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Is sedation for endoscopy as safe as you think?
No full text1118 Minerva Anestesiologica N November 2017
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n this issue of Minerva Anestesiologica, Brumby et al.8 report an observational pilot study assessing the incidence of failure to recover at day 1 and in subsequent days and weeks after either colonoscopy, gastroscopy, or both procedures combined in 102 patients of over the age of 18 years. Recovery was evaluated not only using physiologic endpoints but also evaluating other aspects such as nociception, emotion, activities of daily living (ADL), and cognition on the following day as well as over a 1-month follow-up period using the multidimensional Postoperative Quality of Recovery Scale (PostopQRS ). All the patients received total intravenous anesthesia with propofol alone or in combination with opioids. Some participants received midazolam or opioids in the pre-operative period. The authors have seen that incomplete recovery is common after colonoscopy, gastroscopy or both procedures. Failure to recover was mainly due to failure in nociceptive and cognitive recovery at day 1 with modest but clinically important differences in early quality of recovery between the procedures.
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orrectly, the authors underline that recovery after endoscopic procedures should be defined by a multidimensional tool able to assess emotive, functional and cognitive domains.
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his is particularly important because the patients must be discharged as soon as possible and should return to preoperative levels of independency in activities of daily living.
Anesthesia demand for colonoscopy and gastroscopy is increasing each year and this is due to need of diagnostic or screening programs and therapeutic management of acute pathologies or neoplastic diseases. Because of the air or CO 2 insufflation for adequate distention and visualization of the gastrointestinal lumen, the endoscopic procedures are associated with significant pain and discomfort, therefore sedation is often required to improve patient tolerance and safety.1, 2 Propofol alone or combined with midazolam and opioids is commonly used for sedation although drugs as etomidate and dexmedetomidine have been introduced.3, 4 Usually, the procedures are ambulatory and the patients must be discharged soon after the endoscopy. Adverse events during sedation for endoscopy are very low and anesthetic techniques are performed to provide sedation minimizing hemodynamic changes and allowing faster emergence and patient’s discharge. Patients can return to their daily lives safely and promptly as soon as have recovered to pre-procedural baseline physical performance.5 However, optimal recovery after sedation for endoscopy is not always observed.
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ommonly, a patient’s discharge is related to recovery time, adverse events and physiological parameters such as level of consciousness and stability of vital signs.6, 7
EDITORIAL
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s sedation for endoscopy as safe as you think?
Germano DE COS MO 1 *, Elisabetta CONGEDO 2
1Department of Anesthesia and Intensive Care, Sacro Cuore Catholic University, Rome, Italy; 2Department of Anesthesia and Intensive Care, Antonio Perrino Hospital, Brindisi, Italy
*Corresponding author: Germano De Cosmo, Department of Anesthesia and Intensive Care, Sacro Cuore Catholic University, via G. Moscati 31, 00168 Rome, Italy. E-mail: [email protected]
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omment on p. 1161.
Minerva Anestesiologica 2017 November;83(11):1118-20
DOI : 10.23736/S0375-9393.17.12260-1
© 2017 EDIZIONI MINERVA INERVAINERVA MEDICA
O
nline version at http://www.minervamedica.it
COPYRIGHT© 2017 EDIZIONI MINERVA MEDICA
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
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SA
FET Y OF SE DATIONATION FOR EN DOSCO PY DE COS MO
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ol. 83 - No. 11 Minerva Anestesiologica 1119sedated with propofol or remifentanil.14 Allen et al. have shown that the incidence of post-procedural cognitive impairment was similar in patients randomized to light versus deep sedation. In addition, the authors have not considered pain an important risk factor for post procedural cognitive dysfunction, especially if the endoscopic procedure is diagnostic and not operative.16
S
harma et al. have investigated cognitive function in 108 patients with cirrhosis undergoing endoscopy under sedation with propofol. Before and two hours after endoscopy psychometric tests have been administered to evaluate cognitive function. The authors have not found a worsening of the psychometric tests after the endoscopy.17
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hese differences can be due to several factors: the type and sensitivity of the psychometric tests used, the variation also in the healthy subjects’ performance at a few days away, the too small simple size. There is a wide confidence interval of evaluated parameters that indicates that there is a great variation of response in the various subjects, due to a small simple size.18-20
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n conclusion, thousands of endoscopic procedures are performed daily and the main question that this article raises is to understand what means recovery from a procedure: an adequate recovering goes beyond vital functions. Incomplete recovery can last up to one month and is mainly due to nociceptive and cognitive impairment that could also occur in young people undergoing minor procedures. Therefore, subsequent studies might need to investigate if and how a low impact procedure can induce cognitive impairment and the main parameters that should be assessed to consider a patient overall recovered utilizing appropriate tests that can identify the most vulnerable patients.
References
1. A Allen ML. Safety of deep sedation in the endoscopy suite. Curr Opin Anaesthesiol 2017;30:501-6.
2. L Leslie K, Allen ML, Hessian EC , Peyton PJ, Kasza J, Courtney A, et al. Safety of sedation for gastrointestinal
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n literature, the reported incidence of Postoperative Cognitive Dysfunction (POC D) varies from 20% to 60% between 6 weeks to 3 months after surgery and the causes of this variability are related to type of surgery, duration, patient’s age and cultural level.9
T
he prevalence of POC D has primarily been studied in elderly patients undergoing cardiac surgery.10 However, its frequency should be very rare after endoscopic procedure especially in young people because stress associated to endoscopic procedures is very low as well as the increase of pro-inflammatory cytokines that play a pivotal role in cognitive dysfunction.11, 12
T
he novelty of the study by Brumby et al. is that the people enrolled are young, without risk factors for postoperative cognitive dysfunction, and not undergoing major surgery.
S
urprisingly, a not negligible percentage of patients had a cognitive impairment not only in the early post-procedural period but until one month and perhaps for a longer time if follow-up period would be prolonged. Patients in the gastroscopy group have a lower frequency of overall recovery.
We have to consider that both endoscopic procedures have affected not only cognitive function but also pain. Authors do not report if there is a correlation between POC D and the presence of pain despite they have seen that patients undergoing combined procedures had more pain over the entire 1-month follow-up period and a more cognitive impairment at day 1 than participants having only colonoscopy.
However, these results should be observed with caution not only because endoscopic procedures have been considered with little impact on daily physiological activity and on cognitive and nociceptive domain but also because few studies have been performed, and only for few days.13-15 Moreover, the studies performed give different results.
T
heodorou et al. have demonstrated cognitive impairment up to 120 minutes after propofol/midazolam/fentanyl or nitrous oxide/sevoflurane sedation for colonoscopy.13 Instead, Moerman et al. have not found cognitive dysfunction
after 15 min in colonoscopy patients
COPYRIGHT© 2017 EDIZIONI MINERVA MEDICA
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
or other proprietary information of the Publisher.
DE COS MO SA SA FET Y OF SE DATIONATION FOR EN DOSCO PY
1120 Minerva Anestesiologica N November 2017gedo E, De Cosmo G. Cognitive Dysfunction after Surgery: An Emergent Problem. J Alzheimers Dis Parkinsonism 2017;7:1.
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14. Moerman ATAT, Foubert LA , Herregods LL , Struys MM, De Wolf DJ, De Looze DA, et al. Propofol versus remifentanil for monitored anaesthesia care during colonoscopy. Eur J Anaesthesiol 2003;20:461-6.
15. Fredman B, Lahav M, Zohar E, Golod M, Paruta I, Jedeikin R. The effect of midazolam premedication on mental and psychomotor recovery in geriatric patients undergoing brief surgical procedures. Anesth Analg 1999;89:1161-6.
16. A Allen M, Leslie K, Hebbard G, Jones I, Mettho T, Maruff P. A randomized controlled trial of ligh versus deep propofol sedation for elective outpatient colonoscopy: recall, procedural condition and recovery. Can J Anesth 2015;62:1169-78.
17. S Sharma P, Singh S, Sharma BC, Kumar M, Garg H, Kumar A, et al. Propofol sedation during endoscopy in patients with cirrhosis, and utility of psychometric tests and critical flicker frequency in assessment of recovery from sedation. Endoscopy 2011;43:400-5.
18. S tark PA, Myles PS, Burke JA. Development and psychometric evaluation of a postoperative quality of recovery score: the QoR-15. Anesthesiology 2013; 118:1332-40.
19. Bowyer AJ, Royse CF. Postoperative recovery and outcomes--what are we measuring and for whom? Anaesthesia 2016;71(Suppl 1):72-7.
20. N Newman S, Wilkinson DJ, Royse CF. Assessment of early cognitive recovery after surgery using the Post-operative Quality of Recovery Scale. Acta Anaesthesiol Scand 2014;58:185-91.
endoscopy in a group of university-affiliated hospitals: a prospective cohort study. Br J Anaesth 2017;118:90-9.
3. Padmanabhan U, Leslie K. Australian anaesthetists’ practice of sedation for gastrointestinal endoscopy in adult patients. Anaesth Intensive Care 2008;36:436-41.
4. Davy A, Fessler J, Fischler M, le Guen M. Dexmedetomidine and general anesthesia: a narrative literature review of its major indications for use in adults undergoing non-cardiac surgery. Minerva Anestesiol 2017 Jun 22. [Epub ahead of print]
5. L Leung FW. Trend in use of sedation for low-risk endoscopy. Looking beyond monitored anesthesis care. JAMA 2017;317:2006-7.
6. Feldman LS , Lee L, Fiore J Jr. What outcomes are important in the assessment of Enhanced Recovery After Surgery (ERAS ) pathways? Can J Anaesth 2015;62:120-30.
7. L Lee L, Tran T, Mayo NE , Carli F, Feldman LS . What does it really mean to “recover” from an operation? Surgery 2014;155:211-6.
8. Brumby AM, Heiberg J, Te C, Royse CF. Quality of recovery after gastroscopy, colonoscopy or both endoscopic procedures: an observational pilot study. Minerva Anestesiol 2017;83:1161-8.
9. R Royse CF, Andrews DT, Newman SN , Stygall J, Williams Z, Pang J, et al. The influence of propofol or desflurane on postoperative cognitive dysfunction in patients undergoing coronary artery bypass surgery. Anaesthesia 2011;66:455-64.
10. N Newman MF, Mathew JP, Grocott HP, Mackensen GB, Monk T, Welsh-Bohmer KA, et al. Central nervous system injury associated with cardiac surgery. Lancet 2006;368:694-703.
11. De Cosmo G, Sessa F, Fiorini F, Congedo E. Effect of remifentanil and fentanyl on postoperative cognitive function and cytokines level in elderly patients undergoing major abdominal surgery. J Clin Anesth 2016;35:40-6.
12. C Canistro G, Levantesi L, Oggiano M, Sicuranza R, ConConflicts
of interest.—The authors certify that there is no conflict of interest with any financial organization regarding the material discussed in the manuscript.
Article first published online: July 12, 2017. - Manuscript accepted: July 5, 2017. - Manuscript received: June 27, 2017.
(Cite this article as: De Cosmo G, Congedo E. Is sedation for endoscopy as safe as you think? Minerva Anestesiol 2017;83:1118-20. DOI : 10.23736/S0375-9393.17.12260-1)
COPYRIGHT© 2017 EDIZIONI MINERVA MEDICA
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
or other proprietary information of the Publisher
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are based, and we compare ACA results based on two different types of co-citation counting - the traditional type that
only counts the first one among a cited work's authors on the one hand and a non-traditional type that takes into
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Laryngeal mask airway, so many limitations?
Get PDFWe read with great interest the article published by
Rossi et al., entitled “Safety aspects of desflurane anesthesia
and laryngeal mask airway.”1 We would like to
comment on the patient-related factors limiting laryngeal
mask airway (LMA) usage.
LMA is usually used in children under 15 years of
age and is proven to be safe and effective. Actually,
there is a growing interest in its use in association with
desflurane.
Despite desflurane is less commonly used in this
range of population, recent studies reported a relative
safe use of this halogenated also in children whose airways
were supported with laryngeal mask. For example,
Lerman et al. report a frequency of airway events
with desflurane similar to those with isoflurane after
LMA removal with an awake patient.2 Furthermore, the
difference in events removing LMA in awake patients
or deep anesthesia is similar in desflurane and sevoflurane
use.3
Lastly, in our experience, the safe LMA profile together
with desflurane pharmacokinetic, permits to
perform anesthesia in young patients undergoing orthopedic
surgery also in association with loco-regional analgesia.
Second-generation supraglottic airway devices
have contributed to the increase in LMA use, therefore
these show that obesity is not a factor limiting its use. A
Cochrane Review published in 2013 reported a failure
positioning LMA rate of 3% to 5% in obese patients
but also a good oxygenation with this device.4 According
to 2011 NAP4, the limitation regarding LMA use
in obese patients includes patients whose surgery was
performed in the lithotomy position and/or head down
position.5 In addition, in a group of “cervical disorder”
like neck flexing difficulty, we suppose that, with caution
and surgery related possibilities, LMA can prevent
difficulties during intubation and also results as ventilation
device bridging to the orotracheal intubation when
it is mandatory.
In conclusion, we want to congratulate the authors
for a clear and well written paper. However, in our opinion,
LMA could provide more possibilities.
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No full textIt is unclear whether shorter wave latencies of middle-latency-auditory- evoked-potentials may be associated to cognitive function other than nondeclarative memory. We investigated the presence of declarative, nondeclarative and dreaming memory in propofol-anaesthetized patients and any relationship to intraoperatively registered middle-latency-auditory-evoked- potentials. An audiotape containing one of two stories was presented to patients during anaesthesia. Patients were interviewed on dream recall immediately upon emergence from anaesthesia. Declarative and nondeclarative memories for intraoperative listening were assessed 24 h after awakening without pointing out positive findings. Six patients who reported dream recall showed an intraoperative Pa latency less than that of patients who were unable to remember any dreams (P<0.001). A high responsiveness degree of primary cortex was associated to dream recall formation during anaesthesia. © 2007 Lippincott Williams & Wilkins, Inc
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