: All adverse events extracted from the electronic database and local registry were analyzed. Although the data analysis was retrospective, the adverse events themselves were documented prospectively. These events were evaluated after subdivision into propofol-based anesthesia and intravenous conscious sedation groups. RESULTS: Cardiorespiratory events, including cardiac arrest, were the most common adverse events during esophagogastroduodenoscopy, while bleeding was more frequent in patients undergoing colonoscopy. Pancreatitis was the most frequent adverse event in patients undergoing endoscopic retrograde cholangiopancreatography. The frequencies of most adverse events were significantly higher in patients anesthetized with propofol. Automatic regression modeling showed that the type of sedation, the American Society of Anesthesiologists physical status classification, and the procedure type were some of the predictors of immediate life-threatening complications. CONCLUSIONS: Clearly, our regression modeling suggests a strong association between the type of sedation as well as various patient factors and the frequency of adverse events. The possible reasons for our results are the changing demographics, the worsening comorbidities of the patient population, and the increasing technical complexity of these procedures. Although extensive use of propofol has increased patient satisfaction and procedure acceptability, its use is also associated with more frequent adverse events.

Propofol alternatives in gastrointestinal endoscopy anesthesia

Although propofol has been the backbone for sedation in gastrointestinal endoscopy, both anesthesiologists and endoscopists are faced with situations where an alternative is needed. Recent national shortages forced many physicians to explore these options. A midazolam and fentanyl combination is the mainstay in this area. However, there are other options. The aim of this review is to explore these options. The future would be, invariably, to move away from propofol. The reason is not in any way related to the drawbacks of propofol as a sedative. The mandate that requires an anesthesia provider to administer propofol has been a setback in many countries. New sedative drugs like Remimazolam might fill this void in the future. In the meantime, it is important to keep an open eye to the existing alternatives

Remimazolam: the future of its sedative potential

Remimazolam [CNS 7056] is a new drug innovation in anesthesia. It combines the properties of two unique drugs already established in anesthesia - Midazolam and remifentanil. It acts on GABA receptors like midazolam and has organ-independent metabolism like remifentanil. It is likely to be the sedative of the future, as preliminary phase II trials have shown minimal residual effects on prolonged infusions. It has potential to be used as a sedative in ICU and as a novel agent for procedural sedation. Unlike most rapidly acting intravenous sedatives available presently, the propensity to cause apnea is very low. Availability of a specific antagonist [flumazenil] adds to its safety even in cases of overdose. The present review discusses remimazolam's potential as a new drug in anesthesia along with the presently available literary evidence

Goudra ventilating bite block to reduce hypoxemia during endoscopic retrograde cholangiopancreatography

We describe the airway management of a patient presenting for ERCP with a bite block that allows positive pressure ventilation.

Effectiveness of high dose remifentanil in preventing coughing and laryngospasm in non-paralyzed patients for advanced bronchoscopic procedures

Anesthesia for bronchoscopy presents unique challenges, as constant stimulus due to bronchoscope needs to be obtunded using drugs with a minimal post-procedure residual effect. Remifentanil for maintenance is an ideal choice, but optimal doses are yet to be determined. Bronchoscopic procedures were prospectively evaluated for 4 months studying the frequency of complications and anesthesia techniques. Anesthesia was maintained on remifentanil/propofol infusion avoiding neuromuscular blockers. Laryngeal mask airway was used for the controlled ventilation [with high oxygen concentration] that also served as a conduit for bronchoscope insertions. Anesthesiologists were blinded to the study [avoiding performance bias] and the Pulmonologist was blinded to the anesthesia technique [to document unbiased procedural satisfaction scores]. Procedures were divided into 2 groups based on the dose of remifentanil used for maintenance: Group-H [high dose -0.26 to 0.5 micro g/kg/min and Group-NH [non-high dose <0.25 micro,g/kg/min]. Observed 75 procedures were divided into Group-H [42] and Group-NH [33]. Number of statistical difference was found in demography, procedural profile, hemodynamic parameters and total phenylephrine used. Chi-square test showed Group-NH had significantly higher frequency of laryngospasm [P= 0.047] and coughing [F= 0.002]. The likelihood ratio of patient coughing and developing laryngospasm in Group-NH was found to be 4.56 and 10.97 times respectively. Minimum pulse-oximeter saturation was statistically higher in Group-H [98.80% vs. 96.50% P= 0.009]. Pulmonologist satisfaction scores were significantly better in Group-H. High dose of remifentanil infusion is associated with a lower incidence of coughing and laryngospasms during bronchoscopy. Simultaneously, it improves Pulmonologist's satisfaction and procedural conditions

Dos casos de calambre refractario del escribano en la clínica de dolor: ¿está la respuesta en la toxina botulínica? / Two cases of refractory writer's cramp in pain clinic: Is botulinum the answer?

Introducción: El calambre del escribano es un trastorno doloroso refractario que suele manifestarse como enfermedad incapacitante tras un período corto de escritura. La terapia convencional con agentes neurogénicos como la carbamazepina muchas veces no beneficia a estos pacientes. En la literatura moderna se ha resaltado el uso de la toxina botulínica en distonías focales, de manera que su uso también podría extrapolarse a los pacientes con espasmo del escribano. Objetivo: Evaluar la eficacia y la seguridad de la toxina botulínica en casos de calambre refractario del escribano. Metodología: Presentamos 2 casos de calambre refractario del escribano. Se evaluó a los pacientes para determinar el grupo de los músculos de la mano que estaban comprometidos. Una vez identificados los músculos se inyectó en ellos la toxina botulínica y se utilizó la respuesta clínica como base para determinar la dosis total requerida. Se hizo seguimiento a los pacientes a fin de evaluar el grado de alivio y cualquier efecto adverso asociado. Resultados: Los 2pacientes presentaron un grado significativo de alivio clínico tras la aplicación de la toxina botulínica. El tiempo de escritura mejoró y los 2 pacientes refirieron un alivio significativo del dolor. En ambos casos fue necesario repetir la inyección después de 3-6 meses, aunque la afección fue menor en cada recaída y fue posible suspenderles la medicación oral. Uno de los pacientes presentó leve debilidad de la mano, que tuvo un impacto clínico menor y revirtió a la normalidad en un lapso de 2-3 semanas. Este hecho no afectó la satisfacción de los pacientes con el tratamiento, considerando que la enfermedad primaria era incapacitante y afectaba el trabajo profesional de todos los días. Conclusión: La toxina botulínica es una alternativa terapéutica segura y eficaz para tratar a los pacientes afectados con calambre refractario del escribano que consulten la clínica de dolor.

Introduction: Writer’s cramp is a refractory painful disorder, often presenting as a disabling disease while writing for a short duration. The conventional therapy in the form of neurogenic agents such as carbamazepine often fails to benefit these patients. Modern literature has highlighted the used of botulinum toxin in focal dystonisas and hence its use can also be extrapolated in patients of writer’s cramps. Aim: Evaluating the efficacy and safety of botulinum toxin in refractory writer’s cramps. Methodology:We present 2 cases of diagnosed refractory writer’s cramp. These patients were evaluated for group of handmuscles involved. Once themuscles were identified, botulinum toxin was injected into these muscles and clinical response was used to iterate the total dose of botulinum needed. These patients were followed up for degree of relief and any associated adverse effects. Results: Both patients showed significant clinical relief after the use of botulinum toxin. Their writing time improved and both patients reported a significant pain relief. The patients required repeat injection 3-6 months, however with each reoccurrence their ailment decreased and they could be taken off oral medication. Minor clinically insignificant reversible weakness was seen in one patient, which reverted to normal in 2-3 weeks time which did not affect patients’ satisfaction to treatment, as the primary disease was disabling for daily professional work. Conclusion: Botulinum toxin is a safe and effective therapeutic option for treating patients of refractory writer’s cramp presenting in the pain clinic.

Outpatient endoscopic retrograde cholangiopancreatography: safety and efficacy of anesthetic management with a natural airway in 653 consecutive procedures

Endoscopic retrograde cholangiopancreatography [ERCP] is a unique diagnostic and therapeutic procedure performed in high risk patients in prone/semi-prone position. Propofol based deep sedation has emerged as the method of choice however, the ability to predict possible complications is yet un-explored. The present study aimed to evaluate known high risk-factors for general anesthesia [American Society of Anesthesiologists [ASA] status, body mass index [BMI], and Mallampati class] for their ability to affect outcomes in ERCP patients. Retrospective data of 653 patients who underwent ERCP during a period of 26 months at university hospital of Pennsylvania was reviewed. Patient-specific and procedure specific data was extracted. Desaturation was defined by fall of pulse oximeter saturation below 95% and its relation to patient specific high risk-factors was analyzed. Only 45 patients had transient de-saturation below 95% without any residual sequlae. No statistically significant relation between desaturation episodes and patients higher ASA status or BMI or modified Mallampati [MMP] class was found. Despite 60% patients being ASA III/IV none required emergency intubation or procedural interruption. Optimal oxygenation and airway patency was maintained with high degree of success using simple airway maneuvers or conduit devices [nasal/oral trumpet] with oxygen supplementation in all patients. Unlike general anesthesia, pre-operative patient ASA status, higher MMP or increasing BMI does not bear relation with likelihood of patients desaturating during ERCP. In presence of vigilant apnea monitoring and careful dose titration of maintenance anesthetics with airway conduits, general anesthesia, emergency intubations, and procedure interruptions can be avoided

2. Optical coherence tomography of the retina. new technology - new insights

Optical imaging is an emerging new technology, which can produce cross-sectional images of very high resolutions. Micro architecture of biological tissues is tomographically imaged by measuring the echo time delay and intensity of backreflected or backscattered light. This technology is now able to generate real-time in situ images of normal and abnormal tissue architecture with resolution of 1.5 to 15 microns, which are not possible with other conventional imaging tools such as ultrasound, MRI or CT

Post traumatic Parkinson's syndrom - a case report

A rare case of Parkinson's syndrome following head injury is described. The ocular abnormalties did not show any recovery. Early recognition of ocular changes helps to limit the imaging investigations to the cavernous sinus area. Aneurysm of the internal carotid artery, metastasis and trauma are the common aetiological factors in the few reported cases

Outcome of ocular trauma with retained intraocular foreign bodies

Ocular trauma associated with intraocular foreign bodies [IOFB] presents a challenging task to the treating physician. Outcome of eye injuries with retained foreign material is unpredictable and methods of their management are still controversial. 49 cases of intraocular foreign bodies were retrospectively studied to determine the nature of injuries and final visual results. IOFB were not seen in females and in children. Mostly the expatriate workers engaged in different industrial activities were found to be at high risk. A large number of IOFB [91.8%] were magnetic in nature and majority of them [69.38%] were located in the posterior segment of the eye. Overall outcome of patients was comparable to other studies but visual recovery was not as good as reported from developed regions of the world. Health education of vulnerable workers, upgrading of facilities and strategies of management are suggested

Pseudophakia retinal detachment

Study the outcome of pseudophakic retinal detachment surgery. Setting: Retina service, Ophthalmology department, Salmaniya Medical Centre, Bahrain. Subjects and Design: Review of medical records of all patients who presented to our unit between July 1987 and June 1995. A total of 14 cases of pseudophakic retinal detachments were analysed. Simple technique of episcleral buckling was found to be adequate to repair the detachment in 85.7% of cases. Single procedure was successful in 78.6% of patients. 64.3% of the cases regained 6/18 or better vision after surgery. Conclusions: Overall outcome of this small series of patients was comparable to the reports in the literature. Patients should be made aware of the risk of postoperative retinal detachment and its warning signals. The number of patients of this disease is likely to increase in the future and upgrading of existing facilities is suggested

Profile of retinal venous occlusion in Bahraini Population

Retinal vein occlusion is an important event and carries considerable morbidity in terms of visual upset and long term consequences. Influence of geographical, ethnic and associated systemic disorders in the pathogenesis of retinal venous obstruction is not well understood and remains controversial. 48 cases of retinal vein occlusion were retrospectively studied in Salmaniya Medical Centre to find out the underlying medical conditions and influence of ethnic components of Bahraini society. The disease was found to occur at a younger age here as compared to the White European population. Incidence of diabetes mellitus was noted to be high in this study. Both central as well as branch retinal vein occlusions were common in Bahrainis but branch retinal vein occlusions were more prevalent in Indians and Pakistanis. Ocular morbidity was caused more often by central retinal vein obstruction. Further prospective studies are suggested to understand better the unusual characteristics of this disease in this part of the world so as to formulate appropriate plans for its management