Gemma Rossi

Sedation and monitoring for gastrointestinal endoscopy: A nationwide web survey in Italy

BACKGROUND Best strategy of sedation/analgesia in gastrointestinal (GI) endoscopy is still debated. AIMS OF THE STUDY To evaluate sedation and monitoring practice among Italian gastroenterologists and to assess their opinion about non-anaesthesiologist propofol administration. METHODS A 19-item survey was mailed to all 1192 members of the Italian Society of Digestive Endoscopy (SIED). For each respondent were recorded demographic data, medical specialty, years of practise and practise setting. RESULTS A total of 494 SIED members returned questionnaires, representing a response rate of 41.4%. The most employed sedation pattern was benzodiazepines for oesophagogastroduodenoscopies (EGDS) in 50.8% of procedures, benzodiazepines plus opioids for colonoscopy and enteroscopy in 39.5% and 35.3% of procedures, respectively, propofol for endoscopic retrograde colangiopancreatography (ERCP) and endoscopic ultrasound (EUS) in 42.3% and 35.6% of procedures, respectively. With regard to propofol use, 66% respondents stated that propofol was exclusively administered by anaesthesiologists. However, 76.9% respondents would consider non-anaesthesiologist propofol administration after appropriate training. Pulse oximetry is the most employed system for procedural monitoring. Supplemental O(2) is routinely administered by 39.3% respondents. CONCLUSIONS Use of sedation has become a standard practise during GI endoscopy in Italy. Pattern varies for each type of procedure. Pulse oximetry is the most employed system of monitoring. Administration of propofol is still directed by anaesthesiologists.

A single-centre prospective, cohort study of the natural history of acute pancreatitis

BACKGROUND The natural history of acute pancreatitis is based on clinical studies that aim to elucidate the course of disease on the basis of predicted risk factors. AIMS To evaluate the long-term occurrence of recurrent acute pancreatitis and chronic pancreatitis in a cohort of patients following an initial episode of acute pancreatitis. METHODS 196 patients were enrolled consecutively and studied prospectively. Clinical characteristics, exogenously/endogenously-associated factors, and evolution to recurrent acute pancreatitis and chronic pancreatitis were analyzed. RESULTS 40 patients developed recurrent acute pancreatitis 13 of whom developed chronic pancreatitis. In a univariate analysis, recurrent acute pancreatitis was associated with an idiopathic aetiology (p<0.001), pancreas divisum (p=0.001), and higher usage of cigarettes and alcohol (p<0.001; p=0.023). Chronic pancreatitis was associated with a severe first episode of acute pancreatitis (p=0.048), PD (p=0.03), and cigarette smoking (p=0.038). By multivariate analysis, pancreas divisum was an independent risk factor for recurrent acute pancreatitis (OR 11.5, 95% CI 1.6-83.3). A severe first-episode of acute pancreatitis increased the risk of progressing to chronic pancreatitis by nine-fold. CONCLUSIONS Special attention should be given to patients who experience a severe first attack of acute pancreatitis as there appears to be an increased risk of developing chronic pancreatitis over the long term.

Target Controlled Infusion for non-anaesthesiologist propofol sedation during gastrointestinal endoscopy: The first double blind randomized controlled trial

BACKGROUND Target Controlled Infusion is a sophisticated tool for providing optimal sedation regimen avoiding under or oversedation in gastrointestinal endoscopy. AIMS To compare standard moderate sedation vs. non-anaesthesiologist-administered propofol sedation during gastrointestinal endoscopy. METHODS Randomized controlled trial of 70 consecutive colonoscopies and 70 consecutive esophagogastroduodenoscopies (EGD). Standard group (n=70), received fentanyl (1 μg/kg)+midazolam (0.03-0.04 mg/kg) or midazolam only; propofol group (n=70), received fentanyl (1 μg/kg)+propofol Target Controlled Infusion (1.2-1.6 μg/ml) or propofol Target Controlled Infusion only. Discharge time, endoscopist satisfaction and patient satisfaction were recorded in all endoscopies. RESULTS Colonoscopy: discharge time was significantly shorter in the propofol than the standard group (1.1 ± 0.3 vs. 5 ± 10.2 min, respectively; P=0.03). Endoscopist satisfaction was significantly higher (98.3 ± 11.4/100 vs. 87.2±12/100; P=0.001); patient satisfaction was significantly higher (95 ± 9.3/100 vs. 85.5 ± 14.4/100; P=0.002) in the propofol compared to the standard group. EGD: discharge time was not significantly different in the propofol and standard groups (1.1 ± 0.7 vs. 3.9 ± 9.2 min, respectively; P=0.146). Endoscopist satisfaction was significantly higher (92.7 ± 14.3/100 vs. 82.8 ± 21.2/100; P=0.03); patient satisfaction was significantly higher (93.8 ± 18.2/100 vs. 76.5 ± 25.2/100; P=0.003). In the propofol group 94.3% of patients vs. 71.4% of patients in standard group asked to receive the same sedation in the future (P=0.021). CONCLUSION Target Controlled Infusion is a promising method for non-anaesthesiologist-administered propofol sedation.

Two dosages of remifentanil for patient-controlled analgesia vs. meperidine during colonoscopy: A prospective randomized controlled trial

UNLABELLED BACKGROUND AND STUDY: Combined use of opiates and benzodiazepines often results in delayed discharge after colonoscopy. AIMS To compare sedation quality of two dosages of patient controlled analgesia remifentanil with one another and with that of a midazolam-meperidine association during colonoscopy. METHODS Ninety patients undergoing colonoscopy were randomly assigned to three groups. Group M received a meperidine bolus (0.7 mg/kg) and sham patient controlled analgesia. Group R1 received remifentanil 0.5 μg/kg and group R2 remifentanil 0.8 μg/kg together with a patient-controlled analgesia pump injecting further boluses (2-min lock-out). Technical difficulties of the examination, gastroenterologists and patients satisfaction with sedoanalgesia were evaluated after colonoscopy on a 100 mm Visual Analogue Scale. Patients satisfaction was assessed 24 h later. RESULTS Group M had more adverse events (p = 0.044), required more rescue boluses (p = 0.0010), had lower Observers Assessment of Alertness and Sedation Scale score at the end of the procedure (p = 0.0016) and longer discharge time (p = 0.0001). Groups R1 and R2 did not differ with respect to these variables. Patients degree of pain and satisfaction with sedo-analgesia, endoscopists technical difficulty and satisfaction were not different among groups. CONCLUSIONS Remifentanil patient controlled analgesia is a safe approach to sedation for colonoscopy.