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Nasal airway strips (NAS) for esophagogastroduodenoscopy (EGD) with conscious sedation
CLINICAL ENDOSCOPIC PRACTICE 85
87
NASAL AIRWAY STRIPS(NAS) FOR ESOPHAGOGASTRODUODENOSCOPY (EGD) WITH CONSCIOUS SEDATION AG Cacciarelli, M Nyitray, EN Ferran, MC Castellano, P Caride, N M G u a l t i e r i , JG Robilotti. Section of Gastroenterology, Department of Medicine St. Vincent's Hospital and Medical Center, New York, NY
ACQUISITION OF COGNITIVE AND TECHNICAl COMPETENCE IN ERCP: A PROSPECTIVEMULTICENTER STUDY. M Canto, A Chak, MV Sivak, Jr., BJ Pollack, G Ella, J Barnett, M Kochman, W Long, G Ginsberg, R Bedford, M Khandelwal, T McGarrity, A Damianos, W Wassef, A Zfass, A FoxxOrrenstein, M Dabezies. Case Western Reserve Univ, Univ of Mich, Univ Hssp of Penn, UCLA, Penn Stale Univ, Medical College of VA, Temple Univ. Very little is known about the processof acquisition of cognitive and technical skills in ERCP.AIM: To describe the learning curve for cognitive and technical skills in diagnosticand therapeutic ERCPin a variety of GI fellowship training programs. METHODS: Over a 2-year period, 16 attendings skilled in ERCP supervissd and graded 38 GI trainees (6 advanced or ADV, 32 regular or REG) from 7 university medical centers. 4 centers had formal ADV training programs. Cognitive and technical skills for each component of diagnostic ERCP (pracannulation, CBD and PD cannulation) and each therapeutic maneuver were graded immediately following ERCP using pretested standardized scales. To adjust the learning curves, the difficulty of each ERCP component was estimated using a standardized scale pretested against procedure time. Cognitive skills were also evaluated before and after the training period with a pretested written test. RESULTS: Mean difficulty scores for ERCP were highly correlated with actual times for procannulation and cannulation (Spearman corr coeft=.45-.57, p=.O001). All REG trainees and 1 ADV trainee had no prior ERCP experience. After adjusting for procedure difficulty, the CBD and PD cannulation learning curves for REG trainees had initial steep slopes and continued rise without a plateau at competent score levels. In contrast, those for ADV trainees showed early gradual rise then plateau at competent levels. Mean CBD cannulation scores were significantly higher for ADV trainees than for REG troinees(p<.OOOl). Successful PD cannulation scores were no different (p=.21). High cognitive scores were achieved very early in the learning process and continue to gradually rise. Mean trainee pretest scores were markedly lower than attending scores (p=,OO01) but the differences decreased after the training period (p=.O4), CONCLUSION: Trainees in advanced training programs achieve technical diagnostic and therapeutic ERCP skills more rapidly than REG trainees. Majority of REG trainees do not achieve technical competence at the end of their training, Cognitive skills im ERCP are more rapidly acquired than technical skills. They are significantly improved throughout the course of training but do not achieve attending levels.
INTRODUCTION: NAS are used by patients who suffer from snoring, professional athletes(most commonly professional football players in the NFL), and individuals participating in any [itness or athletic activity. OBJECTIVE: To determine if NAS have an effect on oxygen saturation(02 Sat) during conscious sedation for EGD. NAS may decrease the incidence of desaturation. METHODS: Patients were enrolled and served as their own controls. History for CHF, COPD, asthma, rhinitis, and sinus or snoring problems were elicited. Patients were given 2L of oxygen by nasal cannula. Oximetry was used to measure 02 eat. Sedation was performed using Versed or Valium and Demerol. 02 Sat was measured pre-sedation, 5 minutes post-medlcation, and 5 minutes post-EGD with and without NAS in each patient. Measurements of 02 Sat were recorded for 2 minutes and a mean value was calculated after the NAS had been in place or removed for two minutes. RESULTS: 20 patients were studied. The NAS was not associated with any difference in 02 Sat before, during, or after sedation(p=NS). Mean values of 02 Sat for all 20 patients are as follows. Pre-med(%O2) 5 min post-med 5 min post-EGD w/ NAS 96% 96% 97% w/o NAg 96% 97% 97% CONCLUSION: The use of NAS were found to be of no significance in altering 02 Sat during EGD with conscious sedation.
86 Major Cardiac A r r h y t h m i a s Induced by Naloxone Postendoscopy The Lankenau Hospital, Wynnewood, PA N. Mattock Callahan, D.O. J a m e s J . Thornton, M.D. ~[~e increased use of naloxone following endoscopic procedures with cardiovascular complications has previously been noted. In addition, some endoscopists a d m i n i s t e r naloxone routinely. In a f i v e - y e a r period in a l a r g e c o m m u n i t y t e a c h i n g hospital, we have recogzdzed t h r e e o u t p a t i e n t s with no previous history of cardiac disease who developed major c a r d i a c a r r h y t h m i a s i m m e d i a t e l y postendoscopy, following intravenous naloxone administration. CASE 1: A 6 2 - y e a r - o l d f e m a l e underwent complex upper endoscopy and dilation of the esophagus with meperidine plus d i a z e p a m . Pestprocedure, the p a t i e n t was given naloxone 0.2 rag. IV. Within 30 seconds multiple runs of nonsustained v e n t r i c u i a r t a c h y c a r d i a developed, evenutually s e t t l i n g into sinus t a c h y c a r d i a with e c t o p y . Subsequent c a r d i o v a s c u l a r evaluation was u n r e m a r k a b l e . CASE 2.- A 5 7 - y e a r - o l d f e m a l e underwent colonoscopy with a s t r a i g h t e n i n g device under fluoroscopy with meperidine plus d[azepam. P o s t p r o c e d u r e , the p a t i e n t was given naloxone 0.2mg. IV and within 30 seconds developed sustained v e n t r i c u l a r t a e h y cardia a b o r t e d by a p r e c o r d i a l thump. Subsequent cardiovascular evaluation was unre markable. CASE 3: A 3 0 - y e a r - o l d male underwent upper endoscopy uneventfully with meperidine and midazolam. Narcan 0.2mg IV p o s t procedure resulted in sustained s u p r a v e n t r i c u l a r t a c h y c a r d i a as well as hypertension requiring t r e a t m e n t . Subsequent cardiovascular evaluation was u n r e m a r k a b l e . All p a t i e n t s were on continuous e l e c t r o c a r d i o g r a p h i c , blood pressure and pulse o x i m e t r y monitoring during the procedure. There was no evidence of hypotension: c a r d i a c arrhythmias~ or oxygen d e s a t a r a t i o n a t a n y t i m e during the p r o c e d u r e . The occ~'renee of c a r d i a c a r r h y t h m i a s with nalexone, including ventricular tachycardia~ has been previously recognized usually in patients with underlying h e a r t disease but has not been reported a f t e r endoscopy. We r e p o r t t h r e e episodes of major c a r d i a c a r r h y t h m i a s , two p o t e n t i a l l y lethal, in p a t i e n t s with no evidence of c a r d i a c disease. In all t h r e e instances, the naloxone was given as a routine pustendoscopic p r o c e d u r e . This finding seriously challenges t h e use of naloxene routinely a f t e r endoscopy.
AB46
GASTROINTESTINAL ENDOSCOPY
"~88 OUTCOME OF TRAINING IN DIAGNOSTIC AND THERAPEUTIC ERCP: A PROSPECTIVEMULTICENTERSTUDY M Canto, A Chak, MV Sivak, Jr., BJ Pollack• G Elta, J Barnett, M Kochman, W Long, G Ginsberg, R Bedford, M Khandelwal, T McGarrity, A Damianos, W Waseof, A Zfase, A Foxx-Orrenstein, M Babeziee.Case Western Reserve Univ, Univ Michigan, Univ Hosp of Penn, UCLA, Penn State Univ, Medical College of VA, Temple Univ. GI fellows acquire a varying amount of ERCP experience during their training. AIM: To describe the outcome of training in diagnostic and therapeutic ERCPin GI fellowship training programs. METHODS:From 1994-1996,16 attendinga skilled in ERCPprospectively evaluated GI trainees from 7 university medical centers. Each regular trainee (REG)was allowed st least 20 minutes before the advanced fellow (ADV) or proctor took over. Using pretested objective standardized scales, skills for each component of diagnostic ERCP and each therapeutic manuever were graded immediately after each ERCP. Cognitive and technical ERCP skills were also globally evaluated st conclusion of the training period. RESULTS: 43% of trainees were interested in private practice careers. 94% of trainees were interested in learning ERCP.Trainees participated in a mean of 94% (57-100%) of 2562 ERCPs.6 ADV and 32 REG trainees completed a mean of 250 (range 103-526) and 57 (range 19-212) ERCPs, respectively, (p=.0003) during their training. REG trainees were much less likely than ADV fellows to attain the ASGE minimum threshold (MIN) of 75 diagnostic ERCPs (25% vs. 100%, p=.001), regardless of center (p=.06). ADV trainee CBD and PD cannulation rates were significantly higher than for REGtrainees who reachedMIN:ie. 58% vs 82%(p=,001) and 74% vs 8"P/o(p=.01),respectively. Mean CBD (p=.42) and PD (.o=.24)cennulstion times for ADV and REG trainees were not significantly different. All ADV trainees achieved cognitive and technical competency in diagnostic and therapeutic ERCP. In contrast, only 62% and 59% of REG trainees acquired cognitive competency in diagnostic and therapeutic ERCP, respectively. Only 62~ 3%, and 6% of REG trainees who acquired experience in therapeutic ERCP at centers without ADV programs achieved competency in billary, pancreatic and precut/needla knife sphincterotomy. Only 38% of REG trainees were competent in billary plastic stent placement;none were competent in billary metal and pancreatic stsnt placement. CONCLUSIONS:Diagnostic and therapeutic ERCP experience varies markedly across university-based Gltrainin9 programs. Although interest in learning ERCP is high, a minority of REG fellows trained in ERCP eventually attain technical competence st the end of fellowship. Minimum thresholds for evaluating competence in diagnostic and therapeutic ERCPshould be reevaluated.
VOLUME 45, NO. 4, 1997
87
NASAL AIRWAY STRIPS(NAS) FOR ESOPHAGOGASTRODUODENOSCOPY (EGD) WITH CONSCIOUS SEDATION AG Cacciarelli, M Nyitray, EN Ferran, MC Castellano, P Caride, N M G u a l t i e r i , JG Robilotti. Section of Gastroenterology, Department of Medicine St. Vincent's Hospital and Medical Center, New York, NY
ACQUISITION OF COGNITIVE AND TECHNICAl COMPETENCE IN ERCP: A PROSPECTIVEMULTICENTER STUDY. M Canto, A Chak, MV Sivak, Jr., BJ Pollack, G Ella, J Barnett, M Kochman, W Long, G Ginsberg, R Bedford, M Khandelwal, T McGarrity, A Damianos, W Wassef, A Zfass, A FoxxOrrenstein, M Dabezies. Case Western Reserve Univ, Univ of Mich, Univ Hssp of Penn, UCLA, Penn Stale Univ, Medical College of VA, Temple Univ. Very little is known about the processof acquisition of cognitive and technical skills in ERCP.AIM: To describe the learning curve for cognitive and technical skills in diagnosticand therapeutic ERCPin a variety of GI fellowship training programs. METHODS: Over a 2-year period, 16 attendings skilled in ERCP supervissd and graded 38 GI trainees (6 advanced or ADV, 32 regular or REG) from 7 university medical centers. 4 centers had formal ADV training programs. Cognitive and technical skills for each component of diagnostic ERCP (pracannulation, CBD and PD cannulation) and each therapeutic maneuver were graded immediately following ERCP using pretested standardized scales. To adjust the learning curves, the difficulty of each ERCP component was estimated using a standardized scale pretested against procedure time. Cognitive skills were also evaluated before and after the training period with a pretested written test. RESULTS: Mean difficulty scores for ERCP were highly correlated with actual times for procannulation and cannulation (Spearman corr coeft=.45-.57, p=.O001). All REG trainees and 1 ADV trainee had no prior ERCP experience. After adjusting for procedure difficulty, the CBD and PD cannulation learning curves for REG trainees had initial steep slopes and continued rise without a plateau at competent score levels. In contrast, those for ADV trainees showed early gradual rise then plateau at competent levels. Mean CBD cannulation scores were significantly higher for ADV trainees than for REG troinees(p<.OOOl). Successful PD cannulation scores were no different (p=.21). High cognitive scores were achieved very early in the learning process and continue to gradually rise. Mean trainee pretest scores were markedly lower than attending scores (p=,OO01) but the differences decreased after the training period (p=.O4), CONCLUSION: Trainees in advanced training programs achieve technical diagnostic and therapeutic ERCP skills more rapidly than REG trainees. Majority of REG trainees do not achieve technical competence at the end of their training, Cognitive skills im ERCP are more rapidly acquired than technical skills. They are significantly improved throughout the course of training but do not achieve attending levels.
INTRODUCTION: NAS are used by patients who suffer from snoring, professional athletes(most commonly professional football players in the NFL), and individuals participating in any [itness or athletic activity. OBJECTIVE: To determine if NAS have an effect on oxygen saturation(02 Sat) during conscious sedation for EGD. NAS may decrease the incidence of desaturation. METHODS: Patients were enrolled and served as their own controls. History for CHF, COPD, asthma, rhinitis, and sinus or snoring problems were elicited. Patients were given 2L of oxygen by nasal cannula. Oximetry was used to measure 02 eat. Sedation was performed using Versed or Valium and Demerol. 02 Sat was measured pre-sedation, 5 minutes post-medlcation, and 5 minutes post-EGD with and without NAS in each patient. Measurements of 02 Sat were recorded for 2 minutes and a mean value was calculated after the NAS had been in place or removed for two minutes. RESULTS: 20 patients were studied. The NAS was not associated with any difference in 02 Sat before, during, or after sedation(p=NS). Mean values of 02 Sat for all 20 patients are as follows. Pre-med(%O2) 5 min post-med 5 min post-EGD w/ NAS 96% 96% 97% w/o NAg 96% 97% 97% CONCLUSION: The use of NAS were found to be of no significance in altering 02 Sat during EGD with conscious sedation.
86 Major Cardiac A r r h y t h m i a s Induced by Naloxone Postendoscopy The Lankenau Hospital, Wynnewood, PA N. Mattock Callahan, D.O. J a m e s J . Thornton, M.D. ~[~e increased use of naloxone following endoscopic procedures with cardiovascular complications has previously been noted. In addition, some endoscopists a d m i n i s t e r naloxone routinely. In a f i v e - y e a r period in a l a r g e c o m m u n i t y t e a c h i n g hospital, we have recogzdzed t h r e e o u t p a t i e n t s with no previous history of cardiac disease who developed major c a r d i a c a r r h y t h m i a s i m m e d i a t e l y postendoscopy, following intravenous naloxone administration. CASE 1: A 6 2 - y e a r - o l d f e m a l e underwent complex upper endoscopy and dilation of the esophagus with meperidine plus d i a z e p a m . Pestprocedure, the p a t i e n t was given naloxone 0.2 rag. IV. Within 30 seconds multiple runs of nonsustained v e n t r i c u i a r t a c h y c a r d i a developed, evenutually s e t t l i n g into sinus t a c h y c a r d i a with e c t o p y . Subsequent c a r d i o v a s c u l a r evaluation was u n r e m a r k a b l e . CASE 2.- A 5 7 - y e a r - o l d f e m a l e underwent colonoscopy with a s t r a i g h t e n i n g device under fluoroscopy with meperidine plus d[azepam. P o s t p r o c e d u r e , the p a t i e n t was given naloxone 0.2mg. IV and within 30 seconds developed sustained v e n t r i c u l a r t a e h y cardia a b o r t e d by a p r e c o r d i a l thump. Subsequent cardiovascular evaluation was unre markable. CASE 3: A 3 0 - y e a r - o l d male underwent upper endoscopy uneventfully with meperidine and midazolam. Narcan 0.2mg IV p o s t procedure resulted in sustained s u p r a v e n t r i c u l a r t a c h y c a r d i a as well as hypertension requiring t r e a t m e n t . Subsequent cardiovascular evaluation was u n r e m a r k a b l e . All p a t i e n t s were on continuous e l e c t r o c a r d i o g r a p h i c , blood pressure and pulse o x i m e t r y monitoring during the procedure. There was no evidence of hypotension: c a r d i a c arrhythmias~ or oxygen d e s a t a r a t i o n a t a n y t i m e during the p r o c e d u r e . The occ~'renee of c a r d i a c a r r h y t h m i a s with nalexone, including ventricular tachycardia~ has been previously recognized usually in patients with underlying h e a r t disease but has not been reported a f t e r endoscopy. We r e p o r t t h r e e episodes of major c a r d i a c a r r h y t h m i a s , two p o t e n t i a l l y lethal, in p a t i e n t s with no evidence of c a r d i a c disease. In all t h r e e instances, the naloxone was given as a routine pustendoscopic p r o c e d u r e . This finding seriously challenges t h e use of naloxene routinely a f t e r endoscopy.
AB46
GASTROINTESTINAL ENDOSCOPY
"~88 OUTCOME OF TRAINING IN DIAGNOSTIC AND THERAPEUTIC ERCP: A PROSPECTIVEMULTICENTERSTUDY M Canto, A Chak, MV Sivak, Jr., BJ Pollack• G Elta, J Barnett, M Kochman, W Long, G Ginsberg, R Bedford, M Khandelwal, T McGarrity, A Damianos, W Waseof, A Zfase, A Foxx-Orrenstein, M Babeziee.Case Western Reserve Univ, Univ Michigan, Univ Hosp of Penn, UCLA, Penn State Univ, Medical College of VA, Temple Univ. GI fellows acquire a varying amount of ERCP experience during their training. AIM: To describe the outcome of training in diagnostic and therapeutic ERCPin GI fellowship training programs. METHODS:From 1994-1996,16 attendinga skilled in ERCPprospectively evaluated GI trainees from 7 university medical centers. Each regular trainee (REG)was allowed st least 20 minutes before the advanced fellow (ADV) or proctor took over. Using pretested objective standardized scales, skills for each component of diagnostic ERCP and each therapeutic manuever were graded immediately after each ERCP. Cognitive and technical ERCP skills were also globally evaluated st conclusion of the training period. RESULTS: 43% of trainees were interested in private practice careers. 94% of trainees were interested in learning ERCP.Trainees participated in a mean of 94% (57-100%) of 2562 ERCPs.6 ADV and 32 REG trainees completed a mean of 250 (range 103-526) and 57 (range 19-212) ERCPs, respectively, (p=.0003) during their training. REG trainees were much less likely than ADV fellows to attain the ASGE minimum threshold (MIN) of 75 diagnostic ERCPs (25% vs. 100%, p=.001), regardless of center (p=.06). ADV trainee CBD and PD cannulation rates were significantly higher than for REGtrainees who reachedMIN:ie. 58% vs 82%(p=,001) and 74% vs 8"P/o(p=.01),respectively. Mean CBD (p=.42) and PD (.o=.24)cennulstion times for ADV and REG trainees were not significantly different. All ADV trainees achieved cognitive and technical competency in diagnostic and therapeutic ERCP. In contrast, only 62% and 59% of REG trainees acquired cognitive competency in diagnostic and therapeutic ERCP, respectively. Only 62~ 3%, and 6% of REG trainees who acquired experience in therapeutic ERCP at centers without ADV programs achieved competency in billary, pancreatic and precut/needla knife sphincterotomy. Only 38% of REG trainees were competent in billary plastic stent placement;none were competent in billary metal and pancreatic stsnt placement. CONCLUSIONS:Diagnostic and therapeutic ERCP experience varies markedly across university-based Gltrainin9 programs. Although interest in learning ERCP is high, a minority of REG fellows trained in ERCP eventually attain technical competence st the end of fellowship. Minimum thresholds for evaluating competence in diagnostic and therapeutic ERCPshould be reevaluated.
VOLUME 45, NO. 4, 1997