Bispectral Index Versus Standard Monitoring in Sedation for Endoscopic Procedures: A Systematic Review and Meta-Analysis

Index of Consciousness monitoring may effectively predict and prevent circulatory stress induced by endotracheal intubation under general anesthesia: a prospective randomized controlled trial

BACKGROUND

The primary objective of anesthesiologists during the induction of anaesthesia is to mitigate the operative stress response resulting from endotracheal intubation. In this prospective, randomized controlled trial, our aim was to assess the feasibility and efficacy of employing Index of Consciousness (IoC, IoC1 and IoC2) monitoring in predicting and mitigating circulatory stress induced by endotracheal intubation for laparoscopic cholecystectomy patients under general anesthesia (GA).

METHODS

We enrolled one hundred and twenty patients scheduled for laparoscopic cholecystectomy under GA and randomly allocated them to two groups: IoC monitoring guidance (Group T, n = 60) and bispectral index (BIS) monitoring guidance (Group C, n = 60). The primary endpoints included the heart rate (HR) and mean arterial pressure (MAP) of the patients, as well as the rate of change (ROC) at specific time points during the endotracheal intubation period. Secondary outcomes encompassed the systemic vascular resistance index (SVRI), cardiac output index (CI), stroke volume index (SVI), ROC at specific time points, the incidence of adverse events (AEs), and the induction dosage of remifentanil and propofol during the endotracheal intubation period in both groups.

RESULTS

The mean (SD) HR at 1 min after intubation under IoC monitoring guidance was significantly lower than that under BIS monitoring guidance (76 (16) beats/min vs. 82 (16) beats/min, P = 0.049, respectively). Similarly, the mean (SD) MAP at 1 min after intubation under IoC monitoring guidance was lower than that under BIS monitoring guidance (90 (20) mmHg vs. 98 (19) mmHg, P = 0.031, respectively). At each time point from 1 to 5 min after intubation, the number of cases with HR ROC of less than 10% in Group T was significantly higher than in Group C (P < 0.05). Furthermore, between 1 and 3 min and at 5 min post-intubation, the number of cases with HR ROC between 20 to 30% or 40% in Group T was significantly lower than that in Group C (P < 0.05). At 1 min post-intubation, the number of cases with MAP ROC of less than 10% in Group T was significantly higher than that in Group C (P < 0.05), and the number of cases with MAP ROC between 10 to 20% in Group T was significantly lower than that in Group C (P < 0.01). Patients in Group T exhibited superior hemodynamic stability during the peri-endotracheal intubation period compared to those in Group C. There were no significant differences in the frequencies of AEs between the two groups (P > 0.05).

CONCLUSION

This promising monitoring technique has the potential to predict the circulatory stress response, thereby reducing the incidence of adverse reactions during the peri-endotracheal intubation period. This technology holds promise for optimizing anesthesia management.

TRAIL REGISTRATION

Chinese Clinical Trail Registry Identifier: ChiCTR2300070237 (20/04/2022).

Safety and efficacy of a low-dose combination of midazolam, alfentanil, and propofol for deep sedation of elderly patients undergoing ERCP

BACKGROUND

Proper sedation of patients, particularly elderly individuals, who are more susceptible to sedation-related complications, is of significant importance in endoscopic retrograde cholangiopancreatography (ERCP). This study aims to assess the safety and efficacy of a low-dose combination of midazolam, alfentanil, and propofol for deep sedation in elderly patients undergoing ERCP, compared to a group of middle-aged patients.

METHODS

The medical records of 610 patients with common bile duct stones who underwent elective ERCP under deep sedation with a three-drug regimen, including midazolam, alfentanil, and propofol at Shandong Provincial Third Hospital from January 2023 to September 2023 were retrospectively reviewed in this study. Patients were categorized into three groups: middle-aged (50-64 years, n = 202), elderly (65-79 years, n = 216), and very elderly (≥ 80 years, n = 192). Intraoperative vital signs and complications were compared among these groups.

RESULTS

The three groups showed no significant difference in terms of intraoperative variation of systolic blood pressure (P = 0.291), diastolic blood pressure (P = 0.737), heart rate (P = 0.107), peripheral oxygen saturation (P = 0.188), bispectral index (P = 0.158), and the occurrence of sedation-related adverse events including hypotension (P = 0.170) and hypoxemia (P = 0.423).

CONCLUSION

The results suggest that a low-dose three-drug regimen consisting of midazolam, alfentanil, and propofol seems safe and effective for deep sedation of elderly and very elderly patients undergoing ERCP procedures. However, further studies are required to verify these findings and clarify the benefits and risks of this method.

Guidelines for reducing the environmental impact of general anaesthesia

OBJECTIVE

To provide guidelines for reducing the environmental impact of general anaesthesia.

DESIGN

A committee of ten experts from SFAR and SF2H and SFPC learned societies was set up. A policy of declaration of competing interests was applied and observed throughout the guideline-writing process. Likewise, it did not benefit from any funding from a company marketing a health product (drug or medical device). The committee followed the GRADE® method (Grading of Recommendations Assessment, Development and Evaluation) to assess the quality of the evidence on which the recommendations were based.

METHODS

We aimed to formulate recommendations according to the GRADE® methodology for three different fields: anaesthesia vapours and gases; intravenous drugs; medical devices and the working environment. Each question was formulated according to the PICO format (Population, Intervention, Comparator, Outcome). The literature review and recommendations were formulated according to the GRADE® methodology.

RESULTS

The experts' work on the synthesis and application of the GRADE® method led to the formulation of 17 recommendations. Since the GRADE® method could not be entirely applied to all of the questions, some of the recommendations were formulated as expert opinions.

CONCLUSION

Based on strong agreement between experts, we produced 17 recommendations designed to guide reducing the environmental impact of general anaesthesia.

Advances in Analgosedation and Periprocedural Care for Gastrointestinal Endoscopy

The number and complexity of endoscopic gastrointestinal diagnostic and therapeutic procedures is globally increasing. Procedural analgosedation during gastrointestinal endoscopic procedures has become the gold standard of gastrointestinal endoscopies. Patient satisfaction and safety are important for the quality of the technique. Currently there are no uniform sedation guidelines and protocols for specific gastrointestinal endoscopic procedures, and there are several challenges surrounding the choice of an appropriate analgosedation technique. These include categories of patients, choice of drug, appropriate monitoring, and medical staff providing the service. The ideal analgosedation technique should enable the satisfaction of the patient, their maximum safety and, at the same time, cost-effectiveness. Although propofol is the gold standard and the most used general anesthetic for endoscopies, its use is not without risks such as pain at the injection site, respiratory depression, and hypotension. New studies are looking for alternatives to propofol, and drugs like remimazolam and ciprofol are in the focus of researchers' interest. New monitoring techniques are also associated with them. The optimal technique of analgosedation should provide good analgesia and sedation, fast recovery, comfort for the endoscopist, patients' safety, and will have financial benefits. The future will show whether these new drugs have succeeded in these goals.

Bispectral Index (BIS) Monitoring and Postoperative Delirium in Elderly Patients Undergoing Surgery: A Systematic Review and Meta-Analysis With Trial Sequential Analysis

OBJECTIVE

To examine the effect of bispectral index (BIS)-guided anesthesia on the incidence of postoperative delirium (POD) in elderly patients undergoing surgery.

DESIGN

A systematic review, meta-analysis, and trial sequential analysis (TSA).

SETTING

In the operating room, postoperative anesthesia care units (PACU), and ward.

PARTICIPANTS

Elderly patients (>60 years old) undergoing surgery.

INTERVENTIONS

The EMBASE, MEDLINE, and CENTRAL databases were searched systematically from their inception until December 2020 for randomized controlled trials comparing BIS and usual care or blinded BIS.

MEASUREMENTS AND MAIN RESULTS

Ten trials (N = 3,891) were included for quantitative meta-analysis. In comparison to the control group, there was no significant difference in the incidence of POD in elderly patients randomized to BIS-guided anesthesia (odds ratio [OR] 0.71, 95% CI 0.47-1.08, I² = 76%, p = 0.11, level of evidence = very low, TSA = inconclusive). The authors' review demonstrated that elderly patients with BIS-guided anesthesia were significantly associated with a lower incidence of postoperative cognitive dysfunction (POCD) (OR 0.64, 95% CI 0.46-0.88, p = 0.006), extubation time (mean difference [MD] -3.38 minutes, 95% CI -4.38 to -2.39, p < 0.00001), time to eye opening (MD -2.17 minutes, 95% CI -4.21 to -0.14, p = 0.04), and time to discharge from the PACU (MD -10.77 minutes, 95% CI -11.31 to - 10.23, p < 0.00001).

CONCLUSION

The authors' meta-analysis demonstrated that BIS-guided anesthesia was not associated with a reduced incidence of POD, but it was associated with a reduced incidence of POCD and improved recovery parameters.

Patient-Controlled Sedation Versus Clinician-Administered Sedation for Endoscopic Retrograde Cholangiopancreatography: A Systematic Review

Patient-controlled sedation (PCS) has been explored as a sedation method in endoscopic retrograde cholangiopancreatography (ERCP), yet a comprehensive review article on this topic is lacking. We performed a systematic review to compare PCS against clinician-administered sedation. The primary objectives are to compare the sedative dosage used and the sedation depth, while secondary objectives are to compare sedation failure rates, clinician intervention rates, and patient satisfaction. A systematic literature search was conducted on MEDLINE, EMBASE, and the Cochrane Library Database using the terms "ERCP," "Sedation," "Patient-controlled," and related terms. Randomized controlled trials comparing PCS against clinician-administered sedation in adults undergoing ERCP were included. Articles without English full texts were excluded. Studies were reviewed by 2 independent reviewers. The Cochrane Risk of Bias tool was used for quality assessment of individual included trials. This systematic review is registered in the International Prospective Register of Systematic Reviews (CRD42020198647). A total of 2619 articles were identified from the literature search. A total of 2615 articles were excluded based on the exclusion criteria. Four articles (comprised of 4 independent trials involving 425 patients) were included in analysis. When compared with clinician-administered sedation, PCS in ERCP may lead to lower propofol dosage used and lower sedation depth. The sedation failure rates appear to be higher in PCS, whereas lower rates of airway maneuvers are required. No significant difference was observable for patient satisfaction rates between PCS and clinician-administered sedation. The included studies demonstrated unclear to high risk of bias, particularly in randomization, incomplete outcome data, and outcome measurement. PCS appears to be a feasible option for sedation in ERCP. Nonetheless, large-scale, high-quality trials will be required before PCS can be regularly implemented in ERCP.

Bispectral index monitoring of the clinical effects of propofol closed-loop target-controlled infusion: Systematic review and meta-analysis of randomized controlled trials

BACKGROUND

To investigate whether closed-loop systems under bispectral index anesthesia depth monitoring can reduce the intraoperative propofol dosage.

METHODS

All randomized controlled trials (RCTs) on reducing propofol dosage under closed-loop systems were collected, and the literature was screened out, the abstracts and full texts were carefully read, and the references were tracked, data extraction and quality evaluation were conducted on the included research, and the RevMan5.3 software was used for meta-analysis. The main results were propofol and the incidence of adverse reactions such as hypertensive hypotension and postoperative cognitive dysfunction. A total of 879 cases were included in 8 articles, including 450 occurrences in the closed-loop system group and 429 cases in the open-loop system group.

RESULTS

Compared with manual control, closed-loop systems under bispectral index anesthesia depth monitoring reduced the dose of propofol (MD: -0.62, 95% CI: -1.08--0.16, P = .008), with heterogeneity (I2 = 80%). Closed-loop systems significantly reduced the incidence of abnormal blood pressure (MD: -0.02, 95%CI: -0.05-0.01, P = .15, I2 = 74%) and postoperative cognitive dysfunction (MD: -0.08, 95% CI: -0.14 -0.01, P = .02, I2 = 94%).

CONCLUSION

Bispectral index monitoring of propofol closed-loop target-controlled infusion system can reduce the amount of propofol, reduce the incidence of adverse reactions such as hypertensive or hypotension and postoperative cognitive dysfunction.

Guidelines for sedation in gastroenterological endoscopy (second edition)

Sedation in gastroenterological endoscopy has become an important medical option in routine clinical care. Here, the Japan Gastroenterological Endoscopy Society and the Japanese Society of Anesthesiologists together provide the revised "Guidelines for sedation in gastroenterological endoscopy" as a second edition to address on-site clinical questions and issues raised for safe examination and treatment using sedated endoscopy. Twenty clinical questions were determined and the strength of recommendation and evidence quality (strength) were expressed according to the "MINDS Manual for Guideline Development 2017." We were able to release up-to-date statements related to clinical questions and current issues relevant to sedation in gastroenterological endoscopy (henceforth, "endoscopy"). There are few reports from Japan in this field (e.g., meta-analyses), and many aspects have been based only on a specialist consensus. In the current scenario, benzodiazepine drugs primarily used for sedation during gastroenterological endoscopy are not approved by national health insurance in Japan, and investigations regarding expense-related disadvantages have not been conducted. Furthermore, including the perspective of beneficiaries (i.e., patients and citizens) during the creation of clinical guidelines should be considered. These guidelines are standardized based on up-to-date evidence quality (strength) and supports on-site clinical decision-making by patients and medical staff. Therefore, these guidelines need to be flexible with regard to the wishes, age, complications, and social conditions of the patient, as well as the conditions of the facility and discretion of the physician.

Can Bispectral Index Monitoring (EEG) be an Early Predictor of Respiratory Depression under Deep Sedation during Endoscopic Retrograde Cholangiopancreatography?

Objectives:

The more often the endoscopy sedation is performed, the more the risk of adverse events, and therefore, advanced monitoring becomes more and more essential in endoscopy units. The present study aims to evaluate whether the Bispectral Index (BIS) monitoring is an early predictor of respiratory depression and to determine the compliance between commonly used clinical sedation score.

Methods:

This study was approved by the ethics committee. The sample consisted of 60 patients aged 18 to 50 years with an American Society of Anesthesiologists (ASA) physical status of I scheduled for endoscopic retrograde cholangiopancreatography (ERCP). All patients received propofol mediated sedation. Ramsay sedation score (RSS) was used as a clinical sedation score to assess the depth of sedation. Participants were attached to a BIS monitor. Perioperative hemodynamics, BIS values, the mean dose of propofol, procedure duration, apnea, frequency of oxygen desaturation and airway-related interventions, as well as demographic parameters, were recorded. BIS scores were blinded to RSS data.

Results:

The study sample consisted of 60 patients (36 females) aged 18 to 50 years (mean: 36.10±8.02). The mean procedure time and the dose of propofol were 32.70±1.79 min and 287.17±59.66 mg, respectively. The cut-off values for respiratory depression were as follows. At the 15th min of measurement, the BIS score of 60 had 96.2% sensitivity and 42.9% specificity. At the 20th min of measurement, the BIS score of 59.50 had 98.2% sensitivity and 100.0% specificity. At the 25th min of measurement, the BIS score of 59.00 had 98.3% sensitivity and 50.0% specificity. Regression analysis showed that the mean BIS score (p=0.000, 95%CI-0.110-0.043) increased by 0.076 with a unit increase in the RSS.

Conclusion:

BIS was highly correlated with RSS, and therefore, can be used to avoid respiratory depression during sedation.

Comparison of dexmedetomidine-propofol and ketamine-propofol administration during sedation-guided upper gastrointestinal system endoscopy

BACKGROUND

Dexmedetomidine and ketamine popular sedative agents that result in minimal respiratory depression and the presence of analgesic activity. We aimed to compare the effectiveness and safety of a dexmedetomidine-propofol combination and a ketamine-propofol combination during upper gastrointestinal system endoscopy.

METHODS

The study commenced after receiving approval from the local ethics committee. Patients between 18 and 60 years in the American Society of Anesthesiologists (ASA) I and II groups were included. Patients who had severe organ disease, who had allergies to the study drugs, and who refused to participate were excluded. Cases were randomized into a dexmedetomidine-propofol group (Group D, n = 30) and a ketamine-propofol group (Group K, n = 30). Cardiac monitoring, peripheral oxygen saturation, and bispectral index (BIS) monitoring were performed. Group D received 1 mg/kg dexmedetomidine + 0.5 mg/kg propofol intravenous (IV) bolus, 0.5 μg/kg/h dexmedetomidine + 0.5 mg/kg/h propfol infusion. Group K received 1 mg/kg ketamine + 0.125 mL/kg propofol iv bolus, 0.25 mg/kg/h ketamine + 0.125 mL/kg/h propfol infusion. Patients were followed up with a Ramsay Sedation Scale (RSS) of ≥4. Means, standard deviations, lowest and highest frequency values, and ratio values were used for descriptive statistics, and the SPSS 22.0 program was used for statistical analyses.

RESULTS

In Group K, recovery time and mean blood pressure (MBP) values were significantly shorter. Furthermore, coughing rate, pulse, and BIS values were higher than in Group D (P < .05). Although there were no significant differences between the groups in terms of endoscopic tolerance and endoscopist satisfaction, we observed that the dexmedetomidine group experienced more comfortable levels of sedation.

CONCLUSION

Dexmedetomidine-propofol and ketamine-propofol combinations may be suitable and safe for endoscopy sedation due to their different properties. It was observed that the dexmedetomidine-propfol combination was superior in terms of sedation depth and that the ketamine-propofol combination was superior in terms of early recovery. As a result, we suggest the dexmedetomidine-propofol combination for upper gastrointestinal system endoscopy sedation due to hemodynamic stability and minimal adverse effects.

Wavelet and pain rating index for inhalation anesthesia: A randomized controlled trial

BACKGROUND

Wavelet index (WLi) and pain rating index (PRi) are new parameters for regulating general anesthesia depth based on wavelet analysis.

AIM

To investigate the safety and efficacy of using WLi or PRi in sevoflurane anesthesia.

METHODS

This randomized controlled trial enrolled 66 patients scheduled for elective posterior lumbar interbody fusion surgery under sevoflurane anesthesia between September 2017 and February 2018. A random number generator was used to assign the eligible patients to three groups: Systolic blood pressure (SBP) monitoring group, WLi monitoring group, and PRi monitoring group. The main anesthesiologist was aware of the patient grouping and intervention used. The primary endpoint was anesthesia recovery time. Secondary endpoints included extubation time, sevoflurane consumption, number of unwanted events/ interventions, number of adverse events and postoperative visual analogue scale for pain.

RESULTS

A total of 62 patients were included in the final analysis (SBP group, n = 21; WLi group, n = 21; and PRi group, n = 20). There were no significant differences among the three groups in patient age, gender distribution, body mass index, American Society of Anesthesiologists class, duration of surgery, or duration of anesthesia. Anesthesia recovery time was shorter in the WLi and PRi groups than in the SBP group with no significant difference between the WLi and PRi groups. Extubation time was shorter in the WLi and PRi groups than in the SBP group. Sevoflurane consumption was lower in the WLi and PRi groups than in the SBP group. Nicardipine was more commonly needed to treat hypertension in the WLi and PRi groups than in the SBP group.

CONCLUSION

Regulation of sevoflurane anesthesia depth with WLi or PRi reduced anesthesia recovery time, extubation time and sevoflurane consumption without intraoperative unwanted events.

Effects of Depth of Anesthesia Monitored by IoC on Patients Undergoing Laparoscopic Radical Resection of Colorectal Cancer

Index of consciousness (IoC) consisting of IoC1 and IoC2, is a new analgesia monitoring indicator in anesthesia evaluation in the laparoscopic radical resection of colorectal cancer. Although the precise anesthetic dosage adjusted by IoC1 has been confirmed to enhance the recovery and reduce the complications of anesthesia, the most appropriate range of IoC2 during anesthesia remains unclear. To investigate the correlation between IoC2 and peri-operative indicators of patients during laparoscopic radical resection of colorectal cancer, the current randomized, controlled, and single-blinded clinical trial was performed. Participants were divided randomly into three groups with different anesthesia depth monitored by IoC2 during their laparoscopic radical resections. Primary outcomes included the dosage of remifentanil. Secondary outcomes included other physiological indexes and complications. The remifentanil dosage and the awakening time increased as IoC2 decreased. The incidences of hypotension and hypoxemia decreased with the elevated IoC2, but the risk of intra-operative awareness also increased. The impact caused by anesthesia to the immune system and health-related life quality of the patients descended with reduced anesthetic level. The IoC2 range of 35–45 could represent the most appropriate anesthetic depth during laparoscopic radical resection, which provides a new perspective for the clinical treatment of colon cancer.

Target-controlled propofol infusion with or without bispectral index monitoring of sedation during advanced gastrointestinal endoscopy

BACKGROUND AND AIM

Target-controlled infusion (TCI) uses averaged pharmacokinetic datasets derived from population samples to automatically control the infusion rate. Bispectral index (BIS) technology non-invasively measures levels of consciousness during surgical procedures. We compared the efficacy and safety of propofol TCI with or without BIS monitoring for sedation during advanced gastrointestinal endoscopy.

METHODS

This prospective study enrolled 200 patients who were premedicated with midazolam 2 mg and alfentanil 0.4 mg before undergoing advanced gastrointestinal endoscopy. The initial target blood concentration of propofol was set at 1.0 μg/mL, and adjustments of 0.2 μg/mL were made as necessary to maintain moderate-to-deep sedation. Patients were randomized to either the BIS-blind group and evaluated for depth of anesthesia by monitoring scores of 1-2 on the Modified Observer's Assessment of Alertness/Sedation scale (n = 100) or to the BIS-open group and monitored by BIS scores of 60-80 (n = 100). The primary outcome was the total amount of propofol required to maintain anesthesia. Secondary outcomes were sedation-induced adverse events, recovery, and quality of sedation (endoscopist and patient satisfaction).

RESULTS

The mean propofol infusion rate was significantly higher in patients not monitored by BIS scores than in those who were (5.44 ± 2.12 vs 4.76 ± 1.84 mg/kg/h; P = 0.016). Levels of satisfaction were higher for endoscopists who used BIS monitoring than in those who did not.

CONCLUSIONS

Mean infusion rates were higher in propofol TCI without BIS monitoring compared with propofol TCI with BIS during advanced gastrointestinal endoscopy. Endoscopists expressed satisfaction with BIS monitoring.

Evaluation of bispectral index monitoring efficacy in endoscopic patients who underwent retrograde cholangiopancreatography and received sedoanalgesia

INTRODUCTION

Bispectral index (BIS) monitoring provides an objective, non-invasive measurement of the level of consciousness in a sedated patient.

AIM

In this prospective study, we aimed to investigate the hypothesis that risk of respiratory depression could be reduced and the desired level of sedation with minimal doses of propofol could be achieved by using BIS monitoring in endoscopic retrograde cholangiopancreatography (ERCP) procedures.

MATERIAL AND METHODS

Sixty patients in the ASA 1-2 category, who were scheduled for an ERCP with sedation, were randomly divided into two groups. The procedure was performed, and sedation was administered so that the patient's Ramsay Sedation Score (RSS) would be 4-5 in the first group (group 1) and the patient's BIS value would be 65-75 in the second group (group 2). Cardiopulmonary complications, the total duration of the procedure, and the total amount of propofol administered were recorded.

RESULTS

The mean SpO2 measurements at the third minute, fifth minute, and 10th minute were higher in the BIS group (p < 0.001) (p < 0.05). The mean number of respirations during the third, fifth, 10th, and 15th minute of sedation was significantly higher in the RSS group than in the BIS group (p < 0.05). There was no difference between the groups in terms of recovery time, total propofol amount, and additional doses of bolus propofol.

CONCLUSIONS

BIS monitoring during sedation with propofol for ERCP did not reduce total propofol use, but it may be an efficient guide for the timing of additional dose administration, which could reduce the risk of respiratory depression, and it could be used safely as an objective method in the follow-up of level of sedation.

Bispectral Index Monitoring During Anesthesia Promotes Early Postoperative Recovery of Cognitive Function and Reduces Acute Delirium in Elderly Patients with Colon Carcinoma: A Prospective Controlled Study using the Attention Network Test

Background

Bispectral index (BIS) monitoring can reduce the duration of anesthesia. This study aimed to evaluate the effects of BIS monitoring during surgery for resection of colon carcinoma in elderly patients using the Attention Network Test (ANT) to study alerting, orienting, and executive functions, and the Confusion Assessment Method (CAM).

Material/Methods

Eighty-one patients (65–75 years) underwent radical surgery for colon carcinoma with general intravenous anesthesia, propofol (6–8 mg/kg/h), vecuronium (0.03–0.05 mg/kg/min), and remifentanil (0.1–0.2 μg/kg/min). The BIS group (n=41) underwent adjustment of anesthesia to maintain a BIS value between 40–60; the non-BIS group (N=40) underwent standard intraoperative hemodynamic monitoring. Primary endpoints were alerting, orienting, and executive functions assessed pre-operatively and on postoperative days 1 and 5 using the ANT; the secondary endpoint was delirium during the first five postoperative days, assessed using the CAM.

Results

Propofol and remifentanil doses were significantly lower in the BIS group compared with the non-BIS group (P<0.001). Alerting, orienting, and executive functions showed no differences between the two groups pre-operatively but were impaired in both groups on postoperative day 1 compared with pre-operative levels (P<0.001). On postoperative day 5, alerting (P=0.607) and orienting (P=0.851) functions recovered in the BIS group but remained impaired in the non-BIS group (P<0.001). Delirium was significantly lower in the BIS group compared with the non-BIS group (17.5% vs. 27.5%) (P<0.001).

Conclusions

BIS-guided anesthesia was associated with reduced anesthetic exposure, early postoperative recovery of alerting and orienting functions, and reduced postoperative delirium.

Effects of small-dose remifentanil combined with index of consciousness monitoring on gastroscopic polypectomy: a prospective, randomized, single-blinded trial

BACKGROUND

With the development of painless diagnosis and treatment, remifentanil, a synthetic opioid agonist, is increasingly used in gastroscopy for its rapid, short-term, and potent analgesic effect. However, the dosage of remifentanil used in endoscopy is unclear. Index of consciousness (IOC) is a new anesthesia depth-monitoring indicator that can be divided into index of consciousness 1 (IOC₁) and index of consciousness 2 (IOC₂); IOC₁ is used for estimating a patient's sedation state, whereas IOC₂ reflects analgesic depth. We hypothesized that combining with IOC₁ and IOC₂ monitoring may be helpful to identify an optimal remifentanil dosage in gastroscopic polypectomy.

METHODS

One hundred twenty patients scheduled for gastroscopic polypectomy were enrolled and were randomly assigned to remifentanil 2 ng/mL (group R2), 4 ng/mL (group R4), or 6 ng/mL (group R6), and 40 cases were in each group. During the anesthesia period, remifentanil was kept at the initial given concentration but propofol was adjusted according to IOC₁. The primary outcomes were the dosage of propofol and remifentanil. The secondary outcomes were the variety of IOC₁ and IOC₂, patients' awakening time, and peri-operative adverse reactions such as hypotension, hypertension, bradycardia, tachycardia, body movements, hypoxemia, therapy interruption, nausea, vomiting, aspiration, and intra-operative awareness.

RESULTS

With the increasing dosage of remifentanil, the propofol dosage and patients' awakening time decreased significantly, the morbidity of hypertension and body movements also declined, but the incidence of hypotension, bradycardia, and hypoxemia rose. In group R2, the value of IOC₂ remained above 50 during the treatment. However, IOC₂ dropped to below 30 at the beginning of the gastroscopy in group R6, and there was statistical difference in hypoxemia between groups R2 and R6 (P <0.05).

CONCLUSIONS

With the help of IOC monitoring, we found that a target concentration of remifentanil 4 ng/mL is comparatively ideal in patients under gastroscopic polypectomy.

TRIAL REGISTRATION

Chinese Clinical Trial Register: ChiCTR-OOD-16009489 , on October 19, 2016.

Paradigm shift: should the elderly undergo propofol sedation for DBE? A prospective cohort study

OBJECTIVE

Evaluate the safety of propofol-assisted double balloon enteroscopy (DBE) in elderly patients against a younger cohort.

DESIGN

Prospective cohort study.

SETTING

All patients undergoing DBE over a 30-month period were recruited at our tertiary centre.

PATIENTS

215 procedures in 161 patients were performed. An age cut-off of 65 years and above was used to define those who were elderly.

INTERVENTIONS

Patients were subcategorised into four groups: elderly or young undergoing DBE with propofol or conventional sedation (with midazolam±fentanyl).

MAIN OUTCOME MEASURES

Patient demographics, comorbidities, procedural data, complications, diagnostic and therapeutic yield were compared.

RESULTS

Cardiovascular disease and a higher American Society of Anaethesiologists (ASA) status were more prevalent in elderly patients undergoing DBE with propofol (p<0.05). Common indications for DBE were occult and overt obscure gastrointestinal bleeding and suspected Crohn's disease (elderly vs young: 50.7% vs 42.3%, 17.8% vs 12% and 19.2% vs 26.1%, respectively). Diagnostic yield was higher in elderly compared with young patients (75.3% vs 58.5%, p=0.016). The most common findings in elderly and young patients were angioectasia (30.1% and. 18.3%, respectively) and ulcers (17.8% and 9.2%, respectively), while therapeutic intervention rates were comparable (42.5% vs 32.4%, p=0.18). ASA status did not affect propofol dose (p=0.55) or procedure duration (p=0.31). Tolerance scores were favourable in those receiving propofol compared with conventional sedation (p<0.05). There was no difference in complications between the four groups (p=0.17).

CONCLUSION

Compared with young patients, propofol-assisted DBE in the elderly is safe and has a high diagnostic yield.

Effect of Different Sedation Regimes on Cognitive Functions in Colonoscopy

Aim:

To compare the effects of propofol/remifentanil and meperidine/midazolam on postprocedure cognitive function.

Materials and methods:

A total of 100 American Society of Anesthesiologists (ASA) score I to III patients undergoing elective colonoscopy were taken into the study and divided into two groups. Exclusion criteria were patient refusal, mini mental test (MMT) <26, The Amsterdam Preoperative Anxiety and Information Scale (APAIS) >10, advanced cardiopulmonary or psychiatric disease, chronic alcohol abuse, morbid obesity, and known allergy to study drugs. In group MM, 2 mg midazolam and 20 mg meperidine was given intravenously and additional 1 to 2 mg midazolam and 20 mg meperidine (with a maximum total of 5 mg midazolam and 50 mg meperidine) was given when bispectral index (BIS) was >80. In group RP, 100 μg/kg/minute propofol infusion and 1 μg/kg remifentanil bolus was administered and additional 0.5 μg/kg remifentanil bolus was given when BIS was >80. Observer’s Assessment of Alertness/Sedation scale (OAA/S) and Facial Pain Score (FPS) values were recorded. Cognitive function was measured by Trieger Dot Test (TDT) and Digit Symbol Substitution Test (DSST).

Results:

The study was concluded with 100 patients. Heart rate was slower and BIS values were lower in group RP throughout the procedure. Blood pressure was lower in group RP without clinical significance. There was no difference concerning recovery time and visual analog scores (VASs). In group MM, TDT scores were higher and DSST scores were lower. Satisfaction was higher in group RP.

Conclusion:

Propofol/remifentanil combination is better than meperidine/midazolam combination concerning cognitive function in sedation for colonoscopy.

Clinical significance:

The addition of BIS monitorization to evaluate the depth of sedation and the negative effects of midazolam meperidine combination on postprocedural cognitive function.

How to cite this article: Ekmekci P, Erkan G, Yilmaz H, Kazbek BK, Koksoy UC, Doganay G, Tüzüner F. Effect of Different Sedation Regimes on Cognitive Functions in Colonoscopy. Euroasian J Hepato-Gastroenterol 2017;7(2):158-162.

Parotidectomy under sedation and locoregional anesthesia with monitoring of brain activity

BACKGROUND

Parotidectomy is usually performed while the patient is under general anesthesia, however, sedation with locoregional anesthesia could be an alternative.

METHODS

Fifteen adult patients with parotid tumors of the superficial lobe were included in this study. Anesthetic procedure consisted of sedation associated with cervical plexus and auriculotemporal nerve block. Sedation was managed based on the bispectral index.

RESULTS

Superficial parotidectomies were performed in 13 patients, and combined partial resections were performed in 2 patients. The mean operative time was 118.2 ± 16.4 minutes. Conversion to general anesthesia was necessary in only 1 patient. Ten surgeries were performed on an outpatient basis. Definitive facial paralysis occurred in 1 patient. All patients reported total satisfaction with the procedure.

CONCLUSION

In selected cases, parotidectomy under sedation plus locoregional anesthesia is feasible and safe. The careful selection of patients and the close collaboration with an anesthesiologist is the key to a successful procedure. © 2016 Wiley Periodicals, Inc. Head Neck 39: 744-747, 2017.

Extended Monitoring during Endoscopy

Gastrointestinal endoscopic sedation has improved procedural and patient outcomes but is associated with attendant risks of oversedation and hemodynamic compromise. Therefore, close monitoring during endoscopic procedures using sedation is critical. This monitoring begins with appropriate staff trained in visual assessment of patients and analysis of basic physiologic parameters. It also mandates an array of devices widely used in practice to evaluate hemodynamics, oxygenation, ventilation, and depth of sedation. The authors review the evidence behind monitoring practices and current society recommendations and discuss forthcoming technologies and techniques that are poised to improve noninvasive monitoring of patients under endoscopic sedation.