Superiority of split dose midazolam as conscious sedation for outpatient colonoscopy

AIM: To elucidate the efficacy and safety of a split dose of midazolam in combination with meperidine for colonoscopy. METHODS: Eighty subjects undergoing outpatient colonoscopy were randomly assigned to group A or B. Group A (n = 40) received a split dose of midazolam in combination with meperidine. Group B (n = 40) received a single dose of midazolam in combination with meperidine. Outcome measurements were level of sedation, duration of sedation and recovery, degree of pain and satisfaction, procedure-related memory, controllability, and adverse events. RESULTS: Group A had a lower frequency of significant hypoxemia (P = 0.043) and a higher sedation score on withdrawal of the endoscope from the descending colon than group B (P = 0.043). Group B recovered from sedation slightly sooner than group A (P < 0.002). Scores for pain and memory, except insertion-related memory, were lower in group A one week after colonoscopic examination (P = 0.018 and P < 0.030, respectively). Poor patient controllability was noted by the endoscopist and nurse in group B (P = 0.038 and P = 0.032, respectively). CONCLUSION: Split dose midazolam in combination with meperidine resulted in a safer, more equable sedation status during colonoscopic examination and a reduction in procedure-related pain and memory, but resulted in longer recovery time.

Upper gastrointestinal endoscopy:Are preparatory interventions or conscious sedation effective? A randomized trial

AIM: The fears and concerns are associated with gastroscopy (EGD) decrease patient compliance. Conscious sedation (CS) and non-pharmacological interventions have been proposed to reduce anxiety and allow better execution of EGD. The aim of this study was to assess whether CS, supplementary information with a videotape, or presence of a relative during the examination could improve the tolerance to EGD. METHODS: Two hundred and twenty-six outpatients (pts), scheduled for a first-time non-emergency EGD were randomly assigned to 4 groups: Co-group (62 pts): throat anaesthesia only; Mi-group (52 pts): CS with i.v. midazolam; Re-group (58 pts): presence of a relative throughout the procedure; Vi-group (54 pts): additional information with a videotape. Anxiety was measured using the “Spielberger State and Trait Anxiety Scales” The patients assessed the overall discomfort during the procedure on an 100-mm visual analogue scale, and their tolerance to EGD answering a questionnaire. The endoscopist evaluated the technical difficulty of the examination and the tolerance of the patients on an 100-mm visual analogue scale and answering a questionnaire. RESULTS: Pre-endoscopy anxiety levels were higher in the Mi-group than in the other groups (P<0.001). On the basis of the patients' evaluation, EGD was well tolerated by 80.7% of patients in Mi-group, 43.5% in Co-group, 58.6% in Regroup, and 50% in Vi-group (P<0.01). The discomfort caused by EGD, evaluated by either the endoscopist or the patients, was lower in Mi-group than in the other groups. The discomfort was correlated with “age” (P<0.001) and “groups of patients” (P<0.05) in the patients' evaluation, and with “gender” (females tolerated better than males, P<0.001) and “groups of patients” (P<0.05) in the endoscopist's evaluation. CONCLUSION: Conscious sedation can improve the tolerance to EGD. Male gender and young age are predictive factors of bad tolerance to the procedure.

Safety of gastrointestinal endoscopy with conscious sedation in obstructive sleep apnea

AIM To perform a systematic review and meta-analysis to assess the safety of conscious sedation in patients with obstructive sleep apnea(OSA).METHODS A comprehensive electronic search of MEDLINE and EMBASE was performed from inception until March 1, 2015. In an effort to include unpublished data, abstracts from prior gastroenterological society meetings as well as other reference sources were interrogated. After study selection, two authors utilizing a standardized data extraction form collected the data independently. Any disagreements between authors were resolved by consensus among four authors. The methodological quality was assessed using the Newcastle Ottawa tool for observational studies. The primary variables of interest included incidence of hypoxia, hypotension, tachycardia, and bradycardia. Continuous data were summarized as odds ratio(OR) and 95%CI and pooled using generic inverse variance under the random-effects model. Heterogeneity between pooled studies was assessed using the I2 statistic.RESULTS Initial search of MEDLINE and EMBASE identified 357 citations. A search of meeting abstracts did not yield any relevant citations. After systematic review and exclusion consensus meetings, seven studies met the a priori determined inclusion criteria. The overall methodological quality of included studies ranged from moderate to low. No significant differences between OSA patients and controls were identified among any of the study variables: Incidence of hypoxia(7 studies, 3005 patients; OR = 1.11; 95%CI: 0.73-1.11; P = 0.47; I2 = 0%), incidence of hypotension(4 studies, 2125 patients; OR = 1.10; 95%CI: 0.75-1.60; P = 0.63; I2 = 0%), incidence of tachycardia(3 studies, 2030 patients; OR = 0.94; 95%CI: 0.53-1.65; P = 0.28; I2 = 21%), and incidence of bradycardia(3 studies, 2030 patients; OR = 0.88; 95%CI: 0.63-1.22; P = 0.59; I2 = 0%).CONCLUSION OSA is not a significant risk factor for cardiopulmonary complications in patients undergoing endoscopic procedures with conscious sedation.

Safety of same-day endoscopic ultrasound and endoscopic retrograde cholangiopancreatography under conscious sedation

AIM: To assess the tolerability and safety of same-day tandem procedures, endoscopic ultrasound (EUS) followed by endoscopic retrograde cholangiopancreatography (ERCP) under conscious sedation. METHODS: A retrospective review was conducted at Loma Linda University Medical Center, a tertiary-care center. All 54 patients who underwent EUS followed by ERCP (group A) from 2004 to 2006 were included in the study. A second group of 56 patients who underwent EUS only (group B), and a third group of 53 patients who underwent ERCP only (group C) during the same time period were selected consecutively as control groups for comparison. RESULTS: Conscious sedation was used in 96% of patients in group A. Mean dosages of meperidine and midazolam used in group A were signifi cantly higher than in group B or C. Mean recovery time in group A was not statistically longer than in group B or C. Therewas no signifi cant difference in the incidence of sedation-related and procedural-related complications. CONCLUSION: Tandem EUS/ERCP procedure can be safely performed under conscious sedation with minimal adverse events. Combined procedures, however, are associated with higher dosages of sedatives, and slightly longer recovery time.

Sedation reversal trends at outpatient ambulatory endoscopic center vs in-hospital ambulatory procedure center using a triage protocol

BACKGROUND Routine outpatient endoscopy is performed across a variety of outpatient settings.A known risk of performing endoscopy under moderate sedation is the potential for over-sedation,requiring the use of reversal agents.More needs to be reported on rates of reversal across different outpatient settings.Our academic tertiary care center utilizes a triage tool that directs higher-risk patients to the in-hospital ambulatory procedure center(APC)for their procedure.Here,we report data on outpatient sedation reversal rates for endoscopy performed at an inhospital APC vs at a free-standing ambulatory endoscopy digestive health center(AEC-DHC)following risk stratification with a triage tool.AIM To observe the effect of risk stratification using a triage tool on patient outcomes,primarily sedation reversal events.METHODS We observed all outpatient endoscopy procedures performed at AEC-DHC and APC from April 2013 to September 2019.Procedures were stratified to their respective sites using a triage tool.We evaluated each procedure for which sedation reversal with flumazenil and naloxone was recorded.Demographics and characteristics recorded include patient age,gender,body mass index(BMI),American Society of Anesthesiologists(ASA)classification,procedure type,and reason for sedation reversal.RESULTS There were 97366 endoscopic procedures performed at AEC-DHC and 22494 at the APC during the study period.Of these,17 patients at AEC-DHC and 9 at the APC underwent sedation reversals(0.017%vs 0.04%;P=0.06).Demographics recorded for those requiring reversal at AEC-DHC vs APC included mean age(53.5±21 vs 60.4±17.42 years;P=0.23),ASA class(1.66±0.48 vs 2.22±0.83;P=0.20),BMI(27.7±6.7 kg/m^(2) vs 23.7±4.03 kg/m^(2);P=0.06),and female gender(64.7%vs 22%;P=0.04).The mean doses of sedative agents and reversal drugs used at AEC-DHC vs APC were midazolam(5.9±1.7 mg vs 8.9±3.5 mg;P=0.01),fentanyl(147.1±49.9μg vs 188.9±74.1μg;P=0.10),flumazenil(0.3±0.18μg vs 0.17±0.17μg;P=0.13)and naloxone(0.32±0.10 mg vs 0.28±0.12 mg;P=0.35).Procedures at AEC-DHC requiring sedation reversal included colonoscopies(n=6),esophagogastroduodenoscopy(EGD)(n=9)and EGD/colonoscopies(n=2),whereas APC procedures included EGDs(n=2),EGD with gastrostomy tube placement(n=1),endoscopic retrograde cholangiopancreatography(n=2)and endoscopic ultrasound's(n=4).The indications for sedation reversal at AEC-DHC included hypoxia(n=13;76%),excessive somnolence(n=3;18%),and hypotension(n=1;6%),whereas,at APC,these included hypoxia(n=7;78%)and hypotension(n=2;22%).No sedation-related deaths or long-term post-sedation reversal adverse outcomes occurred at either site.CONCLUSION Our study highlights the effectiveness of a triage tool used at our tertiary care hospital for risk stratification in minimizing sedation reversal events during outpatient endoscopy procedures.Using a triage tool for risk stratification,low rates of sedation reversal can be achieved in the ambulatory settings for EGD and colonoscopy.

A pilot study of the effect of pressure-driven lidocaine spray on airway topical anesthesia for conscious sedation intubation

Background Difficult airway remains not only a challenge to the anesthesiologists, but also a life-threatening event to the patients. Awake intubation is the principal choice to deal with difficult airway, and a key point for awake intubation is airway topical anesthesia. Yet, so far there is no ideal topical anesthesia approach for awake intubation. This study aimed at evaluating the effect of pressure-driven （by 10 L/min oxygen flow） lidocaine spray on airway topical anesthesia in order to find a powerful and convenient method for airway topical anesthesia for conscious sedation intubation. Methods Thirty adult patients referred for elective surgery under general anesthesia, aged 18-60 years and Mallampati class I or II, were recruited for the study. Before topical anesthesia, the observer＇s assessment of alert and sedation （OAA/S） scale was controlled between 3 and 4 by intravenous midazolam （0.03 mg/kg）, propofol （2 mg.kgl.h＂1） and remifentanil （0.05 IJg.kg1.rain1）. Ten minutes after sedation, topical anesthesia was performed with the pressure-driven lidocaine spray; the driving pressure was achieved by an oxygen flow of 10 L/min. After topical anesthesia, tracheal intubation was performed and the intubation condition was assessed with modified the Erhan＇s intubation condition score by an experienced anesthesiologist, and a score of less than 10 was considered to be satisfactory. Attempts to intubate the patient were recorded, and the complications such as local anesthetic toxicity, mucosa injury, and respiration depression were also recorded. The mean arterial blood pressure （MAP）, heart rate （HR） and pulse oxygen saturation （SpO2） were recorded at different time points before and after intubation. Patients were asked 24 hours after the operation whether they could recall the events during intubation. Results All patients were intubated at the first attempt, the average intubation condition score was 7.0＋_1.1, from 6 to 10 satisfied intubation condition. MAP and HR increased significantly but mildly immediately after the tracheal intubation （P 〈0.05）, and decreased to the pre-intubation level soon after intubation. There were no related complications and patients had no recall of the intubation procedures. Conclusions Topical anesthesia with pressure driven 2% lidocaine spray, where pressure is achieved by 10 L/min oxygen flow, can offer satisfactory intubation conditions for conscious sedation intubation. （ClinicaITrials.gov registration identifier： NCT01185535）

Concepts and techniques of conscious sedation

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Clinical analysis of propofol deep sedation for 1,104 patients undergoing gastrointestinal endoscopic procedures:A three year prospective study

AIM： To analyze the hemodynamic and respiratory effects of propofol on patients undergoing gastroscopy and colonoscopy. METHODS： In this prospective study, conducted over a period of three years, 1,104 patients referred for a same day GI endoscopy procedure were analyzed. All patients were given a propofol bolus （0.5-1.5 mg/kg）. Arterial blood pressure （BP） was monitored at 3 rain intervals and heart rate and oxygen saturation （SpO2） were recorded continuously by pulse oximetry. Analyzed data acquisition was carried out before, during, and after the procedure. RESULTS： A statistically significant reduction in mean arterial pressure was demonstrated （P〈0.001） when compared to pre-intervention values, but severe hypotension, defined as a systolic blood pressure below 60mmHg, was noted in only 5 patients （0.5%）. Oxygen saturation decreased from 96.5% to 94.4 % （P〈0.001）. A critical decrease in oxygen saturation （〈90%） was documented in 27 patients （2.4%）. CONCLUSION： Our results showed that propofol provided good sedation with excellent pain control, a short recovery time and no significant hemodynamic side effelts if carefully titrated. All the patients （and especially ASA Ⅲ group） require monitoring and care of an anesthesiologist.

How to improve patient satisfaction during midazolam sedation for gastrointestinal endoscopy?

To determine the procedure-related factors that affect sedation satisfaction and to make a suggestion to improve it.METHODSWe prospectively enrolled a total of 456 patients who underwent outpatient endoscopy procedures with midazolam sedation between March 2014 and August 2014. All patients completed both pre- and post-endoscopy questionnaires about sedation expectations and satisfaction.RESULTSThe study cohort included 167 (36.6%) patients who underwent esophagogastroduodenoscopy (EGD), 167 (36.6%) who underwent colonoscopy, and 122 (26.8%) who underwent a combined procedure (EGD and colonoscopy). Over 80% of all patients were satisfied with sedation using midazolam. In univariate and multivariate analyses, total procedure time in the EGD group, younger age (≤ 50 years), and longer colonoscopy withdrawal time in the colonoscopy group were related to decreased satisfaction with sedation. However, in active monitoring and intervention group, there was no decrease in grade of satisfaction despite longer procedure time due to more procedures during colonoscopy. Younger age (≤ 50 years), longer inter-procedure time gap, and colonoscopy withdrawal time were related to decreased satisfaction in the combined EGD and colonoscopy group.CONCLUSIONMidazolam is still a safe and effective sedative for gastrointestinal endoscopy. Satisfaction with sedation depends on several factors including age (≤ 50 years) and procedure time duration. To improve patient satisfaction with sedation, active monitoring of sedation status by the endoscopist should be considered for patients who require long procedure time.

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.

Sedation in gastrointestinal endoscopy: Where are we at in 2014?

Gastrointestinal endoscopies are invasive and unpleasant procedures that are increasingly being used worldwide. The importance of high quality procedures(especially in colorectal cancer screening), the increasing patient awareness and the expectation of painless examination, increase the need for procedural sedation. The best single sedation agent for endoscopy is propofol which, due to its' pharmacokinetic/dynamic profile allows for a higher patient satisfaction and procedural quality and lower induction and recovery times, while ma-intaining the safety of traditional sedation. Propofol is an anesthetic agent when used in higher doses than those needed for endoscopy. Because of this important feature it may lead to cardiovascular and respiratory depression and, ultimately, to cardiac arrest and death. Fueled by this argument, concern over the safety of its administration by personnel without general anesthesia training has arisen. Propofol usage seems to be increasing but it's still underused. It is a safe alternative for simple endoscopic procedures in low risk patients even if administered by non-anesthesiologists. Evidence on propofol safety in complex procedures and high risk patients is less robust and in these cases, the presence of an anesthetist should be considered. We review the existing evidence on the topic and evaluate the regional differences on sedation practices.

Does Anesthesiologist-Directed Sedation Afford Superior Deep Cannulation Rates and Procedural Outcomes for ERCP in the Community Setting?

Aim: To compare outcomes by sedation class in community patients undergoing index endoscopic retrograde cholangiopancreatography (ERCP). Methods: Nineteen hundred sixteen consecutive patients underwent ERCP from May 2005 to May 2011. Eight hundred thirty seven patients were excluded due to prior papillary intervention or attempted ERCP. A total of 1079 patients were included. The 981 patients who underwent gastroenterologist directed sedation (GDS) served as the control population, while the 98 patients who received anesthesiologist directed sedation (ADS) served as the case population. Medical records were analyzed for patient demographics, procedure indication, adverse events, case complexity, procedural failure and sedation failure. Case complexity was defined by the grading system proposed by the working party of the ASGE Quality Committee. Sedation failure was defined by agitation or airway compromise prompting termination of the ERCP. Reasons for procedural failure included surgically altered anatomy, luminal obstruction, and technical failure. Study endpoint was defined as successful deep cannulation of the intended target duct. Results: Demographic distribution did not differ between the GDS and the ADS groups. Cannulation success rates were similar between the two groups, with 89.85% in the GDS group, and 89.58% in the ADS group (P = 0.864). There were no statistical differences between sedation groups in procedural or respiratory adverse events. Technical failure was the predominant basis for deep cannulation failure in both groups. Agitation and airway compromise accounted for deep cannulation failure similarly in both groups. The need for reversal agents was low but similar in both groups. There was no statistical advantage in deep cannulation success rate by complexity grade in either sedation class. Conclusion: Excellent procedural outcomes and low adverse event rates were achieved using GDS, a more accessible and cost-effective method in a community-based setting.

Identifying who best tolerates moderate sedation:Results from a national database of gastrointestinal endoscopic outcomes

BACKGROUND With increasing volume and cost of gastrointestinal endoscopic procedures,the proper selection of patients for moderate sedation becomes increasingly relevant.The current literature lacks consistent findings that allow for appropriate selection of patients for moderate sedation.AIM To analyze a nationwide registry of patients to identify patient and procedural factors associated with lower sedation requirements for endoscopy.METHODS The Clinical Outcomes Research Initiative National Endoscopic Database was queried to assess adult patients undergoing moderate sedation for esophagogastroduodenoscopy(EGD)and colonoscopy from 2008 to 2014.Patients were stratified into two groups[low dose(LD)and high dose sedation]based on sedation requirements.Anthropometric,procedural,and anesthesia data were compared,and multivariable analysis was performed to identify factors associated with LD sedation.RESULTS Of the 371102 patients included in the study,63137 where stratified into the LD sedation group and 307965 were in the high dose group.Moderate sedation was managed primarily by endoscopists(50%)and anesthesia providers(47%).Patients undergoing EGDs and procedures performed in the inpatient setting,in ambulatory surgery centers,intensive care units or hospital wards,required less sedation than colonoscopies,outpatient procedures and procedures done in endoscopy suites,respectively(P<0.0001 for all).On multivariable analysis,factors predictive of tolerance with lower sedation requirements for EGDs and colonoscopies were female gender,age≥50,non-White race,Hispanic descent,body mass index≤25 kg/m^(2),and higher American Society of Anesthesia Class(P<0.0001 for all).CONCLUSION Clinicians should consider these patient profiles in determining which patients will better tolerate moderate sedation vs those better suited for alternative sedation methods.

Awake robotic liver surgery:A case report

BACKGROUND In recent years,minimally invasive liver resection has become a standard of care for liver tumors.Considering the need to treat increasingly fragile patients,general anesthesia is sometimes avoided due to respiratory complications.Therefore,surgical treatment with curative intent is abandoned in favor of a less invasive and less radical approach.Epidural anesthesia has been shown to reduce respiratory complications,especially in elderly patients with pre-existing lung disease.CASE SUMMARY A 77-year-old man with hepatitis-C-virus-related chronic liver disease underwent robotic liver resection for hepatocellular carcinoma.The patient was suffering from hypertension,diabetes and chronic obstructive pulmonary disease.The National Surgical Quality Improvement Program score for developing pneumonia was 9.2%.We planned a combined spinal–epidural anesthesia with conscious sedation to avoid general anesthesia.No modification of the standard surgical technique was necessary.Hemodynamics were stable and bleeding was minimal.The postoperative course was uneventful.CONCLUSION Robotic surgery in locoregional anesthesia with conscious sedation could be considered a safe and suitable approach in specialized centers and in selected patients.

Propofol vs midazolam plus fentanyl for upper gastrointestinal endomicroscopy:A randomized trial

AIM:To compare the endomicroscopic image quality of integrated confocal laser endomicroscopy(iCLE)and sedation efficacy of propofolvs midazolam plus fentanyl(M/F).METHODS:Consecutive outpatients undergoing iCLE were prospectively recruited and randomized to the propofol group(P group)or M/F group.The patient,performing endoscopist and endoscopic assistant were blinded to the randomization.The quality of endomicro-scopic images and anesthetic efficacy outcomes were blindly evaluated after iCLE examination.RESULTS:There were significantly more good quality endomicroscopic images in the propofol group than in the M/F group(72.75%vs 52.89%,P<0.001).The diagnostic accuracy for upper gastrointestinal mucosal lesions using confocal laser endomicroscopy favors the P group,although this did not reach statistical significance.Adverse events and patient assessment were not significantly different for M/F vs propofol except for more frequent intraprocedural recall with M/F.Procedure duration and sedation times were significantly longer in the M/F group,while the scores of endoscopist,anesthetist and assistant assessment were all significantly better in the P group.CONCLUSION:Sedation with propofol might increase the proportion of good quality endomicroscopic images,and may result in improved procedural efficacy and diagnostic accuracy during iCLE examination.

Colonoscopy,pain and fears:Is it an indissoluble trinomial?

Colonoscopy is the reference method in the secondary prevention,diagnosis and,in some cases,treatment of colorectal cancer.It can often cause pain associated with embarrassment,anxiety,and physical and emotional discomfort.Pain intensity is influenced by a lot of factors,and there is a strict relationship among pain,pain perception,and mind.Several methods can be used to break the trinomial colonoscopy,pain and fear.Sedoanalgesia is recommended by several guidelines.If no sedation is offered,the patient must accept a higher chance of unacceptable discomfort and the endoscopist a lower chance of completing the procedure because of patient discomfort.Other non-pharmacologic methods such as acupuncture,music,and hydrocolonoscopy can be used as alternatives to pharmacologic sedoanalgesia.Furthermore,new endoscopic technologies such as variable-stiffness colonoscopes and ultrathin colonoscopes,or the use of carbon dioxide instead of air for colon insufflation,can reduce the pain caused by colonoscopy.In the future,technical improvements such as wireless capsules or robotic probes,will probably enable to overcome the present concept of colonoscopy,avoiding the use of traditional endoscopes.However,at present the poor attention paid by endoscopists to the pain and discomfort caused by colonoscopy can not be justified.There are several methods to reduce pain and anxiety and to break the trinomial colonoscopy,pain and fear.We must use them.

Midazolam dose is associated with recurrence of paradoxical reactions during endoscopy

BACKGROUND Midazolam is commonly used for sedation during gastrointestinal procedures.However,some patients experience paradoxical reactions characterized by excessive movement or excitement.AIM To investigate the rate of recurrence of paradoxical reactions to midazolam during an upper endoscopy.METHODS We retrospectively reviewed 122152 sedative endoscopies among a total of 58553 patients at the Seoul National University Hospital,Healthcare System Gangnam Center,from July 2013 to December 2018.Among them,361 patients with a history of paradoxical reaction during sedative upper endoscopy were enrolled.The characteristics of patients in the recurrent and non-recurrent groups were compared via multivariable analysis using logistic regression.RESULTS Paradoxical reactions occurred in 0.86%(1054/122152)of endoscopies,and in 1.51%(888/58553)of patients.Among the 361 subjects with previous paradoxical reactions in sedative endoscopies,111(30.7%)experienced further paradoxical reactions.Univariable analysis revealed that the total midazolam dose used was higher in the recurrent group(6.74±2.58 mg)than in the non-recurrent group(5.49±2.04 mg;P<0.0001).Patients were administered a lower dose of midazolam than previous doses:1 mg less in the recurrent group and 2 mg less in the non-recurrent group.Multivariable analysis showed that the midazolam dose difference was an independent risk factor for recurrent paradoxical reaction(odds ratio:1.213,95%CI:1.099-1.338,P=0.0001).CONCLUSION The rate of recurrence of paradoxical reactions is significantly associated with midazolam dosage.The dose of midazolam administered to patients with previous paradoxical reactions should be less than that previously used.

Magnetic imaging-assisted colonoscopy vs conventional colonoscopy: A randomized controlled trial

AIM: To compare magnetic imaging-assisted colonoscopy (MIC) with conventional colonoscopy (CC).

Comparison of the effectiveness of dexmedetomidine versus propofol target-controlled infusion for sedation during coblation-assisted upper airway procedure

Background Sedation for the coblation-assisted upper airway procedure has lacked easy modulation between appropriate pain control and airway protection. This study aimed to compare the effectiveness of dexmedetomidine versus target controlled propofol infusion in providing sedation during a coblation-assisted upper airway procedure.

Dexmedetomidine-midazolam versus Sufentanil-midazolam for Awake Fiberoptic Nasotracheal Intubation： A Randomized Double-blind Study

Background： Awake fiberoptic intubation （AFOI） is usually performed in the management of the predicted difficult airway. The aim of this study was to evaluate the feasibility of dexmedetomidine with midazolam （DM） and sufentanil with midazolam （SM） for sedation for awake fiberoptic nasotracheal intubation. Methods： Fifty patients with limited mouth opening scheduled for AFOI were randomly assigned to two groups （n = 25 per group） by a computer-generated randomization schedule. All subjects received midazolam 0.02 mg/kg as premedication and airway topical anesthesia with a modified ＂spray-as-you-go＂ technique. Group DM received dexmedetomidine at a loading dose of 0.5 μg/kg over 10 min followed by a continuous infllsion of 0.25 μg.kg^-1.h ^-1, whereas Group SM received sufentanil at a loading dose of 0.2 μg/kg over 10 rain followed by a continuous infusion of 0.1 μg.kg^-1.h ^-1. As necessary, since the end of the administration of the loading dose of the study drug, an additional dose ofmidazolam 0.5 mg at 2-min intervals was given to achieve a modified Observers＇Assessment of Alertness/Sedation of 2-3. The quality of intubation conditions and adverse events were observed.Results： The scores of ease of the AFOI procedure, patient＇s reaction during AFOI, coughing severity, tolerance after intubation, recall of the procedure and discomfort during the procedure were comparable in both groups （z = 0.572, 0.664, 1.297, 0.467, 0.895, and 0.188, respectively, P 〉 0.05）. Hypoxic episodes similarly occurred in the two groups, but the first partial pressure of end-tidal CO, after intubation was higher in Group SM than that in Group DM （45.2 ± 4.2 mmHg vs. 42.2 ±4.3 mmHg, t = 2.495, P 〈 0.05）. Conclusions： Both dexmedetomidine and sufentanil are effective as an adjuvant for AFOI under airway topical anesthesia combined with midazolam sedation, but respiratory depression is still a potential risk in the sufentanil regimen.