Anesthesia for GI endoscopy in the era of COVID-19

As a result of COVID-19, the last few weeks have necessitated a reevaluation of the sedation paradigm for gastrointestinal (GI) endoscopic procedures. Routine screening and some surveillance procedures have taken a backseat and likely to remain so until a vaccine or effective treatment becomes available. Anesthesia providers and endoscopists are required to adapt to this new reality rapidly. The general aim of sedation remains the same-patient comfort, reduced hypoxia, prevention of aspiration along with rapid recovery, and discharge. The present review focuses on necessary modification to reduce the risk of virus contagion for both patients (from health-care providers) and vice versa. A preprocedure evaluation and consenting should be modified and provided remotely. Unsedated GI endoscopy, sedation with minimal respiratory depression, and modification of general anesthesia are explored. Challenges with supplemental oxygen administration and monitoring are addressed. Guidelines for appropriate use of personal protective equipment are discussed. Measures for limiting aerosolization are deliberated

Oliceridine and its potential to revolutionize GI endoscopy sedation

Providing sedation to patients undergoing gastrointestinal (GI) endoscopy is a controversial and emotive issue. The mainstay of sedation is propofol, whose administration is within the sole jurisdiction of anesthesia providers, at least in the USA. Attempts have been made to seize the authority by the GI community. One of the first attempts was the use of the prodrug of propofol -fospropofol. However, as the drug has a similar adverse effect profile as propofol in terms of respiratory depression, the FDA did not approve its use by providers other than those trained in airway management. Sedasy

Anesthesia for Advanced Endoscopic Procedures

The gastrointestinal endoscopy paradigm is rapidly changing, and technological advancements are largely responsible. In tandem, anesthesia providers are adapting to the changing needs and demands. The challenges are unique. Complications arising from the procedures are both routine, such as aspiration and hypoxia, and procedure specific, such as bleeding, pneumothorax, pneumopericardium, and pneumoperitoneum. It is crucial for the anesthesia provider to have a good understanding of the techniques employed by the endoscopist. A higher index of suspicion is also essential to diagnose and appropriately manage many of the complications. In this review, an effort is made to discuss both procedural aspects and anesthesia challenges. We hope that both endoscopists and anesthesia providers will benefit from this review

Recent developments in devices used for gastrointestinal endoscopy sedation

Hypoxemia is a frequent and potentially fatal complication occurring in patients during gastrointestinal endoscopy. The administration of propofol sedation increases the risk of most complications, especially hypoxemia. Nevertheless, propofol has been increasingly used in the United States, and the trend is likely to increase in the years to come. Patient satisfaction and endoscopist satisfaction along with rapid turnover are some of the touted reasons for this trend. However, propofol sedation generally implies deep sedation or general anesthesia. As a result, hypopnea and apnea frequently occur. Inadequate sedation and presence of irritable airway often cause coughing and laryngospasm, both leading to hypoxemia and potential cardiac arrest. Hence, prevention of hypoxemia is of paramount importance. Traditionally, standard nasal cannula is used to administer supplement oxygen. However, it cannot sufficiently provide continuous positive airway pressure (CPAP) or positive pressure ventilation. Device manufacturers have stepped in to fill this void and created many types of cannulas that provide apneic insufflation of oxygen and CPAP and eliminate dead space. Such measures decrease the incidence of hypoxemia. This review aimed to provide essential information of some of these devices

Emerging Approaches in Intravenous Moderate and Deep Sedation

Successful pharmacological innovations that have made a difference in daily practice are rare in the world of anesthesia and sedation. After many years of research, it seems that we finally have two new drug innovations that are likely to change the paradigm of moderate and deep sedation. These are oliceridine and remimazolam. Both have been in development for over a decade. Oliceridine was synthesized in a lab as an entirely new molecule. It is a biased μ- receptor agonist that acts preferentially on the G-protein pathway (which is responsible for analgesia). At least in lower doses, it has minimal effect on the beta-arrestin pathway, which is responsible for unwanted effects of μ-opioid receptor activation such as respiratory depression and gastrointestinal dysfunction. Like any other μ- receptor agonist, it produces appropriate dose-dependent analgesia. Remimazolam is structurally similar to midazolam; however, it has an additional ester linkage that delivers the kinetics of remifentanil. As a result, while pharmacodynamically identical to midazolam, remimazolam is metabolized by ester hydrolysis and subsequently its elimination is rapid and predictable. The present review discusses the two drugs in detail with a particular emphasis on their potential role in moderate and deep sedation

Factors predicting chronic opioid use after orthopedic surgical procedures

BACKGROUND: Opioid abuse has been an increasing problem since the 1990s. With over 47,000 opioid related deaths recorded in 2017 alone, concerns have been raised regarding the dangers of introducing opioids perioperatively to patients undergoing major surgeries. OBJECTIVES: The present study proposes to examine the frequency, amount, and trends in post-operative opioid consumption in patients undergoing orthopedic surgical procedures. STUDY DESIGN: This was a randomized, retrospective questionnaire-based study. SETTING: Patients who underwent any type of orthopedic surgery at the University of Pennsylvania Presbyterian Hospital from 1/1/2018 to 3/12/2019 were randomly selected and called during the summer of 2019. METHODS: In this retrospective questionnaire-based study, 828 patients were called by telephone in the summer of 2019. These patients were asked a variety of questions involving opioid consumption behavior post-surgery. The study ended after receiving responses from 200 patients. RESULTS: Nineteen (9.5%) patients reported positively for experiencing euphoria while taking opioids post-surgery. Of the 200 patients contacted, 6 patients (3%) reported switching to marijuana instead of opioids. Thirty-eight (19%) patients preferred to take no opioids at all post-surgery, and one patient was found to have given their prescription to a family member or friend. Twenty-one patients (10.5%) were found to have been taking opioids for non-severe pain. Blacks and whites were the most common racial demographics, making up 84 and 109 of the totals, respectively. The odds ratios for all of the predictors showed that the relative risk for opioid misuse was higher for black patients than white patients (OR = 3.034). There was no relationship between the intra- and post-operative opioid administration and long-term opioid misuse. LIMITATIONS: Patients are self-selected and had the option to opt out of the study when contacted. Some patients may not have been available to answer the phone when our study was being conducted. This study was only conducted for orthopedic patients and for patients who received surgery at the University of Pennsylvania Presbyterian Hospital, thus affecting the demographics for our research. CONCLUSIONS: Prescription opioid misuse is more common among the black population. The total opioid consumption is frequently lower than the quantity prescribed. Patients frequently use opioids even though they feel that pain is insufficient to deserve such an intervention. Euphoria is experienced by a significant number of patients taking prescription opioids Often patients do not take any opioids, although they had prescriptions