- Email: [email protected]
Upper endoscopy without conscious sedation
CLINICAL ENDOSCOPIC PRACTICE ~97
99
Recall diagnosis (%) 54 87 94 .06 Conclusions: 1) FMZ markedly Shortens the recovery time following GI endoscopy when standard objective discharge criteria are used as an endpoint 2) FMZ at the studied doses does not predictably reverse the cognitive dysfunction related to sedation. 3) Early resedation after administration of FMZ was not seen in this study. 4) FMZ may reduce antegrade amnesia 5) Larger randomized trials should be performed. (This research was supported by an ASGE Endoscopic Research Award)
UPPER ENDOSCOPYWITHOUT CONSCIOUS SEDATION. DE Fl~ischer, GQ Wang, JA Kidwell, RMAnderson and SM Dawsey. Georgetown University Medical Center, Washington, DC; National Cancer Institute, Bethesda, MD; Cancer Institute CAMS, Beijing, China, Upper endoscopy in the United States is most commonly performed with IV conscious sedation with benzodiazeplnes +/narcotic analgesics. Reports from Asia and Middle East describing upper endoscopy without IV conscious sedation have been viewed with some skepticism. This report describes the experience of an American endoscopy team performing upper endoscopy in rural China without IV conscious sedation. 2,043 asymptomatic men/women in Linxian County, Henan Province, China were screened by balloon cytology and 237 were found to have high grade dysplasia or cancer. 225 of the 237 (95%) agreed to upper endoscopywith iodine spraying and biopsy. METHOD: 115 M (51.1%) and 110 F (49.9%) underwent upper endoscopy. Preparation = NPOafter midnight. Prior to procedure, pts gargled with 5ml of 1% Dicane. The procedure was explained by a Chinese physician.~ With no IV conscious sedation and patient in the l e f t lateral decubltus position a g.5mm video endoscope was passed (Olympus, Lake Success, New York). Successful intubation occurred in each patient. After a complete visual inspection, which was possible in all patients, the esophaguswas sprayed with I030cc 1.2% Lugol's iodine solution. Between i and 8 biopsies were taken in all patients. Procedures lasted 10-20 minutes. In all 237 pts, the goals of the protocol could be carried out. Retching and gagging were commonly seen. No postprocedure recovery was utilized. No complications were noted. CONCLUSIONS: Upper endoscopy without IV conscious sedation was successful in this group of Chinese pts. Retching and gagging were commonly encountered. Patients were comforted by the verbal assurances of the attending Chinese physician. Cultural expectations contribute to the high tolerance. The second stage of this protocol involves endoscopic ultrasonography and endoscopic mucosectomy. These procedures may be more d i f f i c u l t to carry out in unsedated pts because the endoscopes are of larger diameter and movement caused by retching would interfere with the more sophisticated endoscopic studies.
~98
tl00
ROUTI2~E USE OF FLUMAZENIL (FMZ) WITH CONSCIOUS SEDATION SHORTENS RECOVERY TIME FOR GASTROINTESTINAL (GI) ENDOSCOPIC PROCEDURES i~. Faris MI), ~ Jaffe MD, M. Fay NP, MS, L Fox RN, J Emerson MD, MPH; Tucson Veterans Affairs Medical Center, Department of Medicine, University of Arizona, Arizona Clinical Research Center, Tucson, AZ Objectives: To determine whether the routine administration of FMZ following GI endoscopy would affect endpoints such as post-procedure recovery time, encephalopathy, antegrade amnesia, patient tolerance of the procedure, early resedation, and overall safety. Methods: Forty:four patients about to undergo GI endoscopy (22 EGO and 22 colonoscopy) with conscious sedation who were not chronically taking benzodiazepines, were randomized to receive placebo, 0.2 or 0.5 rag of FMZ following the procedure. Physiologic, cognitive, and subjective data were collected immediately before, during, immediately after, 2 hours after, and the day following the procedure. Recovery time (Rec time) was defined as when blood pressure (Bp), oximetry (OX), number connection test (NCT) and Observer's Assessment of Alertness/Sedation scale (OAMS) reached baseline values. Discharge time (D/C time) was defined after data analysis,as when BP,OX, and OAMS reached baseline. Findings: There were no differences in baseline characteristics, drug doses, early resedation, patient comfort, or wi)lingness to repeat the procedure between the groups. No FMZ-related complications were seen.
Discharge endpoints
PlacebQ
0.2m~
0.5rag
0
38.1 34.6
31.3 20.3
31.6 14.1
56
Rec time (min) D/C time (rain)
.0007
Antegrade amnesia
NITROUS OXIDE INHALATION IN
FLEXIBLE SIGMOIDOSCOPY. A.
Fich. R. Efrat, O. Wengrower. G.I Dniversity Hospital, Jerusalem, Israel.
Unit,
Hadassa--~
Flexible sipmoidoscopy is usually performed in the screening of neoplasms without sedation: Howevermost patients report discomfort or pain during the procedure. Nitrous oxide is widely used in dentistry and obstetrics as a safe and effective inhalation sedative. The aim of the present study was to evaluate whether patient self administered nitrous oxide (N2O) improves performance of sigmoidoscopy. Methods:38 patients undergoing routine sigmoidoscopy were randomized to receive either NpO (n=lS) or oxygen(Or) by self administered m~sk (n=20) during the procedure. Patients and endoscopists w e r e unaware of the gas in the mask. Depth of insertion, duration of the procedure, and recovery time were recorded. Patients scored their degree of pain and discomfort.(l best -10 worsel . gesu!s The two 9roups were similar in age and sex. There were no signiflcan~ differences between the study groups with regard to procedure duration, mask time, pain, discomfort, depth of insertion and 05 saturation. The recovery time after procedure was ~significantly longer (3.3min) but clinically unimportant in the N20 group. i
N2O
02
iP
9.4 -+ 1.8 9.0 • 1.4INS Procedure duration (min) 2.25 • 0.4 1.5 • 0.41NS Time mask (min) 28 +- 5.3 17 • 5.31N5 % Mask use 4.7 +- 0.4 3.7 • O.51NS Pain score Discomfort score 1.6 +- 0.4 1.8 • O.41NS 51 • 4.3 48 • 4.3)NS Depht insertion (cm) Recovery time (min) 3.3 • 0.6 0.5 +_ 0.510.02 97.7 +- 0.4 97.7 • 04 (MS 02 Saturation Conclusions: Addition of nitrous oxide inhalation "on demand" does not improve sigmoidoscopy performance and does not diminish pain or patient discomfort.
320
GASTROINTESTINAL ENDOSCOPY
ENDOTRACHEAL INTUBATION FOR AIRWAY PROTECTION IN ENDOSCOPY FOR SEVERE UPPER GASTROINTESTINAL HEMORRHAGE: EFFECT ON PATIENT OUTCOME. ML Freeman. IlK Landsverk, LL Johnson, JW Leatherman, GR Onstad. Departments of GI and Critical Care Medicine, Hennepin County Medical Center, Minneapolis, MN. Aspiration of blood is a potentially disastrous occurrence during emergent endoscopy (EGD) for severe upper GI bleeding (UGIB). Although there are few data on the prevalence of this problem, prophylactic endotracheal intubation (ET) has been advocated for airway protection. Our ICU has adopted an aggressive policy of ET for EGD. METHODS: We compared the outcomes of ICU pts with severe UGIB in 2 separate years, during which similar percentages of pts received endoscopic hemostasis (EH) (38 vs 42%), but use of ET changed; during the index year (1988), prophylactic ET was seldom done, while in the comparison year (1992), ET was routinely done elecfively before or during EGD for risk of aspiration from large amounts of proximal blood, altered mental status, or prior to EH in high-risk ulcers. ]~,EI2L.T.~: Background variables were generally similar for ]CU pts in 1988 (n=101) and 1992 (n=l19) respectively; 66 vs 67% had shock, 36 vs 40% had cirrhosis; and 23 vs 34% had variceal/portal hypertensive bleeding. While overall % of pts intubated at any time in hospitalization did not change (26 vs 29%), use of ET specifically for EGD increased significantly (4 vs 15% [1)<.05]); 57% of ET was for variceal bleeds. OUTCOMES: Comparing 1988 to 1992, there was n o significant reduction of all EGD-related cardiopulmonary complications (5.0 vs 3.4%), no change in new pulmonary infiltrates after endoscopy (13 vs 15%), total aspiration pneumonias (15 vs 17%), or mean ICU days (7.1 vs 6.4); 10(48%) of 21 pts developed new infiltrates post-EGO in spite of ET specifically for airway protection. However, in 1992, there was elimination of deaths directly related to catastrophic aspiration during endoscopy (2 vs 0%), need for post-EGD ET was eliminated (6% vs 0%), and there was an arithmetic decrease in mortality (15.9 vs 11.8%). ~ : In severe UGIB, newly acquired pulmonary infdtrates (13 to 15%) and directly EGD-related cardiopulmonary complications (3.4 to 5%) were common. Frequent use of ET for airway protection during EGO did not significantly change the overall incidence of acquired pneumonias or eardiopulmouary events, but did appear to prevent rare but fatal massive aspiration during EGD. Endotracheal inmbation is recommended for airway protection before EGD in selected unstable UGIB pts but does not appear to consistently prevent aspiration.
V O L U M E 41, NO. 4, 1995
99
Recall diagnosis (%) 54 87 94 .06 Conclusions: 1) FMZ markedly Shortens the recovery time following GI endoscopy when standard objective discharge criteria are used as an endpoint 2) FMZ at the studied doses does not predictably reverse the cognitive dysfunction related to sedation. 3) Early resedation after administration of FMZ was not seen in this study. 4) FMZ may reduce antegrade amnesia 5) Larger randomized trials should be performed. (This research was supported by an ASGE Endoscopic Research Award)
UPPER ENDOSCOPYWITHOUT CONSCIOUS SEDATION. DE Fl~ischer, GQ Wang, JA Kidwell, RMAnderson and SM Dawsey. Georgetown University Medical Center, Washington, DC; National Cancer Institute, Bethesda, MD; Cancer Institute CAMS, Beijing, China, Upper endoscopy in the United States is most commonly performed with IV conscious sedation with benzodiazeplnes +/narcotic analgesics. Reports from Asia and Middle East describing upper endoscopy without IV conscious sedation have been viewed with some skepticism. This report describes the experience of an American endoscopy team performing upper endoscopy in rural China without IV conscious sedation. 2,043 asymptomatic men/women in Linxian County, Henan Province, China were screened by balloon cytology and 237 were found to have high grade dysplasia or cancer. 225 of the 237 (95%) agreed to upper endoscopywith iodine spraying and biopsy. METHOD: 115 M (51.1%) and 110 F (49.9%) underwent upper endoscopy. Preparation = NPOafter midnight. Prior to procedure, pts gargled with 5ml of 1% Dicane. The procedure was explained by a Chinese physician.~ With no IV conscious sedation and patient in the l e f t lateral decubltus position a g.5mm video endoscope was passed (Olympus, Lake Success, New York). Successful intubation occurred in each patient. After a complete visual inspection, which was possible in all patients, the esophaguswas sprayed with I030cc 1.2% Lugol's iodine solution. Between i and 8 biopsies were taken in all patients. Procedures lasted 10-20 minutes. In all 237 pts, the goals of the protocol could be carried out. Retching and gagging were commonly seen. No postprocedure recovery was utilized. No complications were noted. CONCLUSIONS: Upper endoscopy without IV conscious sedation was successful in this group of Chinese pts. Retching and gagging were commonly encountered. Patients were comforted by the verbal assurances of the attending Chinese physician. Cultural expectations contribute to the high tolerance. The second stage of this protocol involves endoscopic ultrasonography and endoscopic mucosectomy. These procedures may be more d i f f i c u l t to carry out in unsedated pts because the endoscopes are of larger diameter and movement caused by retching would interfere with the more sophisticated endoscopic studies.
~98
tl00
ROUTI2~E USE OF FLUMAZENIL (FMZ) WITH CONSCIOUS SEDATION SHORTENS RECOVERY TIME FOR GASTROINTESTINAL (GI) ENDOSCOPIC PROCEDURES i~. Faris MI), ~ Jaffe MD, M. Fay NP, MS, L Fox RN, J Emerson MD, MPH; Tucson Veterans Affairs Medical Center, Department of Medicine, University of Arizona, Arizona Clinical Research Center, Tucson, AZ Objectives: To determine whether the routine administration of FMZ following GI endoscopy would affect endpoints such as post-procedure recovery time, encephalopathy, antegrade amnesia, patient tolerance of the procedure, early resedation, and overall safety. Methods: Forty:four patients about to undergo GI endoscopy (22 EGO and 22 colonoscopy) with conscious sedation who were not chronically taking benzodiazepines, were randomized to receive placebo, 0.2 or 0.5 rag of FMZ following the procedure. Physiologic, cognitive, and subjective data were collected immediately before, during, immediately after, 2 hours after, and the day following the procedure. Recovery time (Rec time) was defined as when blood pressure (Bp), oximetry (OX), number connection test (NCT) and Observer's Assessment of Alertness/Sedation scale (OAMS) reached baseline values. Discharge time (D/C time) was defined after data analysis,as when BP,OX, and OAMS reached baseline. Findings: There were no differences in baseline characteristics, drug doses, early resedation, patient comfort, or wi)lingness to repeat the procedure between the groups. No FMZ-related complications were seen.
Discharge endpoints
PlacebQ
0.2m~
0.5rag
0
38.1 34.6
31.3 20.3
31.6 14.1
56
Rec time (min) D/C time (rain)
.0007
Antegrade amnesia
NITROUS OXIDE INHALATION IN
FLEXIBLE SIGMOIDOSCOPY. A.
Fich. R. Efrat, O. Wengrower. G.I Dniversity Hospital, Jerusalem, Israel.
Unit,
Hadassa--~
Flexible sipmoidoscopy is usually performed in the screening of neoplasms without sedation: Howevermost patients report discomfort or pain during the procedure. Nitrous oxide is widely used in dentistry and obstetrics as a safe and effective inhalation sedative. The aim of the present study was to evaluate whether patient self administered nitrous oxide (N2O) improves performance of sigmoidoscopy. Methods:38 patients undergoing routine sigmoidoscopy were randomized to receive either NpO (n=lS) or oxygen(Or) by self administered m~sk (n=20) during the procedure. Patients and endoscopists w e r e unaware of the gas in the mask. Depth of insertion, duration of the procedure, and recovery time were recorded. Patients scored their degree of pain and discomfort.(l best -10 worsel . gesu!s The two 9roups were similar in age and sex. There were no signiflcan~ differences between the study groups with regard to procedure duration, mask time, pain, discomfort, depth of insertion and 05 saturation. The recovery time after procedure was ~significantly longer (3.3min) but clinically unimportant in the N20 group. i
N2O
02
iP
9.4 -+ 1.8 9.0 • 1.4INS Procedure duration (min) 2.25 • 0.4 1.5 • 0.41NS Time mask (min) 28 +- 5.3 17 • 5.31N5 % Mask use 4.7 +- 0.4 3.7 • O.51NS Pain score Discomfort score 1.6 +- 0.4 1.8 • O.41NS 51 • 4.3 48 • 4.3)NS Depht insertion (cm) Recovery time (min) 3.3 • 0.6 0.5 +_ 0.510.02 97.7 +- 0.4 97.7 • 04 (MS 02 Saturation Conclusions: Addition of nitrous oxide inhalation "on demand" does not improve sigmoidoscopy performance and does not diminish pain or patient discomfort.
320
GASTROINTESTINAL ENDOSCOPY
ENDOTRACHEAL INTUBATION FOR AIRWAY PROTECTION IN ENDOSCOPY FOR SEVERE UPPER GASTROINTESTINAL HEMORRHAGE: EFFECT ON PATIENT OUTCOME. ML Freeman. IlK Landsverk, LL Johnson, JW Leatherman, GR Onstad. Departments of GI and Critical Care Medicine, Hennepin County Medical Center, Minneapolis, MN. Aspiration of blood is a potentially disastrous occurrence during emergent endoscopy (EGD) for severe upper GI bleeding (UGIB). Although there are few data on the prevalence of this problem, prophylactic endotracheal intubation (ET) has been advocated for airway protection. Our ICU has adopted an aggressive policy of ET for EGD. METHODS: We compared the outcomes of ICU pts with severe UGIB in 2 separate years, during which similar percentages of pts received endoscopic hemostasis (EH) (38 vs 42%), but use of ET changed; during the index year (1988), prophylactic ET was seldom done, while in the comparison year (1992), ET was routinely done elecfively before or during EGD for risk of aspiration from large amounts of proximal blood, altered mental status, or prior to EH in high-risk ulcers. ]~,EI2L.T.~: Background variables were generally similar for ]CU pts in 1988 (n=101) and 1992 (n=l19) respectively; 66 vs 67% had shock, 36 vs 40% had cirrhosis; and 23 vs 34% had variceal/portal hypertensive bleeding. While overall % of pts intubated at any time in hospitalization did not change (26 vs 29%), use of ET specifically for EGD increased significantly (4 vs 15% [1)<.05]); 57% of ET was for variceal bleeds. OUTCOMES: Comparing 1988 to 1992, there was n o significant reduction of all EGD-related cardiopulmonary complications (5.0 vs 3.4%), no change in new pulmonary infiltrates after endoscopy (13 vs 15%), total aspiration pneumonias (15 vs 17%), or mean ICU days (7.1 vs 6.4); 10(48%) of 21 pts developed new infiltrates post-EGO in spite of ET specifically for airway protection. However, in 1992, there was elimination of deaths directly related to catastrophic aspiration during endoscopy (2 vs 0%), need for post-EGD ET was eliminated (6% vs 0%), and there was an arithmetic decrease in mortality (15.9 vs 11.8%). ~ : In severe UGIB, newly acquired pulmonary infdtrates (13 to 15%) and directly EGD-related cardiopulmonary complications (3.4 to 5%) were common. Frequent use of ET for airway protection during EGO did not significantly change the overall incidence of acquired pneumonias or eardiopulmouary events, but did appear to prevent rare but fatal massive aspiration during EGD. Endotracheal inmbation is recommended for airway protection before EGD in selected unstable UGIB pts but does not appear to consistently prevent aspiration.
V O L U M E 41, NO. 4, 1995