Endoscopic retrograde cholangiopancreatography under moderate sedation and factors predicting need for anesthesiologist directed sedation: A county hospital experience

AIM: To evaluate variables associated with failure of gastroenterologist directed moderate sedation (GDS) during endoscopic retrograde cholangiopancreatography (ERCP) and derive a predictive model for use of anesthesiologist directed sedation (ADS) in selected patients. METHODS: With institutional review board approval, we retrospectively analyzed consecutive records of all patients who underwent ERCPs between July 1, 2009 to October 1, 2011 to identify patient related and procedure related factors which could predict failure of GDS. For patient related factors, we abstracted and analyzeddata regarding the age, gender, ethnicity, alcohol and illicit drug use habits. For procedure related factors, we abstracted data regarding initial or repeat procedures, indication for performing ERCP, the interventions performed during ERCP, and the grade d difficulty of cannulation as defined in the American Society for Gastrointestinal Endoscopy guidelines. Our outcome of interest was procedural success. If the procedure was not successful, the reasons for failure of procedures were recorded along with immediate post procedure complications. Multivariate analysis was then performed to define factors associated with failure of GDS and a model constructed to predict requirement of ADS. RESULTS: Fourteen percent of patients undergoing GDS could not complete the procedure due to intolerance and 2% due to cardiovascular complications. Substance abuse, male gender, black race and alcohol use were significant predictors of failure of GDS on univariate analysis and substance abuse and higher grade of procedure remained significant on multivariate analysis. Using our predictive model where the presence of substance abuse was given 1 point and planned grade of intervention was scored from 1-3, only 12% patients with a score of 1 would require ADS due to failure of GDS, compared to 50% with a score of 3 or higher. CONCLUSION: We conclude that ERCP under GDS is safe and effective for low grade procedures, and ADS should be judiciously reserved for procedures which have a higher risk of failure with moderate sedation.

Experimental assessment of a modified retrograde traction tracheal intubation method for increasing the success rate of myocardial infarction model in rats

Background Animal models of myocardial infarction （MI） have been widely used to study the pathologi- cal and physiological changes that occur in MI, and to objectively evaluate the efficacy of new treatments. They are an important tool in this procedure. However, the mortality rate of MI animal models has so far been higher than in real-life situations. The aim of this study was to explore the use of a modified retrograde traction tracheal intubation （MRTI） method for increasing the success rate of MI models in rats. Methods Sixty male Sprague-Dawley rats were used in the experiment. Using the MRTI method of artificial airway generation, we established the MI model by ligation of the left anterior descending branch of the coronary artery. We analyzed the effects of MRTI, the use of lidocaine, operative details, nursing considerations during the operation, and post-operative factors on the success rate of the MI model in rats. Results The success rate of generating an MI model in rats can be significantly increased using the following methods： 1） Setting up the artificial airway through the use of MRTI by using a single-lumen central venous catheter; 2） Selecting a ligation site 2 mm be- low the midpoint of the connection between the left atrial appendage and the pulmonary cone; 3） Adding a drop of lidocaine to the surface of the heart to slow down the heart rate, make the operation easier to perform, and prevent arrhythmias postoperatively; 4） Clearing up airway secretions timely both intra and postoperative- ly; 5） Making sure that rats are in a warm state both intra and postoperatively; 6） Preventing wound infection. Conclusions Use of the MRTI method can quickly establish an artificial airway in rats. Intraoperative use of lidocaine, selecting a precise vascular ligation site, and appropriate care both intra and postoperatively can in- crease the success rate of MI model generation.

Shanghai Tower

Owner:Shanghai Tower Construction & Development Co.,Ltd.Contractor:Shanghai Construction Group Co.,Ltd.Architectural Designer:Gensler,USA Structural engineer:Thornton Tomasetti,USA Construction Drawing Designer:Tongji Architectural Design(Group)Co.,Ltd.With a height of 632 m,the Shanghai Tower stands