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An integral part of the practice of gastrointestinal endoscopy is adequate sedation and analgesia. The choice of the appropriate sedation modality is always a balance between optimizing the benefits of sedation and minimizing the potential risks. The American Society of Anesthesiologists (ASA) agrees that appropriate pre-procedure evaluation increases the likelihood of satisfactory sedation and decreases the likelihood of adverse outcomes. A vast majority of endoscopic procedures are diagnostic in nature and performed on relatively healthy patients with an ASA status of 1 or 2. Diagnostic and therapeutic endoscopic interventions include esophagogastroduodenoscopy (EGD), proctoscopy/sigmoidoscopy/colonoscopy, and endoscopic retrograde cholangiopancreatography (ERCP). Sedation for gastrointestinal endoscopy is particularly challenging because of variability during most procedures, characterized by long nonstimulating periods interspersed with significantly stimulating events. Use of a medication reconciliation tool is associated with significant improvements in patient safety.
The A-Line® auditory evoked potential index (AAI) (AEP Monitor/2, Danmeter A/S, Odense, Denmark) is a newly developed composite parameter representing the degree of hypnosis. We conducted a prospective, observational study to explore the performance and validity of the AAI during conventional sedation for gastrointestinal (GI) endoscopy.
Thirty adults of either sex, age <65, scheduled for combined oesophagogastroduodenoscopy (OGD) and colonoscopy under sedation with intravenous (i.v.) midazolam and alfentanil were enrolled. The sedative end-point was set at the Observer’s Assessment of Alertness/Sedation (OAA/S) score less than 4. An AEP Monitor/2 was used in all patients. AAI, sedation scores, heart rate (HR), blood pressure (BP) and SPO2 were recorded every 2 min up to the end of the procedure. Receiver operator characteristic analysis was used to test validity and to select optimal sedation.
There was a significantly positive correlation between AAI and OAA/S scores (ρ = 0.886; P < 0.001). The AAI also showed significant differences between subsequent levels of sedation scores (P < 0.001). AAI greater than 54 indicated fully awake or minimal sedation and values between 54 and 42 were suggestive of moderate sedation. Values between 42 and 34 were associated with moderate to deep sedation and readings below 34 were associated with deep sedation. The relative risk of SPO2 < 95% for OAA/S = 2 compared with 3 was 15.98 (95% confidence interval (CI): 3.94–64.81).
AAI is an effective tool for monitoring sedation during GI endoscopy induced by i.v. midazolam and alfentanil.
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