LAR continues to provide a risk to patient and graft survival: understanding risk factors may allow an improvement in monitoring and early intervention and so prevent early graft loss.
In the UK, more than 2.5 million endoscopic procedures are carried out each year. Most are performed under conscious sedation with benzodiazepines and opioids administered by the endoscopist. However, in prolonged and complex procedures, this form of sedation may provide inadequate patient comfort or result in oversedation. As a result, this may have a negative impact on procedural success and patient outcome. In addition, there have been safety concerns on the high doses of benzodiazepines and opioids used particularly in prolonged and complex procedures such as endoscopic retrograde cholangiopancreatography. Diagnostic and therapeutic endoscopy has evolved rapidly over the past 5 years with advances in technical skills and equipment allowing interventions and procedural capabilities that are moving closer to minimally invasive endoscopic surgery. It is vital that safe and appropriate sedation practices follow the inevitable expansion of this portfolio to accommodate safe and high-quality clinical outcomes. This position statement outlines the current use of sedation in the UK and highlights the role for anaesthetist-led deep sedation practice with a focus on propofol sedation although the choice of sedative or anaesthetic agent is ultimately the choice of the anaesthetist. It outlines the indication for deep sedation and anaesthesia, patient selection and assessment and procedural details. It considers the setup for a deep sedation and anaesthesia list, including the equipment required, the environment, staffing and monitoring requirements. Considerations for different endoscopic procedures in both emergency and elective setting are also detailed. The role for training, audit, compliance and future developments are discussed.
Background and study aims
Cyanoacrylate glue is recommended first-line endoscopic therapy for gastric fundal varices but it is difficult to use and carries a risk of embolization. Thrombin is preferred by many in the UK, but its effectiveness can be difficult to establish at endoscopy and the rate of re-bleeding is higher. Endoscopic ultrasound (EUS) can help assess variceal blood flow and has the potential to improve both targeting and effectiveness of injection therapy. Whereas there is already some data for its use with glue, little data currently exist in relation to its use with thrombin.
Patients and methods
We present a series of patients treated with EUS-guided thrombin injection over the last 4 years. Thrombin was injected under EUS guidance with the intention of obliterating flow within the fundal varices. Outcomes reviewed included whether haemostasis was achieved, the dose of thrombin required for endosonographic variceal obliteration, the incidence of re-bleeding, and procedural related adverse events.
Results
Eight patients received EUS-guided thrombin: 3 with active bleeding and 5 as elective prevention. In 2/3 (66 %) patients with active bleeding haemostasis was achieved after a single dose with complete variceal obliteration. 1/3 (33 %) had no alteration in blood flow despite 10 000 IU. None of the elective prevention group had further bleeding and obliteration was observed in 4/5 (80 %). A range of 600 to 10 000 IU of thrombin was used and there were no adverse procedure-related outcomes.
Conclusions
Our results are promising and suggest that EUS-guided thrombin injection may have a role in managing bleeding from gastric fundal varices.
Cowpea seeds lose their vigour during storage at high temperature and high relative humidity. Present study was conducted to invigorate the performance of high and low vigour seeds (exposed to 45 ± 2o C and 100% RH) by seed priming with different chemicals and concentrations (GA3 (100ppm); CaCl2 (10-3M); Ammonium Molybdate (10-3M); KBr (10-3M); Mg (NO3)2 (10-3M); ZnSO4 (10-3M); hydro primed and dry seed (control) at 15o C for 24 hours. Priming was effective in reducing the time for 50 % germination and mean germination time and increased the germination percentage in low vigour seeds, while energy of germination and final germination percentage in normal seeds displayed a minor increase. Priming of normal / low – vigour seeds improved the vigour of seedling in terms of seedling length and their dry weight and seedling vigour index. Seed priming of fresh and accelerated cowpea seeds increased the electrical conductivity of seed leachate, cell membrane stability, total protein content, a – amylase activity, peroxidase activity and dehydrogenase activity over control dry seeds. Esterase and peroxidase enzymes were completely lost as a result of accelerated ageing, which showed reappearance after priming. Priming showed little improvement in the banding pattern and intensity of enzyme in normal seeds.
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