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Pawit Somnuke,1 Nuanprae Kitisin,1 Phornprasurt Chumklud,1 Pishsinee Kunavuttitagool,1 Penpuk Deepinta,1 Araya Wadrod,2 Warayu Prachayakul,3 Somchai Amornyotin,1 Nattaya Raykateeraroj1 1Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand; 2Department of Nursing, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand; 3Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 10700, ThailandCorrespondence: Nattaya Raykateeraroj, Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand, Tel +66 2 419 7990, Fax +66 2 411 3256, Email raykageeraroj@gmail.comPurpose: 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.Keywords: gastric pH, gastric volume, gastrointestinal endoscopy, hard candy, preoperative fasting guidelines

Ketodex is a combination of ketamine and dexmedetomidine. Ketamine, an old intravenous anesthetic, is a non-narcotic and non-barbiturate drug. It has several properties of the ideal anesthetic agent. However, ketamine can produce the psychological adverse effects. Dexmedetomidine has analgesic, amnesic, sedative and anxiolytic properties. A distinct advantage of dexmedetomidine is the maintenance of respiratory force and preserved airway patency. It converges on a natural sleep pathway, activating pathways that promote endogenous non-rapid eye movement sleep to exert its sedative effect. However, dexmedetomidine can produce bradycardia and hypotension. A combination of ketamine and dexmedetomidine has several benefits in the terms of hemodynamic stability, absence of respiratory depression, post-operative analgesia and recovery. Several previous studies have been demonstrated the therapeutic utility of the combination of ketamine and dexmedetomidine.

Objective: The study is aimed to develop a well-validated anesthesia quality assessment to evaluate patients postoperatively. Materials and Methods: After securing Institutional Review Board approval, the study was registered via ClinicalTrials.gov (NCT 0307996). The Siriraj Anesthesia Quality Assessment Questionnaire was developed and validated under the conceptual/theoretical framework of Maslow’s hierarchy of needs, Hospital Consumer Assessment of Healthcare Providers and System, Patient Satisfaction Questionnaire, Service Quality Questionnaire and Quality of Recover after Anesthesia. A total of 476 qualified responses with obtained consent were included in the study to verify the appropriateness of the tool. Results: The study involved 397 qualified patients (83.4%), aged 47.6±16.6, representing all anesthesia services. Significantly, a binary logistic regression revealed the predicted dependent variables as Process of Care (4.39±0.51) and Physical Support (4.35±0.66) in comparison with a sequence of Accessibility and Convenience (4.33±0.56), Communication and Information (4.00±0.70), Technical Quality (4.46±0.45) Psychological Support (4.57±0.65) and Loyalty (4.52±0.68) in anesthesia quality assessment. Conclusion: Process of Care and Physical Support appeared to be significantly valued features, whereas Communication and Information, Accessibility and Convenience, Technical Quality and Psychological Support were found to be weak points in anesthesia quality assessment.

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.

Gastrointestinal endoscopic (GIE) procedure has become an essential modality for evaluation and management of gastrointestinal tract abnormalities. The safe sedation of patients for this procedure requires a combination of properly trained physicians and appropriate facilities. Moreover, proper selection and preparation of patients, suitable sedative technique, and application of drugs is essential. Irrespective of regimen used, the safe administration of sedative drugs requires an awareness of the individual needs of the patients. To date, the most commonly used sedation technique for GIE procedure is intravenous technique. The use of short acting drug, adequate dose of sedative agents and sedation endpoint as well as appropriate sedation technique has an important role and also increased the safety. Several intravenous sedation techniques are presently used and evaluated. This article reviews and discusses the current status of the intravenous techniques for sedation in various GIE procedures.

Development in anesthesia and operative techniques has considerably reduced morbidity and mortality in the elderly patients. Several anesthetic techniques have been used for elderly patients including general anesthesia, regional anesthesia, intravenous sedation and monitored anesthesia care. However, anesthesiarelatedmortality in these patients is still high. All elderly patients undergoing surgical procedures require a preprocedural evaluation to assess the risks of anesthesia and procedure and to manage problems related to the preexisting medical conditions, monitoring patients during intraprocedural and postprocedural periods as well as postprocedural management. This article considers the age-related physiological changes, preprocedure assessment and preparation, anesthetic techniques, intraoperative care and postoperative care.

Ketamine, an old intravenous anesthetic, is a non-narcotic and non-barbiturate drug. It mainly works by noncompetitive antagonist at the N-methyl-D-aspartate (NMDA) receptors. Ketamine has several properties of the ideal anesthetic agent. Therefore, its properties are interesting in various clinical settings, although it can produce the psychological adverse effects. This present short review aims to describe the pharmacology of ketamine.

This study was to assess the effectiveness of brief advice offered by anesthetic personnel in quitting self-reported smoking in smoker patients who underwent GIE procedures in a developing country. After completing a baseline questionnaire assessing sociopsycho-demographics, tobacco dependence and quitting motivation, 114 smoker patients were randomized into two groups. Patients in Group A were encouraged smoking cessation, and the patients in Group B were not. After six-months of post advice, 12 patients (20.7%) in Group A and four patients (7.1%) in Group B quitted smoking. The number of cigarettes smoked, Fagerstrom score for nicotine dependence, and the patients having a partner who smoked in the continued smoking group was significantly higher than in the quitted smoking group. In conclusion, the brief advice by anesthetic personnel is a relatively effective and easy technique for smoking cessation in ambulatory GIE patients in a tertiary-care hospital in a developing country.

This study was aimed to evaluate and compare the adverse event rate of pharyngeal anesthesia when the topical lidocaine is used as a single agent for unsedated esophagogastroduodenoscopy (UEGD) between healthy adults and cirrhotic patients. Retrospectively analyzed the patients on whom UEGD procedures had been performed during the period of June, 2008 to December, 2009 in Siriraj Hospital. Patients were categorized into two groups. Group A was the healthy adults. Group B was the cirrhotic patients. The primary outcome variable was the adverse event rate. Secondary outcome variables were anesthesia and procedure-related adverse events, and mortality rate. There were 1,398 patients who underwent UEGD procedure during the study period. After matching age, gender, weight, height and duration of procedure, there were 131 patients in group A and 129 patients in group B. All pharyngeal anesthesia was given by residents or anesthetic nurses directly supervised by staff anesthesiologist in the endoscopy room. There were no significant differences in age, gender, weight, height, duration of procedure, and overall adverse event rate between the two groups. Hypertension in group B was significantly greater than in group A. However, tachycardia and hypertension in group B was significantly lower than in group A. All adverse events were transient, easily treated, with no adverse sequelae. UEGD in healthy adults and cirrhotic patients was safe and effective. Although, overall adverse event rate was relatively high, however, all adverse events in both groups were comparable, mild degree, transient and easily treated. No serious adverse events were observed in these two groups.

The study is aimed to develop and assess the quality of an evaluation form used to evaluate the nurse anesthetic trainees' skills in undertaking a pre-use check of an anesthetic machine.An evaluation form comprising 25 items was developed, informed by the guidelines published by national anesthesiologist societies and refined to reflect the anesthetic machine used in our institution. The item-checking included the cylinder supplies and medical gas pipelines, vaporizer back bar, ventilator anesthetic breathing system, scavenging system and emergency back-up equipment. The authors sought the opinions of five experienced anesthetic trainers to judge the validity of the content. The authors measured its inter-rater reliability when used by two achievement scores evaluating the performance of 36 nurse anesthetic trainees undertaking 15-minute anesthetic machine checks and test-retest the reliability correlation scores between the two performances in the seven days interval.The five experienced anesthesiologists agreed that the evaluation form accurately reflected the objectives of anesthetic machine checking, equating to an index of congruency of 1.00. The inter-rater reliability of the independent assessors scoring was 0.977 (p = 0.01) and the test-retest reliability was 0.883 (p = 0.01).An evaluation form proved to be a reliable and effective tool for assessing the anesthetic nurse trainees' checking of an anesthetic machine before the use. This evaluation form was brief clear and practical to use, and should help to improve anesthetic nurse education and the patient safety.

Esophageal stent placement is a minimally invasive procedure for treatment of esophageal strictures that cannot be treated with surgical procedure. It requires some forms of anesthesia. This procedure could be performed in the operating room and in the endoscopy unit.The study is aimed to report and evaluate the choices and techniques, drugs used and complications of anesthesia in the patients undergoing esophageal stent placement procedure in an endoscopy unit outside the operating room in a developing country.Retrospectively analyzed the patients on whom esophageal stent placement had been performed during the period of January, 2010 to December, 2012 in Siriraj Hospital in Thailand. The patients' characteristics, pre-anesthetic problems, anesthetic techniques, drugs, duration of anesthesia, and anesthesia-related complications were assessed and summarized by using descriptive statistics.During the study period, there were 48 procedures. Mean age 63.7 ± 13.4 years. The majority of them was male (72.9%) and classified in ASA physical status II (52.1%). Mean duration of anesthesia was 60.6 ± 36.1 minutes. Most common pre-anesthetic problems were hematologic disease (64.6%), electrolyte imbalance (50.0%), respiratory disease (31.3%) and hypertension (29.2%). General anesthesia with endotracheal tube (64.6%) was the main anesthetic technique. The mainly used sedoanalgesic agents were propofol, fentanyl and midazolam. The most common neuromuscular blocking drugs were succinylcholine and atracurium. Additionally, sevoflurane was the most inhalation agent. The overall anesthesia-related complication rate was 35.4%. Hypotension (31.3%) was the most frequent anesthetic complication.All of the esophageal stent placement procedures, general anesthesia and intravenous sedation techniques could be performed effectively in the appropriate patients. However, clinical signs should be carefully observed and the anesthetic personnel had to optimize the patient's condition for safety and beware of complications.

Service quality is an important factor, which value differs between the patient's satisfaction and expectation. The patient's expectations are important factors for development. This service quality is a key part for improvement of our anesthesia service. In general, an improvement in service design and delivery helps to achieve higher levels of the service quality.To evaluate the level of patient's expectation, patient's satisfaction and the quality of anesthesia care in a university hospital in ThailandThe patient satisfaction questionnaire, developed from service quality criteria and patient satisfaction questionnaire (PSQ-18), was applied to evaluate 467 in patients 24-72 hours after anesthesia care. The patients'expectation was also assessed A proportional stratified randomized allocation was done. The questionnaire consisted of three dimensions; 1) structure: reliabilityempathy, 2) process: assurancetangible and 3) result: responsiveness. Data expectation and satisfaction were analyzed with mean, standard deviation, t-test, ANOVA and normalized gain for the quality of anesthesia care.The patient's satisfaction in our anesthesia care is relatively high. The mean patient's satisfaction score is significantly higher than the mean patient's expectation in all dimensions. This study indicated that an anesthesia service in our hospital was a high quality service in the inpatient aspects.Patient's expectation and satisfaction with anesthesia services in our setting was relatively high. Although most patients never had been any expectation regarding anesthesia service, the information and the involvement in decision- making were the most requirements of the adult inpatients.

The incidence of postoperative nausea and vomiting (PONV) after intrathecal morphine is high. Ramosetron is a 5-HT₃ antagonist that has been shown to reduce PONV in general anesthesia. The objective of this study was to evaluate the efficacy of Ramosetron in preventing PONV MATERIAL AND METHOD: 165 patients undergoing elective gynecological surgery under spinal anesthesia were randomly allocated to two groups: the Ramosetron group (0.1 mg orally, n = 82), and the placebo group (oral corn starch, n = 83). The incidence of PONV severity of nausea and use of rescue antiemetic during the first 24 hour after surgery were evaluated.The incidence of PONV was significantly lower in the Ramosetron group compared with the placebo group (24.4% vs. 44.6%, number needed to treat (NNT) = 5.0). The severity of nausea was significantly lower in the Ramosetron group compared with the placebo group (20.7% vs. 39.8%, NNT = 6.0) in the 24 hour period.Oral Ramosetron 0.1 mg was more effective than placebo in PONV prevention and reduced the incidence of moderate to severe nausea after intrathecal morphine in the first 24 hour after gynecological surgery.

The aim of this study was to evaluate and compare the clinical efficacy of topical pharyngeal anesthesia for unsedated esophagogastroduodenoscopy (UEGD) procedure in sick (American Society of Anesthesiologists [ASA] physical status III-IV) and nonsick (ASA physical status I-II) patients in a teaching hospital in Thailand. We undertook a retrospective review of the anesthesia or sedation service records of adult patients who underwent UEGD procedures from October 2008 to September 2009. All patients were classified into two groups according to the ASA physical status. In group A, the patients had ASA physical status I-II, while in group B, the patients had ASA physical status III-IV. The primary outcome variable of the study was the successful completion of the procedure. The secondary outcome variables were anesthesia and procedure-related adverse events during and immediately after the procedure. After matching age, gender, weight, height and duration of procedure, there were 566 adult patients who underwent UEGD procedures by using topical pharyngeal anesthesia. Of these, 287 patients were in group A and 279 patients were in group B. There were no significant differences in age, gender, weight, height and duration of UEGD procedure between the two groups. All patients in both groups successfully completed the procedure except four patients in group A, and one patient in group B (P=0.188). Anesthesia and procedure-related adverse events in both groups were not significantly different. All adverse events were transient and mild degree with no adverse sequelae. Topical pharyngeal anesthesia for UEGD procedure in sick patients by trained anesthetic personnel with appropriate monitoring was safe and effective. The clinical efficacy of this technique in sick patients was not different or worse than in nonsick patients. Serious adverse events were rare in our population.

Topical pharyngeal anesthesia is generally used as pretreatment for unsedated esophagogastroduodenoscopy (UEGD). The effectiveness of topical pharyngeal anesthesia for UEGD in cirrhotic patients has been limited reports in the medical literature. The study is aimed to study the impact of topical pharyngeal anesthesia for UEGD procedure in cirrhotic patients in the World Gastroenterology Organization Endoscopy Training Center in Thailand. Retrospectively analyzed the patients on whom UEGD procedures had been performed during the period of December, 2007 to May, 2009 in Siriraj Hospital. The patients’ characteristics, duration of procedure, preanesthetic problems and anesthesia-related adverse events were assessed. The primary outcome variable of the study was the successful completion of the procedure. The secondary outcome variables were anesthesia-related adverse events and the alteration of hemodynamic parameters. During the study period, there were 346 cirrhotic patients who underwent UEGD procedure. All UEGD procedures were succeeded except four cases. The mean age of the patients was 55.9±11.9 years, and most were American Society of Anesthesiologists (ASA) class II (53.2%). The mean duration of procedure was 13.5±7.4 minutes. Topical pharyngeal anesthesia for UEGD procedure in the cirrhotic patients is relatively safe and effective. Anesthesiarelated adverse events in the cirrhotic patients were relatively high. However, these adverse events were mild, transient, without specific interventions, with no adverse sequelae.

Smoking is associated with a range of diseases, causing a high level of morbidity and mortality and is a risk factor for several perioperative complications [1]. The consequences of smoking on surgical outcomes are associated with the toxic effects of recent smoke inhalation and the cumulative chronic effects of tobacco exposure. Many smoking patients require some medical interventions and care by anesthesiologists. Consequently, smoking is of direct concerns to periprocedural management [1,2]. The preoperative clinic is an ideal setting to initiate interventions for smoking cessation. Importantly, preprocedural interventions for tobacco use are effective to decrease postprocedural complications and increase the likelihood of long-term abstinence. If intensive interventions are impractical, brief interventions should be implemented in preprocedural clinics as a routine practice [3]. Anesthesiologists should ask their patients about smoking, advice the smokers to quit, and connect them directly to counseling resources. However, most anesthesiologists ask their patients about smoking but frequently do not advise smokers to quit [4].

Background: The use of sedation for gastrointestinal endoscopy (GIE) procedures in elderly patients has been established as a safe and effective technique. However, it is still uncertain whether the situation is valid for Asians. Objective: Evaluate the outcome of intravenous sedation (IVS) for GIE procedures in very elderly patients (>86 years old) in Thailand and compare the clinical efficacy of IVS between very elderly and those younger ( Methods: We undertook a retrospective review of the sedation service records of patients who underwent GIE procedures between 2007 and 2008 at Siriraj Hospital, Thailand. All sedations were administered by anesthetic personnel in the endoscopy room. The cohort was divided into three groups, 86 years old (group 3). Results: Sedation was provided for 1,779 patients (965, 687, and 127 patients in group 1, 2, and 3, respectively) in 2,061 GIE procedures. Fentanyl, midazolam and propofol were the most common IVS drugs used in all three groups. Patients in group 3 required lower mean doses of these intravenous sedatives than those in group 1 or 2 (p Conclusion: IVS for GIE procedure in very elderly patients was associated with higher minor advance events but relatively safe and effective when carried out by trained anesthetic personnel with appropriate monitoring and dose adjustment.

Somchai Amornyotin1,3, Udom Kachintorn2,3, Wiyada Chalayonnawin1,3, Siriporn Kongphlay1,31Department of Anesthesiology, 2Department of Medicine, 3Siriraj GI Endoscopy Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, ThailandIntroduction: The aim of this study was to evaluate and compare the clinical efficacy of propofol-based deep sedation (PBDS) for endoscopic retrograde cholangiopancreatography (ERCP) procedure in sick (American Society of Anesthesiologists [ASA] physical status III–IV) and nonsick (ASA physical status I–II) elderly patients in a teaching hospital in Thailand.Methods: We undertook a retrospective review of the anesthesia or sedation service records of elderly patients who underwent ERCP procedures from October 2007 to September 2008. All patients were classified into two groups according to the ASA physical status. In group A, the patients had ASA physical status I–II, while in group B, the patients had ASA physical status III–IV. The primary outcome variable of the study was the successful completion of the procedure. The secondary outcome variables were sedation-related adverse events during and immediately after the procedure.Results: There were 158 elderly patients who underwent ERCP procedure by using PBDS during the study period. Of these, 109 patients were in group A and 49 patients were in group B. There were no significant differences in age, gender, weight, duration of ERCP, indication of procedure, and the mean dose of fentanyl, propofol, and midazolam between the two groups. All patients in both groups successfully completed the procedure except eight patients in group A and three patients in group B (P = 0.781). Overall, respiratory and cardiovascular adverse events in both groups were not significantly different. All adverse events were easily treated, with no adverse sequelae.Conclusion: In the setting of a developing country, PBDS for ERCP procedure in sick elderly patients by trained anesthetic personnel with appropriate monitoring was safe and effective. The clinical efficacy of this technique in sick elderly patients was not different or worse than in nonsick elderly patients. Serious adverse events were rare in our population.Keywords: deep sedation, endoscopic retrograde cholangiopancreatography, propofol (ERCP), sick, elderly, American Society of Anesthesiologists (ASA), developing country

Gastrointestinal endoscopy (GIE) is a procedure for diagnosis and treatment of gastrointestinal tract abnormalities. This procedure requires some forms of anesthe‐ sia. The goal of procedural anesthesia is safe, effective control of pain and anxiety, as well as an appropriate degree of memory loss or reduced awareness. Generally, the majority of GIE procedures are performed by using topical anesthesia and intravenous sedation. General anesthesia is carried out in long and invasive procedures such as endoscopic retrograde cholangiopancreatography, endoscopic ultrasound, and small bowel enteroscopy, as well in patients with history of failed sedation or drug and substance abuse, uncooperative or pediatric patients, and patients with cardiorespir‐ atory system instabilities. The appropriate anesthetic agents for GIE procedures could be short acting, rapid onset with little adverse effects and also improved safety profiles. To date, the new anesthetic drugs and monitoring equipments for safety and efficacy are available. The present review focuses on pre-anesthetic assessment, anesthetic drugs used, monitoring practices, and post-anesthesia care for anesthesia innovations in GIE procedures.

The rising use of nonanesthesiologist-administered sedation for gastrointestinal endoscopy has clinical significances. Most endoscopic patients require some forms of sedation and/or anesthesia. The goals of this sedation are to guard the patient's safety, minimize physical discomfort, to control behavior and to diminish psychological responses. Generally, moderate sedation for these procedures has been offered by the non-anesthesiologist by using benzodiazepines and/or opioids. Anesthesiologists and non-anesthesiologist personnel will need to work together for these challenges and for safety of the patients. The sedation training courses including clinical skills and knowledge are necessary for the registered nurses to facilitate the patient safety and the successful procedure. However, appropriate patient selection and preparation, adequate monitoring and regular training will ensure that the use of nurse-administered sedation is a feasible and safe technique for gastrointestinal endoscopic procedures.

Ketofol is a combination of ketamine and propofol. To date, there is significant interest in ketofol as an agent for procedural sedation and analgesia. The combination of propofol and ketamine has several benefits in the terms of hemodynamic stability, absence of respiratory depression, post-operative analgesia and recovery. This combination can be mixed in the same syringe or administered independently in the two separate syringes. It can be administered as a bolus or as a continuous infusion for longer procedures. Ketamine-propofol combinations in the different ratios have been studied before. The optimal mixture and dosing of ketamine and propofol has yet to be determined. This short review will highlight recent clinical supports the therapeutic utility of the combination of ketamine and Propofol.

Sedation practices for gastrointestinal endoscopic (GIE) procedures vary widely in different countries depending on health system regulations and local circumstances. The goal of procedural sedation is the safe and effective control of pain and anxiety, as well as to provide an appropriate degree of memory loss or decreased awareness. Sedation-related complications in gastrointestinal endoscopy, once occurred, can lead to significant morbidity and occasional mortality in patients. The risk factors of these complications include the type, dose and mode of administration of sedative agents, as well as the patient's age and underlying medical diseases. Complications attributed to moderate and deep sedation levels are more often associated with cardiovascular and respiratory systems. However, sedation-related complications during GIE procedures are commonly transient and of a mild degree. The risk for these complications while providing any level of sedation is greatest when caring for patients already medically compromised. Significant unwanted complications can generally be prevented by careful pre-procedure assessment and preparation, appropriate monitoring and support, as well as post-procedure management. Additionally, physicians must be prepared to manage these complications. This article will review sedation-related complications during moderate and deep sedation for GIE procedures and also address their appropriate management.

Laparoscopic surgery aims to minimize trauma of the interventional process but still ach‐ ieve a satisfactory therapeutic result. It is commonly performed because of various advan‐ tages such as reduced postoperative pain, faster recovery and more rapid return to normal activities, shorter hospital stay, and reduced postoperative pulmonary complications. The operative technique requires inflating gas into the abdominal cavity to provide a surgical procedure. An intra-abdominal pressure (IAP) of 10-15 mmHg is used. Carbon dioxide (CO2) is commonly used because it does not support combustion, is cleared more rapidly than other gases, and is highly soluble in blood. However, the disadvantage of CO2 is that the absorption of CO2 can cause hypercapnia and respiratory acidosis [1].

Somchai Amornyotin,1,2 Somchai Leelakusolvong,2,3 Wiyada Chalayonnawin,1,2 Siriporn Kongphlay1,21Department of Anesthesiology, 2Siriraj GI Endoscopy Center, 3Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, ThailandIntroduction: Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasonography (EUS) procedures in elderly patients are on the rise, and they play an important role in the diagnosis and management of various gastrointestinal diseases. The use of deep sedation in these patients has been established as a safe and effective technique in Western countries; however, it is uncertain if the situation holds true among Asians. The present study aimed to evaluate the age-dependent safety analysis and clinical efficacy of propofol-based deep sedation (PBDS) for ERCP and EUS procedures in adult patients at a World Gastroenterology Organization (WGO) Endoscopy Training Center in Thailand.Methods: We undertook a retrospective review of anesthesia or sedation service records of patients who underwent ERCP and EUS procedures. All procedures were performed by staff endoscopists, and all sedations were administered by anesthesia personnel in the endoscopy room.Results: PBDS was provided for 491 ERCP and EUS procedures. Of these, 252 patients (mean age, 45.1 ± 11.1 years, range 17–65 years) were in the 80 age group. Common indications for the procedures were pancreatic tumor, cholelithiasis, and gastric tumor. Fentanyl, propofol, and midazolam were the most common sedative drugs used in all three groups. The mean doses of propofol and midazolam in the very old patients were relatively lower than in the other groups. The combination of propofol, midazolam, and fentanyl, as well as propofol and fentanyl, were frequently used in all patients. Sedation-related adverse events and procedure-related complications were not statistically significantly different among the three groups. Hypotension was the most common complication.Conclusion: In the setting of the WGO Endoscopy Training Center in a developing country, PBDS for ERCP and EUS procedures in elderly patients by trained anesthesia personnel with appropriate monitoring is relatively safe and effective. Although adverse cardiovascular events, including hypotension, in this aged group is common, all adverse events were usually transient, mild, and easily treated, with no sequelae.Keywords: deep sedation, propofol, endoscopic retrograde cholangiopancreatography, endoscopic ultrasonography, elderly, developing country

Objectives: To compare and evaluate the clinical efficacy of deep sedation and general anesthesia for esophagogastroduodenoscopy (EGD) in sick pediatric patients (ASA physical status ≥ III) in a tertiary care teaching hospital in Thailand. Subjects and methods: We undertook a retrospective review of the anesthesia service records of sick pediatric patients who underwent EGD. All sick pediatric patients were classified into two groups according to the type of anesthetic technique: group DS (deep sedation) and group GA (general anesthesia). The primary outcome variable of the study was the successful completion of the procedure. Failed procedure is defined as the procedure can not be completed by using DS or GA technique or anesthesia-related serious adverse events such as severe hypoxemia (SpO2 < 85% more than 3 minutes and can not relief by airway management), severe cardiorespiratory instability, are occurred. The secondary outcome variables were anesthesia/sedation-related complications during and immediately after the procedure. Results: 101 sick patients underwent EGD procedure during the study period. Premedications were none prior to the procedure. After matching age, gender, weight and indications of procedures, there were 51 patients in group DS and 27 patients in group GA. There were no significant differences in age, gender, weight, ASA physical status and indications of procedures. However, the duration of anesthesia in group GA was significantly longer than in group DS (p= 0.004).All DS and GA techniques were used successfully in all but one in group DS. Mean dose of propofol and fentanyl in both groups was comparable. Overall complication rate in group DS was significantly higher than in group GA (p= 0.039). However, there were no significant differences in the sedation and procedure related complications, anesthetic personnel and mortality rate. Conclusion: In the setting of the developing country, DS and GA for EGD in sick pediatric patients by experienced anesthesiologist with appropriate monitoring were relatively safe and effective. Serious adverse events were rare in our population.