Safety and efficacy of combined use of propofol and etomidate for sedation during gastroscopy: Systematic review and meta-analysis

BACKGROUND

Sedation with etomidate or propofol alone during gastroscopy has many side effects. A systematic review and meta-analysis were conducted to evaluate the safety and efficacy of the combined use of propofol and etomidate for sedation during gastroscopy.

METHODS

PubMed, Embase, Medline (via Ovid SP), Cochrane library databases, CINAHL (via EBSCO), China Biology Medicine disc (CBMdisc), Wanfang, VIP, and China National Knowledge Infrastructure (CNKI) databases were systematically searched. We included randomized controlled trials (RCTs) comparing the combined use of propofol and etomidate vs etomidate or propofol alone for sedation during gastroscopy. Data were pooled using the random-effects models or fixed-effect model based on heterogeneity.

RESULTS

Fifteen studies with 2973 participants were included in the analysis. Compared to propofol alone, the combined use of propofol and etomidate possibly increased recovery time (SMD = 0.14, 95% CI = 0.04-0.24; P = .005), and the risk for myoclonus (OR = 3.07, 95% CI = 1.73-5.44; P < .001), injection pain, and nausea and vomiting. Furthermore, compared to propofol alone, the combination of propofol and etomidate produced an apparent beneficial effect for mean arterial pressure (MAP) after anesthesia (SMD = 1.32, 95% CI = 0.38-2.26; P = .006), SPO2 after anesthesia (SMD = 0.99, 95% CI = 0.43-1.55; P < .001), apnea or hypoxemia (OR = 0.16, 95% CI = 0.08-0.33; P < .001), injection pain, and body movement. Further, compared to etomidate alone, the combination of propofol and etomidate reduced the risk for myoclonus (OR = 0.15, 95% CI = 0.11-0.22; P < .001), body movement, and nausea and vomiting.

CONCLUSION

The combination of propofol and etomidate might increase recovery time vs that associated with propofol, but it had fewer side effects on circulation and respiration in patients undergoing gastroscopy. The combined use of propofol and etomidate can improve and produce an apparent beneficial effect on the adverse effects of propofol or etomidate alone, and it was safer and more effective than propofol or etomidate alone.

The safety and efficacy of dexmedetomidine versus propofol for patients undergoing endovascular therapy for acute stroke: A prospective randomized control trial

BACKGROUND

It is uncertain if dexmedetomidine has more favorable pharmacokinetic profile than the traditional sedative drug propofol in patients who undergo endovascular therapy for acute stroke. We conducted a prospective randomized control trial to compare the safety and efficacy of dexmedetomidine with propofol for patients undergoing endovascular therapy for acute stroke.

METHODS

A total of 80 patients who met study inclusion criteria were received either propofol (n = 45) or dexmedetomidine (n = 35) between January 2016 and August 2018. We recorded the favorable neurologic outcome (modified Rankin score <3) both at discharge and 3 months after stroke, National Institute of Health Stroke scale (NIHSS) at 48 hours post intervention, modified thrombolysis in myocardial infarction score on digital subtraction angiography, intraprocedural hemodynamics, recovery time, relevant time intervals, satisfaction score of the surgeon, mortality, and complications.

RESULTS

There were no significant differences between the 2 groups (P > .05) with respect to heart rate, respiratory rate, and SPO2 during the procedure. The mean arterial pressure (MAP) was significantly low in the propofol group until 15 minutes after anesthesia was induced. No difference was recorded between the groups at the incidence of fall in MAP >20%, MAP >40% and time spent with MAP fall >20% from baseline MAP. In the propofol group, the time spent with MAP fall >40% from baseline MAP was significantly long (P < .05). Midazolam and fentanyl were similar between the 2 groups (P > .05) that used vasoactive drugs. The time interval from stroke onset to CT room, from stroke onset to groin puncture, and from stroke onset to recanalization/end of the procedure, was not significantly different between the 2 groups (P > .05). The recovery time was longer in the dexmedetomidine group (P < .05). There was no difference between the groups with respect to complications, favorable neurological outcome, and mortality both at hospital discharge and 3 months later, successful recanalization and NIHSS score after 48 hours (P > .05). However, the satisfaction score of the surgeon was higher in the dexmedetomidine group (P < .05).

CONCLUSIONS

Dexmedetomidine was undesirable than propofol as a sedative agent during endovascular therapy in patients with acute stroke for a long-term functional outcome, though the satisfaction score of the surgeon was higher in the dexmedetomidine group.

Pharmacodynamic Analysis of the Influence of Propofol on Left Ventricular Long-Axis Systolic Performance in Cardiac Surgical Patients

BACKGROUND

Propofol induced a decline in the left ventricular (LV) systolic performance in non-cardiac surgery. We tested the hypothesis that propofol decreased the LV contractile function by dose dependent manner in cardiac surgery patients.

METHODS

Anesthesia was maintained with target-controlled infusions of propofol and remifentanil in cardiac surgery patients. With a fixed effect-site concentration (Ce) of remifentanil (20 ng/mL) after sternotomy, the Ce of propofol was adjusted to maintain a Bispectral index of 40-60 (Ce1). Mitral annular Doppler tissue image tracings and other echocardiographic variables, including end-diastolic and end-systolic volumes, stroke volume, and mitral inflow pulse wave Doppler profile at Ce1, were recorded using transesophageal echocardiography. Echocardiographic recordings were repeated after the Ce-values of propofol were doubled and tripled at 10-minute intervals (defined as Ce2 and Ce3, respectively). Serial changes in echocardiographic variables for each Ce of propofol were assessed using generalized linear mixed effect modeling. The pharmacodynamic relationship between the Ce of propofol and peak systolic mitral annular velocity (Sm) was analyzed by logistic regression using non-linear mixed effect modeling (NONMEM).

RESULTS

Means of Ce1, Ce2, and Ce3 were 0.8, 1.6, and 2.4 μg/mL, respectively, and their means of Sm (95% confidence interval) were 9.7 (9.3-10.2), 8.7 (8.2-9.1), and 7.5 cm/sec (7.0-8.0), respectively (P < 0.01). Ce values of propofol and Sm showed a significant inter-correlation and predictability (intercept, 10.8; slope-1.0 in generalized mixed linear modeling; P < 0.01). Ce values producing 10% and 20% decline of Sm with 50%-probability were 1.4 and 2.1 μ/mL, respectively.

CONCLUSION

Propofol reduces LV systolic long-axis performance in a dose-dependent manner.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01826149.

A randomized controlled trial comparing methohexital and propofol for induction in patients receiving angiotensin axis blockade

BACKGROUND

Pharmacologic angiotensin axis blockade (AAB) has been associated with profound hypotension following anesthetic induction with propofol. To combat this problem, investigators have attempted to withhold angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB) preoperatively, or evaluated the effects of different induction agents in conferring greater hemodynamic stability. To date, methohexital has not been compared with the most commonly used induction agent, propofol. Hence, the primary objective was to study the hypothesis that methohexital confers a better hemodynamic profile than propofol for anesthetic induction, in patients receiving AAB. The secondary objective was to investigate the postinduction levels of serum neurohormones in an attempt to explain the mechanisms involved.

METHODS

Forty-five adult, hypertensive patients taking ACEi or ARB and scheduled for elective, noncardiac surgery completed the study. Patients were randomized to receive equi-anesthetic doses of either propofol or methohexital for anesthetic induction. Hemodynamic variables were measured and blood samples were drawn before induction and for 15 minutes afterwards.

RESULTS

Methohexital resulted in less hypotension compared with propofol (P = .01), although the degree of refractory hypotension was similar (P = .37). The postinduction systolic blood pressure (P = .03), diastolic blood pressure (P < .001) and heart rate (P = .03) were significantly higher in the methohexital group. A nonsignificant elevation of serum norepinephrine and epinephrine levels was observed in the methohexital group, while serum arginine vasopressin and angiotensin II levels did not differ between groups.

CONCLUSION

While methohexital was shown to confer greater hemodynamic stability in patients taking ACEi/ARB, the measured hormone levels could not explain the mechanism for this effect.

Diagnosis and treatment of acute alcohol intoxication and alcohol withdrawal syndrome: position paper of the Italian Society on Alcohol

The chronic use of alcohol can lead to the onset of an alcohol use disorder (AUD). About 50% of subjects with an AUD may develop alcohol withdrawal syndrome (AWS) when they reduce or discontinue their alcohol consumption and, in 3-5% of them, convulsions and delirium tremens (DTs), representing life-threatening complications, may occur. Unfortunately, few physicians are adequately trained in identifying and treating AWS. The Italian Society on Alcohol has, therefore, implemented a task force of specialists to draw up recommendations for the treatment of AWS with the following main results: (1) while mild AWS may not require treatment, moderate and severe AWS need to be pharmacologically treated; (2) out-patient treatment is appropriate in patients with mild or moderate AWS, while patients with severe AWS need to be treated as in-patients; (3) benzodiazepines, BDZs are the "gold standard" for the treatment of AWS and DTs; (4) alpha-2-agonists, beta-blockers, and neuroleptics may be used in association when BDZs do not completely resolve specific persisting symptoms of AWS; (5) in the case of a refractory form of DTs, the use of anaesthetic drugs (propofol and phenobarbital) in an intensive care unit is appropriate; (6) alternatively to BDZs, sodium oxybate, clomethiazole, and tiapride approved in some European Countries for the treatment of AWS may be employed for the treatment of moderate AWS; (7) anti-convulsants are not sufficient to suppress AWS, and they may be used only in association with BDZs for the treatment of refractory forms of convulsions in the course of AWS.

Safety of propofol-based anesthesia for colonoscopy in older patients

We retrospectively analyzed whether sedation for colonoscopy in older patients is as safe as in younger patients. This case-control study evaluated 149 consecutive older patients aged ≥65 years and 149 younger patients aged <65 years hospitalized in a tertiary hospital gastroenterology reference center for colonoscopy with propofol sedation. Data on American Society of Anesthesiologists (ASA) class, dose of propofol, dose of intravenous fluids, blood pressure, heart rate, saturation, both before and during anesthesia were collected. Additionally, physician experience, duration of anesthesia, and recovery time were analyzed. The median age was 74,2 years in the older group and 49,4 years in the younger group. Patients were mainly ASA II in both groups. The dose of propofol administered was higher in the younger vs the older group (2,9 vs 2,01 mg/kg, p <0,0001). There were no bradyarrhythmias, no hypotension and no decrease in saturation in either group. There were no differences in blood pressure, heart rate, and saturation in older patients, regardless of whether anesthesia was performed by a resident or a specialist. In this setting, colonoscopy under propofol-based sedation in patients ≥65 years was as safe as in younger patients and there was no difference in safety when the anesthetic was administered by a resident or a specialist in anesthesiology. These data suggest that older patients do not need a longer hospital stay because of sedation.

Sudden seizure during cesarean section: A case report

RATIONALE

A first seizure can range from a fleeting subjective experience or a twitch (myoclonic jerk) through to a tonic-clonic convulsion. A first seizure occurred in a parturient during cesarean section is very rare. We describe the case of a parturient who suffered seizure when the fetus was delivered.

PATIENT CONCERNS

Our patient is a 31-year-old parturient with a first seizure during cesarean section.

DIAGNOSES

Seizure.

INTERVENTIONS

The patient received supportive therapy to maintain oxygen supply and propofol was administered to terminate seizure during cesarean section.

OUTCOMES

after therapy, the patient regained full consciousness and normal spontaneous respiration. She had no recall of the seizure attack. The post-operative recovery was uneventful.

LESSONS

Symptoms during seizure are very important to diagnose. It will be both harmful to mother and the fetus, when the pregnant woman suffers seizure during pregnancy or cesarean delivery. In this situation, supportive therapy need to be immediately initiate and propofol may be the most suitable drug to terminate seizure during cesarean delivery.

Is propofol the optimal sedative in gastrointestinal endoscopy?

Propofol is a sedative agent commonly used for sedation in gastrointestinal endoscopy. Its pharmacologic properties render propofol an almost ideal drug to achieve and maintain the targeted level of sedation in even complex gastrointestinal procedures. When compared with other sedative agents, propofol is associated with better patient and endoscopist satisfaction and shorter recovery times. Furthermore, propofol can be combined with other sedatives to reduce the total dosage required to achieve the targeted sedation. Its safety is demonstrated by multiple studies, in which adverse events occurred very rarely. Nevertheless, the use of propofol by non-anesthesiologists is illegal in many countries and in those permitted, a structured curriculum with clinical training must first be successfully completed. However, various studies have shown that non-anesthesiologist administration of propofol is comparable in efficacy and safety to administration by an anesthesiologist and more cost-effective. The results of numerous studies indicate that propofol is superior in many aspects compared with traditional sedative agents.

Hemodynamic Effects of Propofol for Induction of Rapid Sequence Intubation in Traumatically Injured Patients

Present guidelines for emergency intubation in traumatically injured patients recommend rapid sequence intubation (RSI) as the preferred method of airway management but specific pharmacologic agents for RSI remain controversial. To evaluate hemodynamic differences between propofol and other induction agents when used for RSI in trauma patients. Single-center, retrospective review of trauma patients intubated in the emergency department. Patients were divided in two groups based on induction agent, propofol or nonpropofol. The primary outcome was incidence of hypotension within 30 minutes of intubation. Secondary outcomes included hospital length of stay and inhospital mortality. The study protocol was approved by the Institutional Review Board. Of the 744 patients identified, 83 were analyzed, 43 in the propofol group and 40 in the nonpropofol group. Groups were similar at baseline in terms of pre-RSI hemodynamics, injury mechanism, initial Glasgow Coma Score, and Injury Severity Score. On univariate analysis, although not statistically significant, postintubation hypotension was more common in patients who received propofol compared with those who did not, 39.5 per cent versus 22.5 per cent (P = 0.9). When adjusted for age, Injury Severity Score, and pre-RSI hemodynamics, the risk of hypotension among propofol-treated patients was significantly higher (OR = 3.64; 95% Confidence interval 1.16-13.24). There were no significant differences between groups in hospital length of stay or mortality. Propofol increases the odds of postintubation hypotension in traumatically injured patients. Considerable caution should be used when contemplating the use of propofol the for induction of injured patients requiring RSI because other agents possess more favorable hemodynamic profiles.

The comparison of propofol and midazolam for bronchoscopy: A meta-analysis of randomized controlled studies

BACKGROUND

Propofol and midazolam are widely used for the sedation of bronchoscopy. This systematic review and meta-analysis is conducted to compare the efficacy of propofol and midazolam for bronchoscopy.

METHODS

The databases including PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases are systematically searched for collecting the randomized controlled trials (RCTs) regarding the efficacy of propofol and midazolam for bronchoscopy.

RESULTS

This meta-analysis has included 4 RCTs. Compared with midazolam intervention in patients undergoing bronchoscopy, propofol intervention is associated with remarkably reduced recovery time [standard mean difference (SMD) = -0.74; 95% confidence interval (95% CI) = -1.04 to -0.45; P < .00001], but demonstrates no significant impact on operation time (SMD = -0.01; 95% CI = -0.16 to 0.13; P = .87), induction time (SMD = -0.58; 95% CI = -1.19 to 0.03; P = .06), lowest oxyhemoglobin saturation (SpO2, SMD = 0.24; 95% CI = -0.09 to 0.58; P = .15), SpO2 <90% [risk ratio (RR) = 1.02; 95% CI = 0.82-1.25; P = .88), and major arrhythmias (RR = 0.56; 95% CI = 0.26-1.19; P = .13).

CONCLUSION

Propofol sedation is able to reduce recovery time and shows similar safety compared with midazolam sedation during bronchoscopy.

Winter kill in intensively stocked channel catfish (Ictalurus punctatus): Coinfection with Aeromonas veronii, Streptococcus parauberis and Shewanella putrefaciens

Unusual persistent natural mortality occurred in a floating in-pond raceway system intensively stocked with channel and hybrid catfish beginning in early November 2016 up until March 2017. The temperature during the period of outbreak ranged from 7.2 to 23.7°C. Gross examination of freshly dead and moribund fish revealed pale gills, slight abdominal distension and swollen inflamed vents. Comprehensive necropsy of 20 fish demonstrated vast amounts of bloody ascitic fluid in the coelomic cavity, visceral congestion, splenomegaly and pale friable livers but macroscopically normal kidneys, suggesting systemic bacterial infection. Bacterial cultures were initiated from skin, gills and major internal organs. Following incubation, a mixture of three bacterial colony phenotypes was observed on agar plates. Presumptive biochemical characterization of the isolates followed by 16S-rRNA sequence analysis resulted in the identification of Aeromonas veronii, Streptococcus parauberis and Shewanella putrefaciens. Channel catfish juveniles were experimentally infected with the recovered isolates to fulfil Koch's postulates. Moreover, an antibiogram was used to evaluate the susceptibility of the isolates to antimicrobial drugs approved for use in aquaculture. Aquaflor was used successfully for treatment. Here, we report bacterial coinfection lead by A. veronii and the first identification of S. parauberis and S. putrefaciens from cultured catfish in North America.

Effect of dexmedetomidine on postoperative delirium in elderly patients undergoing hip fracture surgery

Dexmedetomidine is a highly selective central α2 adrenergic receptor agonist, which has anti sympathetic, sedative and analgesic effects. The aim of this study was to investigate the effect of dexmedetomidine on postoperative delirium in elderly patients undergoing hip fracture surgery. The results showed that the dosage of sufentanil and propofol decreased significantly in the experimental group (P<0.05). The price-henry pain scores of 10min, 1H and 6h in the experimental group were significantly reduced after the operation. At the same time, there were 3 cases (4.28%) of postoperative delirium in the experimental group, which were significantly less than 12 cases (17.14%) in the control group. The dosage of propofol in the operation is a risk factor for postoperative delirium. Dexmedetomidin can significantly reduce the amount of propofol in the operation and it has a neuroprotective effect, which can reduce the incidence of postoperative delirium in the elderly. In the elderly patients with hip surgery, its adjuvant to general anesthesia can effectively reduce narcotic drug dosage and reduce the incidence of postoperative delirium.

Pharmacological analysis of dexmedetomidine hydrochloride in pediatric anesthesia during magnetic resonance imaging

Dexmendetomidine hydrochloride (DEX) is a new common adrenergic receptor agonist, which not only keeps children calm but also has analgesic effect. Dexmedetomidine hydrochloride will enable children to maintain the natural non-REM sleep, which can be stimulated sedation or language arousal. The aim of this study is to observe the sedative effect and adverse drug reactions of dexmedetomidine hydrochloride injection and propofol injection in MRI examination. In this study, no children in the experimental group were required to add sedative drugs, and 2 cases in the control group were treated with sedative drugs. In experimental group, it used dexmedetomidine hydrochloride as (1.64±0.91) g/kg; in control group, dosage of narcotic drugs as (5.26±1.82) g/kg, and the total complication rate of the children in the experimental group was lower than that of the control group (P<0.05). After returning to the ward, the doses of phenobarbital sedation were dexmedetomidine group (4.28±1.53) mg/kg and propofol group (6.40±1.71) mg/kg. There was significant difference between the two groups. The total complication rate in the experimental group was lower than that in the control group (P<0.05). The quality of MRI in the test group was significantly higher than that in the control group, which showed that dexmedetomidine hydrochloride could provide a satisfactory sedative effect in the MRI examination of children. To sum up, dexmedetomidine hydrochloride is a wide range of clinical applications. It is an effective drug for the maintenance of sedation in clinical disease treatment. It is flexible in the way of administration and with less adverse reactions. It is suitable for popularization and application in clinical practice.

Perioperative Sedation in Mechanically Ventilated Cardiac Surgery Patients With Dexmedetomidine-Based Versus Propofol-Based Regimens

BACKGROUND

Sedative agents used during cardiac surgery can influence the patient's time to extubation, intensive care unit (ICU) and hospital length of stay, and incidence of delirium.

OBJECTIVE

This study evaluates the effects of the intraoperative and postoperative use of dexmedetomidine versus propofol infusions.

METHODS

This 19-month retrospective observational study at an academic medical center included 278 patients 18 years of age or older who underwent coronary artery bypass grafting (CABG), valve replacement surgery, or combined CABG plus valve surgery, who received either a dexmedetomidine or propofol infusion in addition to general anesthesia intraoperatively. The primary outcome was time to extubation. The secondary outcomes were ICU and hospital length of stay and incidence of delirium.

RESULTS

Use of dexmedetomidine (n = 69) as an intraoperative and postoperative sedative as opposed to propofol (n = 209) was significantly associated with increased likelihood of extubation (ie, shorter time to extubation; hazard ratio = 1.63, 95% CI = 1.21-2.19, P = 0.001). There was no significant association between use of dexmedetomidine and ICU discharge ( P = 0.99), hospital discharge ( P = 0.52), and incidence of delirium ( P = 0.27) after adjusting for other covariates. Conclusion and Relevance: Dexmedetomidine increased the likelihood of extubation when compared with propofol, with no increase in ICU or hospital length of stay or incidence of delirium. Our study is unique in that there was no crossover between patients who received dexmedetomidine and propofol infusions intraoperatively and postoperatively Dexmedetomidine-based regimens could serve as a suitable alternative to propofol-based regimens for fast-track extubation.

Successful Therapeutic Hypothermia in a Propofol-Related Cardiac Arrest Case: A Case Report and Literature Review

Targeted temperature management (therapeutic hypothermia) is a treatment method used to prevent potential complications that can develop in relation to the increased temperature in the brain as a result of cardiac arrest. Due to costs and various health policies there is no comprehensive study in the world that has been able to guide the relevant literature on therapeutic hypothermia. We have presented a 25-year-old female patient in our study who developed cardiac arrest after the administration of propofol for sedation before undergoing a diagnostic upper gastroscopy procedure and received a successful therapeutic hypothermia therapy following a resuscitation of 19 minutes.

[Propofol Infusion Syndrome in a refractory epileptic status case]

INTRODUCTION

Propofol Infusion Syndrome (PRIS) is a rare but potentially lethal adverse reaction secondary to the continuous intravenous infusion of this drug. The diagnosis is based on the com bination of metabolic acidosis, rhabdomyolysis, hyperkalemia, hepatomegaly, renal failure, hyperli pidemia, arrhythmias, and rapidly progressive heart failure.

OBJECTIVE

To report a case of PRIS and literature review.

CLINICAL CASE

A 6-year-old female patient with history of epilepsy secondary to large malformation of cortical development of the right hemisphere. The patient presented a refractory status epilepticus that required admission to the Intensive Care Unit for life support and treatment, which included continuous intravenous infusion of propofol at 10 mg/kg/h. She developed hemo dynamic instability, and after 24 h of treatment an increase of creatine phosphokinase (CPK) levels, metabolic acidosis and elevated lactacidemia were observed. After ruling out other causes, PRIS was diagnosed; therefore, the drug was suspended, achieving hemodynamic stabilization after 24 hours.

DISCUSSION

The diagnosis of PRIS is complex and should be considered in patients who are receiving this drug and present metabolic acidosis or heart failure. The factors that most influence mortality are the cumulative dose of the drug, the presence of fever, and cranial brain injury. In the case described, the patient received a dose higher than 4 mg/kg/h, which is the maximum recommended dose, and responded favorably 12 hours after stopping the drug.

A novel cause of rebreathing carbon dioxide related to removed CLIC-seal on the Dräger Apollo© anesthesia machine

We present a case report involving two sequential, surgically uneventful, laparoscopic cholecystectomies using the same anesthesia machine (Drager Apollo©) for which the level of inspired carbon dioxide was noted to be elevated following various diagnostic interventions including replacing the sodalime, increasing fresh gas flows, and a full inspection of equipment for malfunction. Eventually it was discovered that a rubber ring seal connecting the Dragersorb CLIC system© to the sodalime canister was inadvertently removed during the initial canister exchange resulting in an apparent bypassing of the absorbent and thus an inability of the exhaled gas to contact the sodalime. To our knowledge this is the first such description of this potential cause of elevated inspired carbon dioxide and should warrant consideration when other conventional interventions have failed.

Efficacy and safety of etomidate-midazolam for screening colonoscopy in the elderly: A prospective double-blinded randomized controlled study

BACKGROUND AND AIMS

Recent studies have shown that etomidate is associated with fewer serious adverse events than propofol and has a noninferior sedative effect. We investigated whether etomidate-midazolam is associated with fewer cardiopulmonary adverse events and has noninferior efficacy compared to propofol-midazolam for screening colonoscopy in the elderly.

METHODS

A prospective, single-center, double-blinded, randomized controlled trial was performed. Patients aged over 65 years who were scheduled to undergo screening colonoscopy were randomized to receive either etomidate or propofol based on midazolam. The primary outcome was all cardiopulmonary adverse events. The secondary outcomes were vital sign fluctuation (VSF), adverse events disturbing the procedure, and sedation-related outcomes.

RESULTS

The incidence of cardiopulmonary adverse events was higher in the propofol group (72.6%) than in the etomidate group (54.8%) (P = .040). VSF was detected in 17 (27.4%) and 31 (50.0%) patients in the etomidate and propofol groups, respectively (P = .010). The incidence rate of adverse events disturbing the procedure was significantly higher in the etomidate group (25.8%) than in the propofol group (8.1%) (P = .008). Moreover, the incidence rate of myoclonus was significantly higher in the etomidate group (16.1%) than in the propofol group (1.6%) (P = .004). There was no statistical significance between the 2 groups with respect to sedation times and sedation-related outcomes including patients' and endoscopist's satisfaction. In the multivariate analysis, the etomidate group had significantly low odds ratio (OR) associated with VSF (OR: 0.407, confidence interval: 0.179-0.926, P = .032).

CONCLUSIONS

We recommend using etomidate-midazolam in patients with high ASA score or vulnerable to risk factors; propofol-midazolam may be used as a guideline in patients with low ASA score.

Total spinal block after local anesthetic administration through the wrong access port of a spinal infusion pump

We present a case reported on the SENSAR database. A patient with a spinal infusion pump was admitted for reservoir refill. On administration of 22ml of 0.75% bupivacaine the patient suffered a total spinal block with widespread loss strength and respiratory arrest. The patient required emergency orotracheal intubation, mechanical ventilation and admission to ICU, where extubation was achieved within two hours without incidences. At a later stage it was stated that the local anaesthetic had been administered via the access port for bolus or contrast administration instead of via the access to the reservoir. Analysis of the incident showed up latent factors related to absence lack of personnel training and internal protocols. The following measures were taken: pain unit meeting, alert sent to SENSAR bulletin and training request for members of the service.

Does dexmedetomidine have an antiarrhythmic effect on cardiac patients? A meta-analysis of randomized controlled trials

Background

Cardiac surgery patients often experience several types of tachyarrhythmias after admission to the intensive care unit (ICU), which increases mortality and morbidity. Dexmedetomidine (DEX) is a popular medicine used for sedation in the ICU, and its other pharmacological characteristics are gradually being uncovered.

Purpose

To determine whether DEX has an antiarrhythmic effect after cardiac surgery.

Methods

The three primary databases MEDLINE, Embase (OVID SP) and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched, and all English-language and randomized control-designed clinical publications comparing DEX to control medicines for sedation after elective cardiac surgery were included. Two colleagues independently extracted the data and performed other quality assessments. A subgroup analysis was performed according to the different medicines used and whether cardiopulmonary bypass (CPB) was applied. All tachyarrhythmias that occurred in the atria and ventricles were analyzed.

Results

A total of 1295 patients in 9 studies met the selection criteria among 2587 studies that were screened. After quantitative synthesis, our results revealed that the DEX group was associated with a lower incidence of ventricular arrhythmia (VA, OR 0.24, 95% CI 0.09–0.64, I² = 0%, P = 0.005) than the control group. Subgroup analysis did not reveal a significant difference between the DEX and propofol subgroups (OR 0.13, 95% CI 0.03–0.56, I² = 0%, P = 0.007). Additionally, no difference in the incidence of atrial fibrillation (AF) was observed regardless of the different control medicines (OR 0.82, 95% CI 0.60–1.10, I² = 25%, P = 0.19) or whether CPB was applied.

Conclusions

This meta-analysis revealed that DEX has an antiarrhythmic effect that decreases the incidence of VA compared to other drugs used for sedation following cardiac surgery. DEX may not have an effect on AF, but cautious interpretation should be exercised due to high heterogeneity.

Surgery for triple-negative breast cancer- does the type of anaesthesia have an influence on oxidative stress, inflammation, molecular regulators, and outcomes of disease?

Breast cancer is the most frequently diagnosed cancer in females. Triple negative breast cancer (TNBC) is a molecular subtype of breast cancer which has a high mortality rate because of aggressive proliferation, quick occurrence of metastasis, and lack of effective treatment. New data show evidence that the type of anaesthesia can affect breast cancer recurrence and long-term outcome. Because TNBC lacks targets for modern specific therapy, a perioperative period could be the field of investigations for the long-term outcomes in TNBC influence. We reviewed the literature on research focusing on the influence of anaesthetics to oxidative stress, inflammation, molecular regulators, and TNBC oncological outcomes.

Analysis of anesthesia-controlled operating room time after propofol-based total intravenous anesthesia compared with desflurane anesthesia in functional endoscopic sinus surgery

Anesthesia technique may contribute to the improvement of operation room (OR) efficiency by reducing anesthesia-controlled time. We compared the difference between propofol-based total intravenous anesthesia (TIVA) and desflurane anesthesia (DES) for functional endoscopic sinus surgery (FESS) undergoing general anesthesiaWe performed a retrospective study using data collected in our hospital to compare the anesthesia-controlled time of FESS using either TIVA via target-controlled infusion with propofol/fentanyl or DES/fentanyl-based anesthesia between January 2010 and December 2011. The various time intervals (surgical time, anesthesia time, extubation time, total OR stay time, post anesthesia care unit [PACU] stay time) and the percentage of prolonged extubation were compared between the 2 anesthetic techniques.We included data from 717 patients, with 305 patients receiving TIVA and 412 patients receiving DES. An emergence time >15 minutes is defined as prolonged extubation. The extubation time was faster (8.8 [3.5] vs. 9.6 [4.0] minutes; P = .03), and the percentage of prolonged extubation was lower (7.5% vs. 13.6%, risk difference 6.1%, P < .001) in the TIVA group than in the DES group. However, there was no significant difference between ACT, total OR stay time, and PACU stay time.In our hospital, propofol-based TIVA by target-controlled infusion provide faster emergence and lower chance of prolonged extubation compared with DES anesthesia in FESS. However, the reduction in extubation time may not improve OR efficiency.

Angiotensin converting enzyme inhibitors enhance the hypotensive effects of propofol by increasing nitric oxide production

Propofol anesthesia is usually accompanied by hypotension. Studies have shown that the hypotensive effects of propofol increase in patients treated with angiotensin-converting enzyme inhibitors (ACEi). Given that both propofol and ACEi affect nitric oxide (NO) signaling, the present study tested the hypothesis that ACEi treatment induces pronounced hypotensive responses to propofol by increasing NO bioavailability. In this study we evaluated 65 patients, divided into three groups: hypertensive patients chronically treated with ACEi (HT-ACEi; n = 21), hypertensive patients treated with other antihypertensive drugs instead of ACEi, such as angiotensin II receptor blockers, β-blockers or diuretics (HT; n = 21) and healthy normotensive subjects (NT; n = 23). Venous blood samples were collected at baseline and after 10min of anesthesia with propofol 2mg/kg administrated intravenously by bolus injection. Hemodynamic parameters were recorded at each blood sample collection. Nitrite levels were determined by using an ozone-based chemiluminescence assay, while NOx (nitrites+nitrates) levels were measured by using the Griess reaction. Additionally, experimental approaches were used to validate our clinical findings. Higher decreases in blood pressure after propofol anesthesia were observed in HT-ACEi group as compared with those found in NT and HT groups. Consistently, rats treated with the ACEi enalapril showed more intense hypotensive responses to propofol. The hypotensive effects of propofol were associated with increased NO production in both clinical and experimental approaches. Enhanced increases in nitrite levels after propofol anesthesia were observed in HT-ACEi patients compared with NT and HT groups. Accordingly, rats treated with enalapril showed increased vascular NO formation after propofol anesthesia compared with rats receiving vehicle. Our data show that ACEi enhance the hypotensive responses to propofol anesthesia and increase nitrite concentrations. These findings suggest that increased NO bioavailability may account for the enhanced hypotensive effects of propofol in ACEi-treated patients.

Propofol for the promotion of sleep in adults in the intensive care unit

BACKGROUND

People in the intensive care unit (ICU) experience sleep deprivation caused by environmental disruption, such as high noise levels and 24-hour lighting, as well as increased patient care activities and invasive monitoring as part of their care. Sleep deprivation affects physical and psychological health, and people perceive the quality of their sleep to be poor whilst in the ICU. Propofol is an anaesthetic agent which can be used in the ICU to maintain patient sedation and some studies suggest it may be a suitable agent to replicate normal sleep.

OBJECTIVES

To assess whether the quantity and quality of sleep may be improved by administration of propofol to adults in the ICU and to assess whether propofol given for sleep promotion improves both physical and psychological patient outcomes.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 10), MEDLINE (1946 to October 2017), Embase (1974 to October 2017), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1937 to October 2017) and PsycINFO (1806 to October 2017). We searched clinical trials registers for ongoing studies, and conducted backward and forward citation searching of relevant articles.

SELECTION CRITERIA

We included randomized and quasi-randomized controlled trials with adults, over the age of 16 years, admitted to the ICU with any diagnoses, given propofol versus a comparator to promote overnight sleep. We included participants who were and were not mechanically ventilated. We included studies that compared the use of propofol, given at an appropriate clinical dose with the intention of promoting night-time sleep, against: no agent; propofol at a different rate or dose; or another agent, administered specifically to promote sleep. We included only studies in which propofol was given during 'normal' sleeping hours (i.e. between 10 pm and 7 am) to promote a sleep-like state with a diurnal rhythm.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion, extracted data, assessed risk of bias and synthesized findings.

MAIN RESULTS

We included four studies with 149 randomized participants. We identified two studies awaiting classification for which we were unable to assess eligibility and one ongoing study.Participants differed in severity of illness as assessed by APACHE II scores in three studies and further differences existed between comparisons and methods. One study compared propofol versus no agent, one study compared different doses of propofol and two studies compared propofol versus a benzodiazepine (flunitrazepam, one study; midazolam, one study). All studies reported randomization and allocation concealment inadequately. We judged all studies to have high risk of performance bias from personnel who were unblinded. We noted that some study authors had blinded study outcome assessors and participants for relevant outcomes.It was not appropriate to combine data owing to high levels of methodological heterogeneity.One study comparing propofol with no agent (13 participants) measured quantity and quality of sleep using polysomnography; study authors reported no evidence of a difference in duration of sleep or sleep efficiency, and reported disruption to usual REM (rapid eye movement sleep) with propofol.One study comparing different doses of propofol (30 participants) measured quantity and quality of sleep by personnel using the Ramsay Sedation Scale; study authors reported that more participants who were given a higher dose of propofol had a successful diurnal rhythm, and achieved a greater sedation rhythmicity.Two studies comparing propofol with a different agent (106 participants) measured quantity and quality of sleep using the Pittsburgh Sleep Diary and the Hospital Anxiety and Depression Scale; one study reported fewer awakenings of reduced duration with propofol, and similar total sleep time between groups, and one study reported no evidence of a difference in sleep quality. One study comparing propofol with another agent (66 participants) measured quantity and quality of sleep with the Bispectral Index and reported longer time in deep sleep, with fewer arousals. One study comparing propofol with another agent (40 participants) reported higher levels of anxiety and depression in both groups, and no evidence of a difference when participants were given propofol.No studies reported adverse events.We used the GRADE approach to downgrade the certainty of the evidence for each outcome to very low. We identified sparse data with few participants, and methodological differences in study designs and comparative agents introduced inconsistency, and we noted that measurement tools were imprecise or not valid for purpose.

AUTHORS' CONCLUSIONS

We found insufficient evidence to determine whether administration of propofol would improve the quality and quantity of sleep in adults in the ICU. We noted differences in study designs, methodology, comparative agents and illness severity amongst study participants. We did not pool data and we used the GRADE approach to downgrade the certainty of our evidence to very low.