Etomidate plus propofol versus propofol alone for sedation during gastroscopy: a randomized prospective clinical trial

The EC50 of propofol with different doses of dexmedetomidine during gastrointestinal endoscopy: A double-blind, placebo-controlled trial

PURPOSE

The goal of this study was to evaluate the dose-response relationship between dexmedetomidine and propofol in sedating patients and to determine the optimal dosage of dexmedetomidine during gastrointestinal endoscopy.

METHODS

One hundred fifty patients were divided into 5 groups, each receiving a loading dose of dexmedetomidine (0.4, 0.6, 0.8, 1.0 µg/kg) or saline, with propofol for sedation. The median effective concentration (EC50) of propofol was calculated using the modified Dixon up-and-down approach. Adverse effects, vital signs, procedure, and recovery times were recorded.

RESULTS

The EC50 of propofol in groups NS, D0.4, D0.6, D0.8, and D1.0 were 3.02, 2.44, 1.97, 1.85, and 1.83 µg/mL, respectively. Heart rate in the dexmedetomidine groups decreased more than the NS group (P < .001). The mean arterial pressure (MAP) in the NS group experienced a decline compared to groups D0.8 and D1.0 when the plasma concentration and effect-site concentration reached equilibrium. Additionally, the respiratory rate was found to be lower in groups NS, D0.4, D0.6, and D0.8 (P < .05). Recovery time in groups D0.8 and D1.0 was longer than the NS group (P < .05). Bruggemann comfort scales score was higher in group D1.0 (P < .05). No significant difference was found in the incidences of hypotension and bradycardia, and the dose of ephedrine and atropine. Respiratory depression was significantly reduced in groups D0.8 and D1.0 compared to the NS group.

CONCLUSION

A single dose of 0.6 to 0.8 µg/kg of dexmedetomidine should be recommended in combination with propofol for gastrointestinal endoscopy. And the EC50 of propofol is 1.97 to 1.85 µg/mL.

Modified Manual Chest Compression for Prevention and Treatment of Respiratory Depression in Patients Under Deep Sedation During Upper Gastrointestinal Endoscopy: Two Randomized Controlled Trials

BACKGROUND

We aimed to determine the preventive and therapeutic efficacy of modified manual chest compression (MMCC), a novel noninvasive and device-independent method, in reducing oxygen desaturation events in patients undergoing upper gastrointestinal endoscopy under deep sedation.

METHODS

A total of 584 outpatients who underwent deep sedation during upper gastrointestinal endoscopy were enrolled. In the preventive cohort, 440 patients were randomized to the MMCC group (patients received MMCC when their eyelash reflex disappeared, M1 group) or control group (C1 group). In the therapeutic cohort, 144 patients with oxygen desaturation of a Sp o2 < 95% were randomized to MMCC group (patients who subsequently received MMCC, M2 group) or the conventional treatment group (C2 group). The primary outcomes were the incidence of desaturation episodes with an Sp o2 < 95% for the preventive cohort and the time spent below 95% Sp o2 for the therapeutic cohort. Secondary outcomes included the incidence of gastroscopy withdrawal and diaphragmatic pause.

RESULTS

In the preventive cohort, MMCC reduced the incidence of desaturation episodes <95% (14.4% vs 26.1%; RR, 0.549; 95% confidence interval [CI], 0.37-0.815; P = .002), gastroscopy withdrawal (0% vs 2.29%; P = .008), and diaphragmatic pause at 30 seconds after propofol injection (74.5% vs 88.1%; RR, 0.846; 95% CI, 0.772-0.928; P < .001). In the therapeutic cohort, patients who received MMCC had a significantly shorter time spent below 95% Sp o2 (40 [20-69] seconds vs 91 [33-152] seconds, median difference [95% CI], -39 [-57 to -16] seconds, P < .001), a lower incidence of gastroscopy withdrawal (0% vs 10.4%, P = .018), and more enhanced diaphragmatic movement at 30 seconds after Sp o2 <95% (1.11 [0.93-1.4] cm vs 1.03 [0.7-1.24] cm; median difference [95% confidence interval], 0.16 [0.02-0.32] cm; P = .015).

CONCLUSIONS

MMCC may exert preventive and therapeutic effects against oxygen desaturation events during upper gastrointestinal endoscopy.

Effect of butorphanol on visceral pain in patients undergoing gastrointestinal endoscopy: a randomized controlled trial

BACKGROUND

Butorphanol slightly influences the respiratory and circulatory systems, has a better effect on relieving the discomfort caused by mechanical traction, and has a low incidence of postoperative nausea and vomiting (PONV). Combined butorphanol and propofol may suppress postoperative visceral pain, which is avoidable in gastrointestinal endoscopy. Thus, we hypothesized that butorphanol could decrease the incidence of postoperative visceral pain in patients undergoing gastroscopy and colonoscopy.

METHODS

This was a randomized, placebo-controlled, and double-blinded trial. Patients undergoing gastrointestinal endoscopy were randomized to intravenously receive either butorphanol (Group I) or normal saline (Group II). The primary outcome was visceral pain after the procedure 10 min after recovery. The secondary outcomes included the rate of safety outcomes and adverse events. Postoperative visceral pain was defined as a visual analog scale (VAS) score ≥ 1.

RESULTS

A total of 206 patients were enrolled in the trial. Ultimately, 203 patients were randomly assigned to Group I (n = 102) or Group II (n = 101). In total, 194 patients were included in the analysis: 95 in Group I and 99 in Group II. The incidence of visceral pain at 10 min after recovery was found to be statistically lower with butorphanol than with the placebo (31.5% vs. 68.5%, respectively; RR: 2.738, 95% CI [1.409-5.319], P = 0.002), and the notable difference was in pain level or distribution of visceral pain (P = 0.006).

CONCLUSIONS

The trial indicated that adding butorphanol to propofol results in a lower incidence of visceral pain after surgery without noticeable fluctuations in circulatory and respiratory functions for gastrointestinal endoscopy patients.

TRIAL REGISTRATION

Clinicaltrials.gov NCT04477733 (PI: Ruquan Han; date of registration: 20/07/2020).

Etomidate versus propofol for sedation in gastrointestinal endoscopy: A systematic review and meta-analysis of outcomes

BACKGROUND

Propofol is increasingly being used for sedation in gastrointestinal endoscopy; however, owing to its side effects, an alternative drug is needed. We aimed to compare the safety, satisfaction, and efficacy outcomes of etomidate versus propofol in patients undergoing gastrointestinal endoscopy, including advanced endoscopic procedures.

METHODS

We systematically searched Embase, PubMed, Cochrane Central Register of Controlled Trials, CINAHL (via EBSCO), China National Knowledge Infrastructure, and Web of Science (1946-April 2020) databases for randomized controlled trials of gastrointestinal endoscopy (upper gastrointestinal endoscopy, colonoscopy, and advanced endoscopy) using etomidate or propofol as sedatives. We pooled odds ratios (ORs) for the safety profile and patient and anesthesiologist satisfaction using mixed-effects conditional logistic models and standardized mean differences for efficiency outcomes using random-effects models.

RESULTS

Twenty-four studies involving 3875 patients were included. Compared with propofol, etomidate resulted in significantly reduced apnea (OR: 0.22; 95% confidence interval [CI]: 0.13-0.37; P < .001), hypoxemia (OR: 0.43; 95% CI: 0.35-0.54; P < .001), hypotension (OR: 0.20; 95% CI: 0.11-0.36; P < .001), and bradycardia (OR: 0.52; 95% CI: 0.30-0.91; P = .02) but led to increased myoclonus (OR: 8.54; 95% CI: 5.20-14.01; P < .001) and lowered anesthesiologist satisfaction (OR: 0.60; 95% CI: 0.39-0.91; P = .02).

CONCLUSION

Etomidate may be a good alternative to propofol for gastrointestinal endoscopy, especially advanced endoscopy. Etomidate appears to be safe as an inducer for hemodynamically unstable patients or older adult patients undergoing gastrointestinal endoscopy.

Median Effective Dose of an Etomidate-Propofol Mixture with Dezocine in Inhibiting the Response to Gastroscope Insertion: Gender Differences in a Randomized Controlled Study Using Dixon’s Up-and-Down Method

What Is Known and Objective. Appropriate doses of sedatives are crucial for a successful, painless upper gastrointestinal endoscopy. Hence, we conducted a randomized controlled study to explore the effects of dezocine on the median effective dose (ED50) of the etomidate-propofol (E-P) mixture in prohibiting response to gastroscope insertion in patients of different genders. Methods. Patients aged 18–65 years enrolled in the study of the American Society of Anesthesiologists (ASA) with physical status I or II undergoing elective gastroscopy were included. Patients were randomly assigned to the male normal saline group (MS group), male dezocine group (MD group), female normal saline group (FS group), and female dezocine group (FD group). All patients were anesthetized with an E-P mixture of 1 : 1. The FD and MD groups were intravenously injected (i.v.) 50 µg/kg dezocine 5 min before anesthesia, while the FS and MS groups were injected with an equal volume of normal saline 5 min before anesthesia. According to the preexperiment, the initial dose of the E-P mixture for the FD and MD groups was 0.4 and 0.3 mL/kg for the FS and MS groups. The variation proportion was set as 0.9 between dosages. Dixon’s up-and-down method was adopted to confirm the dose of the E-P mixture for the next patient, which was reduced if the insertion was performed successfully; otherwise, the dose was increased. Centered isotonic regression was employed to determine the ED50 and 90% confidence interval (CI) values of the E-P mixture in the four groups. The total amount of E-P mixture consumed was recorded as well as the adverse events of patients. Results. The ED50 and 90% CI of the MS, MD, FS, and FD groups were 0.315 (0.285–0.349), 0.206 (0.175–0.237), 0.329 (0.305–0.355), and 0.207 (0.188–0.227) mL/kg, respectively. The MD group was <MS group ( $P\le 0.001$ ), and the FD group was <FS group ( $P\le 0.001$ ); no statistical difference was observed between the MS and FS groups and MD and FD groups. Dezocine reduced the total amount of E-P mixture consumed and the overall incidence of adverse events. What Is New and Conclusion. Dezocine significantly decreased the ED50 of the E-P mixture in inhibiting the response of patients to gastroscope insertion and the occurrence rate of adverse events. Further, gender had no impact on the ED50 of the E-P mixture.

Efficacy and safety of propofol target-controlled infusion combined with butorphanol for sedated colonoscopy

BACKGROUND

Propofol is a short-acting, rapid-recovering anesthetic widely used in sedated colonoscopy for the early detection, diagnosis and treatment of colon diseases. However, the use of propofol alone may require high doses to achieve the induction of anesthesia in sedated colonoscopy, which has been associated with anesthesia-related adverse events (AEs), including hypoxemia, sinus bradycardia, and hypotension. Therefore, propofol co-administrated with other anesthetics has been proposed to reduce the required dose of propofol, enhance the efficacy, and improve the satisfaction of patients receiving colonoscopy under sedation.

AIM

To evaluate the efficacy and safety of propofol target-controlled infusion (TCI) in combination with butorphanol for sedation during colonoscopy.

METHODS

In this controlled clinical trial, a total of 106 patients, who were scheduled for sedated colonoscopy, were prospectively recruited and assigned into three groups to receive different doses of butorphanol before propofol TCI: Low-dose butorphanol group (5 μg/kg, group B1), high-dose butorphanol group (10 μg/kg, group B2), and control group (normal saline, group C). Anesthesia was achieved by propofol TCI. The primary outcome was the median effective concentration (EC50) of propofol TCI, which was measured using the up-and-down sequential method. The secondary outcomes included AEs in perianesthesia and recovery characteristics.

RESULTS

The EC50 of propofol for TCI was 3.03 μg/mL [95% confidence interval (CI): 2.83-3.23 μg/mL] in group B2, 3.41 μg/mL (95%CI: 3.20-3.62 μg/mL) in group B1, and 4.05 μg/mL (95%CI: 3.78-4.34 μg/mL) in group C. The amount of propofol necessary for anesthesia was 132 mg [interquartile range (IQR), 125-144.75 mg] in group B2 and 142 mg (IQR, 135-154 mg) in group B1. Furthermore, the awakening concentration was 1.1 μg/mL (IQR, 0.9-1.2 μg/mL) in group B2 and 1.2 μg/mL (IQR, 1.025-1.5 μg/mL) in group B1. Notably, the propofol TCI plus butorphanol groups (groups B1 and B2) had a lower incidence of anesthesia AEs, when compared to group C. Furthermore, no significant differences were observed in the rates of AEs in perianesthesia, including hypoxemia, sinus bradycardia, hypotension, nausea and vomiting, and vertigo, among group C, group B1 and group B2.

CONCLUSION

The combined use with butorphanol reduces the EC50 of propofol TCI for anesthesia. The decrease in propofol might contribute to the reduced anesthesia-related AEs in patients undergoing sedated colonoscopy.

The median effective concentration of propofol in combination with different doses of esketamine during gastrointestinal endoscopy in adults

We designed a four-arm randomized controlled trial to investigate the median effective concentration (EC50) of propofol in combination with different doses of esketamine inducing appropriate depth of anaesthesia during gastrointestinal endoscopy in adults. One hundred patients aged 18-65 years planning for gastrointestinal endoscopy were divided into four groups randomly: esketamine 0, 0.15, 0.25 and 0.5 mg/kg groups (n = 25). Propofol doses followed the Dixon and Massey up-and-down method with different starting between groups. The primary endpoint was the EC50 of propofol. Secondary outcomes included the cumulative dose of propofol, the duration of the procedure, recovery time, and adverse effects. The EC50 (median, 95% confidence interval) of propofol was significantly less in the esketamine 0.5 mg/kg group compared with the esketamine 0, 0.15, and 0.25 mg/kg groups [1.34 (1.15, 1.54) vs. 3.48 (3.25, 3.71), 2.82 (2.58, 3.07), and 2.36 (2.11, 2.61), respectively; p < 0.001]. The total dose of propofol (mean ± SD) required for the whole procedure was significantly less in the esketamine 0.5 mg/kg group compared with the esketamine 0, 0.15, and 0.25 mg/kg groups [95.5 ± 43.1 vs. 277.4 ± 49.0, 207.8 ± 31.6, and 135.1 ± 27.7, respectively; p < 0.001]. The recovery time was significantly longer in esketamine 0 and 0.5 mg/kg group compared with other two groups (p < 0.001). More patients in the esketamine 0.5 mg/kg group experienced visual disturbance compared with the other groups (p = 0.016). Additionally, the incidence of hypotensionin the esketamine 0 mg/kg group after inducation was higher compared with other groups (p < 0.001). In summary, the administration of esketamine significantly and dose-dependently reduced the dose of propofol required to accomplish procedures.

New sedatives and analgesic drugs for gastrointestinal endoscopic procedures

Procedural sedation has become increasingly common in endoscopy. Sedatives and analgesics induce anxiolysis and amnesia. In addition, an appropriate level of sedation is necessary for safe procedures including therapeutic endoscopy. Midazolam and propofol are the most commonly used drugs in sedative endoscopy. In recent years, the need to ascertain the safety and effectiveness of sedation has increased in practice. Therefore, new sedatives and analgesic drugs for optimal sedative endoscopy, have recently emerged. This article reviews the characteristics of sedatives and analgesics, and describes their clinical use in gastrointestinal endoscopy.

Intravenous Lidocaine Significantly Reduces the Propofol Dose in Elderly Patients Undergoing Gastroscopy: A Randomized Controlled Trial

Objective

Propofol-based sedation has been widely used for gastroscopy, but the risk of respiratory suppression in elderly patients should not be overlooked. Intravenous (IV) lidocaine during surgery can reduce the demand for propofol and the incidence of cardiopulmonary complications. We examined whether IV lidocaine reduces the dose of propofol and the occurrence of adverse events during gastroscopy in elderly patients.

Methods

We conducted a prospective, single-center, double-blind randomized controlled trial in elderly patients aged ≥65 years with ASA I-II. Subjects were randomly assigned to the lidocaine group (Group L, n=70), who received IV 1.5 mg kg⁻¹ lidocaine followed by a continuous infusion of 4 mg kg⁻¹ h⁻¹ lidocaine, or the normal saline group (Group N, n=70), who received an equal volume of saline in the same way.

Results

IV lidocaine reduced the total and maintenance propofol dose in Group L (p<0.001), with no significant effect on the induction dose. The incidence of intraoperative hypoxia (p=0.035), emergency airway management events (p=0.005), duration of gastroscopy (p<0.05), consciousness recovery time (p<0.001), and postoperative pain (p=0.009) were all reduced in Group L. Patient (p=0.025) and gastroscopist (p=0.031) satisfaction was higher in Group L. Intraoperative hemodynamic parameters, the respiratory rate, the incidence of sedation-related events and anesthesiologist satisfaction were similar between the two groups.

Conclusion

IV lidocaine can significantly reduce the amount of propofol, the incidence of hypoxia and postoperative pain during gastroscopy in elderly patients, with a higher patient and gastroscopist satisfaction.

Comparison of a Nasal Mask and Traditional Nasal Cannula During Intravenous Anesthesia for Gastroscopy Procedures: A Randomized Controlled Trial

BACKGROUND:

Hypoxemia can occur during gastroscopy under intravenous anesthesia. The aim of this randomized controlled trial was to evaluate whether oxygenation using a nasal mask can reduce the incidence of hypoxemia during gastroscopy under intravenous anesthesia compared with a traditional nasal cannula.

METHODS:

A total of 574 patients scheduled for gastroscopy under intravenous anesthesia were enrolled and randomly assigned to receive either a nasal mask or a traditional nasal cannula for oxygenation. The primary outcome was the incidence of hypoxemia. The secondary outcomes included the incidence of severe hypoxemia, duration of hypoxemia, minimum oxygen saturation, the proportion of emergency airway management, length of procedure, recovery time, and the satisfaction of the anesthetist and gastroenterologists as well as other adverse events (including cough, hiccups, nausea and vomiting, reflux, aspiration, and laryngospasm).

RESULTS:

A total of 565 patients were included in the analysis: 282 patients in the nasal cannula group and 283 patients in the nasal mask group. The incidence of hypoxemia was lower in the nasal mask group (18.0%) than in the nasal cannula group (27.7%; relative risk [RR] = 0.65; 95% confidence interval [CI], 0.48–0.89; P = .006), and the hypoxemia lasted a median of 18.0 seconds (interquartile range, 10.0–38.8) in the nasal mask group and 32.5 seconds (20.0–53.5) in the nasal cannula group (median difference –14.50; 95% CI, −22.82 to −1.34; P = .047). The proportion of patients requiring emergency airway management was significantly lower in the nasal mask group (8.8%) than in the nasal cannula group (19.1%; RR, 0.46; 95% CI, 0.30–0.73; P < .001). No difference was found in the overall incidence of other adverse events between the 2 groups (nasal mask 20.8%; nasal cannula 17.0%; RR, 1.23; 95% CI, 0.87–1.73; P = .25). Satisfaction was higher with the nasal mask than with the nasal cannula from the perspective of anesthetists (96.1% for nasal mask versus 84.4% for nasal cannula; RR, 1.14; 95% CI, 1.08–1.20; P < .001) and gastroenterologists (95.4% for mask versus 81.9% for cannula; RR, 1.17; 95% CI, 1.10–1.24; P < .001). There were no significant differences in the incidence of severe hypoxemia, minimum oxygen saturation, length of procedure, or recovery time between the 2 groups.

CONCLUSIONS:

Nasal mask oxygenation reduced the incidence of hypoxemia during anesthesia for gastroscopy under intravenous anesthesia.

The Efficacy and Safety of Remimazolam Tosilate versus Etomidate-Propofol in Elderly Outpatients Undergoing Colonoscopy: A Prospective, Randomized, Single-Blind, Non-Inferiority Trial

Objective

The optimal sedation regime during endoscopy remains controversial, especially for elderly outpatients. In this study, we compared the efficacy and safety between remimazolam tosilate (RT) and etomidate-propofol (EP) in elderly outpatients undergoing colonoscopy.

Methods

A total of 260 elderly outpatients undergoing sedative colonoscopy were randomized into two groups. Patients in the RT group received a 0.075-mg/kg maintenance dose of remimazolam following an initial dose of 0.15 mg/kg, whereas patients in the EP group (10 mL:20 mg etomidate plus 10 mL:100 mg propofol) received a 0.05-mL/kg maintenance dose following an initial dose of 0.1 mL/kg to maintain a Modified Observer’s Assessment of Alertness/Sedation score of ≤3 during the procedure. The primary endpoint was the success of the procedure. Secondary endpoints included time metrics, hemodynamics, consumption of fentanyl, etomidate, propofol, and remimazolam, intraoperative body movement, patient and endoscopist satisfaction scores, supplemental dose of sedative and fentanyl, and incidence and severity of adverse events.

Results

The procedure success rate was 96.52% in the RT group and 100% in the EP group. The difference in procedure success rate between the RT and EP groups was −3.48% (95% confidence interval: −6.81%, −0.15%). Four patients in the RT group required rescue midazolam. Compared with patients in the RT group, the onset time of the EP group was significantly lower (p < 0.05), whereas time to fully alert (p = 0.001), ready for discharge (p = 0.001), and hospital discharge (p = 0.002) were all significantly higher in the EP group. However, there were no significant differences in procedure time (p = 0.846) or cecal intubation time (p = 0.320) between the two groups. Although the frequency of intraoperative body movement was higher in the RT group, the difference was not significant (p = 0.508). There were no significant differences in patients’ demographic and baseline characteristics, supplemental doses of sedative and fentanyl, or patient and endoscopist satisfaction scores (p > 0.05). Muscular tremor and pain on injection were recorded more frequently in the EP group (p < 0.05). However, there were no significant differences in hypoxia, respiratory depression, or incidence of postoperative nausea and vomiting. The severity of adverse events was all mild (grade 1) across both groups.

Conclusion

RT may have non-inferior efficacy and a higher safety profile than EP in elderly outpatients undergoing colonoscopy, which suggests that RT may be more suitable for elderly outpatients undergoing colonoscopy.

Physical and Chemical Compatibility of Etomidate and Propofol Injectable Emulsions

INTRODUCTION

The mixture of etomidate and propofol is widely used in clinical practice to improve efficacy of general anesthesia and to minimize side effects. As a thermodynamically unstable system, emulsion is prone to destabilization through mechanisms including coalescence, flocculation, and creaming. Such unwanted phenomenon can induce fat embolism after intravenous administration. This study was aimed to investigate the physical and chemical stability of the mixture of etomidate and propofol in the dosage form of emulsion.

METHODS

This compatibility study focused on the critical quality attributes (CQAs) of drug-containing emulsions, such as appearance, pH, particle size and distribution, zeta potential, the observation under centrifugation, and drug content and impurity.

RESULTS

As the results, there were no significant changes in the CQAs of the mixed emulsions up to 24 h after mixing at refrigeration temperature (4°C), room temperature (25°C), and body temperature (37°C).

CONCLUSIONS

These results demonstrate that etomidate emulsion is physically and chemically compatible with propofol emulsions up to 24 h at 4°C, 25°C, and 37°C, suggesting that etomidate and propofol can be administrated in mixture without adversely affecting product characteristics, at least in vitro.

Anesthetic effect of different doses of butorphanol in patients undergoing gastroscopy and colonoscopy

Background

This study aimed to investigate the anesthetic effect of butorphanol with different doses in patients undergoing gastroscopy and colonoscopy.

Methods

480 patients undergoing gastroscopy and colonoscopy were recruited and randomly divided into four groups to receive different doses of butorphanol (Group A = 2.5 μg/kg, Group B = 5 μg/kg, Group C = 7.5 μg/kg and Group D = 10 μg/kg). Butorphanol was administered 5 min before propofol infusion. The primary outcome was the incidence of body movement. Secondary outcomes were postoperative recovery time, length of stay in the Post-Anesthesia Care Unit (PACU), the total dose of propofol, and the incidence of intraoperative hypoxemia, propofol injection pain, cough, postoperative nausea and vomiting, drowsiness, and dizziness.

Results

The incidence of body movement and the dose of propofol in Group C and D were lower than those in Group A and B (P < 0.05). The incidence and intensity of propofol injection pain and the incidence of cough in Group B, C, and D were lower than those in Group A (P < 0.05). The length of stay in PACU and the incidence of postoperative drowsiness and dizziness were higher in Group D than in Group A, B, and C (P < 0.05).

Conclusion

Intravenous pre-injection of 7.5 μg/kg butorphanol with propofol can be the optimal dosage for patients undergoing gastroscopy and colonoscopy.

Trial registration: Trial registration: Chinese Clinical Trial Registry, ChiCTR2000031506. Registered 3 April 2020—Retrospectively registered, http://www.medresman.org.cn.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-021-01262-8.

Clinical observation of the combined use of propofol and etomidate in painless gastroscopy

OBJECTIVE

This study is aims to compare the anesthetic safety of propofol combined with etomidate for painless gastroscopy.

METHODS

Three hundred patients undergoing painless gastroscopy were randomly assigned to P, PE1, and PE2 groups. Patients were anesthetized with propofol (P group) or propofol combined with etomidate (volume ratio 1: 1, PE1 group; volume ratio 2: 1, PE2 group). The hemodynamics and adverse reactions were observed. The sleep quality satisfaction and nature of dreams were recorded.

RESULTS

Compared with pre-anesthesia, the mean arterial pressure and heart rate of the 3 groups were significantly slower during the examination and at the end of the examination. PE1 group had a higher incidence of muscle spasm, body moving, choking, and deglutition. The incidence of hypoxemia and injection pain was higher in P group. P and PE2 group had higher sleep quality satisfaction and dream incidence after awaking. However, there was no difference in the nature of dreams among 3 groups.

CONCLUSION

Our data indicate that the combination of 10 ml 1.0% propofol and 5 ml 0.2% etomidate for painless gastroscopy reduces adverse reactions while not affecting the patients respiratory function. Moreover, it is safe and effective, which is worthy of clinical application and promotion.

Noninvasive continuous monitoring versus intermittent oscillometric measurements for the detection of hypotension during digestive endoscopy

BACKGROUND

Hemodynamic monitoring during digestive endoscopy is usually minimal and involves intermittent brachial pressure measurements. New continuous noninvasive devices to acquire instantaneous arterial blood pressure may be more sensitive to detect procedural hypotension.

PURPOSE

To compare the ability of noninvasive continuous monitoring with that of intermittent oscillometric measurements to detect hypotension during digestive endoscopy.

METHODS

In this observational prospective study, patients scheduled for gastrointestinal endoscopy and colonoscopy under sedation were monitored using intermittent pressure measurements and a noninvasive continuous technique (ClearSight™, Edwards). Stroke volume was estimated from the arterial pressure waveform. Mean arterial pressure and stroke volume values were recorded at T1 (prior to anesthetic induction), T2 (after anesthetic induction), T3 (gastric insufflation), T4 (end of gastroscopy), T5 (colonic insufflation). Hypotension was defined as mean arterial pressure < 65 mmHg.

RESULTS

Twenty patients (53±17 years) were included. Six patients (30%) had a hypotension detected using intermittent pressure measurements versus twelve patients (60%) using noninvasive continuous monitoring (p = 0.06). Mean arterial pressure decreased during the procedure with respect to T1 (p < 0.05), but the continuous method provided an earlier warning than the intermittent method (T3 vs T4). Nine patients (45%) had at least a 25% reduction in stroke volume, with respect to baseline.

CONCLUSION

Noninvasive continuous monitoring was more sensitive than intermittent measurements to detect hypotension. Estimation of stroke volume revealed profound reductions in systemic flow. Noninvasive continuous monitoring in high-risk patients undergoing digestive endoscopy under sedation could help in detecting hypoperfusion earlier than the usual intermittent blood pressure measurements.

A randomized controlled trial for measuring effects on cognitive functions of adding ketamine to propofol during sedation for colonoscopy

BACKGROUND

The purpose of this study was to evaluate the effects of adding ketamine to propofol on cognitive functions in patients undergoing sedation for colonoscopy.

METHODS

In this randomized, double-blinded, and controlled study, 200 patients were randomly allocated to ketamine/propofol admixture group (Group KP, n = 100), and propofol group (Group P, n = 100). Patients in Group KP received 0.25 mg/kg of ketamine and 0.5 mg/kg of propofol. Patients in Group P received 0.5 mg/kg propofol. Cognitive functions were measured using CogState battery before and after the colonoscopy procedure. Ninety five patients in Group KP and 92 patients in Group P had completed the CogStates tests and were included in the data analysis.

RESULTS

Compared with before procedure baseline, the performance on detection and identification tasks were significantly impaired after the procedure in both Group KP (P = .004, P = .001) and Group P patients (P = .005, P < .001). However, one-card learning accuracy and One-back memory was only impaired in Group KP patients (P = .006, P = .040) after the endoscopy but left intact in Group P patients. Group KP patients showed more severe impairment in one-card learning accuracy compared with Group P patients (P = .044). Group KP patients have better 5 minutes MAP (P = .005) and were also less likely to suffer from complications such as respiratory depression (P = .023) and hypotension (P = .015). OAA/S scores, BIS, MAP, complications, recovery times, and endoscopist and patient satisfaction were similar between the 2 groups.

CONCLUSION

Although adding ketamine to propofol for sedation in colonoscopy provided fewer complications such as respiratory depression and hypotension, it also causes more impairment in cognitive functions.

High-flow nasal oxygenation versus standard oxygenation for gastrointestinal endoscopy with sedation. The prospective multicentre randomised controlled ODEPHI study protocol

INTRODUCTION

Hypoxaemia is a major complication during gastrointestinal endoscopy (GIE) procedures (upper/lower) when performed under deep sedation in the procedure room. Standard oxygen therapy (SOT) is used to prevent hypoxaemia. Data suggest that risk factors for hypoxaemia under deep sedation during GIE are obstructive sleep apnoea syndrome, a body mass index above 30 kg/m², high blood pressure, diabetes, heart disease, age over 60 years old, high American Society of Anesthesiologists physical status class and the association of upper and lower GIE. High-flow nasal oxygenation (HFNO) may potentially improve oxygenation during GIE under deep sedation. We hypothesised that HFNO could decrease the incidence of hypoxaemia in comparison with SOT.

METHODS AND ANALYSIS

The ODEPHI (High-flow nasal oxygenation versus standard oxygenation for gastrointestinal endoscopy with sedation. The prospective multicentre randomised controlled) study is a multicentre randomised controlled trial comparing HFNO to SOT during GIE (upper and/or lower) under deep sedation administered by anaesthesiologists in the procedure room. Three hundred and eighty patients will be randomised with a 1:1 ratio in two parallel groups.The primary outcome is the occurrence of hypoxaemia, defined by a pulse oximetry measurement of peripheral capillary oxygen saturation (SpO₂) below or equal to 92% during the GIE procedure. Secondary outcomes include prolonged hypoxaemia, severe hypoxaemia, need for manoeuvres to maintain upper airway patency and other adverse events.

ETHICS AND DISSEMINATION

This study has been approved by the ethics committee (CPP Sud Est Paris V, France), and patients are included after informed consent. The results will be submitted for publication in peer-reviewed journals. As provided for by French law, patients participating in the study are informed that they have the possibility to ask the investigators, once the study is completed, to be informed of the overall results of the study. Thus, a summary of the results will be sent by post to the participants on request.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT03829293).

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.

Etomidate Sedation for Advanced Endoscopic Procedures

BACKGROUND AND STUDY AIM

Although propofol is widely used for sedation for endoscopic procedures, concerns remain regarding cardiopulmonary adverse events. Etomidate has little effect on the cardiovascular and respiratory systems, but patient satisfaction analysis is lacking. We compared the efficacy and safety of balanced propofol and etomidate sedation during advanced endoscopic procedures.

METHODS

As a randomized noninferiority trial, balanced endoscopic sedation was achieved using midazolam and fentanyl, and patients were randomly assigned to receive propofol (BPS) or etomidate (BES) as add-on drug. The main outcomes were sedation efficacy measured on a 10-point visual analog scale (VAS) and safety.

RESULTS

In total, 186 patients (94 in the BPS group and 92 in the BES group) were evaluated. BES did not show noninferiority in terms of overall patient satisfaction, with a difference in VAS score of -0.35 (97.5 % confidence interval -1.03 to ∞, p = 0.03). Among endoscopists and nurses, BES showed noninferiority to BPS, with differences in VAS scores of 0.06 and 0.08, respectively. Incidence of cardiopulmonary adverse events was lower in the BES group (27.7 versus 14.1 %, p = 0.023). Hypoxia occurred in 5.3 and 1.1 % of patients in the BPS and BES group (p = 0.211). Myoclonus occurred in 12.1 % (11/92) in the BES group. BES had lower risk of overall cardiopulmonary adverse events (odds ratio 0.401, p = 0.018).

CONCLUSIONS

BES was not noninferior to BPS in terms of patient satisfaction. However, BES showed better safety outcomes in terms of cardiopulmonary adverse events.

Comparison of propofol monotherapy and propofol combination therapy for sedation during gastrointestinal endoscopy: A systematic review and meta-analysis

BACKGROUND AND AIM

Previous randomized controlled trials have reported conflicting findings comparing propofol combination therapy (PCT) with propofol monotherapy (PMT) for sedation of patients undergoing gastrointestinal endoscopy. Therefore, a systematic review was carried out to compare the efficacy and safety of PCT and PMT in such patients.

METHODS

We searched MEDLINE, EMBASE and CENTRAL databases to identify all randomized controlled trials that compared the efficacy and safety of PCT and PMT for sedation of patients undergoing gastrointestinal endoscopy. Primary endpoints were incidence of respiratory complications, hypotension and arrhythmia, dose of propofol used, and recovery time. Procedure duration and the satisfaction of patients and doctors were also evaluated.

RESULTS

A total of 2250 patients from 22 studies were included in the final analysis. The combined analysis did not show any difference between PCT and PMT in the incidence of respiratory complications (risk ratio [RR], 0.80; 95% CI, 0.52 to 1.23; I2 = 58.34%), hypotension (RR, 1.06; 95% CI, 0.63 to 1.78; I2 = 72.13%), arrhythmia (RR,1.40; 95% CI, 0.74 to 2.64; I2 = 43.71%), recovery time (standardized mean difference [SMD], 0.16; 95% CI, -0.49 to 0.81; I2 = 95.9%), procedure duration (SMD, 0.04; 95% CI, -0.05 to 0.14; I2 = 0.0%), patient satisfaction (SMD, 0.13; 95% CI, -0.26 to 0.52; I2 = 89.63%) or doctor satisfaction (SMD, 0.01; 95% CI, -0.15 to 0.17; I2 = 0.00%). However, the dose of propofol used was significantly lower in PCT than in PMT (SMD, -1.38; 95% CI, -1.99 to -0.77; I2 = 97.70%).

CONCLUSION

PCT showed comparable efficacy and safety to PMT with respect to respiratory complications, hypotension and arrhythmia, recovery time, procedure duration, patient satisfaction, and doctor satisfaction. However, the average dose of propofol used was higher in PMT.

Effect of the midazolam added with propofol-based sedation in esophagogastroduodenoscopy: A randomized trial

BACKGROUND AND AIM

Although propofol has been widely used for sedation during esophagogastroduodenoscopy (EGD), adverse events including hypoxia and hypotension may be a concern in the propofol-based sedation. We aimed to analyze whether administration of midazolam would improve safety and efficacy of propofol-based sedation in EGD.

METHODS

One hundred twenty patients who were scheduled to undergo diagnostic EGD were randomly assigned to either midazolam plus propofol (MP) or propofol alone groups. In the MP group, 2 mg of midazolam and 10 mg of propofol were given initially. In the propofol alone group, 40-60 mg of propofol was given initially. In both groups, 20 mg of propofol was given repeatedly to maintain moderate sedation as needed. Vital signs including oxygen saturation were monitored every 2 min. After the patients fully recovered, satisfaction score was investigated from endoscopists, nurses, and patients, respectively.

RESULTS

The baseline characteristics did not differ between the MP and propofol alone groups. The mean required doses of propofol was (mean ± standard deviation) 0.3 ± 0.3 and 0.8 ± 0.2 mg/kg in the MP and propofol alone groups, respectively (P < 0.001). In addition, sedation-related adverse events and recovery time did not differ between the two groups. The proportion of satisfactory did not differ between the two groups (MP vs propofol alone; proportion; patient, 95.0% vs 93.3%, P > 0.999; endoscopist, 73.3% vs 80.0%, P = 0.064; nurse, 73.3% vs 76.7%, P = 0.551).

CONCLUSION

Adding midazolam to propofol did not reduced the safety and efficacy, and sedation using propofol alone could be suitable for sedation during diagnostic EGD.

Efficacy and safety of etomidate-based sedation compared with propofol-based sedation during ERCP in low-risk patients: a double-blind, randomized, noninferiority trial

BACKGROUND AND AIMS

Etomidate is a short-acting intravenous hypnotic with a safety profile that is superior to alternative drugs such as propofol. However, there is a lack of evidence on the safety of etomidate in ERCP. The objective of this study was to compare efficacy and safety profiles of etomidate and propofol for endoscopic sedation.

METHODS

This single-center, randomized, double-blind, noninferiority trial included patients with American Society of Anesthesiologists (ASA) physical status I to II who had been scheduled for ERCP. All patients received .05 mg/kg midazolam intravenously as pretreatment before receiving etomidate or propofol. Either etomidate or propofol was then administered according to group allocation. The primary endpoint was an overall respiratory event. A noninferiority margin of 10% was assumed.

RESULTS

Sixty-three and 64 patients were enrolled in the etomidate and propofol groups, respectively. Respiratory events were identified in 10 patients (15.6%) in the etomidate group and 16 patients (25.4%) on the propofol group, with a rate difference of -9.8% (1-sided 97.5% confidence interval, -∞ to 4.2%). The overall incidence of cardiovascular events tended to be higher in the etomidate group (67.2% vs 50.8%, P = .060). In particular, tachycardia (heart rate > 100 beats/min) was more common in the etomidate group than in the propofol group (64.1% vs 34.9%, P = .001). Transient hypotension tended to be less common in the etomidate group (6.3 vs 15.9%, P = .084).

CONCLUSIONS

Etomidate-based sedation during ERCP was noninferior to propofol-based sedation in terms of the overall incidence of respiratory events in patients with ASA physical status I to II. (International Clinical Trials Registry Platform number: KCT0001926.).

The Comparison of Etomidate and Propofol Anesthesia in Patients Undergoing Gastrointestinal Endoscopy: A Systematic Review and Meta-Analysis

INTRODUCTION

Etomidate and propofol played an important role in the sedation of patients undergoing gastrointestinal endoscopy. We conducted a systematic review and meta-analysis to compare their efficacy and safety.

MATERIALS AND METHODS

PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases were systematically searched. Randomized controlled trials assessing the effect of etomidate versus propofol for the anesthesia of patients undergoing gastrointestinal endoscopy were included. Two investigators independently searched articles, extracted data, and assessed the quality of included studies. The primary outcomes were anesthesia duration and recovery time. Meta-analysis was performed using random-effect model.

RESULTS

Six randomized controlled trials involving 1115 patients were included in the meta-analysis. Overall, compared with propofol, etomidate resulted in comparable anesthesia duration [standard mean difference (Std. MD)=-0.03; 95% confidence interval (CI), -0.16 to 0.10; P=0.66], recovery time (Std. MD=0.25; 95% CI, -0.42 to 0.92; P=0.47), mean arterial pressure at intubation (Std. MD=0.44; 95% CI, -0.26 to 1.15; P=0.21), heart pulse at intubation (Std. MD=0.93; 95% CI, -0.69 to 2.55; P=0.26), SPO2 at intubation (Std. MD=-0.52; 95% CI, -1.04 to 0.01; P=0.05), patient satisfaction [odds risk (OR)=0.42; 95% CI, 0.11-1.66; P=0.22], hypotension (OR=0.14; 95% CI, 0.02-1.22; P=0.07), changes of heart rate (OR=0.97; 95% CI, 0.61-1.53; P=0.88), nausea-vomiting (OR=2.02; 95% CI, 0.73-5.57; P=0.17), and the reduction in apnea or hyoxemia (OR=0.39; 95% CI, 0.24-0.64; P=0.0002), and injection pain (OR=0.03; 95% CI, 0.01-0.08; P<0.00001), but the increase in myoclonus (OR=8.54; 95% CI, 3.14-23.20; P<0.0001).

CONCLUSIONS

Between etomidate and propofol, no significant difference was revealed regarding anesthesia duration, recovery time, mean arterial pressure at intubation, heart pulse at intubation, SPO2 at intubation, patient satisfaction, hypotension, changes of heart rate and nausea-vomiting. Compared with propofol, etomidate showed reduced apnea or hyoxemia, and injection pain, but with an increased myoclonus.

Propofol decreases etomidate-related myoclonus in gastroscopy

OBJECTIVE

Myoclonus, a common complication during intravenous induction with etomidate, is bothersome to both anesthesiologists and patients. This study explored the preventive effect of pretreatment with propofol on etomidate-related myoclonus.

METHODS

This was a prospective, double-blind, clinical, randomized controlled study. Totally, 363 patients who were scheduled for a short-duration, painless gastrointestinal endoscopy were divided into 5 groups. Four groups received 0 mg/kg (E group), 0.25 mg/kg (LPE group), 0.50 mg/kg (MPE group), or 0.75 mg/kg (HPE group) propofol pretreatment before etomidate anesthesia. Another group only received 1 to 2 mg/kg of propofol (P group) as anesthesia. The incidence and severity of myoclonus, patient circulation and respiratory status, and intraoperative and postoperative complications were recorded.

RESULTS

The incidence of myoclonus in the LPE group (26.8%), MPE group (16.4%), HPE group (14.9%), and P group (0) was lower than the E group (48.6%, P < .05). The incidence of grade 1, 2, and 3 of myoclonus in the LPE group, MPE group, HPE group, and P group was significantly lower than the E group, and that in the P group was lower than the LPE group (P < .05). The incidence of hypoxemia in the P group was higher than the E group, and the incidence of adverse events in the HPE group and P group was lower than the E group (P < .05).

DISCUSSION

Pretreatment with propofol was feasible for preventing etomidate-related myoclonus. Furthermore, as propofol dosage increased, its effect on reducing the incidence and severity of myoclonic movements induced by etomidate increased.