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Dr.Samji
Dr.Komanapalli
Dr.Roy
Marshfield clinic, Wisconsin.
CARBON DIOXIDE
INSUFFLATION IN ERCP
:A SYSTEMATIC REVIEW
ERCP is a valuable technique used as a
diagnostic and therapeutic option for many
pancreatic and biliary pathologies.
Air insufflation is used for insufflation of
duodenum.
Abdominal pain and nausea are the non
specific complaints of ERCP
INTRODUCTION
Carbon dioxide is easily absorbed and
excreted compared to air.
So carbon dioxide was thought to decrease
abdominal distension there by decrease
abdominal pain.
To compare the effect of carbon dioxide to
air insufflation in ERCP.
To assess the safety of carbon dioxide
insufflation in ERCP.
AIMS OF THE STUDY
Post procedural abdominal pain
Post procedural abdominal distension
Dose of sedation
Safety of carbon dioxide insufflation.
OUTCOMES
PubMed, Medline, Cochrane database and recent abstracts from major conference proceedings were searched.
RCT’s comparing role of CO2 and air insufflation in ERCP were included.
Standard forms were used to extract data by two independent reviewers.
We included all the studies that compared CO2 to Air insufflation in ERCP through 7/2012.
SEARCH STRATEGY
2625 Publications
2620 excluded
5 RCT included 3 abstracts
included
2 RCT 1 Retrospective
8 studies were included in our systematic review.7
studies are randomized double blinded control trials and
1 study is retrospective study.
Total number of 925 patients are included in 8 studies.
No significant difference in patient population noted.
GENERAL DESCRIPTION OF STUDIES
INCLUSION CRITERIA
Adult pts. requiring ERCP.
No consent
Age < 20 years
Significant pre procedural abdominal pain
Patients with COPD.
Pregnant patients
Chronic use of narcotics-long acting opioid daily more than 45 days.
Acute pancreatitis
Poor health status.
One study included patients with COPD without CO2 retention or requiring oxygen, CAD,OSA.(Dellon etal)
EXCLUSION CRITERIA
GENERAL CHARECTERISTICS
NAME OF STUDY Number of patients AGE Sex(female) CO2 DELIVERY PROCEDURE TIME
CO2 AIR CO2 AIR CO2 AIR CO2 AIR
Brettheur etal 58 58 57+16 54+18 72% 62% OLYMPUS ECR 43+27 48+25
Dellon etal 36 38 60.1+15 59.7+16.6 47% 50% OLYMPUS ECR 39.3 35.1
Lugiano etal 37 39 66.1+14.6 67.1+16.4 59% 53% E Z EM inc 34.1+17.8 37.3+17.6
Maple etal 50 50 57 51.7 52% 50% E Z EM INC 31.1 31.6
kutawani etal 40 40 66.1+9.8 68.7+10.9 37% 40% OLYMPUS ECR 45+24.75 43+22.4
Arjunan etal 147 151
sweelinchen etal 34 27 58.4 58.4
Bhalme etal 60 60 29 33
Abdominal pain was measured by different scales
and at different point of times.
No significant difference in pre procedural
abdominal pain .
EFFECT ON POST PROCEDURAL
ABDOMINAL PAIN
CO2 AIR CO2 AIR CO2 AIR CO2 AIR CO2 AIR CO2 AIR CO2 AIR CO2 AIR
15 15 5.7+5.4 6.2+6.7 0.38 1.51 12.8+19.6 10.5+21.0 0.5 0.48
5 19 10+4.4 35+12 0.38 0.37 16.4+25.2 10.8+19.3 0.61+0.67 0.84+0.95 0.7 1.9 0% 10%
1.4+2 0.9+2 7 21 8+2.5 28.1+9.6 20.8+32.2 22.3+27.8 28% 48%
10 22 7+2.5 14.1+4.7 18.3+25.4 19.5+26.7 28% 48%
1.1+1.9 0.5+1.3 4 20 4.2+3.4 5+2.8 15.0+24.7 15.5+24.0
Sweelinchen Dellon Arjunan
24 hours
Pain scale
pre procedure
1 hour
3 hours
6 hours
Bhalme
VAS 10 point
Not significant Not significant
Not significant
Maple
VAS 10 point VAS 100 mm VAS 100mm VAS 10 point VAS 100mm VAS 1-10cm VAS 10 point
Kutawani Brettheur Lugiano
Post procedural abdominal pain was less in
carbon dioxide group till 6 hours after
procedure.
There was no significant difference between 2
groups 24 hours after procedure.
EFFECT ON POST PROCEDURAL ABDOMINAL
DISTENSION
Kutawani Breetheur Lugiano Dellon Arjunan Maple
SCALE GVS-Xray Xray VAS100mm abd girth-cm Abd girth cm Abd girth-cm
CO2 AIR CO2 AIR CO2 AIR CO2 AIR CO2 AIR CO2 AIR
0.11+0.04 0.10+0.05 4.2+3.4 4.5+3.7 101.5+15 105.5+16
0.14+0.06 0.31+0.11 13% 29% 8.8+5.3 31.7+19.2 102.2+14 106.2+17.4
3.8+5.9 21.0+11.1 0.7+3.8 0.8+4.8 0.69+1.12 1.02+1.32 0.3 2.1
Pre procedure
Post procedure
Rate of increase
4 out of 6 studies noticed significant decrease
in abdominal distension in CO2 group compared
to air group.
1 study noticed that 29% patients in air group
had moderate to severe distension compared to
13% in CO2 group.
EFFECT ON DOSE OF SEDATION
Kutawani Breetheur Dellon Bhalme Lugiano Sweelin Maple
CO2 AIR CO2 AIR CO2 AIR CO2 AIR
Type of sedation fentanyl,midazolam Midazolam,pethidineFentanyl,midazolam Fentanyl,midazolam Propofol Propofol Propofol
Fentanyl (mcg) 115+48.9 130+53.5 155.6 162.2 75 75
Pethidine (mg) 54.4+24.5 38.5+11.1 35.2+27.9 44.0+37.3
Midazolam(mg) 7.3+3.6 8.4+3.7 6.3+3.6 6.4+2.8 9.1 10.7 4 4.5
Diazepam (mg) 2+0.8 2+0
Scopolamineine(mg) 23+6.6 20.6+2.4
Promethazinezine(mg) 17 25
Glucagon (mg) 1.2+0.4 1.1+0.2 0.5 0.3
No significant difference in dose of sedation
used between 2 groups
No significant difference in dose of
antispastic drugs used.
SAFETY OF CARBON DIOXIDE
INSUFFLATION
Kutawani Brettheur Lugiano Dellon Arjunan Maple Bhalme
Co2 monitoring SPO2 SPCO2 PETCO2 SPCO2 PETCO2 SPO2 SPO2
CO2 AIR CO2 AIR CO2 AIR CO2 AIR CO2 AIR
Baseline 97.8+1.3 97.7+1.3 NS NS 29.8+1.8 30+1.6 40.5 40.3
97.1+1.4 96.6+1.3 NS NS 32.6+2.6 30.7+1.3 46.1 45.2 NS NS
32.6+2.6 30.7+1.3 50 48.7
Post procedure
Maximum CO2
No significant respiratory depression or
respiratory complications noted with CO2
insufflation.
No significant adverse events or complications
noted in CO2 group compared to air group.
Carbon dioxide insufflation in ERCP can reduce post
procedural abdominal pain and the effect lasts till 6
hours after procedure.
Abdominal distension was less in carbon dioxide group
compared to air group.
There was no significant difference in dose of sedation
and dose of antispastic drugs used.
CONCLUSIONS
Carbon dioxide insufflation is found to be safe in
ERCP
Safety still needs to be established in patients
with COPD, obstructive sleep apnea, morbid
obesity, patients who has multiple co morbid
conditions and medically unstable patients.