Sedation for upper gastrointestinal endoscopy: a comparative study of propofol and midazolam

Safer colonoscopy with patient-controlled analgesia and sedation with propofol and alfentanil

BACKGROUND

The aim of this study was to assess the efficacy of patient-controlled analgesia and sedation with propofol/alfentanil for colonoscopy compared with continuous drug infusion and conventional nurse-administered medication.

METHODS

One hundred fifty patients undergoing colonoscopy on an outpatient basis were randomly assigned to 1 of 3 medication regimens. To maintain blinding, all patients were connected to an infusion pump. Group I patients could self-administer boluses of 4.8 mg propofol and 125 microg alfentanil without restriction. Group II patients received a continuous infusion with 0.048 mg/kg propofol and 0.12 microg/kg alfentanil per minute. Group III patients received intravenous premedication with 0.035 mg/kg midazolam and 0.35 mg/kg meperidine.

RESULTS

There were no differences between the groups with respect to pain (visual analogue scale) and procedure time. Patient-controlled analgesia and sedation with propofol/alfentanil (group I) resulted in less of an increase in the transcutaneous partial pressure of carbon dioxide (p = 0.0004) during colonoscopy and less of a decrease in mean arterial blood pressure (p = 0.0021) during recovery, as well as more complete recovery (p = 0.0019) after 45 minutes compared with conventional administration of midazolam/meperidine. Furthermore, patient-controlled analgesia and sedation yielded a higher degree of patient satisfaction than continuous infusion of propofol/alfentanil (p = 0.0033) or nurse-administered midazolam/meperidine (p = 0.0094).

CONCLUSIONS

Patient-controlled administration of propofol and alfentanil for colonoscopy may provide a better margin of safety than conventional administration of midazolam and meperidine and results in a higher level of patient satisfaction and shorter recovery.

Gastroenterologist-administered propofol for therapeutic upper endoscopy with graphic assessment of respiratory activity: a case series

BACKGROUND

Traditional methods of sedation and analgesia for advanced endoscopic procedures can be inadequate and frequently prolong recovery room observation. Propofol is a rapidly acting agent that produces an excellent hypnotic state, but its use is typically limited to anesthesiologist-assisted cases because of the inadequacy of current monitoring standards to reliably detect early stages of respiratory depression.

METHODS

Ten patients undergoing advanced upper endoscopic procedures (endoscopic retrograde cholangiopancreatography, endoscopic ultrasound, esophageal stent placement) received a propofol infusion under the control of a second qualified gastroenterologist with advanced cardiac life support skills. Graphic assessment of respiratory activity was made by using a sidestream carbon dioxide detecting cannula. Patient satisfaction was measured with a 100 mm visual analog scale. Recovery scores were measured by standardized scoring of discharge criteria.

RESULTS

Monitoring with graphic assessment of respiratory activity detected early phases of respiratory depression, resulting in a timely decrease in the propofol infusion without significant hypoxemia, hypercapnia, hypotension, or arrhythmias. Satisfaction scores were extremely high (median score 92 of 100) and 9 of 10 patients met discharge criteria at 15 minutes after discontinuation of the propofol infusion.

CONCLUSIONS

With the use of monitoring by graphic assessment of respiratory activity, propofol infusion by a second qualified gastroenterologist for prolonged upper endoscopic procedures is safe and results in high levels of patient satisfaction with rapid recovery times.

Sedation for endoscopy

A review of the recent literature reveals an increasing published opinion in favour of unsedated endoscopy. However, recent studies show that the majority of US patients are unwilling or unable to tolerate this. In order for there to be a shift towards unsedated endoscopy, physicians will have to change patients' expectations. The indications for diagnostic and therapeutic endoscopic procedures continue to expand, involving increasingly complex techniques that require a high degree of patient cooperation. There is still a need to refine the sedative regimen for these cases.

Deep sedation with inhaled sevoflurane for pediatric outpatient gastrointestinal endoscopy

BACKGROUND

Sevoflurane is an inhaled anesthetic agent with ideal properties for achieving deep sedation during pediatric outpatient gastrointestinal endoscopy. This is a comparison of experience with this gas and other sedation methods used in the authors' hospital.

METHODS

Retrospective chart review and statistical analysis of data from children receiving inhaled sevoflurane administered by an anesthesiologist through laryngeal insufflation, intravenous propofol, or intravenous midazolam-fentanyl-ketamine in any combination to achieve deep sedation for outpatient gastrointestinal endoscopy. Anesthesia was administered in a dedicated procedure room. The intravenous drugs were administered by pediatric intensivists in the intensive care unit. The same endoscopist performed all the procedures.

RESULTS

A total of 248 procedures were reviewed (midazolam-fentanyl-ketamine 67, propofol 114, and sevoflurane 67). All patients were adequately sedated with sevoflurane, and no intravenous access was required. Time (in minutes) to awakening (midazolam-fentanyl-ketamine 47.15, propofol 36.12, sevoflurane 5.70), discharge (midazolam-fentanyl-ketamine 141.99, propofol 91.20, sevoflurane 53.34), and total time, including induction and procedure (midazolam-fentanyl-ketamine 163.97, propofol 119.40, sevoflurane 73.93), were significantly lower for sevoflurane (P < 0.01). The complication rate for sevoflurane (4.5%) was lower (P < 0.05) than for midazolam-fentanyl-ketamine (13.4%) and for propofol (17.5%). Charges for room use and medications were also lower for sevoflurane (P < 0.01). The total charges for sedation (U.S.$) were comparable for sevoflurane (688.10) and propofol (723.08) but were higher for midazolam-fentanyl-ketamine (855.10, P < 0.01).

CONCLUSIONS

Deep sedation with inhaled sevoflurane for pediatric outpatient gastrointestinal endoscopy is as safe as conventional sedation techniques, potentially less expensive, increases endoscopy unit productivity, and eliminates the inconvenience associated with obtaining intravenous access in children.

A randomized, double-blind study of the use of droperidol for conscious sedation during therapeutic endoscopy in difficult to sedate patients

BACKGROUND

Droperidol has been used in combination with narcotics and benzodiazepines to achieve conscious sedation. We performed a randomized, double-blind, study of droperidol in patients at risk for difficult sedation scheduled for therapeutic endoscopy.

METHODS

Patients with regular ethanol, narcotic, or benzodiazepine usage, suspected sphincter of Oddi dysfunction, or a history of difficult sedation were eligible for the study. Patients were randomized to receive either droperidol or placebo along with midazolam and meperidine as preprocedure sedation. Time to achieve sedation, interruptions due to undersedation, medication dosages, recovery time, and subjective assessments of sedation were recorded.

RESULTS

One hundred one patients were randomized. The droperidol group had significantly fewer procedure interruptions and observer ratings of difficulty with sedation and required significantly less midazolam (23%) and meperidine (16%) than the placebo group. There were no significant differences in time to achieve sedation, incomplete procedures, procedure length, recovery room time, or complications. There were significantly higher observer ratings of the quality of sedation for patients who received droperidol.

CONCLUSIONS

Droperidol is a useful adjunct to conscious sedation in patients who are difficult to sedate. Its use results in significantly fewer interruptions due to poor sedation and improved sedation ratings compared with sedation using midazolam and meperidine alone.

The pediatric sedation unit: a mechanism for pediatric sedation

OBJECTIVES

We have created a pediatric sedation unit (PSU) in response to the need for uniform, safe, and appropriately monitored sedation and/or analgesia for children undergoing invasive and noninvasive studies or procedures in a large tertiary care medical center. The operational characteristics of the PSU are described in this report, as is our clinical experience in the first 8 months of operation.

METHODS

A retrospective review of quality assurance data was performed. These data included patient demographics and chronic medical diagnoses, procedure, or study performed; sedative or analgesic medication given; complications (defined prospectively); and sedation and monitoring time. Patient-specific medical records related to the procedure and sedation were reviewed if a complication was noted in the quality assurance data.

RESULTS

Briefly, the PSU was staffed with an intensivist and pediatric intensive care unit nurses. Patients were admitted to the PSU and assessed medically for risk factors during sedation. Continuous heart rate, respiratory rate, and pulse oximetry monitoring were used, and blood pressure was determined every 5 minutes. After sedation and stabilization, with monitoring continued, the patient was transported to the site to undergo the procedure or study. The pediatric intensive care unit nurse remained with the patient at all times. All necessary emergency equipment was transported with the patient. After the procedure or study was completed, the patient was returned to the PSU for recovery to predetermined parameters. We were able to analyze 458 episodes of sedation for this review. Procedures and studies included radiologic examinations, cardiac catheterization, orthopedic manipulations, solid organ and bone marrow biopsy, gastrointestinal endoscopy, bronchoscopy, evoked potential measurements, and others. Patients were 2 weeks to 32 years of age. The average time from initiation of sedation to last dose of medication administered was 84 minutes. The average time from initiation of sedation to full recovery was 120 minutes. Sedative and analgesia medications use was not standardized; however, the majority of children needing sedation received propofol or midazolam. For patients requiring analgesia, ketamine or fentanyl was added. In 79 of 458 (12%) sedation episodes, complications were documented. Mild hypotension (4.4%), pulse oximetry <93% (2.6%), apnea (1.5%), and transient airway obstruction (1.3%) were the most common complications noted. Cancellation of 11 (2.4%) procedures was attributable to complications. No long-term morbidity or mortality was seen.

CONCLUSIONS

Many children require sedation or analgesia during procedures or studies. Safe sedation is best ensured by appropriate presedation risk assessment and with monitoring by a care provider trained in resuscitative measures who is not involved in performing the procedure itself. Uniformity of care in a large institution is a standard met by the creation of a centralized service, with active input from the department of anesthesiology. We present the PSU as a model for achieving these goals.

Endoscopic retrograde cholangiopancreatography under general anesthesia: indications and results

BACKGROUND

Conscious sedation is usually used during endoscopic retrograde cholangiopancreatography (ERCP). Little is known about the indications and outcomes for ERCP in patients who cannot undergo conscious sedation and therefore require general anesthesia. We retrospectively evaluated the indications and outcome for patients undergoing ERCP who required general anesthesia at four teaching hospitals over a 2-year period.

METHODS

Of 1200 ERCPs performed over a 2-year period, 65 patients required general anesthesia. Retrospective chart analysis was undertaken to determine indications and outcomes of ERCP performed under general anesthesia. Eleven patients underwent sphincter of Oddi manometry.

RESULTS

The major indication for general anesthesia was substance abuse. Therapeutic intervention was successful in 45 of 48 patients; 6 of the 63 patients had complications, all mild and not related to the anesthesia. Sphincter of Oddi manometry was normal in 7 patients; 4 patients had elevated basal pressures.

CONCLUSIONS

ERCP under general anesthesia may be considered when conscious sedation fails to achieve a satisfactory level of sedation for a successful and safe ERCP. Procedure-related complication rates appear to be comparable if not lower with general anesthesia.

Propofol versus midazolam for sedation during percutaneous transluminal angioplasty

PURPOSE

To prospectively and randomly compare use of propofol versus midazolam for sedation during percutaneous transluminal angioplasty (PTA).

MATERIALS AND METHODS

Forty patients (27 men, 13 women; mean age 64.4 years +/- 12.2) who underwent PTA of the arteries below the diaphragm were prospectively randomized for sedation with propofol or midazolam. Both drugs were administered after an initial bolus injection by means of continuous infusion to achieve conscious sedation at levels II-III according to the Ramsay classification. Patients and interventionalists were blinded to the applied sedative. Both groups were similar with regard to American Society of Anesthesiology status, heart rate, blood pressure, arterial oxygen pressure (pO2), arterial carbon dioxide pressure (pCO2), arterial oxygen saturation (SpO2), and visual analogue scores for general condition, anxiety, and pain. During PTA, heart rate, blood pressure, and pulse oximetry (tpO2) were monitored continually. Every 30 minutes, an arterial blood gas analysis was performed. Visual analogue scores were obtained before, during, and after intervention.

RESULTS

Decreases in SpO2, pO2, and tpO2 were significantly greater after sedation with midazolam (P < .05; t test). The increase in pCO2 was significantly greater after midazolam (P < .05; t test). No significant difference between the drugs was found with regard to any of the other parameters. Both drugs resulted in sufficient sedation and anxiolysis (P < .01 for both drugs for visual analogue score for anxiety before and during PTA; matched pairs test). Satisfaction of the interventionalist was significantly greater for propofol (P < .05; t test).

CONCLUSION

Propofol causes less respiratory depression than midazolam for equivalent sedation and anxiolysis in patients undergoing PTA.