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Simulation-Based Gastrointestinal Endoscopy Sedations: A Novel Validation to Multidrug Pharmacodynamic Modeling. Pharmaceutics 2022; 14:pharmaceutics14102056. [PMID: 36297491 PMCID: PMC9610933 DOI: 10.3390/pharmaceutics14102056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 09/15/2022] [Accepted: 09/20/2022] [Indexed: 11/16/2022] Open
Abstract
Pharmacodynamic models have described the interactions between anesthetics. Applying the models to clinical practice is still problematic due to inherent limitations: 1. modeling conditions are different from practice. 2. One model can only describe one endpoint. To tackle these, we propose a new method of model validation for recovery and intraprocedural sedation adequacy with a three-drug pharmacodynamic model using six published clinical studies that contain midazolam, opioid, and propofol. Mean drug dose, intraprocedural sedation level, procedure, and recovery time are extracted from each study. Simulated drug regimens are designed to best approximate study conditions. A published deep sedation model is used for simulation. Model-predicted recovery time and intraprocedural sedation scores are compared with the original clinical study outcomes. The model successfully predicted recovery times in eight out of nine regimens. Lower doses of midazolam are associated with faster recovery. Model prediction of intraprocedural sedation level was compatible with the clinical studies in five out of seven regimens. The three-drug pharmacodynamic model describes the course of gastrointestinal endoscopy sedations from clinical studies well. Model predictions are consistent with the results from clinical studies. The approach implies that large scale validation can be performed repeatedly.
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Okamoto A, Kamata K, Miyata T, Yoshikawa T, Ishikawa R, Yamazaki T, Nakai A, Omoto S, Minaga K, Yamao K, Takenaka M, Chiba Y, Sakurai T, Nishida N, Kitano M, Kudo M. Bispectral index-guided propofol sedation during endoscopic ultrasonography. Clin Endosc 2022; 55:558-563. [PMID: 35817564 PMCID: PMC9329640 DOI: 10.5946/ce.2022.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 02/21/2022] [Indexed: 11/22/2022] Open
Abstract
Background/Aims Bispectral index (BIS) monitors process and display electroencephalographic data are used to assess the depth of anesthesia. This study retrospectively evaluated the usefulness of BIS monitoring during endoscopic ultrasonography (EUS).
Methods This study included 725 consecutive patients who underwent EUS under sedation with propofol. BIS monitoring was used in 364 patients and was not used in 361. The following parameters were evaluated: (1) median dose of propofol; (2) respiratory and circulatory depression; (3) occurrence of body movements; (4) awakening score >8 at the time; and (5) awakening score 2 hours after leaving the endoscopy room.
Results The BIS group received a significantly lower median dose of propofol than the non-BIS group (159.2 mg vs. 167.5 mg; p=0.015) in all age groups. For patients aged ≥75 years, the reduction in heart rate was significantly lower in the BIS group than in the non-BIS group (1.2% vs. 9.1%; p=0.023). Moreover, the occurrence of body movements was markedly lower in the BIS group than in the non-BIS group (8.5% vs. 39.4%; p<0.001).
Conclusions During EUS examination, BIS monitoring is useful for maintaining a constant depth of anesthesia, especially in patients 75 years of age or older.
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Affiliation(s)
- Ayana Okamoto
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osakasayama, Japan
| | - Ken Kamata
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osakasayama, Japan
| | - Takeshi Miyata
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osakasayama, Japan
| | - Tomoe Yoshikawa
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osakasayama, Japan
| | - Rei Ishikawa
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osakasayama, Japan
| | - Tomohiro Yamazaki
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osakasayama, Japan
| | - Atsushi Nakai
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osakasayama, Japan
| | - Shunsuke Omoto
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osakasayama, Japan
| | - Kosuke Minaga
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osakasayama, Japan
| | - Kentaro Yamao
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osakasayama, Japan
| | - Mamoru Takenaka
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osakasayama, Japan
| | - Yasutaka Chiba
- Clinical Research Center, Kindai University Hospital, Osakasayama, Japan
| | - Toshiharu Sakurai
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osakasayama, Japan
| | - Naoshi Nishida
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osakasayama, Japan
| | - Masayuki Kitano
- Second Department of Internal Medicine, Wakayama Medical University School of Medicine, Wakayama, Japan
| | - Masatoshi Kudo
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osakasayama, Japan
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Jang JM, Park SB, Yoon JY, Kwak MS, Cha JM. Gastrointestinal and non-gastrointestinal complication rates associated with diagnostic esophagogastroduodenoscopy under sedation. Medicine (Baltimore) 2022; 101:e29266. [PMID: 35583537 PMCID: PMC9276211 DOI: 10.1097/md.0000000000029266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 04/20/2022] [Indexed: 01/04/2023] Open
Abstract
Esophagogastroduodenoscopy (EGD) under sedation may result in gastrointestinal (GI) and non-GI complications. However, no previous studies have reported 30-day GI and non-GI complications after diagnostic EGD under sedation.We conducted a retrospective, observational study of 30-day GI and non-GI complication rates after outpatient diagnostic EGD under sedation in subjects ≥18 years between January 2012 and December 2017 based on a common data model database. Thirty-day complication rates were compared with EGD under sedation or not, type of sedation drugs (midazolam only vs midazolam/propofol) and age groups (18-64 year vs ≥65 year) for GI (bleeding and perforation) and non-GI complications (pneumonia, acute myocardial infarction, congestive heart failure and cerebral stroke).In total, 39,910 were performed with sedation (midazolam only, n = 16,033 and midazolam/propofol, n = 23,864) and 22,894 were performed without sedation. Elderly patients significantly favored EGD without sedation (P < .01). GI and non-GI complication rates were similar between EGD under sedation and without sedation (all P > .1) except for acute myocardial infarction rate, which was significantly higher in EGD without sedation than EGD under sedation (1.7/10,000 vs 0.3/10,000 persons, P = .043). All GI and non-GI complications were also similar between the midazolam/propofol and midazolam only groups as well as between young and old patients (all P > .1).Outpatient diagnostic EGD under sedation has an excellent safety profile. In addition, it can be safely performed with midazolam only or midazolam/propofol and in young and old patients.
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Affiliation(s)
- Ji Min Jang
- Division of Gastroenterology, Department of Internal Medicine, Kyung Hee University Hospital at Gang Dong, Seoul, Korea
| | - Su Bee Park
- Division of Gastroenterology, Department of Internal Medicine, Kyung Hee University Hospital at Gang Dong, Seoul, Korea
| | - Jin Young Yoon
- Division of Gastroenterology, Department of Internal Medicine, Kyung Hee University Hospital at Gang Dong, Seoul, Korea
- Division of Gastroenterology, Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, Korea
| | - Min Seob Kwak
- Division of Gastroenterology, Department of Internal Medicine, Kyung Hee University Hospital at Gang Dong, Seoul, Korea
- Division of Gastroenterology, Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, Korea
| | - Jae Myung Cha
- Division of Gastroenterology, Department of Internal Medicine, Kyung Hee University Hospital at Gang Dong, Seoul, Korea
- Division of Gastroenterology, Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, Korea
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Wang P, Chen Y, Guo Y, Cao J, Wang H, Mi W, Xu L. Comparison of propofol-nalbuphine and propofol-fentanyl sedation for patients undergoing endoscopic retrograde cholangiopancreatography: a double-blind, randomized controlled trial. BMC Anesthesiol 2022; 22:47. [PMID: 35172747 PMCID: PMC8848940 DOI: 10.1186/s12871-022-01578-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 01/24/2022] [Indexed: 12/02/2022] Open
Abstract
Background Endoscopic retrograde cholangiopancreatography (ERCP) has been increasingly used to treat patients with biliary/pancreatic duct obstruction or stricture outside the operating room. Effective and safe sedation techniques are needed because of painful stimuli and the long duration of the ERCP procedure.Nalbuphine has been shown to cause less respiratory depression during sedation than similar cases without nalbuphine. This study compared the effects of propofol-nalbuphine (PN) and propofol-fentanyl (PF) sedation in patients undergoing ERCP. Methods Four hundred patients scheduled for ERCP procedures were divided into two groups: the PF group (receiving PF sedation,n = 199) and the PN group (receiving PN sedation,n = 201). Vital signs, adverse events during surgery, patient movement scores, pain scores, and adverse events one day post-ERCP were recorded. Results Stable haemodynamics were observed in both groups.Compared to the PF group, the PN group showed significantly decreased respiratory depression (P < 0.0001) and surgical interruptions (P = 0.048).Nalbuphine decreased patient movement by reducing pain from ERCP. Conclusion Nalbuphine, instead of fentanyl, precipitated less respiratory depression while permitting adequate/equivalent sedation for ERCP and therefore provides more efficient and safer sedation. Trial registration ChiCTR, ChiCTR1800016018, Registered 7 May 2018, http://www.chictr.org.cn/showproj.aspx?proj=27085
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Affiliation(s)
- Peiqi Wang
- Department of Anaesthesiology, The First Medical Center, Chinese PLA General Hospital, Beijing, 100853, China
| | - Yan Chen
- Department of Anaesthesiology, The First Medical Center, Chinese PLA General Hospital, Beijing, 100853, China
| | - Ying Guo
- Department of Anaesthesiology, The First Medical Center, Chinese PLA General Hospital, Beijing, 100853, China
| | - Jiangbei Cao
- Department of Anaesthesiology, The First Medical Center, Chinese PLA General Hospital, Beijing, 100853, China
| | - Hong Wang
- Department of Anaesthesiology, The First Medical Center, Chinese PLA General Hospital, Beijing, 100853, China
| | - Weidong Mi
- Department of Anaesthesiology, The First Medical Center, Chinese PLA General Hospital, Beijing, 100853, China.
| | - Longhe Xu
- Department of Anaesthesiology, The First Medical Center, Chinese PLA General Hospital, Beijing, 100853, China. .,Department of Anaesthesiology, The Third Medical Center, Chinese PLA General Hospital, Beijing, 100853, China.
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Nam JH, Jang DK, Lee JK, Kang HW, Kim BW, Jang BI. Propofol Alone versus Propofol in Combination with Midazolam for Sedative Endoscopy in Patients with Paradoxical Reactions to Midazolam. Clin Endosc 2021; 55:234-239. [PMID: 34634857 PMCID: PMC8995981 DOI: 10.5946/ce.2021.126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 05/19/2021] [Indexed: 11/14/2022] Open
Abstract
Background/Aims The efficacy of propofol in gastrointestinal endoscopy for patients with midazolam-induced paradoxical reactions remains unclarified. This study aimed to compare the efficacy and safety of propofol-based sedation in patients who previously experienced paradoxical reactions. Methods This was a prospective, single-blinded, randomized controlled pilot study. Participants with a history of paradoxical reactions to midazolam during a previous esophagogastroduodenoscopy were recruited and randomly assigned to group I (propofol monosedation) or group II (combination of propofol and midazolam). The primary endpoint was the occurrence of a paradoxical reaction. Results A total of 30 participants (mean age, 54.7±12.6 years; male, 19/30) were randomly assigned to group I (n=16) or group II (n=14). There were no paradoxical reactions in group I, but there were two in group II, without a significant difference (p=0.209). The mean dose of propofol was higher in group I than in group II (p=0.002). Meanwhile, the procedure and recovery times did not differ between groups. Conclusions Propofol-based sedation was safe and effective for patients who experienced paradoxical reactions to midazolam. However, caution is needed because few cases of paradoxical reaction again can happen in group II in which midazolam was readministered.
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Affiliation(s)
- Ji Hyung Nam
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Dong Kee Jang
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Jun Kyu Lee
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Hyoun Woo Kang
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Byung-Wook Kim
- Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
| | - Byung Ik Jang
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
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A plea for a unified approach to sedation in gastrointestinal endoscopy in Romania: results from a prospective multicentric trial. ROMANIAN JOURNAL OF INTERNAL MEDICINE 2021; 59:303-311. [DOI: 10.2478/rjim-2021-0011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Indexed: 11/20/2022] Open
Abstract
Abstract
Background. Adequate sedation is a prerequisite for quality endoscopic examination of the digestive tract. We aimed to evaluate the current practices and safety profile of sedation for gastrointestinal endoscopy in Romania and its impact on the technical success of the procedure and procedure-related adverse events.
Methods. We conducted a prospective, multicentric, observational study including all patients undergoing digestive endoscopic procedures under various degrees of sedation. We collected data regarding the endoscopic procedure, type and degree of sedation, drug regimens, personnel in charge of sedation, and relevant patient related information. The main study outcome was the rate of sedation-related adverse events; secondary study outcomes included procedure-related adverse events and the impact of sedation on procedure success.
Results. 1,043 consecutive endoscopic procedures from eight Romanian endoscopy units were included in our study. Sedation regimens were highly variable between participating centers, with 566 (54%) of procedures being performed under sedation provided by an anaesthesiologist. Sedation-related adverse events occurred in 40 cases (3.8%), most of them were mild respiratory and cardiovascular events and all reversed spontaneously.
On multivariate analysis, male gender, procedure type (endoscopic ultrasound and endoscopic retrograde cholangiopancreatography) and deep sedation were risk factors for complications. The endoscopy unit, ASA status, age and type of sedative did not influence the complication rate.
Conclusion. In conclusion, sedation for endoscopic procedures is generally safe, despite a high variability in sedation practices between centers in Romania. Establishing a national guideline on sedation for gastrointestinal endoscopy will ensure consistent and safe practice for these procedures.
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Lee JG, Yoo KS, Byun YJ. Continuous infusion versus intermittent bolus injection of propofol during endoscopic retrograde cholangiopancreatography. Korean J Intern Med 2020; 35:1338-1345. [PMID: 32126750 PMCID: PMC7652665 DOI: 10.3904/kjim.2018.233] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 11/15/2018] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND/AIMS It is unclear whether continuous infusion or intermittent bolus injection of propofol is better for achieving adequate sedation in endoscopic retrograde cholangiopancreatography (ERCP). We aimed to compare the efficacy and safety of continuous infusion and intermittent bolus injection of propofol during therapeutic ERCP. METHODS In this prospective study, we randomly assigned 232 patients undergoing therapeutic ERCP to either continuous infusion (CI group, n = 113) or intermittent bolus injection (BI group, n = 119) of propofol. The primary outcome was the quality of sedation as assessed by the endoscopist. Other sedation-related parameters included sedation induction time, total dose of propofol, recovery time, involuntary patient movement, and adverse events. RESULTS Overall satisfaction with sedation by the endoscopist and monitoring nurse were significantly higher in the CI group than the BI group (mean satisfaction score, 9.66 vs. 8.0 and 9.47 vs. 7.96, respectively, p < 0.01 for both). However, patients in the CI group had a significantly longer sedation induction time (5.28 minutes vs. 4.34 minutes, p < 0.01) and received a higher dose of propofol than patients in the BI group (4.22 mg/kg vs. 2.08 mg/kg, p < 0.01). There was no significant difference in adverse events between the two groups. CONCLUSION Continuous infusion of propofol during therapeutic ERCP had the advantage over intermittent bolus injection of maintaining a constant level of sedation without increasing adverse events. However, it was associated with an increased total dose of propofol and prolonged sedation induction time.
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Affiliation(s)
- Jae Gon Lee
- Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea
| | - Kyo-Sang Yoo
- Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea
- Correspondence to Kyo-Sang Yoo, M.D. Department of Internal Medicine, Hanyang University Guri Hospital, 153 Gyeongchunro, Guri 11923, Korea Tel: +82-31-560-2229 Fax: +82-31-555-2998 E-mail:
| | - Young Jae Byun
- Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea
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Kim JH, Byun S, Choi YJ, Kwon HJ, Jung K, Kim SE, Park MI, Moon W, Park SJ. Efficacy and Safety of Etomidate in Comparison with Propofol or Midazolam as Sedative for Upper Gastrointestinal Endoscopy. Clin Endosc 2020; 53:555-561. [PMID: 32229801 PMCID: PMC7548146 DOI: 10.5946/ce.2019.210] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 02/04/2020] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND/AIMS In this study, we compared the efficacy and safety of etomidate with those of propofol or midazolam for the maintenance of sedation during endoscopy. METHODS The study enrolled patients who underwent sedative endoscopy in our hospital and divided them into three groups. Patients in each group were administered midazolam as induction therapy and were subsequently administered either midazolam (M + M group), propofol (M + P group), or etomidate (M + E group) as maintenance medication. The primary outcome was overall cardiovascular and respiratory adverse events. RESULTS In total, 105 patients who underwent sedative endoscopic examination were enrolled. The outcomes related to the procedure and sedation were not significantly different among the groups. Overall cardiovascular and respiratory adverse events were observed in 9 patients (25.7%) in the M + M group, 8 patients (23.5%) in the M + P group, and 10 patients (27.8%) in the M + E group. The logistic regression analysis revealed that etomidate use was not an independent risk factor for overall cardiovascular and respiratory adverse events. CONCLUSION The outcomes following the use of etomidate for maintenance after induction with midazolam for sedation in upper gastrointestinal endoscopy were not inferior to those following midazolam or propofol use from the perspectives of safety and efficacy.
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Affiliation(s)
- Jae Hyun Kim
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Sanghwan Byun
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Youn Jung Choi
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Hye Jung Kwon
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Kyoungwon Jung
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Sung Eun Kim
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Moo In Park
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Won Moon
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Seun Ja Park
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
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Delgado AADA, de Moura DTH, Ribeiro IB, Bazarbashi AN, dos Santos MEL, Bernardo WM, de Moura EGH. Propofol vs traditional sedatives for sedation in endoscopy: A systematic review and meta-analysis. World J Gastrointest Endosc 2019; 11:573-588. [PMID: 31839876 PMCID: PMC6885729 DOI: 10.4253/wjge.v11.i12.573] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 08/17/2019] [Accepted: 09/11/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Propofol is commonly used for sedation during endoscopic procedures. Data suggests its superiority to traditional sedatives used in endoscopy including benzodiazepines and opioids with more rapid onset of action and improved post-procedure recovery times for patients. However, Propofol requires administration by trained healthcare providers, has a narrow therapeutic index, lacks an antidote and increases risks of cardio-pulmonary complications.
AIM To compare, through a systematic review of the literature and meta-analysis, sedation with propofol to traditional sedatives with or without propofol during endoscopic procedures.
METHODS A literature search was performed using MEDLINE, Scopus, EMBASE, the Cochrane Library, Scopus, LILACS, BVS, Cochrane Central Register of Controlled Trials, and The Cumulative Index to Nursing and Allied Health Literature databases. The last search in the literature was performed on March, 2019 with no restriction regarding the idiom or the year of publication. Only randomized clinical trials with full texts published were included. We divided sedation therapies to the following groups: (1) Propofol versus benzodiazepines and/or opiate sedatives; (2) Propofol versus Propofol with benzodiazepine and/or opioids; and (3) Propofol with adjunctive benzodiazepine and opioid versus benzodiazepine and opioid. The following outcomes were addressed: Adverse events, patient satisfaction with type of sedation, endoscopists satisfaction with sedation administered, dose of propofol administered and time to recovery post procedure. Meta-analysis was performed using RevMan5 software version 5.39.
RESULTS A total of 23 clinical trials were included (n = 3854) from the initial search of 6410 articles. For Group I (Propofol vs benzodiazepine and/or opioids): The incidence of bradycardia was not statistically different between both sedation arms (RD: -0.01, 95%CI: −0.03–+0.01, I2: 22%). In 10 studies, the incidence of hypotension was not statistically difference between sedation arms (RD: 0.01, 95%CI: −0.02–+0.04, I2: 0%). Oxygen desaturation was higher in the propofol group but not statistically different between groups (RD: −0.03, 95%CI: −0.06–+0.00, I2: 25%). Patients were more satisfied with their sedation in the benzodiazepine + opioid group compared to those with monotherapy propofol sedation (MD: +0.89, 95%CI: +0.62–+1.17, I2: 39%). The recovery time after the procedure showed high heterogeneity even after outlier withdrawal, there was no statistical difference between both arms (MD: -15.15, 95%CI: −31.85–+1.56, I2: 99%). For Group II (Propofol vs propofol with benzodiazepine and/or opioids): Bradycardia had a tendency to occur in the Propofol group with benzodiazepine and/or opioid-associated (RD: -0.08, 95%CI: −0.13–−0.02, I2: 59%). There was no statistical difference in the incidence of bradycardia (RD: -0.00, 95%CI: −0.08–+0.08, I2: 85%), desaturation (RD: −0.00, 95%CI: −0.03–+0.02, I2: 44%) or recovery time (MD: -2.04, 95%CI: −6.96–+2.88, I2: 97%) between sedation arms. The total dose of propofol was higher in the propofol group with benzodiazepine and/or opiates but with high heterogeneity. (MD: 70.36, 95%CI: +53.11–+87.60, I2: 61%). For Group III (Propofol with benzodiazepine and opioid vs benzodiazepine and opioid): Bradycardia and hypotension was not statistically significant between groups (RD: -0.00, 95%CI: −0.002–+0.02, I2: 3%; RD: 0.04, 95%CI: −0.05–+0.13, I2: 77%). Desaturation was evaluated in two articles and was higher in the propofol + benzodiazepine + opioid group, but with high heterogeneity (RD: 0.15, 95%CI: 0.08–+0.22, I2: 95%).
CONCLUSION This meta-analysis suggests that the use of propofol alone or in combination with traditional adjunctive sedatives is safe and does not result in an increase in negative outcomes in patients undergoing endoscopic procedures.
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Affiliation(s)
- Aureo Augusto de Almeida Delgado
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403000, Brazil
| | - Diogo Turiani Hourneaux de Moura
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403000, Brazil
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Igor Braga Ribeiro
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403000, Brazil
| | - Ahmad Najdat Bazarbashi
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Marcos Eduardo Lera dos Santos
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403000, Brazil
| | - Wanderley Marques Bernardo
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403000, Brazil
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Julián Gómez L, Fuentes Coronel A, López Ramos C, Ochoa Sangrador C, Fradejas Salazar P, Martín Garrido E, Conde Gacho P, Bailador Andrés C, García-Alvarado M, Rascarachi G, Castillo Trujillo R, Rodríguez Gómez SJ. A clinical trial comparing propofol versus propofol plus midazolam in diagnostic endoscopy of patients with a low anesthetic risk. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2019; 110:691-698. [PMID: 30318893 DOI: 10.17235/reed.2018.5289/2017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND OBJECTIVES propofol and midazolam are two of the most commonly used sedatives in upper gastrointestinal endoscopy (UGE). The objective of this study was to evaluate these two sedation regimens administered to patients who underwent an UGE with regard to security, efficiency, quality of exploration and patient response. PATIENTS AND METHODS a prospective, randomized and double-blind study was performed which included 83 patients between 18 and 80 years of age of a low anesthetic risk (ASA - American Society of Anesthesiologists- I-II) who underwent a diagnostic UGE. Patients were randomized to receive sedation with either placebo plus propofol (group A) or midazolam plus propofol (group B). RESULTS in group A, 42 patients received a placebo bolus (saline solution) and on average up to 115 mg of propofol in boluses of 20 mg. In group B, 41 patients received 3 mg of midazolam and an average of up to 83 mg of propofol in boluses of 20 mg. There were no significant differences in the adverse effects observed in either group and all adverse events were treated conservatively. The patients in group B (midazolam plus propofol) entered the desired sedated state more quickly with no variation in the overall time of the exploration. The quality of the endoscopic evaluation was similar in both groups and the patients were equally satisfied regardless of the sedatives they received. CONCLUSIONS the use of midazolam plus propofol as a sedative does not affect the overall exploration time, a lower dose of propofol can be used and it is as safe as administering propofol as a monotherapy while providing the same level of both exploration quality and patient approval.
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11
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Kim JH, Kim DH, Kim JH. Low-dose midazolam and propofol use for conscious sedation during diagnostic endoscopy. Kaohsiung J Med Sci 2019; 35:160-167. [PMID: 30887720 DOI: 10.1002/kjm2.12028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Accepted: 11/22/2018] [Indexed: 01/26/2023] Open
Abstract
To find the right sedation technique for different types of treatment methods and the right amount of sedatives so the chances of side effects happening can be reduced. This was a retrospective cohort analysis conducted on prospectively collected data. Patients who underwent esophagogastroduodenoscopy only (E group) were sub-divided into two subgroups: (a) Those who received 0.5 mg/kg of propofol (E-a), (b) Those who received 0.025 mg/kg of midazolam and 0.5 mg/kg of propofol (E-b). Patients who underwent esophagogastroduodenoscopy with colonoscopy (EC group) were also sub-divided into three subgroups: (a) Those who received 0.5 mg/kg of propofol (EC-a), (b) Those who received 0.025 mg/kg of midazolam and 0.5 mg/kg of propofol (EC-b), (c) Those who received 25 mg (12.5 mg if body weight < 50 kg or age > 70) of meperidine and 0.025 mg/kg of midazolam along with 0.5 mg/kg of propofol (EC-c). When the level of target was not reached, 10-20 mg of propofol was additionally injected. Sedation efficacy and safety were then compared among groups. E-b and EC-b decreased the overall amount of propofol and reduced side effect of temporary hypoxemia compared to E-a and EC-a. EC-b shortened patient recovery time compared to EC-c and reduced paradoxical reaction. In terms of the patient satisfaction and patient cooperation by endoscopists, there were no significant differences between EC-b and EC-c. Concomitant use of low dosages of both propofol and midazolam is found to be useful and safe when endoscopy needs to be performed.
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Affiliation(s)
- Joo Hyung Kim
- Department of Surgery, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Dae Hyun Kim
- Department of Health Services Administration, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jin Hong Kim
- Department of Internal Medicine, Ajou University School of Medicine, Suwon, Republic of Korea
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12
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Lapidus A, Gralnek IM, Suissa A, Yassin K, Khamaysi I. Safety and efficacy of endoscopist-directed balanced propofol sedation during endoscopic retrograde cholangiopancreatography. Ann Gastroenterol 2019; 32:303-311. [PMID: 31040629 PMCID: PMC6479659 DOI: 10.20524/aog.2019.0360] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Accepted: 01/17/2019] [Indexed: 12/17/2022] Open
Abstract
Background Endoscopist-directed balanced propofol sedation (BPS) appears to be safe and effective for routine endoscopy. However, there are limited data on its use in endoscopic retrograde cholangiopancreatography (ERCP). We evaluated the safety and efficacy of endoscopist-directed BPS for ERCP, and compared patient outcomes with anesthesiologist-administered moderate sedation. Methods This was a retrospective cohort study, using prospectively collected endoscopy data from a tertiary care medical center where endoscopist-directed BPS during ERCP is routine practice. Adverse outcomes included need for bag-mask ventilation or intubation, aborted ERCP due to sedation, hospital admission post-ERCP (outpatients)/change in the level of care (inpatients), and death within 24 h. Results A total of 501 patients underwent ERCP with the use of endoscopist-directed BPS: Cohort 1 - 380 (76%) inpatients, mean age 64.1, 46% male, 24% American Society of Anesthesiologists physical status (ASA) score I, 65% ASA II, 11% ASA III. Concurrently, 24 patients received anesthesiologist-administered moderate sedation: Cohort 2 - 19 (79%) inpatients, mean age 65.0, 67% male, 12% ASA I, 25% ASA II, 38% ASA III, 25% ASA IV. In Cohort 1, none of the adverse outcomes were observed. Propofol dose was inversely correlated with age (r=-0.42, P<0.001), ASA score (r=-0.19, P<0.001), and Mallampati score (r=-0.24, P<0.001). One patient in Cohort 2 who received anesthesiologist-administered BPS required bag-mask ventilation and the ERCP was prematurely aborted because of the sedation. There were no deaths from any cause within 24 h of ERCP. Conclusion Endoscopist-directed BPS appears safe, efficacious, and feasible for ASA I-III patients undergoing inpatient or ambulatory ERCP.
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Affiliation(s)
- Alon Lapidus
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa (Alon Lapidus, Ian M. Gralnek, Iyad Khamaysi), Israel
| | - Ian M Gralnek
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa (Alon Lapidus, Ian M. Gralnek, Iyad Khamaysi), Israel.,Ellen and Pinchas Mamber Institute of Gastroenterology, Hepatology, and Nutrition, Emek Medical Center, Afula (Ian M. Gralnek), Israel
| | - Alain Suissa
- Department of Gastroenterology, Rambam Health Care Campus, Haifa (Alain Suissa, Kamel Yassin, Iyad Khamaysi), Israel
| | - Kamel Yassin
- Department of Gastroenterology, Rambam Health Care Campus, Haifa (Alain Suissa, Kamel Yassin, Iyad Khamaysi), Israel
| | - Iyad Khamaysi
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa (Alon Lapidus, Ian M. Gralnek, Iyad Khamaysi), Israel.,Department of Gastroenterology, Rambam Health Care Campus, Haifa (Alain Suissa, Kamel Yassin, Iyad Khamaysi), Israel
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Han SJ, Lee TH, Yang JK, Cho YS, Jung Y, Chung IK, Park SH, Park S, Kim SJ. Etomidate Sedation for Advanced Endoscopic Procedures. Dig Dis Sci 2019; 64:144-151. [PMID: 30054843 DOI: 10.1007/s10620-018-5220-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 07/18/2018] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Su Jung Han
- Division of Gastroenterology, Department of Internal Medicine, Digestive Disease Center, Cheonan Hospital, Soonchunhyang University School of Medicine, 31, Sooncheonhyang 6-gil, Dongnam-gu, Cheonan-si, Chungcheongnam-do, 31151, Republic of Korea
| | - Tae Hoon Lee
- Division of Gastroenterology, Department of Internal Medicine, Digestive Disease Center, Cheonan Hospital, Soonchunhyang University School of Medicine, 31, Sooncheonhyang 6-gil, Dongnam-gu, Cheonan-si, Chungcheongnam-do, 31151, Republic of Korea.
| | - Jae Kook Yang
- Division of Gastroenterology, Department of Internal Medicine, Digestive Disease Center, Cheonan Hospital, Soonchunhyang University School of Medicine, 31, Sooncheonhyang 6-gil, Dongnam-gu, Cheonan-si, Chungcheongnam-do, 31151, Republic of Korea
| | - Young Sin Cho
- Division of Gastroenterology, Department of Internal Medicine, Digestive Disease Center, Cheonan Hospital, Soonchunhyang University School of Medicine, 31, Sooncheonhyang 6-gil, Dongnam-gu, Cheonan-si, Chungcheongnam-do, 31151, Republic of Korea
| | - Yunho Jung
- Division of Gastroenterology, Department of Internal Medicine, Digestive Disease Center, Cheonan Hospital, Soonchunhyang University School of Medicine, 31, Sooncheonhyang 6-gil, Dongnam-gu, Cheonan-si, Chungcheongnam-do, 31151, Republic of Korea
| | - Il-Kwun Chung
- Division of Gastroenterology, Department of Internal Medicine, Digestive Disease Center, Cheonan Hospital, Soonchunhyang University School of Medicine, 31, Sooncheonhyang 6-gil, Dongnam-gu, Cheonan-si, Chungcheongnam-do, 31151, Republic of Korea
| | - Sang-Heum Park
- Division of Gastroenterology, Department of Internal Medicine, Digestive Disease Center, Cheonan Hospital, Soonchunhyang University School of Medicine, 31, Sooncheonhyang 6-gil, Dongnam-gu, Cheonan-si, Chungcheongnam-do, 31151, Republic of Korea
| | - Suyeon Park
- Department of Statistics, Soonchunhyang University School of Medicine, Seoul, Republic of Korea
| | - Sun-Joo Kim
- Division of Gastroenterology, Department of Internal Medicine, Digestive Disease Center, Cheonan Hospital, Soonchunhyang University School of Medicine, 31, Sooncheonhyang 6-gil, Dongnam-gu, Cheonan-si, Chungcheongnam-do, 31151, Republic of Korea
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Yoon SW, Choi GJ, Lee OH, Yoon IJ, Kang H, Baek CW, Jung YH, Woo YC. Comparison of propofol monotherapy and propofol combination therapy for sedation during gastrointestinal endoscopy: A systematic review and meta-analysis. Dig Endosc 2018; 30:580-591. [PMID: 29526045 DOI: 10.1111/den.13050] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 03/05/2018] [Indexed: 01/22/2023]
Abstract
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.
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Affiliation(s)
- Sang Won Yoon
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Geun Joo Choi
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Oh Haeng Lee
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Il Jae Yoon
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Hyun Kang
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Chong Wha Baek
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Yong Hun Jung
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Young Cheol Woo
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Korea
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Kim MG, Park SW, Kim JH, Lee J, Kae SH, Jang HJ, Koh DH, Choi MH. Etomidate versus propofol sedation for complex upper endoscopic procedures: a prospective double-blinded randomized controlled trial. Gastrointest Endosc 2017; 86:452-461. [PMID: 28284883 DOI: 10.1016/j.gie.2017.02.033] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 02/23/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Although a growing body of evidence demonstrates that propofol-induced deep sedation can be effective and performed safely, cardiopulmonary adverse events have been observed frequently. Etomidate is a new emerging drug that provides hemodynamic and respiratory stability, even in high-risk patient groups. The objective of this study was to compare safety and efficacy profiles of etomidate and propofol for endoscopic sedation. METHODS A total of 128 patients undergoing EUS were randomized to receive either etomidate or propofol blinded administered by a registered nurse. The primary outcome was the proportion of patients with any cardiopulmonary adverse events. RESULTS Overall cardiopulmonary adverse events were identified in 22 patients (34.38%) of the etomidate group and 33 patients (51.56%) of the propofol group, without significant difference (P = .074). However, the incidence of oxygen desaturation (4/64 [6.25%] vs 20/64 [31.25%]; P =.001) and respiratory depression (5/64 [7.81%] vs 21/64 [32.81%]; P =.001) was significantly lower in the etomidate group than in the propofol group. The frequency of myoclonus was significantly higher in the etomidate group (22/64 [34.37%]) compared with the propofol group (8/64 [12.50%]) (P =.012). Repeated measure analysis of variance revealed significant effects of sedation group and time on systolic blood pressure (etomidate group greater than propofol group). Physician satisfaction was greater in the etomidate group than in the propofol group. CONCLUSIONS Etomidate administration resulted in fewer respiratory depression events and had a better sedative efficacy than propofol; however, it was more frequently associated with myoclonus and increased blood pressure during endoscopic procedures. (Clinical trial registration number: KCT0001701.).
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Affiliation(s)
- Mi Gang Kim
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
| | - Se Woo Park
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
| | - Jae Hyun Kim
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
| | - Jin Lee
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
| | - Sea Hyub Kae
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
| | - Hyun Joo Jang
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
| | - Dong Hee Koh
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
| | - Min Ho Choi
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
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Han SJ, Lee TH, Park SH, Cho YS, Lee YN, Jung Y, Choi HJ, Chung IK, Cha SW, Moon JH, Cho YD, Kim SJ. Efficacy of midazolam- versus propofol-based sedations by non-anesthesiologists during therapeutic endoscopic retrograde cholangiopancreatography in patients aged over 80 years. Dig Endosc 2017; 29:369-376. [PMID: 28181706 DOI: 10.1111/den.12841] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 02/06/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIM As society ages, the need for endoscopic retrograde cholangiopancreatography (ERCP) is increasing. This prospective comparative study evaluated the safety and efficacy of midazolam- versus propofol-based sedations by non-anesthesiologists during therapeutic ERCP in patients over 80 years of age. METHODS A total of 100 patients over 80 years of age who required therapeutic ERCP were enrolled and randomly received midazolam + fentanyl (MF group) or propofol + fentanyl (PF group) sedation. Endoscopic sedation was titrated to a moderate level and carried out by trained registered nurses. Main outcome measurements were sedation safety in terms of cardiopulmonary components and efficacy measured on a 10-point visual analogue scale (VAS). RESULTS Regarding safety, hypoxia occurred in seven (14%) in the MF group and in eight patients (16%) in the PF group (P = 0.779). Increased O2 supply was more frequent in the PF group (32% vs 42%), albeit not significantly so. There were no differences in the frequency of hypotension, bradycardia or tachycardia between the two groups. Mean VAS score for overall satisfaction with sedation by patients, endoscopists, and nurses and the scores for pain during the procedures were not different between the two groups. There was no significant difference in the procedure outcomes or rate of ERCP-related complications. CONCLUSIONS There were no significant differences of safety and efficacy between midazolam- and propofol-based sedation in patients over 80 years of age. Increased O2 supply was more frequent in the propofol group, but the prevalence of hypoxia did not differ significantly.
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Affiliation(s)
- Su Jung Han
- Digestive Disease Center, Department of Internal Medicine, Soonchunhyang University School of Medicine, Cheonan, South Korea
| | - Tae Hoon Lee
- Digestive Disease Center, Department of Internal Medicine, Soonchunhyang University School of Medicine, Cheonan, South Korea
| | - Sang-Heum Park
- Digestive Disease Center, Department of Internal Medicine, Soonchunhyang University School of Medicine, Cheonan, South Korea
| | - Young Sin Cho
- Digestive Disease Center, Department of Internal Medicine, Soonchunhyang University School of Medicine, Cheonan, South Korea
| | - Yun Nah Lee
- Digestive Disease Center, Department of Internal Medicine, Soonchunhyang University School of Medicine, Bucheon, South Korea
| | - Yunho Jung
- Digestive Disease Center, Department of Internal Medicine, Soonchunhyang University School of Medicine, Cheonan, South Korea
| | - Hyun Jong Choi
- Digestive Disease Center, Department of Internal Medicine, Soonchunhyang University School of Medicine, Bucheon, South Korea
| | - Il-Kwun Chung
- Digestive Disease Center, Department of Internal Medicine, Soonchunhyang University School of Medicine, Cheonan, South Korea
| | - Sang-Woo Cha
- Digestive Disease Center, Department of Internal Medicine, Soonchunhyang University School of Medicine, Seoul, Korea
| | - Jong Ho Moon
- Digestive Disease Center, Department of Internal Medicine, Soonchunhyang University School of Medicine, Bucheon, South Korea
| | - Young Deok Cho
- Digestive Disease Center, Department of Internal Medicine, Soonchunhyang University School of Medicine, Seoul, Korea
| | - Sun-Joo Kim
- Digestive Disease Center, Department of Internal Medicine, Soonchunhyang University School of Medicine, Cheonan, South Korea
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Gouda B, Gouda G, Borle A, Singh A, Sinha A, Singh PM. Safety of non-anesthesia provider administered propofol sedation in non-advanced gastrointestinal endoscopic procedures: A meta-analysis. Saudi J Gastroenterol 2017; 23:133-143. [PMID: 28611336 PMCID: PMC5470372 DOI: 10.4103/sjg.sjg_501_16] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND/AIMS The aim of the study was to evaluate the safety of non-anesthesia provider (NAPP) administered propofol sedation in patients undergoing non-advanced gastrointestinal (GI) endoscopic procedures. MATERIALS AND METHODS Pubmed, Embase, Cochrane central register of controlled trials, Scopus, and Web of Science databases were searched for prospective observational trials involving non-advanced endoscopic procedures. From a total of 608 publications, 25 [colonoscopy (9), upper GI endoscopy (5), and combined procedures (11)] were identified to meet inclusion criteria and were analyzed. Data was analyzed for hypoxia rates, airway intervention rates, and airway complication rates. RESULTS A total of 137,087 patients were involved. A total of 2931 hypoxia episodes (defined as an oxygen saturation below 90%) were reported with a pooled hypoxia rate of 0.014 (95% CI being 0.008-0.023). Similarly, pooled airway intervention rates and pooled airway complication rates were 0.002 (95% CI being 0.006-0.001) and 0.001 (95% CI being 0.000-0.001), respectively. CONCLUSIONS The rates of adverse events in patients undergoing non-advanced GI endoscopic procedures with NAPP sedation are extremely small. Similar data for anesthesia providers is not available. It is prudent for anesthesia providers to demonstrate their superiority in prospective randomized controlled trials, if they like to retain exclusive ownership over propofol sedation in patients undergoing GI endoscopy.
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Affiliation(s)
- Basavana Gouda
- Department of Anesthesia, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA,Address for correspondence: Dr. Basavana Gouda, Department of Anesthesia, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA. E-mail:
| | - Gowri Gouda
- Department of Anesthesia, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anuradha Borle
- Department of Anesthesia, All India Institute of Medical Sciences, New Delhi, India
| | - Akash Singh
- Department of Anesthesia, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ashish Sinha
- Department of Anesthesiology and Critical Care Medicine, Lewis Katz School of Medicine, Medicine Education and Research, Philadelphia, PA 19140, USA
| | - Preet M. Singh
- Department of Anesthesia, All India Institute of Medical Sciences, New Delhi, India
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Abstract
OPINION STATEMENT Sedation practices in the endoscopy suite have changed dramatically in the decades since the introduction of routine colonoscopy and esophagogastroduodenoscopy (EGD). Patients initially received moderate sedation (or even no sedation), but now frequently receive monitored anesthesia care (MAC). This significant shift has introduced anesthesiologists to the endoscopy suite along with new sedative medications and safety concerns. Appreciating the ramifications of this change requires an understanding of sedation depth, patient selection, drug use, sedation delivery, patient monitoring, recovery from sedation, and patient outcomes. Furthermore, the changing landscape of healthcare quality and reimbursement challenges us to provide the best possible care for our patients in the most economical way possible. The endoscopy suite is a unique sedation environment, and it is the purpose of this article to review those elements that contribute to a uniquely demanding work environment.
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Development and Validation of a Prediction Model for Admission After Endoscopic Retrograde Cholangiopancreatography. Clin Gastroenterol Hepatol 2015; 13:2323-32.e1-9. [PMID: 26122761 PMCID: PMC4655134 DOI: 10.1016/j.cgh.2015.06.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 06/12/2015] [Accepted: 06/12/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS In outpatients undergoing endoscopic retrograde cholangiopancreatography (ERCP) with anesthesia, rates of and risk factors for admission are unclear. We aimed to develop a model that would allow physicians to predict hospitalization of patients during postanesthesia recovery. METHODS We conducted a retrospective study of data from ERCPs performed on outpatients from May 2012 through October 2013 at the Indiana University School of Medicine. Medical records were abstracted for preanesthesia, intra-anesthesia, and early (within the first hour) postanesthesia characteristics potentially associated with admission. Significant factors associated with admission were incorporated into a logistic regression model to identify subgroups with low, moderate, or high probabilities for admission. The population was divided into training (first 12 months) and validation (last 6 months) sets to develop and test the model. RESULTS We identified 3424 ERCPs during the study period; 10.7% of patients were admitted to the hospital, and 3.7% developed post-ERCP pancreatitis. Postanesthesia recovery times were significantly longer for patients requiring admission (362.6 ± 213.0 minutes vs 218.4 ± 71.8 minutes for patients not admitted; P < .0001). A higher proportion of admitted patients had high-risk indications. Admitted patients also had more severe comorbidities, higher baseline levels of pain, longer procedure times, performance of sphincter of Oddi manometry, higher pain during the first hour after anesthesia, and greater use of opiates or anxiolytics. A multivariate regression model identified patients who were admitted with a high level of accuracy in the training set (area under the curve, 0.83) and fair accuracy in the validation set (area under the curve, 0.78). On the basis of this model, nearly 50% of patients could be classified as low risk for admission. CONCLUSION By using factors that can be assessed through the first hour after ERCP, we developed a model that accurately predicts which patients are likely to be admitted to the hospital. Rates of admission after outpatient ERCP are low, so a policy of prolonged observation might be unnecessary.
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Khoi CS, Wong JJ, Wang HC, Lu CW, Lin TY. Age correlates with hypotension during propofol-based anesthesia for endoscopic retrograde cholangiopancreatography. ACTA ACUST UNITED AC 2015; 53:131-4. [PMID: 26627000 DOI: 10.1016/j.aat.2015.10.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2015] [Revised: 10/07/2015] [Accepted: 10/19/2015] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure used for diagnostic and therapeutic purposes. Most of the patients may feel pain, anxiety, and discomfort during this procedure, so conscious sedation is usually used during ERCP. General anesthesia would be considered if conscious sedation fails to achieve the requirement of the endoscopists. Several studies showed that propofol-based sedation could provide a better recovery profile. However, propofol has a narrow therapeutic window and complications may occur beyond this window. The present study aimed to find out the complications and the associated risk factors during ERCP procedure under propofol-based deep sedation. METHODS We retrospectively reviewed data from anesthetic and procedure records of the patients who underwent ERCP under propofol-based deep sedation from January 2006 to July 2010 at Far Eastern Memorial Hospital, Taipei, Taiwan. All propofol-based deep sedations were conducted by anesthesiologists. The incidence of complications was determined and the independent risk factors identified by the multivariable logistic regression model. RESULT Propofol-based deep sedation was provided for 552 patients who received ERCP procedure. The majority of the patients were male, the mean age was 60 ± 16 years and American Society of Anesthesiologists physical status II-III. Almost 30% of patients experienced hypotension during the procedure, although no mortality or morbidity was associated with this complication. Sex, age, anesthetic time, American Society of Anesthesiologists status, hypertension, and arrhythmia were significantly different (p < 0.05) between patients with hypotension and without hypotension during the procedure. Multivariable logistic regression identified sex and age to be the independent predictors of hypotension. CONCLUSION Hypotension was the most frequent anesthetic complication during procedure under propofol-based deep sedation, but this method was safe and effective under appropriate monitoring. Age is the strongest predictor of hypotension and therefore propofol-based deep sedation should be conducted with caution in the elderly.
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Affiliation(s)
- Chong-Sun Khoi
- Department of Anesthesiology, Far Eastern Memorial Hospital, Ban-Chiao, Taipei County, Taiwan
| | - Jen-Jeng Wong
- Department of Anesthesiology, Far Eastern Memorial Hospital, Ban-Chiao, Taipei County, Taiwan
| | - Hao-Chin Wang
- Department of Anesthesiology, Far Eastern Memorial Hospital, Ban-Chiao, Taipei County, Taiwan
| | - Cheng-Wei Lu
- Department of Anesthesiology, Far Eastern Memorial Hospital, Ban-Chiao, Taipei County, Taiwan; Department of Mechanical Engineering, Yuan Ze University, Chung-Li, Taiwan.
| | - Tzu-Yu Lin
- Department of Anesthesiology, Far Eastern Memorial Hospital, Ban-Chiao, Taipei County, Taiwan; Department of Mechanical Engineering, Yuan Ze University, Chung-Li, Taiwan
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Haytural C, Aydınlı B, Demir B, Bozkurt E, Parlak E, Dişibeyaz S, Saraç A, Özgök A, Kazancı D. Comparison of Propofol, Propofol-Remifentanil, and Propofol-Fentanyl Administrations with Each Other Used for the Sedation of Patients to Undergo ERCP. BIOMED RESEARCH INTERNATIONAL 2015; 2015:465465. [PMID: 26576424 PMCID: PMC4631853 DOI: 10.1155/2015/465465] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Revised: 07/22/2015] [Accepted: 07/28/2015] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Using single anesthetic agent in endoscopic retrograde cholangiopancreatography (ERCP) may lead to inadequate analgesia and sedation. To achieve the adequate analgesia and sedation the single anesthetic agent doses must be increased which causes undesirable side effects. For avoiding high doses of single anesthetic agent nowadays combination with sedative agents is mostly a choice for analgesia and sedation for ERCP. AIM The aim of this study is to investigate the effects of propofol alone, propofol + remifentanil, and propofol + fentanyl combinations on the total dose of propofol to be administered during ERCP and on the pain scores after the process. MATERIALS AND METHOD This randomized study was performed with 90 patients (ASA I-II-III) ranging between 18 and 70 years of age who underwent sedation/analgesia for elective ERCP. The patients were administered only propofol (1.5 mg/kg) in Group Ι, remifentanil (0.05 μg/kg) + propofol (1.5 mg/kg) combination in Group II, and fentanyl (1 μg/kg) + propofol (1.5 mg/kg) combination in Group III. All the patients' sedation levels were assessed with the Ramsey Sedation Scale (RSS). Their recovery was assessed with the Aldrete and Numerical Rating Scale Score (NRS) at 10 min intervals. RESULTS The total doses of propofol administered to the patients in the three groups in this study were as follows: 375 mg in Group I, 150 mg in Group II, and 245 mg in Group III. CONCLUSION It was observed that, in the patients undergoing ERCP, administration of propofol in combination with an opioid provided effective and reliable sedation, reduced the total dose of propofol, increased the practitioner satisfaction, decreased the pain level, and provided hemodynamic stability compared to the administration of propofol alone.
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Affiliation(s)
- Candan Haytural
- Anesthesia Clinic, Türkiye Yüksek Ihtisas Education and Research Hospital, Kızılay S. No. 4, Sıhhıye, Altındağ, 06810 Ankara, Turkey
| | - Bahar Aydınlı
- Anesthesia Clinic, Türkiye Yüksek Ihtisas Education and Research Hospital, Kızılay S. No. 4, Sıhhıye, Altındağ, 06810 Ankara, Turkey
| | - Berna Demir
- Anesthesia Clinic, Türkiye Yüksek Ihtisas Education and Research Hospital, Kızılay S. No. 4, Sıhhıye, Altındağ, 06810 Ankara, Turkey
| | - Elif Bozkurt
- Anesthesia Clinic, Caycuma State Hospital, Zonguldak, Turkey
| | - Erkan Parlak
- Gastroenterology Clinic, Sakarya University Faculty of Medicine, Sakarya, Turkey
| | - Selçuk Dişibeyaz
- Gastroenterology Clinic, Türkiye Yüksek İhtisas Hospital, Ankara, Turkey
| | - Ahmet Saraç
- Anesthesia Clinic, Türkiye Yüksek Ihtisas Education and Research Hospital, Kızılay S. No. 4, Sıhhıye, Altındağ, 06810 Ankara, Turkey
| | - Ayşegül Özgök
- Anesthesia Clinic, Türkiye Yüksek Ihtisas Education and Research Hospital, Kızılay S. No. 4, Sıhhıye, Altındağ, 06810 Ankara, Turkey
| | - Dilek Kazancı
- Anesthesia Clinic, Türkiye Yüksek Ihtisas Education and Research Hospital, Kızılay S. No. 4, Sıhhıye, Altındağ, 06810 Ankara, Turkey
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Shin S, Oh TG, Chung MJ, Park JY, Park SW, Chung JB, Song SY, Cho J, Park SH, Yoo YC, Bang S. Conventional versus Analgesia-Oriented Combination Sedation on Recovery Profiles and Satisfaction after ERCP: A Randomized Trial. PLoS One 2015; 10:e0138422. [PMID: 26402319 PMCID: PMC4581832 DOI: 10.1371/journal.pone.0138422] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 08/27/2015] [Indexed: 12/28/2022] Open
Abstract
Background The importance of providing effective analgesia during sedation for complex endoscopic procedures has been widely recognized. However, repeated administration of opioids in order to achieve sufficient analgesia may carry the risk of delayed recovery after propofol based sedation. This study was done to compare recovery profiles and the satisfaction of the endoscopists and patients between conventional balanced propofol sedation and analgesia-oriented combination sedation for patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). Methods Two hundred and two adult patients scheduled for ERCP were sedated by either the Conventional (initial bolus of meperidine with propofol infusion) or Combination (repeated bolus doses of fentanyl with propofol infusion) method. Recovery profiles, satisfaction levels of the endoscopists and patients, drug requirements and complications were compared between groups. Results Patients of the Combination Group required significantly less propofol compared to the Conventional Group (135.0 ± 68.8 mg vs. 165.3 ± 81.7 mg, P = 0.005). Modified Aldrete scores were not different between groups throughout the recovery period, and recovery times were also comparable between groups. Satisfaction scores were not different between the two groups in both the endoscopists and patients (P = 0.868 and 0.890, respectively). Conclusions Considering the significant reduction in propofol dose, the non-inferiority of recovery profiles and satisfaction scores of the endoscopists and patients, analgesia oriented combination sedation may be a more safe yet effective sedative method compared to conventional balanced propofol sedation during ERCP.
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Affiliation(s)
- Seokyung Shin
- Department of Anesthesiology and Pain Medicine, Severance Hospital, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50–1 Yonsei-ro, Seodaemun-gu, 03722, Seoul, Korea
| | - Tak Geun Oh
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, 50–1 Yonsei-ro, Seodaemun-gu, 03722, Seoul, Korea
| | - Moon Jae Chung
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, 50–1 Yonsei-ro, Seodaemun-gu, 03722, Seoul, Korea
| | - Jeong Youp Park
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, 50–1 Yonsei-ro, Seodaemun-gu, 03722, Seoul, Korea
| | - Seung Woo Park
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, 50–1 Yonsei-ro, Seodaemun-gu, 03722, Seoul, Korea
| | - Jae Bok Chung
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, 50–1 Yonsei-ro, Seodaemun-gu, 03722, Seoul, Korea
| | - Si Young Song
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, 50–1 Yonsei-ro, Seodaemun-gu, 03722, Seoul, Korea
| | - Jooyoun Cho
- Department of Anesthesiology and Pain Medicine, Severance Hospital, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50–1 Yonsei-ro, Seodaemun-gu, 03722, Seoul, Korea
| | - Sang-Hun Park
- Department of Anesthesiology and Pain Medicine, Severance Hospital, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50–1 Yonsei-ro, Seodaemun-gu, 03722, Seoul, Korea
| | - Young Chul Yoo
- Department of Anesthesiology and Pain Medicine, Severance Hospital, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50–1 Yonsei-ro, Seodaemun-gu, 03722, Seoul, Korea
- * E-mail: (SB); (YCY)
| | - Seungmin Bang
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, 50–1 Yonsei-ro, Seodaemun-gu, 03722, Seoul, Korea
- * E-mail: (SB); (YCY)
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Safety of Non-anesthesia Provider-Administered Propofol (NAAP) Sedation in Advanced Gastrointestinal Endoscopic Procedures: Comparative Meta-Analysis of Pooled Results. Dig Dis Sci 2015; 60:2612-27. [PMID: 25732719 DOI: 10.1007/s10620-015-3608-x] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Accepted: 02/21/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS The aim of the study was to evaluate the safety of non-anesthesia provider (NAAP)-administered propofol sedation for advanced endoscopic procedures with those of anesthesia provider (AAP). METHODS PubMed, EMBASE, Cochrane Central Register of Controlled Trials, Scopus, and Web of Science databases were searched for prospective observational trials involving advanced endoscopic procedures. From a total of 519 publications, 26 were identified to meet inclusion criteria (10 AAPs and 16 NAAPs) and were analyzed. Data were analyzed for hypoxia rate, airway intervention rates, endoscopist, and patient satisfaction scores and total propofol administered. RESULTS Total number of procedures in NAAP and AAP groups was 3018 and 2374, respectively. Pooled hypoxia (oxygen saturation less than 90 %) rates were 0.133 (95 % CI 0.117-0.152) and 0.143 (95 % CI 0.128-0.159) in NAAP and AAP, respectively. Similarly, pooled airway intervention rates were 0.035 (95 % CI 0.026-0.047) and 0.133 (95 % CI 0.118-0.150), respectively. Pooled patient satisfaction rate, pooled endoscopist satisfaction rate, and mean propofol administered dose for NAAP were 7.22 (95 % CI 7.17-7.27), 6.03 (95 % CI 5.94-6.11), and 251.44 mg (95 % CI 244.39-258.49) in that order compared with 9.82 (95 % CI 9.76-9.88), 9.06 (95 % CI 8.91-9.21), and 340.32 mg (95 % CI 327.30-353.33) for AAP. CONCLUSIONS The safety of NAAP sedation compared favorably with AAP sedation in patients undergoing advanced endoscopic procedures. However, it came at the cost of decreased patient and endoscopist satisfaction.
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Burtea DE, Dimitriu A, Maloş AE, Săftoiu A. Current role of non-anesthesiologist administered propofol sedation in advanced interventional endoscopy. World J Gastrointest Endosc 2015; 7:981-986. [PMID: 26265991 PMCID: PMC4530331 DOI: 10.4253/wjge.v7.i10.981] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 06/21/2015] [Accepted: 07/23/2015] [Indexed: 02/05/2023] Open
Abstract
Complex and lengthy endoscopic examinations like endoscopic ultrasonography and/or endoscopic retrograde cholangiopancreatography benefit from deep sedation, due to an enhanced quality of examinations, reduced discomfort and anxiety of patients, as well as increased satisfaction for both the patients and medical personnel. Current guidelines support the use of propofol sedation, which has the same rate of adverse effects as traditional sedation with benzodiazepines and/or opioids, but decreases the procedural and recovery time. Non-anesthesiologist administered propofol sedation has become an option in most of the countries, due to limited anesthesiology resources and the increasing evidence from prospective studies and meta-analyses that the procedure is safe with a similar rate of adverse events with traditional sedation. The advantages include a high quality of endoscopic examination, improved satisfaction for patients and doctors, as well as decreased recovery and discharge time. Despite the advantages of non-anesthesiologist administered propofol, there is still a continuous debate related to the successful generalization of the procedures.
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Lee SJ, Lee TH, Park SH, Lee YN, Jung Y, Choi HJ, Cha SW, Moon JH, Cho YD, Kim SJ. Efficacy of carbon dioxide versus air insufflation according to different sedation protocols during therapeutic endoscopic retrograde cholangiopancreatography: prospective, randomized, double-blind study. Dig Endosc 2015; 27:512-521. [PMID: 25625612 DOI: 10.1111/den.12448] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Accepted: 01/21/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND AIM Therapeutic endoscopic retrograde cholangiopancreatography (ERCP) tends to require considerable air insufflation, which results in abdominal pain or distension. We investigated the efficacy of carbon dioxide (CO2 ) compared with air insufflation when using two different sedation protocols in therapeutic ERCP. METHODS Patients who required therapeutic ERCP were randomly assigned to four groups based on preliminary data: air insufflation with balanced propofol sedation (BPS), air with propofol + opioid sedation (PS), CO2 with BPS, and CO2 with PS. Post-ERCP abdominal pain, distension and nausea by the 10-point visual analogue scale (VAS), and gas volume score (GVS) by the four-point ordinal scale were measured according to the time interval. Overall satisfaction with sedation, sedation efficacy, and complications were also measured. RESULTS The CO2 with BPS group showed lowest mean VAS score for abdominal pain (immediately after recovery, P = 0.002; and 3 h post-ERCP, P = 0.047) and distension (immediately after recovery, P = 0.018; 3 h post-ERCP, P < 0.01; and 24 h post-ERCP, P = 0.042). Overall satisfaction with sedation was greater in the CO2 with BPS group (P = 0.005). Mean GVS at 2 h and 12 h post-ERCP was significantly lower in the CO2 with BPS group (P < 0.05). There were no significant differences in procedure or sedation-related complications. CONCLUSION CO2 with BPS showed the lowest VAS score for early abdominal pain, distension and GVS, and had a higher score for overall satisfaction for sedation.
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Affiliation(s)
- Su Jin Lee
- Digestive Disease Center, Department of Internal Medicine, Soonchunhyang University Hospital, Soonchunhyang University School of Medicine, Cheonan, Republic of Korea
| | - Tae Hoon Lee
- Digestive Disease Center, Department of Internal Medicine, Soonchunhyang University Hospital, Soonchunhyang University School of Medicine, Cheonan, Republic of Korea
| | - Sang-Heum Park
- Digestive Disease Center, Department of Internal Medicine, Soonchunhyang University Hospital, Soonchunhyang University School of Medicine, Cheonan, Republic of Korea
| | | | - Yunho Jung
- Digestive Disease Center, Department of Internal Medicine, Soonchunhyang University Hospital, Soonchunhyang University School of Medicine, Cheonan, Republic of Korea
| | | | | | | | | | - Sun-Joo Kim
- Digestive Disease Center, Department of Internal Medicine, Soonchunhyang University Hospital, Soonchunhyang University School of Medicine, Cheonan, Republic of Korea
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Management of anesthetic emergencies and complications outside the operating room. Curr Opin Anaesthesiol 2015; 27:437-41. [PMID: 24762955 DOI: 10.1097/aco.0000000000000088] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
PURPOSE OF REVIEW Anesthesia outside the operating room is commonly uncomfortable and risky. In this setting, anesthetic emergencies or complications may occur. This review aims to report the most recent updates regarding the management of prehospital anesthesia, anesthesia in the trauma and emergency rooms, and anesthesia for endoscopy and interventional radiology. RECENT FINDINGS After tracheal intubation failure, airway control of outpatients could be achieved by pharmacologically assisted laryngeal mask insertion. Management of traumatic injured patients is best guided in the frame of checklists. Monitoring sedation in this setting is challenging notably because of the threat of haemodynamic instability. Unfortunately, BIS monitoring cannot be recommended to guide sedation in this setting. Ketamine can be used to prevent hypotension during prehospital anesthesia or procedural sedation, especially as its neuroprotective effects have been recently best understood. Target-controlled infusion propofol administration with small concentration increments is adapted to prevent hypotension and hypoxaemia during sedation for gastrointestinal endoscopy and interventional radiology. Target-controlled infusion remifentanil administration is also adapted to many procedures. SUMMARY Anesthesia outside the operating room requires careful monitoring to avoid side-effects and education of nonanaesthetists when they are involved. A useful tool is to continuously improve the protocols and checklists to make anesthesia in this setting safer.
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Cheriyan DG, Byrne MF. Propofol use in endoscopic retrograde cholangiopancreatography and endoscopic ultrasound. World J Gastroenterol 2014; 20:5171-5176. [PMID: 24833847 PMCID: PMC4017032 DOI: 10.3748/wjg.v20.i18.5171] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Revised: 01/12/2014] [Accepted: 03/13/2014] [Indexed: 02/07/2023] Open
Abstract
Compared to standard endoscopy, endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) are often lengthier and more complex, thus requiring higher doses of sedatives for patient comfort and compliance. The aim of this review is to provide the reader with information regarding the use, safety profile, and merits of propofol for sedation in advanced endoscopic procedures like ERCP and EUS, based on the current literature.
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Anaesthetic considerations for endoscopic retrograde cholangio-pancreatography procedures. Curr Opin Anaesthesiol 2014; 26:475-80. [PMID: 23635608 DOI: 10.1097/aco.0b013e3283620139] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to evaluate the current literature on the use of general anaesthesia and propofol deep sedation for patients undergoing endoscopic retrograde cholangio-pancreatography (ERCP) procedures. Propofol is primarily an anaesthetic agent, but its use in a sedative capacity has resulted in the extensive off-label administration of this drug by gastroenterologists and other nonanaesthesia personnel. This has created controversy and enabled the gastroenterology community to gather evidence and campaign for US Food and Drug Administration approval to administer propofol to patients undergoing ERCP and other endoscopic procedures. RECENT FINDINGS General anaesthesia appears to be a well tolerated technique for patients undergoing ERCP procedures, although there is a scarcity of publications in this field. The available evidence from prospective and retrospective cohort studies suggests a low incidence of serious outcomes (from sedation-related incidents) in patients undergoing ERCP procedures under propofol deep sedation. However, data from the American Society of Anesthesiologists closed claims analysis report suggests that endoscopy procedures performed under monitored anaesthetic care using propofol as a sedative agent can result in serious patient harm. SUMMARY Deep sedation with propofol, administered by anaesthesia personnel, can be used as an alternative to general anaesthesia for a select group of patients undergoing ERCP procedures. Further research is necessary to clarify the nature and parameters of deep sedation.
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Abstract
Sedation allows patients to tolerate unpleasant endoscopic procedures by relieving anxiety, discomfort, or pain. It also reduces a patient's risk of physical injury during endoscopic procedures, while providing the endoscopist with an adequate setting for a detailed examination. Sedation is therefore considered by many endoscopists to be an essential component of gastrointestinal endoscopy. Endoscopic sedation by nonanesthesiologists is a worldwide practice and has been proven effective and safe. Moderate sedation/analgesia is generally accepted as an appropriate target for sedation by nonanesthesiologists. This focused review describes the general principles of endoscopic sedation, the detailed pharmacology of sedatives and analgesics (focused on midazolam, propofol, meperidine, and fentanyl), and the multiple regimens available for use in actual practice.
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Affiliation(s)
- Sung-Hoon Moon
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
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Lee TH, Lee CK. Endoscopic sedation: from training to performance. Clin Endosc 2014; 47:141-50. [PMID: 24765596 PMCID: PMC3994256 DOI: 10.5946/ce.2014.47.2.141] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2014] [Revised: 02/25/2014] [Accepted: 02/26/2014] [Indexed: 12/24/2022] Open
Abstract
Adequate sedation and analgesia are considered essential requirements to relieve patient discomfort and pain and ultimately to improve the outcomes of modern gastrointestinal endoscopic procedures. The willingness of patients to undergo sedation during endoscopy has increased steadily in recent years and standard sedation practices are needed for both patient safety and successful procedural outcomes. Therefore, regular training and education of healthcare providers is warranted. However, training curricula and guidelines for endoscopic sedation may have conflicts according to varying legal frameworks and/or social security systems of each country, and well-recognized endoscopic sedation training systems are not currently available in all endoscopy units. Although European and American curricula for endoscopic sedation have been extensively developed, general curricula and guidelines for each country and institution are also needed. In this review, an overview of recent curricula and guidelines for training and basic performance of endoscopic sedation is presented based on the current literature.
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Affiliation(s)
- Tae Hoon Lee
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Chang Kyun Lee
- Division of Gastroenterology, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul, Korea
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Dietrich CG, Kottmann T, Diedrich A, Drouven FM. Sedation-associated complications in endoscopy are not reduced significantly by implementation of the German S-3-guideline and occur in a severe manner only in patients with ASA class III and higher. Scand J Gastroenterol 2013; 48:1082-7. [PMID: 23834761 DOI: 10.3109/00365521.2013.812237] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION The German guideline for sedation in gastrointestinal endoscopy was published in 2008. Several recommendations in this guideline, especially concerning staffing and structural requirements for sedation, have low evidence and therefore are subject to discussion in the field. AIM Comparison of endoscopic complications in a department specialized for gastrointestinal and pulmological diseases before and after implementation of the German guideline grouped in sedation-associated and non-sedation-associated complications. METHODS Prospective documentation of complications with retrospective analysis of two patient groups (before guideline: 1.5.2008-30.4.2010; after guideline: 1.5.2010-30.4.2012) at which the sedation technique remained the same (balanced propofol sedation, BPS). RESULTS Both investigation periods covered almost 7000 procedures. Interventional and general complications were nonsignificantly elevated in the latter group (1.27% before vs. 1.55% after guideline, p = 0.08). Saturation decline (in both groups 0.26%) was unchanged, and circulation-associated complications (0.27% vs. 0.13%, p = 0.07) were reduced nonsignificantly. Necessity for the administration of flumazenil and for intensive care monitoring was reduced in a nonsignificant manner after the implementation of the guideline. Severe complications (reanimation, apnea, and death) were unchanged, and no patient with ASA I-II suffered from a severe complication. Propofol consumption was higher after guideline implementation. CONCLUSIONS The recommendations of the new German sedation guideline do not significantly reduce complications in endoscopic procedures. Especially, procedures involving patients with ASA classes I and II do not require an additional staff member solely for sedation. Prospective randomized studies might be necessary to optimize the utilization of resources.
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Affiliation(s)
- Christoph G Dietrich
- Medical Clinic, Bethlehem-Hospital, Academic Affiliated Hospital of the Technical University Aachen, Stolberg/Rhld, Germany.
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A much sought-after drug--propofol sedation for GI endoscopy: always better but who cares? Dig Dis Sci 2012; 57:1980-2. [PMID: 22744431 DOI: 10.1007/s10620-012-2282-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Accepted: 06/07/2012] [Indexed: 12/09/2022]
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