Somchai Amornyotin

Introduction: Sedation practices for colonoscopy indeed vary widely around the globe. Due to a lack of data on intravenous paracetamol, we aimed to investigate the clinical efficacy of intravenous paracetamol compared to intravenous fentanyl under propofol deep sedation for colonoscopy. Methods: A total of 225 patients who underwent colonoscopy at Siriraj Hospital were randomly assigned to two groups. All patients underwent deep sedation with propofol and received intravenous (iv) paracetamol (group P, n = 113) or iv fentanyl (group F, n = 112). All patients received a premedication of 0.02– 0.03 mg/kg of midazolam intravenously. Fifteen to thirty minutes before the procedure, patients in group P were administered 1000 mg of iv paracetamol, while those in group F received 0.001 mg/kg of iv fentanyl. All patients were oxygenated with 100% O₂ via a nasal cannula, and deep sedated with titrated intravenous propofol. The primary outcome measure was the success rate of colonoscopy. The colonoscope reaching the ileocecal valve was an important marker for a successful colonoscopy. Secondary outcome measures included endoscopist and patient satisfaction, patient tolerance, ease of the procedure, and sedation-related complications during and immediately after the procedure. Results: All colonoscopies were successfully completed. There were no significant differences in patient characteristics, duration of the procedure, endoscopist and patient satisfaction, patient tolerance, or ease of the procedure between the two groups. However, group F experienced significantly higher rates of upper airway obstruction and oxygen desaturation during the procedure compared to group P. No serious complications were observed in either group. Conclusion: Intravenous paracetamol with propofol deep sedation in adult patients is non-inferior to intravenous fentanyl for successful colonoscopy completion. Sedation-related complications were relatively lower in the propofol deep sedation with iv paracetamol group compared to the propofol deep sedation with iv fentanyl group. Registration: This trial was registered with the Thai Clinical Trial Registry (TCTR 20190321002).

Corrigendum for the article Hard-Candy Consumption Does Not Have an Effect on Volume and pH of Gastric Content in Patients Undergoing Elective Gastrointestinal Endoscopic Procedures: A Randomized Controlled Trial

Purpose: This study aimed to determine the effect of hard candies on gastric content volume and pH in patients undergoing elective esophagogastroduodenoscopy and colonoscopy. Additionally, the study evaluated the difficulty of the procedure, complications, and satisfaction levels of the endoscopist and patient. Patients and Methods: A randomized controlled study equally recruited 108 outpatients to candy and control groups. The patients in the candy group could consume sugar-free candies within 2 hours before anesthesia, while the controls remained fasted. The endoscopic procedure began under topical pharyngeal anesthesia and intravenous sedation. A blinded endoscopist suctioned the gastric volume through an endoscope. A blinded anesthesia provider tested the gastric pH with a pH meter. The primary outcome variables were gastric volume and pH. The secondary outcome variables were complications, the difficulty of the procedure, and endoscopist and patient satisfaction. Results: The characteristics of both patient groups were comparable. The mean gastric volume of the candy group (0.43 [0.27– 0.67] mL/kg) was not significantly different from that of the control group (0.32 [0.19– 0.55] mL/kg). The gastric pH of both groups was similar: 1.40 (1.10– 1.70) for the candy group and 1.40 (1.20– 1.90) for the control group. The procedure-difficulty score of the candy group was higher than that of the control group. The satisfaction scores rated by the endoscopist and the patients in both groups were comparable. In addition, most endoscopists and patients in the candy and control groups reported being “very satisfied”. No complications were observed in either group. Conclusion: Hard candies did not affect gastric volume or pH. Elective gastrointestinal endoscopic procedures in adult patients who preoperatively consume candies could proceed to prevent delays and disruption of workflows.

The geriatric population experiences significant alterations of numerous organ systems as a result of the aging process. They also have several co-morbidities including hypertension, cardiac disease, diabetes, cerebrovascular disease and renal dysfunction. Geriatric patients are considerably vulnerable and especially sensitive to the stress of trauma, surgery and anesthesia. A high incidence of postoperative complications in this population is observed. Appropriate perioperative care was required for geriatric patients. To date, development in anesthesia and surgical techniques has substantially reduced morbidity and mortality in the geriatric patients. Several anesthetic techniques have been utilized for these patients. However, anesthesia-related mortality in geriatric patients is quiet high. All geriatric patients undergoing surgical procedures require a preprocedural evaluation and preparation, monitoring patients during intraprocedural and postprocedural periods as well as postprocedural management. This chapter highlights the physiological changes, preprocedure assessment and preparation, anesthetic techniques, intraprocedural and postprocedural management in geriatric population.

Patients presenting for vascular surgery typically have significant comorbidities. Procedures can vary from minor to quite large with significant blood loss and fluid shifts, and can be elective or emergent. Perioperative morbidity and mortality in the context of co-existing cardiovascular disease, diabetes, dementia and other factors all provide great concern to the anesthesiologist in their approach towards the vascular patient. The anesthetic approach to such patients must therefore be taken with great forethought. Many times, these procedures can be localized to a particular extremity or well-defined set of dermatomes, and regional anesthesia has become one important option for the complicated vascular patient. In this chapter, the risks, benefits, and feasibility of various regional techniques are discussed in the context of patients presenting for carotid endarterectomy, vascular access placement, and major lower extremity vascular surgery.

Objective: The aim of the study was to compare the ventilatory effect between propofol deep sedation technique with and without midazolam in hepatic tumor patients undergoing radiofrequency ablation procedure. Methods: Three hundred and seventy-four patients who underwent radiofrequency ablation procedure in a single year were randomly assigned to the deep sedation without midazolam group (A, n = 187) and deep sedation with midazolam group (B, n = 187). Patients in group A received normal saline, and those in group B received 0.02 mg/kg of midazolam intravenously in equivalent volume. All patients were oxygenated with 100% O2 via nasal cannula and sedated with intravenous fentanyl and the titration of intravenous propofol. Ventilatory parameters, including oxygen saturation, end tidal carbon dioxide, and respiratory rate every five minutes, during and after the procedure, as well as the duration of sleep and sedation score in the recovery room, were recorded. Results: There were no significant differences in the patients’ characteristics, duration of procedure, total dose of propofol, ventilatory parameters including oxygen saturation, end tidal carbon dioxide, and respiratory rate, as well as sedation score at 20, 25, 30, 35, and 40 min after the procedure, between the two groups. However, mean sedation score at 5, 10, and 15 min after the procedure, in group B, was significantly lower than in group A. In addition, the duration of sleep after the procedure, in group B, was significantly greater than in group A. No serious ventilatory adverse effects were observed either group. Conclusion: Propofol deep sedation with and without midazolam for hepatic tumor patients who underwent radiofrequency ablation procedure was safe and effective. A low dose of midazolam in propofol deep-sedation technique did not create serious ventilatory effects.

The endocannabinoid system is involved in various physiological pathways in the human body. A large number of endogenous cannabinoids have been acknowledged, and cannabinoid receptor type 1 (CB-1) and cannabinoid receptor type 2 (CB-2) have been categorized.