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Douglas K Rex

Publications and source records attributed to Douglas K Rex.

At least 37 records · Page 2Linked to original sources
PubMed2006

Propofol alone titrated to deep sedation versus propofol in combination with opioids and/or benzodiazepines and titrated to moderate sedation for colonoscopy.

BACKGROUND: Propofol by nonanesthesiologists is controversial because the drug is commonly used to produce deep sedation or general anesthesia. Propofol in combination with opioids and/or benzodiazepines can be titrated to moderate sedation, which might be safer. AIM: To compare recovery time, patient satisfaction, and other end points with propofol alone titrated to deep sedation versus propofol combination therapy with opioids and/or benzodiazepines. METHOD: A randomized controlled clinical trial of propofol alone titrated to deep sedation versus fentanyl plus propofol versus midazolam plus propofol versus fentanyl plus midazolam plus propofol in 200 outpatients undergoing colonoscopy. Each combination regimen was titrated to moderate sedation. RESULTS: Patients receiving propofol alone received higher doses of propofol and had deeper sedation scores compared with combination therapy (both p < 0.001). Patients receiving combination regimens were discharged more quickly (median 13.0-14.7 versus 18.1 min) than those receiving propofol alone (p < 0.01). There were no differences in vital signs or oxygen saturations among the study arms. There were no significant differences in pain or satisfaction among the study arms in the recovery area. At a follow-up phone call, patients receiving fentanyl and propofol remembered more of the procedure than those in the other regimens (p < 0.005) and remembered more pain than those receiving propofol alone (p < 0.02). CONCLUSIONS: Propofol in combination with fentanyl and/or midazolam can be titrated to moderate levels of sedation without substantial loss of satisfaction and with shorter recovery times compared with propofol titrated to deep sedation throughout the procedure.

Adjuvants, Anesthesia↗
PubMed2006

Efficacy of bispectral monitoring as an adjunct to nurse-administered propofol sedation for colonoscopy: a randomized controlled trial.

BACKGROUND AND AIMS: Bispectral (BIS) monitoring provides an objective, non-invasive measure of the level of consciousness in sedated patients. BIS has been shown to lag behind the level of sedation during induction and emergence of sedation with propofol. In this study, we sought to determine whether BIS is a useful adjunctive maneuver to registered nurse-administered propofol sedation (NAPS) as measured by reductions in recovery time and doses of propofol administered. METHODS: A randomized controlled trial of 102 outpatients presenting for colonoscopy was performed. BIS values were recorded continuously in all subjects. Patients were randomized to receive NAPS with BIS visible to nurse and endoscopist versus BIS invisible to nurse and endoscopist. In phase 1 (47 patients), the nurse and endoscopist team were instructed to consider BIS (when visible) as only adjunctive information with regard to titrating sedation. In phase 2 (55 patients), the nurse endoscopist team was instructed to use BIS as the primary endpoint for titration of sedation, and to target BIS to greater than 60 (60-70 is deep sedation). RESULTS: In phase 1, the mean (SD) BIS value from scope-in (SI) to scope-out (SO) for BIS was 59.3 (9.9) and was not different from controls at 59.9 (10.1; p= 0.82). The mean (SD) propofol dose (mg/min) was 15.8 (5.6) and 17.2 (6.2) for BIS and controls, respectively (p= 0.45). The mean (SD) recovery time with BIS visible in phase 1 was 20.6 min (5.5) versus 19.2 min (4.5) in controls (p= 0.34). In phase 2, the mean (SD) BIS from SI to SO in those randomized to have BIS visible was 64.1 (5.4) versus 63.1 (8.5) in controls (p= 0.58). The mean (SD) dose of propofol (mg/min) was 16.1 (11.2) and 16.4 (12.3) for BIS and control groups, respectively (p= 0.92). The mean (SD) recovery time in phase 2 with BIS visible was 18.7 (3.5) versus 20.1 (5.6) in controls (p= 0.27). CONCLUSIONS: BIS did not lead to reductions in mean propofol dose or recovery time when used as an adjunct to NAPS for colonoscopy, or when used as the primary target for sedation. No clinically important role for BIS monitoring as an adjunct to NAPS has yet been established.

Adult↗
PubMed2006

Maximizing detection of adenomas and cancers during colonoscopy.

Some patients who undergo colonoscopy that appeared to have cleared the colorectum of neoplasia return within a short interval (1-3 yr) with colorectal cancer. Although several a priori mechanisms could account for this occurrence, wide variation in detection rates of adenomas and cancer at colonoscopy suggests that suboptimal colonoscopic technique is a significant contributor. Optimal technique with white-light colonoscopy involves taking adequate time for inspection during withdrawal (an average of at least 6 min in normal colons), interrogating the proximal sides of folds, flexures, and valves, clearing fluid and debris, and distending adequately. Some adjunctive techniques are directed toward exposing more colonic mucosa during colonoscopy. Wide-angle colonoscopy appears to improve efficiency but does not eliminate miss rates. Colonoscopy in retroflexion was unsuccessful in reducing miss rates in one study, whereas cap-fitted colonoscopy was successful in reducing miss rates in one small study. Techniques to improve detection of flat lesions include pancolonic chromoendoscopy (CE). In two randomized controlled trials, CE improved adenoma detection, but CE does not appear to provide substantially greater yields than those obtained by the more sensitive white-light colonoscopists. Narrow band imaging and autofluorescence are being assessed for improved detection of flat lesions. Adenoma detection rates are an important measure of the quality of colonoscopy and should be reported to endoscopists in quality improvement programs in colonoscopy.

Adenoma↗
PubMed2006

Best of DDW 2006.

Highlights from the 2006 Digestive Disease Week May 20-25, 2006, Los Angeles, CA. In this meeting review, many of our editorial board members report on Digestive Disease Week 2006. They highlight the most noteworthy presentations in their respective areas of expertise, including the latest treatments, technologies, and diagnostic advances in ulcerative colitis, Crohn's disease, Helicobacter pylori infection, gastroesophageal reflux disease, irritable bowel syndrome, colorectal cancer, pancreatic and biliary disease, and liver disease.

Digestive System Diseases↗
PubMed2006

Advances in colonoscopic imaging.

Recent studies have indicated that the levels of protection against colorectal cancer provided by colonoscopy and polypectomy may be considerably lower than what was once commonly believed. Improvements in colonoscopic detection of neoplasia could be enormously beneficial in reducing the incidence of colorectal cancer related to missed lesions. Factors that interfere with detection of neoplasia during colonoscopy, as well as technologic advances that can improve both neoplasia detection and real-time determination of polyp histology, are reviewed.

Colonic Polyps↗
PubMed2005

Screening and surveillance of colorectal cancer.

Although colorectal cancer (CRC) is the second leading cause of cancer deaths in the United States, it is preventable. Screening modalities include fecal occult blood testing, flexible sigmoidoscopy, double-contrast barium enema, and colonoscopy. Colonoscopy allows effective detection and removal of precursor adenomatous polyps and is the dominant CRC screening modality. Emerging technologies include CT and MR colonography and fecal DNA tests. Effective and cost-effective surveillance after polypectomy and curative CRC resection requires balancing the protective effect of polypectomy while maximizing intervals between examinations; thus, estimation of the risk of recurrence determines the intensity of surveillance for individual patients.

Colonoscopy↗
PubMed2005

Sedation and the technical performance of colonoscopy.

The use of sedation for routine endoscopic procedures, including colonoscopy, varies widely across cultures. This variation in sedation practice is greater than any other culturally based variation in the technical performance of endoscopy. This article sequentially reviews the technical performance of colonoscopy in patients who undergo unsedated colonoscopy, sedation with narcotics and benzodiazepines, and deep sedation with propofol. For each of these approaches to colonoscopy, the advantages and disadvantages also are listed and discussed.

Benzodiazepines↗
PubMed2005

Colon polyp retrieval after cold snaring.

BACKGROUND: The removal of small colon polyps by cold snare transection without electrocautery effectively eliminates polyps, and anecdotal reports indicate a low risk of bleeding and perforation. Concerns about using cold snaring have centered on the risk of immediate bleeding and the difficulty in retrieving the polyp. The objective was to determine the retrieval rates of polyps after cold snaring after two different methods of resection and retrieval. METHODS: Consecutive polyps were identified by a single colonoscopist who chose the technique of polypectomy (hot snare, cold snare, or cold forceps). If cold snaring was chosen, an independent observer assigned the polyp to method A (cold resection of polyp without tenting and then suction of the transected polyp into a trap) or method B (ensnare the polyp, pull it into the colonoscope channel, and then transect it while suctioning). The size and the approximate location of all polyps were recorded and all collected specimens were sent separately for histologic examination. Results Of 519 consecutively encountered polyps, 400 were removed by cold snare: 197 were assigned to method A and 203 to method B. The mean size of polyps that were cold snared was 3.5 mm. The mean time to remove and to retrieve polyps with method A was 14.5 seconds (n = 58) and with method B was 18.1 seconds (n = 60) ( p = 0.03). There were no complications from cold snaring. The rate of successful retrieval with method A was 100% (197 of 197 polyps) and with method B was 98% (199 of 203 polyps) ( p = 0.04). CONCLUSIONS: Cold snare removal of colon polyps is associated with a high polyp retrieval rate. Each of two methods of polyp retrieval was effective. Snare transection without tenting of the polyp, followed by suctioning of the specimen off the polyp site, was more efficient, though the difference in efficiency was minimal. Difficulty or failure to retrieve polyps should not be a concern with regard to cold snare polypectomy.

Cold Temperature↗
PubMed2005

Trained registered nurses/endoscopy teams can administer propofol safely for endoscopy.

BACKGROUND & AIMS: Propofol has advantages as a sedative for endoscopic procedures. Its administration by anesthesia specialists is associated with high cost. Administration by nonanesthesiologists is controversial because of concerns about safety, particularly respiratory depression. METHODS: Three endoscopy units developed programs to train registered nurses supervised only by endoscopists in the administration of propofol for endoscopic procedures. The rate of adverse respiratory events was tracked from the inception of the programs. To estimate whether training nurses to give propofol on a widespread basis might be effective, we evaluated the individual safety records of all nurses and endoscopists involved in propofol delivery at the 3 centers. RESULTS: Among a total of 36,743 cases of nurse-administered propofol sedation (NAPS) at the 3 centers, there were no cases requiring endotracheal intubation or resulting in death, neurologic sequelae, or other permanent injury. The rate of respiratory events requiring assisted ventilation was not significantly different among the 3 centers and ranged from just <1 per 500 cases to just <1 per 1000 cases among the 3 centers. There was no individual nurse or physician for whom the rate of respiratory events requiring assisted ventilation differed from the overall rate of events at the respective centers. CONCLUSIONS: Trained nurses and endoscopists can administer propofol safely for endoscopic procedures. Nurse-administered propofol sedation is one potential solution to the high cost associated with anesthetist-delivered sedation for endoscopy.

Anesthesia↗
PubMed2005

Preprocedure patient values regarding sedation for colonoscopy.

BACKGROUND: Adherence rates for screening colonoscopy remain low. There are little data describing pre-colonoscopy patient concepts, values, and preferences for sedation during colonoscopy. In this study, we sought to investigate preprocedure patient values regarding sedation use for colonoscopy. METHODS: Questionnaires were administered to 210 consecutive outpatients presenting for colonoscopy. An unscaled visual analog scale was used to value each of eight statements relating to sedation. RESULTS: The statement receiving the highest valuation was "I don't want to feel any pain" (mean score, 82 +/- 21), followed by "I want to go to sleep and not wake up until the procedure is over" (mean score, 71 +/- 31), and "I want to be alert as soon as possible after the procedure" (mean score, 65 +/- 30). The statement receiving the lowest value was "I'd like to watch as much of the procedure as I can" (22 +/- 29). Patients who preferred to undergo colonoscopy without sedation were more likely to be men (P = 0.001) and more likely to have graduate or professional educational degrees (P < 0.001). CONCLUSIONS: Our data suggest that, on average, American patients place the highest valuation on experiencing no pain during colonoscopy, waking up promptly after the procedure, and for going to sleep and not waking up until the procedure is over. However, unsedated colonoscopy does appeal to a small minority of patients, primarily men with graduate educations.

Colonoscopy↗
PubMed2005

Insertability and safety of a shape-locking device for colonoscopy.

BACKGROUND: Loop formation during colonoscopy insertion results in patient pain and delays in advancement of the colonoscope tip. AIM: To assess the insertability and safety of a novel shape-locking guide (ShapeLock, USGI, San Clemente, CA) that resists looping during colonoscopy. RESULTS: In 54 patients, both a disposable and a partly reusable version of the ShapeLock received high scores (mean scores >9.0 on 1-10 scale) for ease of insertion, and ability to maneuver the colonoscope through the shape locked device. No significant trauma resulted from use of the device. CONCLUSION: A novel shape-locking device for colonoscopy can be readily and safely inserted into the colon and locked. The device warrants controlled evaluation to determine in which, if any cases, it may be useful for either experienced colonoscopists and/or those with less or minimal experience.

Adult↗
PubMed2005

Impact of bending section length on insertion and retroflexion properties of pediatric and adult colonoscopes.

BACKGROUND: Colonoscopes with short bending sections facilitate retroflexion but their effect on other aspects of colonoscope insertion are unknown. We sought to determine the impact of short bending on cecal insertion, terminal ileal intubation, and proximal colon retroflexion. METHODS: Two studies were performed. In study 1, we randomized 104 adult patients with intact colons to undergo colonoscopy with a standard pediatric colonoscope (Olympus PCF-160), a prototype pediatric colonoscope with short bending in four directions (PCF-AYL), or a prototype pediatric colonoscope with short bending in two directions, and normal bending in two directions (PCF-AY3L). In study 2, we randomized 70 patients with intact colons to undergo colonoscopy with a prototype 170 degrees wide angle colonoscope (CFQ160-WL) with a standard bending section length or to a prototype 170 degrees colonoscope with a short bending section (CFQ160-W2L). RESULTS: In study 1, the cecum was reached in all patients. Using the AYL, the cecal intubation time (4.08 min) was significantly longer when compared to both the PCF-160 (2.62 min; p=0.0001) and the AY3L (3.25 min; p=0.02). The AYL required the application of abdominal pressure (79%) and activation of the variable stiffness device (70%) more frequently when compared to both the PCF-160 (32%; p=0.0001 and 41%; p=0.02, respectively) and the AY3L (34%; p=0.0003 and 41%; p=0.02, respectively). Successful cecal retroflexion was possible less often with the PCF-160 (57%) when compared to either the AYL (94%; p=0.005) or AY3L (91%; p=0.001). The ability to intubate the terminal ileum was similar in all three groups (PCF-160 and AY3L 100%; AYL 94%) as was the time needed to intubate (p=0.73). Depth of ti intubation was deeper for the PCF-160 when compared to the AYL (p=0.0002) or AY3L (p=0.02). There was a trend toward deeper ileal intubation with the AY3L compared to AYL (p=0.09). In study 2, no difference was noted in cecal intubation time (p=0.1) or in frequency of application of abdominal pressure (p=0.28), position change (p=0.15), or activation of the stiffening device (p=0.46). Cecal retroflexion was successful more often when using the W2L when compared to the WL (p=0.00001). CONCLUSION: Short bending sections facilitate proximal colon retroflexion for both pediatric and adult colonoscopes, but can negatively impact cecal insertion and terminal ileal intubation in pediatric colonoscopes. A pediatric colonoscope with short bending in only two directions had good function for both cecal insertion and proximal colon retroflexion.

Cecum↗