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.