Clinical Endoscopy

Anesthesia care provider sedation versus conscious sedation for endoscopic ultrasound–guided tissue acquisition: a retrospective cohort study: Sneha Shaha, Yinglin Gao, Jiahao Peng, Kendrick Che, John J. Kim, Wasseem Skef; Clin Endosc 2023;56(5):658-665. Published online July 3, 2023; DOI: https://doi.org/10.5946/ce.2023.006

Graphical Abstract Abstract PDF PubReader ePub: Background
/Aims: We aimed to study the effects of sedation on endoscopic ultrasound–guided tissue acquisition.
Methods
We conducted a retrospective study evaluating the role of sedation in endoscopic ultrasound–guided tissue acquisition by comparing two groups: anesthesia care provider (ACP) sedation and endoscopist-directed conscious sedation (CS).
Results
Technical success was achieved in 219/233 (94.0%) in the ACP group and 114/136 (83.8%) in the CS group (p=0.0086). In multivariate analysis, the difference in technical success between the two groups was not significant (adjusted odds ratio [aOR], 0.5; 95% confidence interval [CI], 0.234–1.069; p=0.0738). A successful diagnostic yield was present in 146/196 (74.5%) in the ACP group and 66/106 (62.3%) in the CS group, respectively (p=0.0274). In multivariate analysis, the difference in diagnostic yield between the two groups was not significant (aOR, 0.643; 95% CI, 0.356–1.159; p=0.142). A total of 33 adverse events (AEs) were observed. The incidence of AEs was significantly lower in the CS group (5/33 CS vs. 28/33 ACP; OR, 0.281; 95% CI, 0.095–0.833; p=0.022).
Conclusions
CS provided equivalent technical success and diagnostic yield for malignancy in endoscopic ultrasound–guided tissue acquisition. Increased AEs were associated with anesthesia for the endoscopic ultrasound–guided tissue acquisition.

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New sedatives and analgesic drugs for gastrointestinal endoscopic procedures: Jae Min Lee, Yehyun Park, Jin Myung Park, Hong Jun Park, Jun Yong Bae, Seung Young Seo, Jee Hyun Lee, Hyung Ku Chon, Jun-Won Chung, Hyun Ho Choi, Jun Kyu Lee, Byung-Wook Kim, Endoscopic Sedation Committee of the Korean Society of Gastrointestinal Endoscopy; Clin Endosc 2022;55(5):581-587. Published online August 29, 2022; DOI: https://doi.org/10.5946/ce.2021.283

Procedural sedation has become increasingly common in endoscopy. Sedatives and analgesics induce anxiolysis and amnesia. In addition, an appropriate level of sedation is necessary for safe procedures including therapeutic endoscopy. Midazolam and propofol are the most commonly used drugs in sedative endoscopy. In recent years, the need to ascertain the safety and effectiveness of sedation has increased in practice. Therefore, new sedatives and analgesic drugs for optimal sedative endoscopy, have recently emerged. This article reviews the characteristics of sedatives and analgesics, and describes their clinical use in gastrointestinal endoscopy.

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Jung Wan Choe, Jong Jin Hyun, Seong-Jin Son, Seung-Hak Lee
Clinical Endoscopy.2024; 57(4): 476. CrossRef
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Dong Chan Joo, Gwang Ha Kim
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Chung Hyun Tae, Ju Yup Lee, Moon Kyung Joo, Chan Hyuk Park, Eun Jeong Gong, Cheol Min Shin, Hyun Lim, Hyuk Soon Choi, Miyoung Choi, Sang Hoon Kim, Chul-Hyun Lim, Jeong-Sik Byeon, Ki-Nam Shim, Geun Am Song, Moon Sung Lee, Jong-Jae Park, Oh Young Lee
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Sara Lyckner, Michelle S. Chew, Andreas Nilsson
iGIE.2023; 2(3): 292. CrossRef
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The Korean Journal of Gastroenterology.2023; 82(3): 107. CrossRef
Drugs used for sedation in gastrointestinal endoscopy
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Journal of the Korean Medical Association.2022; 65(11): 735. CrossRef

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Endoscopist-Directed Propofol: Pros and Cons: Eun Hye Kim, Sang Kil Lee; Clin Endosc 2014;47(2):129-134. Published online March 31, 2014; DOI: https://doi.org/10.5946/ce.2014.47.2.129

Abstract PDF PubReader ePub

Concerns about the safety of endoscopist-directed propofol (EDP) have been voiced that propofol should be given only by healthcare professionals trained in the administration of general anesthesia. Here we discuss the safety and drawbacks of EDP for routine endoscopic procedures. Currently, both diagnostic and therapeutic endoscopy are well tolerated and accepted by both patients and endoscopists due to the application of sedation in most clinics worldwide. Accordingly, propofol use is increasing in many countries. It is crucial for endoscopists to be very familiar with the use of propofol or a combination of drugs. However, the controversy regarding the administration of sedation by an endoscopist or an anesthesiologist continues. Until now, there have been no randomized control trials comparing sedation induced by propofol administered by an endoscopist or by an anesthesiologist. It might be difficult to perform this kind of study. For the convenience and safety of sedative endoscopy, it would be important that EDP be generally applied to endoscopic procedures, and for more safety, an anesthesiologist may automatically take care of particular patients at high risk of suffering from propofol side effects.

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Age-Stratified Propofol Dosage for Pediatric Procedural Sedation and Analgesia
Huib van Dijk, Mark P. Hendriks, Marga M. van Eck-Smaling, Leo van Wolfswinkel, Kim van Loon
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Risk Factors for Prolonged Hospital Stay after Endoscopy
Toshihiro Nishizawa, Shuntaro Yoshida, Osamu Toyoshima, Tatsuya Matsuno, Masataka Irokawa, Toru Arano, Hirotoshi Ebinuma, Hidekazu Suzuki, Takanori Kanai, Kazuhiko Koike
Clinical Endoscopy.2021; 54(6): 851. CrossRef
Effects of Sedation Performed by an Anesthesiologist on Pediatric Endoscopy: a Single-Center Retrospective Study in Korea
Sung Min Yang, Dae Yong Yi, Geun Joo Choi, In Seok Lim, Soo Ahn Chae, Sin Weon Yun, Na Mi Lee, Su Yeong Kim, Eung Sang Choi
Journal of Korean Medical Science.2020;[Epub] CrossRef
Propofol Sedation by Pediatric Gastroenterologists for Endoscopic Procedures: A Retrospective Analysis
Aya Khalila, Itai Shavit, Ron Shaoul
Frontiers in Pediatrics.2019;[Epub] CrossRef
Letter to the Editor: Is Propofol Good Choice for Procedural Sedation? Evaluation of Propofol in Comparison with Other General Anesthetics for Surgery in Children Younger than 3 Years
Soon Chul Kim
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A clinical trial comparing propofol versus propofol plus midazolam in diagnostic endoscopy of patients with a low anesthetic risk
Laura Julián Gómez, Ana Fuentes Coronel, Carmen López Ramos, Carlos Ochoa Sangrador, Paola Fradejas Salazar, Eva Martín Garrido, Pilar Conde Gacho, Carmen Bailador Andrés, María García-Alvarado, Gabriella Rascarachi, Rocio Castillo Trujillo, Santiago Jos
Revista Española de Enfermedades Digestivas.2018;[Epub] CrossRef
Safety of Non-anesthesiologist Administration of Propofol for Gastrointestinal Endoscopy
Jun Kyu Lee, Dong Kee Jang, Won Hee Kim, Jung-Wook Kim, Byung Ik Jang
The Korean Journal of Gastroenterology.2017; 69(1): 55. CrossRef
Adverse Events by Sedation Type in Gastrointestinal Endoscopy
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Clinical Endoscopy.2017; 50(2): 97. CrossRef
Efficacy and safety of a patient-positioning device (EZ-FIX) for endoscopic retrograde cholangiopancreatography
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World Journal of Gastroenterology.2015; 21(19): 5995. CrossRef
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Comparison between Midazolam Used Alone and in Combination with Propofol for Sedation during Endoscopic Retrograde Cholangiopancreatography: Yu Seok Kim, Myung-Hwan Kim, Seung Uk Jeong, Byung Uk Lee, Sang Soo Lee, Do Hyun Park, Dong-Wan Seo, Sung Koo Lee; Clin Endosc 2014;47(1):94-100. Published online January 24, 2014; DOI: https://doi.org/10.5946/ce.2014.47.1.94

Abstract PDF PubReader ePub

Background/Aims

Endoscopic retrograde cholangiopancreatography (ERCP) is an uncomfortable procedure that requires adequate sedation for its successful conduction. We investigated the efficacy and safety of the combined use of intravenous midazolam and propofol for sedation during ERCP.

Methods

A retrospective review of patient records from a single tertiary care hospital was performed. Ninety-four patients undergoing ERCP received one of the two medication regimens, which was administered by a nurse under the supervision of a gastroenterologist. Patients in the midazolam (M) group (n=44) received only intravenous midazolam, which was titrated to achieve deep sedation. Patients in the midazolam pulse propofol (MP) group (n=50) initially received an intravenous combination of midazolam and propofol, and then propofol was titrated to achieve deep sedation.

Results

The time to the initial sedation was shorter in the MP group than in the M group (1.13 minutes vs. 1.84 minutes, respectively; p<0.001). The recovery time was faster in the MP group than in the M group (p=0.031). There were no significant differences between the two groups with respect to frequency of adverse events, pain experienced by the patient, patient discomfort, degree of amnesia, and gag reflex. Patient cooperation, rated by the endoscopist as excellent, was greater in the MP group than in the M group (p=0.046).

Conclusions

The combined use of intravenous midazolam and propofol for sedation during ERCP is more effective than midazolam alone. There is no difference in the safety of the procedure.

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Andreas Nilsson, Benjamin Grossmann, Eric Kullman, Eva Uustal, Folke Sjöberg, Lena Nilsson
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Clinical Endoscopy.2014; 47(4): 324. CrossRef

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Conscious Sedation During Gastrointestinal Endoscopy: Midazolam vs Propofol: Ja Seol Koo, M.D. and Jai Hyun Choi, M.D.; Korean J Gastrointest Endosc 2011;42(2):67-73. Published online February 28, 2011

Abstract PDF: Endoscopy is increasingly performed with the patient under conscious sedation in many countries. The majority of patients can be adequately and safely sedated during routine upper endoscopy and colonoscopy with a combination of a benzodiazepine and opioid. Midazolam is a water-soluble benzodiazepine that is characterized by a rapid onset of action and a shorter duration compared with that of the other drugs of the same class. The major side effect of midazolam is respiratory depression, which can be reversed by flumazenil, a benzodiazepine-specific antagonist. Propofol is a lipid-soluble agent that has the advantages of a more rapid onset of action and a shorter recovery time compared to that of midazolam. However, it should be used with caution since it can lead to hypotension and respiratory depression. Propofol can be safely and effectively administered by nonanesthesiology physicians and nurses provided that they have received adequate training. Two models have been proposed for the administration of propofol by endoscopists: nurse-administered propofol sedation (NAPS) and combination propofol (propofol plus other agents) sedation. In order to modify the pharmacological disadvantages of propofol, fospropofol sodium, a water-soluble prodrug of propofol, has recently been developed. In addition, new delivery systems have been devised: patient-controlled sedation and computer-assisted personalized sedation, in which the computer continuously monitors the patient's condition and adjusts the dose of propofol accordingly. Endoscopists must have a thorough understanding of the medications used for endoscopic sedation and they must acquire the skills necessary for the treatment of cardiopulmonary complications. Therefore, it is necessary to develop a practice guideline pertaining to endoscopic sedation and also training programs for physicians and nurses in Korea. (Korean J Gastrointest Endosc 2011;42:67-73)

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A Gigantic Gastric Mucosal Rupture When Performing Endoscopy under Conscious Sedation in a Patient with Hiatal Hernia: Pyoung Rak Choi, M.D., Won Moon, M.D., Chan Bok Park, M.D., Eun Ho Park, M.D., Ji Suk Lee, M.D., Kyu Jong Kim, M.D., Moo In Park, M.D. and Seun Ja Park, M.D.; Korean J Gastrointest Endosc 2009;38(3):137-141. Published online March 30, 2009

Abstract PDF: Mallory-Weiss syndrome is a tear in the gastro-esophageal junction or its adjacent mucosa, and this occurs due to nausea or vomiting that is caused by various etiologic factors. It may occur in patients with excessive retching and struggling when undergoing upper gastrointestinal endoscopy, and its underlying factors are esophageal hiatal hernia, atrophic gastritis and old age. There are currently only rare reports about gigantic gastric mucosal rupture during performance of upper gastrointestinal endoscopy in patients with esophageal hiatal hernia. We recently experienced a 76-year-old woman who developed a gigantic gastric mucosal rupture that ranged from the gastro-esophageal junction to the gastric angle. This occurred during performance of standard upper gastrointestinal endoscopy with the patient under sedation and the patient had a concurrent esophageal hiatal hernia. The patient was treated conservatively for the rupture. Herein we report on our case along with a review of the relevant literature. (Korean J Gastrointest Endosc 2009;38:137-141)

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A Case of Esophageal Submucosal Dissection that Developed during Conscious Sedation Endoscopy: Hong Jun You, M.D., Moo In Park, M.D., Kyu Jong Kim, M.D., Won Moon, M.D., Sun Jung Kim, M.D., Sung Woo Yang, M.D., Se Young Park, M.D., Woo Seong Jeon, M.D., Dong Yang Park, M.D., Jun Young Song, M.D. and Seun Ja Park, M.D.; Korean J Gastrointest Endosc 2007;35(5):328-331. Published online November 30, 2007

Abstract PDF: Esophageal submucosal dissection is a rare condition, resulting in the separation of the submucosa and muscle layer by mucosal laceration and bleeding. Possible causes are external trauma, foreign body entrapment, endoscopic instrumentation and even spontaneous dissection. Typical endoscopic findings show a false lumen from the torn mucosa and a muscle layer in the false lumen. Esophagography shows a "double barrelled" appearance. A dissection can be resolved with conservative management. We experienced a case of a submucosal dissection of the esophagus with perforation, an unusual complication of conscious sedation endoscopy. (Korean J Gastrointest Endosc 2007;35:328-331)

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Conscious Sedation with Midazolam Combined with Propofol for Colonoscopy: Ja Seol Koo, M.D., Jai Hyun Choi, M.D., Sung Woo Jung, M.D., Woo Sik Han, M.D., Jong Sup Lee, M.D., Hyung Joon Yim, M.D., Yoon Tae Jeen, M.D., Hoon Jai Chun, M.D., Hong Sik Lee, M.D., Sang Woo Lee, M.D., Chang Duck Kim, M.D. and Ho Sang Ryu, M.D.; Korean J Gastrointest Endosc 2007;34(6):298-303. Published online June 30, 2007

Abstract PDF: Background/Aims: There is increasing interest in the use of propofol as a sedative agent for colonoscopy. We evaluated the safety and efficacy of the synergistic sedation with midazolam combined with low-dose propofol versus that of midazolam alone. Methods: A total of 56 patients from among those who underwent total colonoscopy between August 2004 and October 2004 were randomly assigned to one of three medication treatment groups. Group A (n=18) received low-dose midazolam (0.03 mg/kg IV) plus propofol, group B (n=19) received high-dose midazolam (0.07 mg/kg IV) plus propofol, and group C (n=19) received high-dose midazolam alone. The patients' vital signs were monitored throughout the course of the study. The recovery time and quality as well as the patients' comfort level were also assessed. Results: There were no significant differences in baseline characteristics among the treatment groups. There were also no differences in the duration and insertion time of the colonoscopy among the three groups. The patients' comfort level and cardiorespiratory parameters during colonoscopy were similar among the three groups. The sedation efficacy and recovery times were also similar among the three groups. Conclusions: Midazolam combined with low-dose propofol as a sedative for colonoscopy exhibits similar effects on safety, patient' comfort level and recovery time to those of midazolam alone.

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The Evalution of Patient Anxiety Associated with Upper Gastrointestinal Endoscopy: Jin Su Jang, M.D., Moon Kyung Joo, M.D., Jin Nam Kim, M.D., Yong Sik Kim, M.D., Yoon Tae Jeen, M.D., Hoon Jai Chun, M.D., Hong Sik Lee, M.D., Sang Woo Lee, M.D., Jai Hyun Choi, M.D., Chang Duck Kim, M.D. and Ho Sang Ryu, M.D.; Korean J Gastrointest Endosc 2007;34(2):65-70. Published online March 2, 2007

Abstract PDF: Background
/Aims: Upper gastrointestinal (UGI) endoscopy is a necessary procedure for making the diagnosis of UGI diseases. However, it may evoke anxiety due to the procedural discomfort before endoscopy. There have been few detailed studies that have evaluated the anxiety of patients who undergo UGI endoscopy in Korea. The aim of this study is to evaluate the patient's anxiety associated with UGI endoscopy and to determine the methods to improve the tolerance of patients to UGI endoscopy. Methods: From May to September 2004, we assessed 38 patients who received UGI endoscopy for the first time as outpatients at Korea University, Anam Hospital. One group was examined with UGI endoscopy after being sedated. The patient's anxiety was rated at baseline and immediately before the procedure. Results: Endoscopy was associated with a significant increase in anxiety (prior to procedure, 48.53 vs. baseline, 43.58, p＜0.001) but not trait anxiety (43.92 vs. 43.63, p=0.70). The procedural anxiety was not influenced by gender, age or the education level, but it was correlated with conscious sedation (without CS, 5.67±0.23 vs. with CS, 4.06±0.16, p＜0.05). Conclusions: Sedating the patient during UGI endoscopy is an effective method to lower procedural anxiety.

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An Evaluation of Websites about Endoscopy under Conscious Sedation: Hyun Jeong Lee, M.D., Young Jae Oh, M.D., Il Chol Hong, M.D., Jun Haeng Lee, M.D., Poong-Lyul Rhee, M.D., Jae J. Kim, M.D. and Jong Chul Rhee, M.D.; Korean J Gastrointest Endosc 2006;32(5):307-312. Published online May 30, 2006

Abstract PDF: Background
/Aims: The internet has become an important source of medical information not only for doctors but also for patients. Therefore, this study evaluated the quality of medical information on endoscopy under conscious sedation on the internet in Korea. Methods: 147 patients (mean age: 51 years, male：female 76：71) who visited the gastroenterology clinic were surveyed using a questionnaire about use of medical information on the Internet. The first 20 Internet sites using the key word 'endoscopy under sedation' were retrieved from the 5 most frequently used Internet search engines. The quality of information from a total of 63 websites was evaluated using a checklist. Results: Among a total 63 sites about endoscopy under sedation, 46 sites (73.0%) were made by private hospitals or private clinics and 60 sites (95%) were made for patients. The definition of endoscopy under conscious sedation was accurately mentioned in only 7 sites (11%). The complications and risk factors were mentioned in 29 sites (46%). Conclusions: Most websites made by private hospitals or private clinics overemphasized the merits of sedation. Websites with a more balanced point of view by official organizations may help improve the quality of medical information on the Internet. (Korean J Gastrointest Endosc 2006;32:307⁣312)

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Effects of Chronic Alcohol Consumption on Midazolam Induced Sedation during Colonoscopy: Young Sook Park, M.D., Jong Yong Lee, M.D., Yu Seoung Seo, M.D., Chung Hyeon Kim, M.D., Jung Don Lee, M.D., Hyun Suk Lee, M.D., Kye Hyung Kwon, M.D.,Tae Hun Kim, M.D. and Yun Ju Jo, M.D.; Korean J Gastrointest Endosc 2004;29(6):495-499. Published online December 30, 2004

Abstract PDF: Background
/Aims: It is suggested that patients consuming large amounts of alcohol are difficult to be sedated by midazolam probably due to cross tolerance. We studied to know the adequate administration doses of midazolam in patients with chronic alcohol consumption. Methods: Study I; We prospectively studied 117 outpatients presenting for colonoscopy. According to alcohol consumption we divided four groups such as group I: 0 g/day, group II: ＜10 g/day, group III: 10∼40 g/day, group IV: ＞40 g/day. We initially administered 0.06 mg/kg midazolam and add up to spontaneous eye closure. We measured grade of amnesia, level of consciousness, endoscopist's assessment and VAS scale for pain after recovery. Study II; We measured induction time after 0.08 mg/kg midazolam in 60 patients who drink alcohol. Results: Additional amount of midazolam was not significantly different between the groups (group I: 0.0145 mg/ kg, group II: 0.0214 mg/kg, group III: 0.0181 mg/kg, group IV: 0.0199 mg/kg). There were no differences of sedation parameters between the groups. However the induction time was prolonged and correlated with alcohol consumption. Conclusions: For adequate sedation in patients with chronic alcohol consumption, longer induction time rather than increasing dosage is required. (Korean J Gastrointest Endosc 2004;29:495⁣499)

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내시경적 역행성 췌담관조영술에서 Midazolam 에 의한 얕은 진정 후의 역설적 반응에 관한 예측인자 ( Predictable Factors for Paradoxical Reactions in Conscious Sedation with Midazolam During ERCP ): Korean J Gastrointest Endosc 2001;23(6):451-460. Published online November 30, 2000

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