The safety of NAAP sedation compared favorably with AAP sedation in patients undergoing advanced endoscopic procedures. However, it came at the cost of decreased patient and endoscopist satisfaction.

Background/AimsThe landscape of sedation for gastrointestinal (GI) endoscopic procedures and the nature of the procedures themselves have changed over the last decade. In this study, an attempt is made to analyze the frequency and etiology of all major adverse events associated with GI endoscopy. MethodsAll adverse events extracted from the electronic database and local registry were analyzed. Although the data analysis was retrospective, the adverse events themselves were documented prospectively. These events were evaluated after subdivision into propofol-based anesthesia and intravenous conscious sedation groups. ResultsCardiorespiratory events, including cardiac arrest, were the most common adverse events during esophagogastroduodenoscopy, while bleeding was more frequent in patients undergoing colonoscopy. Pancreatitis was the most frequent adverse event in patients undergoing endoscopic retrograde cholangiopancreatography. The frequencies of most adverse events were significantly higher in patients anesthetized with propofol. Automatic regression modeling showed that the type of sedation, the American Society of Anesthesiologists physical status classification, and the procedure type were some of the predictors of immediate life-threatening complications. ConclusionsClearly, our regression modeling suggests a strong association between the type of sedation as well as various patient factors and the frequency of adverse events. The possible reasons for our results are the changing demographics, the worsening comorbidities of the patient population, and the increasing technical complexity of these procedures. Although extensive use of propofol has increased patient satisfaction and procedure acceptability, its use is also associated with more frequent adverse events.

The bronchoscopic procedures have seen a remarkable increase in both numbers and complexity. Although many anesthesia providers have kept pace with the challenge, the practice is varied and frequently suboptimal. Shared airway during bronchoscopy poses unique challenges. The available reviews have tried to address this lacuna; however, these have frequently dealt with the technical aspects of bronchoscopy than anesthetic challenges. The present review provides evidence-based management insights into anesthesia for bronchoscopy-both flexible and rigid. A systematic approach toward pre-procedural evaluation and risk stratification is presented. The possible anatomical and physiological factors that can influence the outcomes are discussed. Pharmacological principles guiding sedation levels and appropriate selection of sedatives form the crux of safe anesthetic management. The newer and safer drugs that can have potential role in anesthesia for bronchoscopy in the near future are discussed. Ventilatory strategies during bronchoscopy for prevention of hypoxia and hypercarbia are emphasized.

Application of the enhanced recovery after surgery (ERAS) to the bariatric surgical procedures is at its early stages with little consolidated evidence. This meta-analysis evaluates present literature and indicates pathways for development of evidence-based standardized ERAS protocols for bariatric surgery. Comparative trials between ERAS and conventional bariatric surgery published till June 2016 were searched in the medical database. Comparisons were made for length of stay (LOS), readmission, complications (major/minor), and reoperation rates. Trial sequential analysis (TSA) for the strength of meta-analysis was performed for the primary outcome LOS. Five subgroups with a total of 394 and 471 patients in ERAS and conventional group respectively were included. LOS was shorter in ERAS group by 1.56 ± 0.18 days (random-effects, p < 0.001, I = 93.07 %). The sample size in ERAS was well past the "information size" variable which was calculated to be 189 as per the TSA for power 85%. MH odds ratio [1.41 (95% CI 1.13 to1.76)] was higher for minor complications in the ERAS group (fixed effects, I = 0, p < 0.001). Superiority/inferiority of ERAS could not be established for major or overall complications, readmission, and anastomotic leak rates. No publication bias was found in the included trials (Egger's test, X-intercept = 6.14, p = 0.66). Evaluation based on Cochrane collaboration recommendations suggested that all the five included trials had a high risk of methodological bias. ERAS protocols for bariatric procedures allow faster return to home for patients. The present bariatric ERAS protocols have high heterogeneity and would benefit from standardization. Minor complication rates increase with implementation of ERAS, however without any significant effect on overall patient morbidity. Further randomized trials comparing ERAS with conventional care are required to consolidate these findings.

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Etomidate is clearly better in terms of seizure duration potential (both motor and EEG) than propofol and thiopental. Superiority/inferiority over methohexital could not be demonstrated with the presently available literature.

Background:In this meta-analysis, we explore the role of repetitive transcranial magnetic stimulation (rTMS), a noninvasive neuromodulation technique in the treatment of chronic pain.Methods:Studies comparing rTMS and conventional treatment for chronic pain were searched. The comparison was made for decrease in the pain scores with and without (sham) the use of rTMS after a follow-up interval of 4–8 weeks. All reported pain scores were converted into a common scale ranging from “0” (no pain) to “10” (worst pain).Results:Nine trials with 183 patients in each of the groups were included in the analysis. The decrease in pain scores with rTMS was 1.12 (95% confidence interval [CI] being 1.46–0.78) (fixed effects, I2 = 0%, P < 0.001) and in sham-rTMS was 0.28 (95% CI being 0.49–0.07) (Fixed effects, I2 = 0, P = 0.01). The pooled mean drop in pain scores with rTMS therapy was higher by 0.79 (95% CI being 0.26–1.33) (fixed effects, I2 = 0, P < 0.01). The duration and frequency of rTMS were highly variable across trials. Publication bias was unlikely (Egger's test, X-intercept = 0.13, P = 0.75).Conclusions:Use of rTMS improves the efficacy of conventional medical treatment in chronic pain patients. This treatment is not associated with any direct adverse effects. However, the duration and frequency of rTMS therapy is presently highly variable and needs standardization.