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.

Thrombocytopenia represents a risk for deterioration of liver function after radiofrequency ablation in patients with hepatocellular carcinoma.

BACKGROUND/AIMS: We evaluated changes in liver function parameters and risk factors for the deterioration of liver function 12 months after percutaneous radiofrequency ablation (RFA) therapy in patients with hepatocellular carcinoma (HCC). METHODS: The subjects in this retrospective study comprised 102 patients with HCC who had undergone RFA therapy and exhibited no recurrence of HCC 12 months thereafter. Serial changes in serum total bilirubin and albumin, prothrombin time, and Child-Pugh score were evaluated before RFA and 3, 6, 9, and 12 months thereafter. Deterioration of liver function was defined when the Child-Pugh score increased by at least 2 at 12 months after RFA therapy. We determined the factors related to aggravation of liver function after RFA therapy. RESULTS: Liver function had deteriorated 12 months after RFA in 29 patients (28.4%). Serum albumin levels decreased significantly from before (3.7±0.1 g/dL, mean±SD) to 12 months after RFA therapy (3.3±0.1 g/dL, P=0.002). The Child-Pugh score increased significantly during the same time period (from 6.1±0.2 to 7.2±0.3, P<0.001). Pre-RFA thrombocytopenia (≤100,000/mm(3)) was revealed as a significant risk factor for the deterioration of liver function after RFA. However, no patients had episodes of bleeding as a complication of RFA. CONCLUSIONS: Among the liver-function parameters, serum albumin level was markedly decreased in HCC patients over the course of 24 months after RFA therapy. A pre-RFA thrombocytopenia represents a major risk factor for the deterioration of liver function.

The cap-assisted technique enhances colonoscopy training: prospective randomized study of six trainees.

BACKGROUND: Colonoscopy and polypectomy procedures have effectively reduced the incidence of colorectal cancer. Currently, competence in colonoscopy is an essential part of the education program for gastrointestinal (GI) trainees. However, considerable training is required for the optimal performance of a colonoscopy. METHODS: This study involved six colonoscopy trainees, three of whom used the cap whereas the others did not. Each trainee managed 100 cases of screening colonoscopy from beginning to end. The cecal intubation success rate, cecal intubation time, polyp detection rate, adenoma detection rate, advanced adenoma detection rate, and adenocarcinoma detection rate were checked. The rate of successful cecal intubation and the cecal intubation time were reviewed every 10 cases. RESULTS: The cecal intubation rate was 80.7 % (242/300) in the cap group and 63.3 % (190/300) in the non-cap group. The average cecal intubation time was 13.7 min in the cap group and 18.7 min in the non-cap group. The statistical analysis of these results suggested that the cap group had a significantly higher success rate (p < 0.001) and a shorter cecal intubation time (p < 0.001) than the non-cap group. However, the two groups did not differ significantly in the detection rate for polyps (45.3 vs 43 %; p = 0.565), adenomas (26.3 vs 25 %; p = 0.709), advanced adenomas (2.6 vs 0.6 %; p = 0.056), or adenocarcinomas (5.3 vs 3 %; p = 0.153). CONCLUSION: Cap-assisted colonoscopies might help to increase the rate of cecal intubation success and shorten the cecal intubation time for GI trainees.

Clinical characteristics and outcomes of pneumococcal bacteremia in adult patients with liver cirrhosis.

Few studies have assessed the clinical characteristics and outcomes of invasive pneumococcal diseases in cirrhotic patients. We reviewed the medical records of adult cirrhotic patients with pneumococcal bacteremia from January 1997 to April 2006. During this time, 62 episodes of pneumococcal bacteremia occurred in 59 patients with liver cirrhosis, 45 (76.3%) of whom were classified as Child-Pugh grade C. The most common source of infection was spontaneous bacterial peritonitis (SBP) (45.8%), followed by primary bacteremia (40.7%) and pneumonia (10.1%). The 30-day mortality rate was 16.9%, with all fatalities in patients classified as Child-Pugh grade C. The median model for end-stage liver disease score of patients who died was significantly higher than that of survivors (26.5 versus 17.0, P=0.001). Pneumococcal bacteremia in adult cirrhotic patients was more commonly associated with SBP than with pneumonia. Most cases of bacteremia and fatal outcomes occurred in patients with advanced cirrhosis.

Effects of antiarrhythmic drugs on inappropriate shocks in patients with implantable cardioverter defibrillators.

BACKGROUND: Patients with atrial fibrillation (AF) or congestive heart failure (CHF) are more vulnerable to inappropriate shocks from implantable cardioverter-defibrillators (ICDs), but the effect of antiarrhythmic drugs in these patients remains unknown. METHODS AND RESULTS: A total of 55 patients with AF and/or CHF (New York Heart Association functional class > or =III) who had ICDs were divided into 3 groups [amiodarone (n=24), sotalol (n=12), beta-blocker (n=19)] and the cumulative rates of inappropriate shocks were compared. The baseline characteristics of the 3 groups were not significantly different. The 4-year event rate of inappropriate shocks was 27.3% in the amiodarone group, 54.3% in the sotalol group, and 70.6% in the beta-blocker group (amiodarone vs beta-blocker: log-rank p=0.003; sotalol vs beta-blocker: log-rank p=0.16; amiodarone vs sotalol: log-rank p=0.29). Amiodarone reduced the risk of inappropriate shocks significantly as compared with beta-blockers (hazard ratio (HR) 0.17; 95% confidence interval (CI) 0.05-0.64; p=0.008), whereas sotalol did not (HR 0.57; 95%CI 0.19-1.68; p=0.3). Amiodarone was discontinued in 4 patients (16.7%) because of pulmonary toxicity and the dose was reduced in 4 patients (16.7%) because of a thyroid function abnormality. CONCLUSIONS: Amiodarone is more effective than sotalol or beta-blockers in preventing inappropriate ICD shocks in patients with AF or CHF, but it has a significant risk of drug-related adverse effects.

Skin necrosis after a low-dose vasopressin infusion through a central venous catheter for treating septic shock.

This is a report on a case of severe skin necrosis in a vasodilatory septic shock patient after the infusion of low-dose vasopressin through a central venous catheter. An 84-year-old male was hospitalized for edema on both legs at Asan Medical Center, Seoul, Korea. On hospital day 8, the patient began to complain of dyspnea and he subsequently developed severe septic shock caused by E. coli. After being transferred to the medical intensive care unit, his hypotension, which was refractory to norepinephrine, was controlled by an infusion of low-dose vasopressin (0.02 unit/min) through a central venous catheter into the right subclavian vein. After the infusion of low-dose vasopressin, severe skin necrosis with bullous changes developed, necessitating discontinuation of the low-dose vasopressin infusion. The patient expired from refractory septic shock. Although low-dose vasopressin can control hypotension in septic shock patients, low-dose vasopressin must be used with caution because ischemic complications such as skin necrosis can develop even with administration through a central venous catheter.