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

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