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Supplemental oxygen during endoscopy in patients with ischemic heart disease
cated, symptomatic pseudocysts with ductal communication or transmural compression. For more complex pseudocyst cases, input from multiple sources (surgeon, therapeutic endoscopist, interventional radiologist, and clinician with pancreatic expertise) is recommended. Glen A. Lehman, MD Indianapolis, Indiana
REFERENCES 1. Hammel P, Levy P, Voitot H, et al. Preoperative cyst fluid analysis is useful for the differential diagnosis of cystic lesions of the pancreas. Gastroenterology 1995;108:1230-5. 2. Banks PA. A new classification system for acute pancreatitis. Am J Gastroenterol 1994;89:151-2. 3. Montorsi M, Zago M, Mosca F, et al. Efficacy ofoctreotide in the prevention of pancreatic fistula after elective pancreatic resections: a prospective, controlled, randomized clinical trial. Surgery 1995;117:26-31. 4. Pederzoli P, Bassi C, Vesentini S, Campedelli A. A randomized multicenter clinical trial of antibiotic prophylaxis of septic complications in acute necrotizing pancreatitis with imipenem. Surg Gynecol Obstet 1993;176:480-3. 5. Aloia T, Solomkin J, Pink AS, et al. Candida in pancreatic infection: a clinical experience. Am Surg 1994;60:793-6. 6. Henriksen FW, Hancke S. Percutaneous cytogastrostomy for chronic pancreatic pseudocyst. Br J Surg 1994;81:1525-8. 7. Barthet M, Sahel J, Bodiou-Bertei C, Bernard JP. Endoscopic transpapillary drainage ofpancreatic pseudocysts. Gastrointest Endosc 1995;42:208-13. 8. Catalano MF, Geenen JE, Schmalz MJ, Johnson GK, Dean RS, Hogan WJ. Treatment of pancreatic pseudocysts with ductal communication by transpapillary pancreatic duct endoprosthesis. Gastrointest Endosc 1995;42:214-8. 9. Smits ME, Rauws EAJ, Tytgat GNJ, Huibregtse K. The efficacy of endoscopic treatment of pancreatic pseudocysts. Gastrointest Endosc 1995;42:202-7. 10. Binmoeller KF, Seifert H, Walter A, Soehendra N. Transpapillary and transmural drainage of pancreatic pseudocysts. Gastrointest Endosc 1995;42:219-24. 11. Howell DA, Lehman GA, Baron TH, et al. Endoscopic treatment of pancreatic pseudocysts: a retrospective multicenter analysis [Abstract]. Gastrointest Endosc 1995;41:424. 12. Hariri M, Slivka A, Carr-Locke DL, Banks PA. Pseudocyst drainage predisposes to infection when pancreatic necrosis is unrecognized. Am J Gastroenterol 1994;89:1781-4.
Supplemental oxygen during endoscopy in patients with ischemic heart disease
range, even in absence of s u p p l e m e n t a l oxygen (i.e., decrease was statistically significant, b u t clinically insignificant). The a u t h o r s also found t h a t 35% of control and 50% of cardiac p a t i e n t s h a d ST segment changes on Holter recordings, most of which were concurrent with hypoxia; supplem e n t a l oxygen significantly decreased the prevalence of such ST s e g m e n t abnormalities. Although ST segment changes m a y be due to myocardial ischemia, its clinical significance is difficult to determine. Most authorities do not recommend Holter monitoring as a screening t e s t for ischem i a because of its low specificity for myocardial ischemia. 2-6 As the results o f J u r e l l et al. show, false positive results m a y occur in a s u b s t a n t i a l portion of Holter recordings. Alternatively, Holter monitors m a y mischaracterize myocardial ischemia, including infarction, in p a t i e n t s with angiographically proven coronary a r t e r y disease. 7, s I n view of these uncertainties a n d the additional costs (patient charge of $59.90 at Oregon H e a l t h Sciences University Medical Center) associated with a d m i n i s t e r i n g supp l e m e n t a l oxygen to all p a t i e n t s with ischemic h e a r t disease, it seems p r u d e n t to monitor p a t i e n t s closely with pulse oximetry and a d m i n i s t e r s u p p l e m e n t a l oxygen only to p a t i e n t s who become hypoxic.
John G. Lee, MD Oregon Health Sciences University Portland VAMC Portland, Oregon REFERENCES 1. Jurell K, O'Connor K, Slack J, et al. Effect of supplemental oxygen on cardiopulmonary changes during gastrointestinal endoscopy. Gastrointest Endosc 1994;40:665-70. 2. Deanfield J, Ribiero P, Oakley K, Kriker S, Selwyn A. Analysis of ST segment changes in normal subjects: implications for ambulatory monitoring in angina pectoris. Am J Cardiol 1984; 54:1321-5. 3. Crawford M, Mendoza C, O'Rourke R, White D, Boucher C, Gorwit J. Limitations of continuous ambulatory electrocardiogram monitoring for detecting coronary artery disease. Ann Intern Med 1978;89:1-5. 4. Kohli R, Cashman P, Lahiri A, Raftery E. The ST segment of the ambulatory electrocardiogram in a normal population. Br Heart J 1988;60:4-16. 5. Berman D, Rozanski A, Knoebel S. The detection of silent ischemia: cautions and precautions. Circulation 1987;75:101-5. 6. Robson D, Belten S. ST segment changes in normal men during ambulatory electrocardiograph. Eur Heart J 1986;7:223-6. 7. Krucoff M. Poor performance of lead V5 in single and dual channel ST segment monitoring during coronary occlusion. J Electrocardiol 1988;21(suppl):S30-4. 8. Marsch S, Castelli I, Schaefer H, Skarvan K Failure of continuous three channel Holter monitoring to detect acute peri-operative myocardial ischemia. Anesthesia 1992;47:34-7.
To the Editor:
Response:
J u r e l l et al. 1 recommended s u p p l e m e n t a l oxygen to prev e n t hypoxia a n d myocardial ischemia in p a t i e n t s with a history of ischemic h e a r t disease undergoing endoscopy. Their results showed t h a t oxygen s a t u r a t i o n levels decreased significantly after conscious sedation in p a t i e n t s not receiving s u p p l e m e n t a l oxygen; however, the m e a n postsedation oxygen s a t u r a t i o n w a s still w i t h i n t h e n o r m a l
I t has clearly been shown t h a t m a n y p a t i e n t s receiving conscious sedation have episodes of oxygen d e s a t u r a t i o n a n d t h a t s u p p l e m e n t a l oxygen largely reverses this trend. As Dr. Lee points out, the m e a n oxygen s a t u r a t i o n level following sedation in p a t i e n t s not receiving s u p p l e m e n t a l oxygen r e m a i n e d w i t h i n the n o r m a l r a n g e (91.7% in the c a r -
VOLUME 42, NO. 3, 1995
G A S T R O I N T E S T I N A L E N D O S C O P Y 275
REFERENCES 1. Hammel P, Levy P, Voitot H, et al. Preoperative cyst fluid analysis is useful for the differential diagnosis of cystic lesions of the pancreas. Gastroenterology 1995;108:1230-5. 2. Banks PA. A new classification system for acute pancreatitis. Am J Gastroenterol 1994;89:151-2. 3. Montorsi M, Zago M, Mosca F, et al. Efficacy ofoctreotide in the prevention of pancreatic fistula after elective pancreatic resections: a prospective, controlled, randomized clinical trial. Surgery 1995;117:26-31. 4. Pederzoli P, Bassi C, Vesentini S, Campedelli A. A randomized multicenter clinical trial of antibiotic prophylaxis of septic complications in acute necrotizing pancreatitis with imipenem. Surg Gynecol Obstet 1993;176:480-3. 5. Aloia T, Solomkin J, Pink AS, et al. Candida in pancreatic infection: a clinical experience. Am Surg 1994;60:793-6. 6. Henriksen FW, Hancke S. Percutaneous cytogastrostomy for chronic pancreatic pseudocyst. Br J Surg 1994;81:1525-8. 7. Barthet M, Sahel J, Bodiou-Bertei C, Bernard JP. Endoscopic transpapillary drainage ofpancreatic pseudocysts. Gastrointest Endosc 1995;42:208-13. 8. Catalano MF, Geenen JE, Schmalz MJ, Johnson GK, Dean RS, Hogan WJ. Treatment of pancreatic pseudocysts with ductal communication by transpapillary pancreatic duct endoprosthesis. Gastrointest Endosc 1995;42:214-8. 9. Smits ME, Rauws EAJ, Tytgat GNJ, Huibregtse K. The efficacy of endoscopic treatment of pancreatic pseudocysts. Gastrointest Endosc 1995;42:202-7. 10. Binmoeller KF, Seifert H, Walter A, Soehendra N. Transpapillary and transmural drainage of pancreatic pseudocysts. Gastrointest Endosc 1995;42:219-24. 11. Howell DA, Lehman GA, Baron TH, et al. Endoscopic treatment of pancreatic pseudocysts: a retrospective multicenter analysis [Abstract]. Gastrointest Endosc 1995;41:424. 12. Hariri M, Slivka A, Carr-Locke DL, Banks PA. Pseudocyst drainage predisposes to infection when pancreatic necrosis is unrecognized. Am J Gastroenterol 1994;89:1781-4.
Supplemental oxygen during endoscopy in patients with ischemic heart disease
range, even in absence of s u p p l e m e n t a l oxygen (i.e., decrease was statistically significant, b u t clinically insignificant). The a u t h o r s also found t h a t 35% of control and 50% of cardiac p a t i e n t s h a d ST segment changes on Holter recordings, most of which were concurrent with hypoxia; supplem e n t a l oxygen significantly decreased the prevalence of such ST s e g m e n t abnormalities. Although ST segment changes m a y be due to myocardial ischemia, its clinical significance is difficult to determine. Most authorities do not recommend Holter monitoring as a screening t e s t for ischem i a because of its low specificity for myocardial ischemia. 2-6 As the results o f J u r e l l et al. show, false positive results m a y occur in a s u b s t a n t i a l portion of Holter recordings. Alternatively, Holter monitors m a y mischaracterize myocardial ischemia, including infarction, in p a t i e n t s with angiographically proven coronary a r t e r y disease. 7, s I n view of these uncertainties a n d the additional costs (patient charge of $59.90 at Oregon H e a l t h Sciences University Medical Center) associated with a d m i n i s t e r i n g supp l e m e n t a l oxygen to all p a t i e n t s with ischemic h e a r t disease, it seems p r u d e n t to monitor p a t i e n t s closely with pulse oximetry and a d m i n i s t e r s u p p l e m e n t a l oxygen only to p a t i e n t s who become hypoxic.
John G. Lee, MD Oregon Health Sciences University Portland VAMC Portland, Oregon REFERENCES 1. Jurell K, O'Connor K, Slack J, et al. Effect of supplemental oxygen on cardiopulmonary changes during gastrointestinal endoscopy. Gastrointest Endosc 1994;40:665-70. 2. Deanfield J, Ribiero P, Oakley K, Kriker S, Selwyn A. Analysis of ST segment changes in normal subjects: implications for ambulatory monitoring in angina pectoris. Am J Cardiol 1984; 54:1321-5. 3. Crawford M, Mendoza C, O'Rourke R, White D, Boucher C, Gorwit J. Limitations of continuous ambulatory electrocardiogram monitoring for detecting coronary artery disease. Ann Intern Med 1978;89:1-5. 4. Kohli R, Cashman P, Lahiri A, Raftery E. The ST segment of the ambulatory electrocardiogram in a normal population. Br Heart J 1988;60:4-16. 5. Berman D, Rozanski A, Knoebel S. The detection of silent ischemia: cautions and precautions. Circulation 1987;75:101-5. 6. Robson D, Belten S. ST segment changes in normal men during ambulatory electrocardiograph. Eur Heart J 1986;7:223-6. 7. Krucoff M. Poor performance of lead V5 in single and dual channel ST segment monitoring during coronary occlusion. J Electrocardiol 1988;21(suppl):S30-4. 8. Marsch S, Castelli I, Schaefer H, Skarvan K Failure of continuous three channel Holter monitoring to detect acute peri-operative myocardial ischemia. Anesthesia 1992;47:34-7.
To the Editor:
Response:
J u r e l l et al. 1 recommended s u p p l e m e n t a l oxygen to prev e n t hypoxia a n d myocardial ischemia in p a t i e n t s with a history of ischemic h e a r t disease undergoing endoscopy. Their results showed t h a t oxygen s a t u r a t i o n levels decreased significantly after conscious sedation in p a t i e n t s not receiving s u p p l e m e n t a l oxygen; however, the m e a n postsedation oxygen s a t u r a t i o n w a s still w i t h i n t h e n o r m a l
I t has clearly been shown t h a t m a n y p a t i e n t s receiving conscious sedation have episodes of oxygen d e s a t u r a t i o n a n d t h a t s u p p l e m e n t a l oxygen largely reverses this trend. As Dr. Lee points out, the m e a n oxygen s a t u r a t i o n level following sedation in p a t i e n t s not receiving s u p p l e m e n t a l oxygen r e m a i n e d w i t h i n the n o r m a l r a n g e (91.7% in the c a r -
VOLUME 42, NO. 3, 1995
G A S T R O I N T E S T I N A L E N D O S C O P Y 275