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Patients with obesity are more susceptible to hypoxemia. Anesthetic management for patients with obesity undergoing painless gastroscopy presents a severe challenge for anesthesiologists. Esketamine is a NMDA antagonist that has been proven to be beneficial for ameliorating respiratory depression owing to its sympathomimetic effect; however, there are no relevant reports on its use in patients with obesity. We designed a randomized controlled trial to evaluate whether esketamine can be the ideal adjuvant to propofol sedation in patients with obesity undergoing painless gastroscopy. A total of 104 patients with obesity undergoing painless gastroscopy were randomly divided into group C (propofol+saline) and group S (propofol+esketamine 0.25 mg/kg). Anesthesia was induced by 2 mg/kg propofol with saline or esketamine. The consumption of propofol, hemodynamic parameters, duration of procedure, induction time, postoperative awakening time, and orientation recovery time were recorded. Adverse events and satisfaction scores were also recorded. Propofol consumption was 274.4±22.6 mg and 201.3±16.6 mg in groups C and S, respectively. The induction time of groups C and S were 25.4±2.3 s and 17.8±1.9 s, respectively. The postoperative awakening times of groups C and S were 6.2±1.1 min and 4.8±1.3 min, respectively. Hemodynamic parameters were more stable in group S than in group C. The incidence of adverse events such as injection pain, hypoxemia, hypotension, bradycardia, choking, and body movement were significantly lower in group S. The satisfaction scores of the endoscopist and anesthesiologist were (4.58±0.49 vs 3.71±0.83) and (4.75±0.44 vs 3.33±0.92), respectively. The combination of propofol and esketamine (0.25 mg/kg) improves the safety and reduces the incidence of adverse events in patients with obesity during painless gastroscopy. Thus, this method is worthy of clinical application. ChiCTR 2200062547.

Objective: Remimazolam is a novel benzodiazepine sedative that provides effective sedation, stable haemodynamics, and minimal adverse effects during intravenous general anaesthesia. The aim of this study was to determine the 50% effective dose (ED50) of remimazolam combined with different doses of esketamine for painless gastroscopy and to evaluate the efficacy and safety of this combination. Methods: This was a randomised, double-blind, up-and-down sequential allocation study. Patients undergoing painless gastroscopy who met all the inclusion criteria and did not meet any of the exclusion criteria were randomised in a 1:1:1 ratio into the ES0 group (0 mg/kg of esketamine), ES1 group (0.2 mg/kg of esketamine), and ES2 group (0.4 mg/kg of esketamine). The initial dose of remimazolam was 0.3 mg/kg in each group, with the dose increased or decreased by 0.05 mg/kg for the subsequent patient based on the success or failure of sedation in the previous patient. The trial was concluded when seven successful failure crossovers were achieved. The ED50 and 95% confidence intervals (CI) of remimazolam were calculated using Probit regression. Haemodynamic parameters, time to induction of anaesthesia, time to gastroscopy, time to awakening from anaesthesia, and adverse events were recorded. Results: A total of 59 patients were included in the final analysis: 19 in the ES0 group, 23 in the ES1 group, and 17 in the ES2 group. The ED50 (95% CI) of remimazolam in the ES0, ES1, and ES2 groups was 0.344 (0.302–0.389) mg/kg, 0.289 (0.249–0.328) mg/kg, and 0.193 (0.145–0.239) mg/kg, respectively. Additionally, the ES1 and ES2 groups exhibited more stable haemodynamics compared to the ES0 group. However, the ES1 and ES2 groups had significantly longer recovery times than the ES0 group. The incidence of hypotension was higher in the ES0 group compared to the ES1 and ES2 groups. Conclusion: The ED50 of remimazolam combined with 0 mg/kg, 0.2 mg/kg, and 0.4 mg/kg of esketamine for induction of anaesthesia during painless gastroscopy was 0.344 mg/kg, 0.289 mg/kg, and 0.193 mg/kg, respectively. Combining esketamine with remimazolam for induction of anaesthesia during painless gastroscopy offers advantages in terms of haemodynamic stability and reduced adverse effects.

Zheng L, Wang Y, Ma Q, et al. Drug Des Devel Ther. 2023;17:1347-1356. Page 1351, Hemodynamic Results, second sentence, the text \"HR, SBP, DBP, and SpO2 were significantly lower at T2, T3, and T4 in group C than in group S (P<0.05)\" should read \"SpO2 was significantly lower at T2, T3, and T4 in group C than in group S. The HR, SBP and DBP were significantly lower at T2 and T3, while higher at T4 in group C than in group S (P<0.05)\". The authors apologize for this error.

Hypoxemia is a common complication associated with anesthesia in painless gastroscopy. With the aging of the social population, the number of cases of hypoxemia among middle-aged and elderly patients is increasing. However, tools for predicting hypoxemia in middle-aged and elderly patients are lacking. In this study, we investigated the risk factors for hypoxemia in middle-aged and elderly outpatients undergoing painless gastroscopy based on machine learning and constructed a risk prediction model. In this retrospective study, we included the data on 1,348 outpatients undergoing painless gastroscopy. In total, 26 characteristic variables, including demographic information, past medical history, and clinical data of the patients were included, and BorutaShap was used for feature selection. Five machine learning algorithm models, including logistic regression (LR), support vector machine (SVM), random forest (RF), extreme gradient boosting (XGB), and light gradient boosting machine (LightGBM), were selected. The best models were selected based on the area under the receiver operating characteristic curve (AUROC). Model feature importance was explained and analyzed using Shapley Additive Explanations (SHAP). The endpoint event of this study was considered to be hypoxemia during the procedure, defined as at least one occurrence of pulse oxygen saturation below 90% without probe misalignment or interference from the beginning of anesthesia induction to the end of painless gastroscopy. In the final cohort of 984 patients, 11% of patients (108/984) experienced hypoxemia during the painless gastroscopy procedure. The AUROCs of the five models were as follows: Logistic Regression (AUROC = 0.893, 95CI: 0.881–0.899), SVM (AUROC = 0.855, 95CI: 0.812–0.884), Random Forest (AUROC = 0.914, 95CI: 0.889–0.924), XGB (AUROC = 0.902, 95CI: 0.865–0.919), and LightGBM (AUROC = 0.891, 95CI: 0.847–0.917). Regarding the explanation of the importance of SHAP features, preoperative variables (baseline SpO2, body mass index, and micrognathia) and intraoperative variables (operating time of gastroscopy, induction dose of etomidate and propofol mixture, append anesthetic, cough, and repeated pharyngeal irritation) significantly contributed to the model. We identified eight potential risk factors related to the occurrence of hypoxemia in middle-aged and elderly patients undergoing painless gastroscopy, based on machine learning feature engineering. Among the five machine learning algorithms, RF exhibited the best predictive performance in the internal test set and had a certain degree of generalization ability in the external validation set, which indicated that the RF model was more suitable for the data framework of this study. This model was more likely to enhance the accuracy of hypoxemia prediction in middle-aged and elderly patients undergoing painless gastroscopy, and thus, it is suitable for assisting anesthesiologists in clinical decision-making.

Background With the development of comfortable medical care, the application of intravenous anesthesia in painless gastroscopy is becoming increasingly widespread. However, anesthetic drugs may have adverse effects on postoperative cognitive function, and the risk of postoperative cognitive dysfunction (POCD) is particularly worthy of attention in the elderly population. Our aim is to evaluate the effect of intravenous anesthesia on postoperative cognitive function (POCF) in patients undergoing painless gastroscopy, with a focus on identifying potential risks of POCD and guiding clinical anesthesia practices. Methods Analyzing randomized controlled trials (RCTs) published in English that assessed the impact of intravenous anesthesia on POCF in patients over 60 years old undergoing elective gastrointestinal endoscopy. The literature search spanned databases including PubMed、Embase、Web of Science、Scopus、Cochrane, and Clinical Key. Study inclusion and exclusion criteria were rigorously defined, and the Cochrane bias risk assessment tool was utilized to evaluate study quality. Meta-analyses were performed using RevMan 5.3, with heterogeneity assessed via I-square statistics. Results From a total of 432 articles identified, 7 studies involving 219 patients met the inclusion criteria. The meta-analysis revealed no significant difference in the incidence rates of POCD on Day 1 and Day 3 postoperatively between patients undergoing intravenous versus inhalation anesthesia. However, on Day 7, the incidence of POCD was significantly lower in the intravenous anesthesia group, with a combined Odds Ratio (OR) of 0.96 (95% Confidence Interval (CI): 0.73–1.26, I^2 = 34%, n  = 7, P  < 0.00001). Furthermore, plasma levels of S-100β protein, a marker for neural injury, were significantly lower in the intravenous anesthesia group, with a Mean Difference (MD) of 0.34 (95% CI: 0.23–0.48, I^2 = 0%, n  = 5, P  < 0.00001). Conclusion Intravenous anesthesia for painless gastroscopy appears to be associated with a lower incidence of POCD on Day 7 postoperatively, suggesting a potentially reduced risk of early postoperative cognitive decline compared to inhalation anesthesia. The findings indicate that intravenous anesthesia may be preferable in minimizing the risk of POCD, particularly in older adults undergoing painless gastroscopy. However, further high-quality, large-scale RCTs are warranted to validate these results and explore the effects across different patient demographics.

Before undergoing painless gastroscopy, patients are required to fast and no drinking for at least 4 h which is unpleasant for older patients. The aim of this study is to increase the preprocedural comfort of older patients by reducing the duration of fasting and no drinking before painless gastroscopy while ensuring safety. Older patients aged more than 65 years who underwent painless gastroscopy were randomly allocated to the study group ( = 452) and the control group ( = 452). Those in the study group consumed 250 ml of opaque liquid 4 h prior to painless gastroscopy and 250 ml of water 2 h before the procedure. Those in the control group consumed the same food and water as those in the study group for 6-8 and 4 h, respectively. The primary outcome was patient comfort before the examination. The secondary outcomes included safety, gastroscopy effect and satisfaction in each group. All outcomes were analyzed using both intention-to-treat (ITT) and per-protocol (PP) approaches. In the study group, the incidence of thirst, hunger, dizziness, and fatigue before gastroscopy was significantly lower than that in the control group (33.4% . 42.7%, 20.1% . 28.1%, 3.1% . 7.5% and 4.9% . 11.7%, respectively; all < 0.01). However, in the gastroscopic assessments of both groups, only a small fraction of the patients exhibited gastric reflux, gastric fluid or food retention, aspiration pneumonia (2.0% . 0.9%, 4.4% . 3.1%, 1.5% . 1.1%, 0.4% . 0.2%, respectively; all > 0.05).Additionally, there was no difference in visual field clarity between the two groups (1.00 (1.00, 2.00) . 1.00 (1.00, 2.00), > 0.05), but the satisfaction of the study group was significantly greater than that of the control group (97.00 (96.00, 99.00) . 93.00 (92.00, 95.00), < 0.01). In this random trial of older patients undergoing painless gastroscopy, ingestion of 250 ml opaque liquid 4 h before, followed by 250 ml water 2 h before, improved pre-procedure comfort and patient satisfaction compared with conventional fasting. We observed no statistically significant increase in clinically identified gastric reflux, aspiration, or impaired endoscopic field clarity; however, the incidence of such adverse events was low, and the trial was not powered to exclude small increases in rare but serious complications. Larger studies would be required to definitively establish safety equivalence.

To investigate the median effective dose (ED ) and 95% effective dose (ED ) of oliceridine combined with propofol for painless gastroscopy in adults. Patients underwent painless gastroscopy were divided to male and female cohorts. A modified Dixon's up-and-down sequential method was employed, with an initial oliceridine dose of 20 μg·kg for both cohorts. Subsequent dosing adjustments were determined by the procedural success or failure of the preceding patient. The oliceridine dose was increased or decreased by a ratio of 1:1.2 for positive responses or negative responses. We recorded the time of successful induction, examination time, vital signs (HR, SpO and MAP) at predefined phases (including baseline T , post-induction time T , completion time T , and departure time T ), induction dose and total dose of propofol, dose of oliceridine, intraoperative adverse events (including hypoxemia, respiratory depression, hypotension, and bradycardia), postoperative adverse events (including nausea, vomiting, and dizziness), and vasoactive agent administration during the procedure. Probit analysis was subsequently performed to determine the ED , ED and corresponding 95% confidence intervals (CIs) of oliceridine in painless gastroscopy combined with propofol. The ED and ED of oliceridine combined with propofol were determined as 12.63 μg·kg (95% CI: 11.43-13.79) and 14.46 μg·kg (95% CI: 13.41-20.33) in males, and 10.38 μg·kg (95% CI: 9.02-11.96) and 13.19 μg·kg (95% CI: 11.62-28.23) in females. Male negative subgroup required higher oliceridine doses (P < 0.05), while female negative subgroup had lower total propofol dose yet higher oliceridine doses (P < 0.05). Females in the negative subgroup used more propofol (P < 0.05), and both sexes' negative subgroups consumed more oliceridine (P < 0.05). In males, SpO rose at T and T (P < 0.01), and MAP dropped at T and T (P < 0.05). In females, HR decreased at T (P < 0.05), SpO increased at T (P < 0.05), and MAP fell at T and T (P < 0.05). Adverse events included postoperative dizziness (12.50%), nausea (4.17%), and fatigue (4.17%) in females, and vomiting (5.56%) in males. The use of oliceridine (13.19-14.46 μg·kg ) and propofol was associated with safety, efficacy, and lower complication rates during painless gastroscopy. https://www.chictr.org.cn/showproj.html?proj=249883, identifier ChiCTR2400093609.

The risk of hypoxemia in painless gastroscopy has been widely recognized, but reliable predictors are still lacking. Tongue ultrasonography has been shown to facilitate the identification of difficult airways. In this study, we hypothesize that tongue ultrasonography may predict hypoxemia during painless gastroscopy, and aim to develop a predictive model for hypoxemia based on its prognostic value. This study included 304 patients underwent painless gastroscopy. Common and tongue ultrasound indicators were used for the prediction, including body mass index (BMI), Mallampati test score, tongue thickness (TT) and hyomental distance. Univariate and multivariate logistic regression were used to identify independent predictors of hypoxemia. Nomograms were constructed to predict hypoxemia based on the logistic regression analysis results and established risk factors documented in prior literature. Receiver operating characteristic (ROC) curves were used to evaluate the accuracy of the nomograms. The nomogram was internally validated. BMI, Mallampati score, TT, and popofol dose were integrated for hypoxemia nomogram. The areas under the ROC curves were 0.833 (95% confidence interval (CI) [0.762-0.904]). The calibration curve and decision curve analysis of the prediction model indicated that the model could have favourable predictive ability. Nomograms based on tongue ultrasonography could be a reliable tool in predicting hypoxemia during painless gastroscopy.

Wei Fu,1 Junlong Zhao,2 Yan Geng3 1Department of Gastroenterology, The 925th Hospital of PLA Joint Logistics Support Force, Guiyang, People's Republic of China; 2State Key Laboratory of Cancer Biology, Department of Medical Genetics and Developmental Biology, School of Basic Medicine, Fourth Military Medical University, Xi'an, People's Republic of China; 3Department of Gastroenterology, The 923th Hospital of PLA Joint Logistics Support Force, Nanning, 530021, People's Republic of ChinaCorrespondence: Yan Geng, The 923th Hospital of PLA Joint Logistics Support Force, Nanning, 530021, People's Republic of China, Email drggyn@163.com

Understanding the different pharmacodynamic responses to narcotics in patients with or without obesity is particularly important for the safety of gastroscopy sedation. This study aimed to determine the median effective dose (ED50) of ciprofol combined with low-dose sufentanil to inhibit the response to gastroscope insertion in obese or nonobese patients. A total of 27 obese patients (BMI 30-40 kg/m2) and 25 nonobese patients (BMI 18-25 kg/m2), aged between 18 and 65 years, with ASA physical status of 1-2, were included in this study. All patients underwent painless gastroscopy and received intravenous sufentanil at a dose of 0.1 μg/kg, followed by ciprofol administration. The initial dose of ciprofol for the first patient in both groups was 0.4 mg/kg, the subsequent dose was determined by the response of the previous patient to gastroscope insertion (cough, choking, body movement, etc.) using Dixon's up-and-down method. The dose was increased or decreased by 0.05 mg/kg depending on the observed responses. Data collection continued until 7 crossover points were obtained. Probit regression and bootstrapping methods were employed to calculate the median effective dose (ED50) and 95% confidence intervals (CIs). The ED50 values were then compared between the obese and nonobese patient groups. The ED50 of ciprofol combined with sufentanil inhibiting response to gastroscope insertion in patients with obesity was 0.186 mg/kg with 95% CI of 0.153∼0.209 mg/kg, was significantly lower than patients with nonobese was 0.237 mg/kg with 95% CI of 0.206∼0.253 mg/kg (p < 0.05). The ED50 values of ciprofol combined with sufentanil inhibiting response to gastroscope insertion in patients with obesity was lower than in patients with normal weight. https://www.chictr.org.cn/bin/project/edit?pid=202873, identifier ChiCTR2300074216.