Endo-anesthesia: a primer.

Gastrointestinal (GI) endoscopy has witnessed a Cambrian explosion of techniques, indications, and expanding target populations. GI endoscopy encompasses traditional domains that include preventive measures, palliation, as alternative therapies in patients with prohibitive risks of more invasive procedures, and indicated primary treatments. But, it has expanded to include therapeutic and diagnostic interventional endosonography, luminal endoscopic resection, third space endotherapy, endohepatology, and endobariatrics. The lines between surgery and endoscopy are blurred on many occasions within this paradigm. Moreover, patients with high degrees of co-morbidity and complex physiology require more nuanced peri-endoscopic management. The rising demand for endoscopy services has resulted in the development of endoscopy referral centers that offer these invasive procedures as directly booked referrals for regional and rural patients. This further necessitates specialized programs to ensure appropriate evaluation, risk stratification, and optimization for safe sedation and general anesthesia if needed. This landscape is conducive to the organic evolution of endo-anesthesia to meet the needs of these focused and evolving practices. In this primer, we delineate important aspects of endo-anesthesia care and provide relevant clinical and logistical considerations pertaining to the breadth of procedures.

Oliceridine- Opioid of the 21st Century.

Oliceridine (Olinvyk® Trevena, PA, USA) was approved by the United States Food and Drug Administration for clinical use on Aug 8, 2020. Even though, the indication of its approval is very restrictive (to manage moderate-to-severe acute pain in adults when the pain is severe enough), for such an innovative opioid, off-label indications are bound to abound. What could be described as the "opioid of the century," it aims to overcome some of the stubbornest barriers to opioid prescribing, namely addiction liability, respiratory depression, and gastrointestinal (GI) side effects, just to name a few. The novel opioid accomplishes this by a unique mechanism of action. By selectively acting on the G-protein sub-pathway in preference to the beta-arrestin, it aims to mitigate these unwanted µ-opioid receptors-associated opioid side effects, while preserving its analgesic activity. What remains to be seen, however, is if these observations seen in phases 2 and 3 trials will be borne in actual large-scale clinical use, both inside and outside the USA. Unfortunately, the field of anesthesia is rife with innovations that have shown enormous promise at the research stage, only to end up as damp squibs when released to the clinicians for general use. Rapcuronium and althesin are some such examples. We aim to present some of the contentious and emerging issues associated with this drug and some of the potential pitfalls of this new opioid.

The analgesic efficacy of intravenous dexamethasone for post-caesarean pain: A systematic review with meta-analysis and trial sequential analysis.

BACKGROUND: Analgesic efficacy of intravenous dexamethasone has not been well defined after caesarean delivery. We performed a systematic review and meta-analysis to evaluate the impact of peri-operative dexamethasone administration on postoperative pain after caesarean delivery. OBJECTIVES: We investigated the impact of perioperative intravenous dexamethasone on postoperative pain after caesarean delivery. The two primary outcomes of interest were early (4 to 6 h) resting pain scores and time to first rescue analgesia. DESIGN: A systematic review and meta-analysis of randomised controlled trials (RCTs). DATA SOURCES: PubMed, EMBASE, Scopus and the Cochrane central registers of controlled trials were searched to identify RCTs from inception to April 2021. ELIGIBILITY CRITERIA: Prospective RCTs comparing the role of intravenous dexamethasone with non-active control were eligible for inclusion. Exclusion criteria included trials comparing various doses of dexamethasone without any control treatment arm, dexamethasone with other active drugs and trials comparing different routes of dexamethasone, for example, wound infiltration. RESULTS: Thirteen RCTs constituting of 988 parturients undergoing caesarean delivery were included. Patients receiving dexamethasone had lower pain scores at rest at 4 to 6 h after surgery, mean difference -1.29 [95% confidence interval (CI), -1.85 to -0.73], P < 0.0001, with low quality of evidence (I2 = 94%). Moderate quality of evidence (I2 = 17%) suggested that the time to first rescue analgesia in the dexamethasone group was significantly longer, mean difference 2.64 h (95% CI, 1.85 to 3.42), P  < 0.0001. Trial sequential analysis for pain scores suggested the benefit of dexamethasone; however, the requisite information size (RIS) could not be reached, whereas RIS was adequate for time to rescue analgesia. Significant reduction in pain scores at all times and opioid consumption at 24 h with dexamethasone were observed with sparse reporting on adverse effects. CONCLUSION: Peri-operative intravenous dexamethasone was associated with a significant decrease in postoperative pain scores at rest and a longer time to first rescue analgesia, along with a small but statistically significantly reduced opioid consumption after caesarean delivery compared with nonactive control.

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.

US Residents' Perspectives on the Introduction, Conduct, and Value of American Board of Anesthesiology's Objective Structured Clinical Examination-Results of the 1st Nationwide Questionnaire Survey.

INTRODUCTION: Passing the Objective Structured Clinical Examination (OSCE) is currently a requirement for the vast majority (not all) of candidates to gain American Board of Anesthesiology (ABA) initial certification. Many publications from the ABA have attempted to justify its introduction, conduct and value. However, the ABA has never attempted to understand the views of the residents. METHODS: A total of 4237 residents at various training levels from 132 programs were surveyed by asking to fill a Google questionnaire prospectively between March 8th, 2021 and April 10th, 2021. Every potential participant was sent an original email followed by 2 reminders. RESULTS: The overall response rate was 17.26% (710 responses to 4112 invitations). On a 5-point Likert scale with 1 as "very inaccurate" and 5 as "very accurate," the mean accuracy of objective structured clinical examination (OSCE) in assessing communication skills and professionalism was 2.3 and 2.1 respectively. In terms of the usefulness of OSCE training for improving physicians' clinical practice, avoiding lawsuits, teaching effective communication with patients and teaching effective communication with other providers, the means on a 5-point Likert scale with 1 as "Not at all useful" and 5 as "Very useful" were 1.86, 1.69, 1.79, and 1.82 respectively. Residents unanimously thought that factors such as culture, race/ethnicity, religion and language adversely influence the assessment of communication skills. On a 5-point Likert scale with 1 as "not at all affected" and 5 as "very affected," the corresponding scores were 3.45, 3.19, 3.89, and 3.18 respectively. Interestingly, nationality and political affiliation were also thought to influence this assessment, however, to a lesser extent. In addition, residents believed it is inappropriate to test non-cardiac anesthesiologists for TEE skills (2.39), but felt it was appropriate to test non-regional anesthesiologists in Ultrasound skills (3.29). Lastly, nearly 80% of the residents think that money was the primary motivating factor behind ABA's introduction of the OSCE. Over 96% residents think that OSCE should be stalled, either permanently scrapped (60.8%) or paused (35.8%). CONCLUSIONS: Anesthesiology residents in the United States overwhelmingly indicated that the OSCE does not serve any useful purpose and should be immediately halted.

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.

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.

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.

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.

An Overview of Health Care Worker Reported Deaths During the COVID-19 Pandemic.

OBJECTIVES: As of May 13, 2020, 1004 health care worker (HCW) deaths due to coronavirus disease 2019 (COVID-19) have been reported globally. This study seeks to organize deaths by demographic group, including age, gender, country, and occupation. METHODS: We collected data from a crowdsourced list of global HCW COVID-19 deaths published by Medscape, including age, gender, country, occupation, and physician specialty. RESULTS: As of May 13, 2020, of 1004 HCW deaths, 550 were physicians. The average age of physician death is 62.49, skewed right, and nonphysician is 52.62, approximately symmetrical. The majority of U.S. HCW deaths are male (64.1%). General practitioners and family medicine and primary care physicians account for 26.9% of physician deaths. Anesthesiologists and emergency medicine and critical care physicians account for 7.4%. The United States has the highest number of HCW deaths but a similar number as a fraction of national cases and deaths compared with other developed countries. CONCLUSIONS: Among HCWs globally, in the United States there have been more reported deaths of physicians, primary care physicians, males, and HCWs versus opposing groups. Further research is needed to understand relative risks of death due to COVID-19 in each of these demographic groups.

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. Sedasys® was the next attempt, which was a computer-assisted personalized sedation system. As a result of insufficient sedation that could be provided with the device, although very successful in research settings, it was not a commercial success. It seems that remimazolam is the next effort in this direction. It is likely to fail in this regard unless its respiratory depressant properties and failure rates could be addressed. G protein-biased µ-receptor agonists are a new class of opioids exhibiting analgesic properties similar to morphine without equivalent respiratory depressant properties. Oliceridine is the prototype. As a result, the drug can be additive to midazolam or remimazolam and allow screening colonoscopy to be comfortably completed without the need for propofol. For an anesthesia provider, the administration of oliceridine can eliminate the need for drugs such as fentanyl that add to the respiratory depressant properties of propofol. As a result, oliceridine has the potential to render the sedation for GI endoscopy procedures both safe and cost-effective.

The analgesic efficacy of quadratus lumborum block in caesarean delivery: a meta-analysis and trial sequential analysis.

PURPOSE: Quadratus lumborum block (QLB) has recently gained popularity for postoperative analgesia after cesarean delivery (CD) as it provides both visceral and somato-sensory blockade of the abdomen. Aim of this meta-analysis was to evaluate the analgesic potential of QLB after CD. METHODS: Electronic database from inception to December 2019 was searched systematically for randomized-controlled trials comparing QLB with injection of inactive solution in women undergoing CD. Primary outcome was consumption of morphine at 24 h. Morphine consumption at 48 h, dynamic and static pain scores at various time intervals were the secondary outcomes studied. RESULTS: Seven trials met the inclusion criteria. Morphine consumption was reduced significantly with QLB in comparison to sham or no block at 24 h (mean difference [MD] - 9.84 mg; 95% confidence interval [CI] - 18.16, - 0.50; p = 0.04; I2 = zero). Adequate "information size" for above outcome was confirmed with trial sequential analysis, ruling out any possibility of a false-positive result. QLB significantly reduced pain scores at rest (MD - 1.13; 95% CI - 1.75, - 0.56; p = 0.00) and on movement (MD - 1.48; 95% CI - 2.5, - 0.46; p = 0.01) at 6 h. However, statistically significant difference in pain scores persisted only for dynamic pain at 24 h (MD - 0.55; 95% CI - 1.04, - 0.06; p = 0.03). QLB does not provide any additional analgesic benefit to the parturient receiving intrathecal morphine. CONCLUSION: QLB significantly reduces opioid requirements in CD and may have analgesic effects lasting 24 h.

Medical, Political, and Economic Considerations for the Use of MAC for Endoscopic Sedation: Big Price, Little Justification?

The last few decades of gastrointestinal (GI) endoscopy have seen phenomenal growth. In many aspects, GI endoscopy has led the field of nonsurgical interventional medicine. In many aspects, this growth is facilitated by advancements in sedation-both drugs and techniques. Unfortunately, the topic of GI endoscopy sedation is also mired in many controversies, mainly emanating from the cost of anesthesia providers. While no one debates their role in the majority of advanced endoscopic procedures, the practice of universal propofol sedation in the USA, delivered by anesthesia providers, needs a closer look. In this review, medical, political, and economic considerations of this important topic are discussed in a very frank and honest way. While such ubiquitous propofol use has increased satisfaction of both patients and gastroenterologists, there is little justification. More importantly, going by the evidence, there is even less justification for the mandated anesthesia providers use for such delivery. Unfortunately, the FDA could not be convinced otherwise. The new drug fospropofol met the same fate. Approval of SEDASYS®, the first computer-assisted personalized sedation system, was a step in the right direction, nevertheless an insufficient step that failed to takeoff. As a result, in spite of years of research and efforts of many august societies, the logjam of balancing cost and justification of propofol sedation has continued. We hope that recent approval of remimazolam, a novel benzodiazepine, and potential approval of oliceridine, a novel short-acting opioid, might be able to contain the cost without compromising the quality of sedation.

Correction to: Recent Developments in Drugs for GI Endoscopy Sedation.

The original version of the article is unfortunately missing the surname of last author in the author group. Last author name was published as 'Preet Mohinder' and the full name of the author is 'Preet Mohinder Singh'.

Recent Developments in Drugs for GI Endoscopy Sedation.

Providing sedation for patients undergoing gastrointestinal (GI) endoscopy continues to be a debated topic in both anesthesia and gastroenterology circles. Sedation approaches are widely varied across the globe. While propofol administration is embraced by more endoscopists and patients, its administration evolves controversy. Whereas trained nurses and gastroenterologists are allowed to administer propofol for GI endoscopy sedation in Europe and Asia, it is the sole privilege of anesthesia providers in the USA. However, the costs of anesthesia providers are significant and threaten to derail the screening colonoscopy practice. Efforts were made by both drug and device manufacturers to find alternatives. Fospropofol was one such effort that did not live up to the expectations due to respiratory depressant properties that were similar to propofol. Use of a new tool to administer propofol in the form of Sedasys® was the next experiment that tried to find alternative to anesthesia providers. The device did not succeed due to inadequate sedation. The latest effort is remimazolam, a new benzodiazepine that has quicker recovery profile. In the interim, many drug combinations such as propofol-dexmedetomidine and propofol-ketamine are improving the safety without compromising the quality of sedation. This review attempts to discuss the new drug innovations and drug combinations of existing sedatives for the benefit of readers.

Efficacy of New Long-Acting Bupivacaine HTX-011 in Providing Pain Relief for Patients Undergoing Elective Surgery - A Meta-analysis of Prospective Randomized Controlled Trials.

BACKGROUND: The aim of the present meta-analysis is to critically analyze the various prospective randomized controlled trials comparing the safety and efficacy of a new, yet unapproved long-acting local anesthetic HTX-011. This is a combination of bupivacaine and meloxicam, and like its predecessors' liposomal bupivacaine and SABER bupivacaine, the combination slowly releases bupivacaine and provides therapeutic analgesic concentrations at the site of infiltration. METHODS: We performed a meta-analysis of 7 randomized clinical trials comparing the use of HTX-011 with placebo and/or bupivacaine in patients undergoing abdominoplasty, bunionectomy, and herniorrhaphy. Comparisons were made for the patients who were opioid free at 24 h, pain scores at 24 h, patients likely to be opioid free at 72 h, and reduction of morphine consumption at 72 h. RESULTS: While comparing pain scores at 24 h, we found that the use of HTX-011 was associated with a significant decrease in pain score in relation to both bupivacaine and placebo. The overall comparison of 12 groups showed that with HTX-011, patients are 3.25 times more likely to be opioid free at 72 h than either placebo or control. More patients were free of opioid at 24 h in the HTX-011 group when compared to bupivacaine. Finally, the consumption of morphine was less by 10.61 (95% CI: 8.13-13.09) in 14 groups that reported such consumption. CONCLUSION: HTX-011 has a clear advantage in comparison to both placebo and bupivacaine and provides better pain relief and reduces opioid consumption.