Safety of non-anaesthesiologist-administered propofol sedation in ERCP

Effect of sex differences in remifentanil requirements for inhibiting the response to a CO2 pneumoperitoneum during propofol anesthesia: an up-and-down sequential allocation trial

Background

A CO₂ pneumoperitoneum during a laparoscopic procedure causes violent hemodynamic changes. However, the remifentanil required to inhibit the cardiovascular response to a CO₂ pneumoperitoneum combined with propofol remains unknown. Moreover, the sex of the patient may influence the response to opioids, which can affect this requirement. The main objective of this study was to compare the required median effective concentration (EC₅₀) of remifentanil for inhibiting the cardiovascular response to a CO₂ pneumoperitoneum between female and male patients during propofol anesthesia.

Methods

The current study is an up-and-down sequential allocation trial. Forty-six patients with American Society of Anesthesiologists physical status I or II, a body mass index 18 to 30 kg/m², aged 20 to 60 years, and scheduled for laparoscopic surgery were enrolled. Induction of anesthesia was performed by target-controlled infusion. The effective effect-site concentration (Ce) of propofol was 4 μg/ml. The Ce of remifentanil was initially 4 ng/ml and then adjusted to a predetermined level after I-gel laryngeal mask airway insertion. The Ce of remifentanil for each patient was determined by the response of the previous patient using the modified Dixon “up-and-down” method. The first patient received remifentanil at 5.0 ng/ml Ce, and the step size between patients was 0.5 ng/ml.

Results

Patients characteristics including age, body mass index, American Society of Anesthesiologists physical status, type of surgery and surgery duration, were comparable between male and female patients. The EC₅₀ of remifentanil required to inhibit the response to a CO₂ pneumoperitoneum based on the Dixon “up-and-down” method in women (4.17 ± 0.38 ng/ml) was significantly lower than that in men (5.00 ± 0.52 ng/ml) during propofol anesthesia (P = 0.01).

Conclusions

The EC₅₀ of remifentanil required to inhibit the response to a CO₂ pneumoperitoneum was lower in women than in men during propofol anesthesia.

Trial registration

The study was registered at http://www.chictr.org.cn (ChiCTR-IOR-17011906, 8th, July, 2017).

Randomised Study Comparing the use of Propofol Versus Dexmedetomidine as a Sedative Agent for Patients Presenting for Lower Gastrointestinal Endoscopy

Objectives::

Dexmedetomidine, the alpha 2 agonist sedative and an analgesic agent may be beneficial in sedation for endoscopic intervention. Our aim was to compare the use of dexmedetomidine versus the traditional use of propofol as a sedative agent for colonoscopies.

Methods::

This study included 100 patients presenting for elective colonoscopy under sedation with random and equal allocation of patients into two groups; group P, in which patients received propofol in a loading dose of 1.5 mg/kg and maintenance dose of 0.5 mg/kg/hr, and group D, in which patients received dexmedetomidine at a loading dose of 1ug/kg and maintenance dose of 0.5 ug/kg/hr. In addition to the demographic data, time to recovery, time of discharge, and endoscopist rating were measured. Also, the hemodynamic parameters were recorded, and also the incidence of postoperative complications.

Results::

The basic patients' characteristics, time to recovery, and time of discharge were comparable between the two groups. Moreover, the endoscopist did not significantly report more convenient procedure with one group over the other. Also, there was no significant difference in hemodynamic parameters or in the incidence of complications between the two studied groups. However the use of dexmedetomidine decreased the incidence of hypoxemia.

Conclusion::

The use of dexmedetomidine seems to have a similar effect to the use of propofol as a sedative agent for lower GIT endoscopy with the positive effect of dexmedetomidine in decreasing the incidence of perioperative hypoxemia.

Safety and efficacy of endoscopist-directed balanced propofol sedation during endoscopic retrograde cholangiopancreatography

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.

Comparison of training mode of professional gastrointestinal endoscopy nurses between China and foreign countries

In recent years, there is great development in diagnostic and therapeutic gastrointestinal endoscopy, and its wide clinical applications pose new challenges for specific gastrointestinal endoscopic nursing techniques. This paper compares the training system of professional gastrointestinal endoscopy nurses between China and foreign countries according to the training tendency of specialized nurses to discuss the training system, training content and appraisal system in China, in order to improve the level of endoscopic nursing and gastrointestinal endoscopic industries to provide better services for patients.

Median effective concentration of remifentanil for the inhibition of laryngoscope-induced cardiovascular responses

The aim of this study was to calculate the median effective concentration (EC₅₀) of remifentanil (Rem) for the inhibition of laryngoscope-induced cardiovascular responses, and to observe its effects on the cardiovascular system and stress system. The study included 20 patients, who underwent time-scheduled vocal cord polyp resection with monitoring of heart rate (HR), mean blood pressure (MBP) and auditory evoked potential (AEP)-based A-line ARX Index (AAI). The Rem concentration was initially 5 ng/ml in the first patient, and the concentration selected for each subsequent patient was calculated from the previous case on the basis of whether or not cardiovascular reactions occurred. The HR, MBP and AAI at baseline, after the induction of anesthesia, and before and after the insertion of a self-retaining laryngoscope were recorded, with a change >15% recorded as a positive cardiovascular response. The EC₅₀ sequential method was used to calculate the EC₅₀ of Rem for the inhibition of laryngoscope-induced responses. Cortisol, interleukin-6 and blood glucose levels before and after laryngoscope insertion were also measured. The target-controlled concentrations for the 20 patients were as follows: 2 cases at 5 ng/ml, 6 cases at 4.2 ng/ml, 6 cases at 3.5 ng/ml, 4 cases at 2.9 ng/ml and 2 cases at 2.4 ng/ml. The EC₅₀ of Rem for the inhibition of laryngoscope-induced responses was 3.5 ng/ml with a 95% confidence interval (CI) of 3.47-3.60 ng/ml. A reasonable dose for inhibiting laryngoscope-induced responses was within the range 2.9-4.2 ng/ml. In conclusion, Rem exhibited an EC₅₀ of 3.5 ng/ml for the inhibition of laryngoscope-induced cardiovascular responses, with a 95% CI of 3.47-3.60 ng/ml, and a reasonable dose for the inhibition of such responses was 2.9-4.2 ng/ml.

Cardiac arrests in patients undergoing gastrointestinal endoscopy: A retrospective analysis of 73,029 procedures

BACKGROUND/AIMS

Airway difficulties leading to cardiac arrest are frequently encountered during propofol sedation in patients undergoing gastrointestinal (GI) endoscopy. With a noticeable increase in the use of propofol for endoscopic sedation, we decided to examine the incidence and outcome of cardiac arrests in patients undergoing gastrointestinal (GI) endoscopy with sedation.

PATIENTS AND METHODS

In this retrospective study, cardiac arrest data obtained from the clinical quality improvement and local registry over 5 years was analyzed. The information of patients who sustained cardiac arrest attributable to sedation was studied in detail. Analysis included comparison of cardiac arrests due to all causes until discharge (or death) versus the cardiac arrests and death occurring during the procedure and in the recovery area.

RESULTS

The incidence of cardiac arrest and death (all causes, until discharge) was 6.07 and 4.28 per 10,000 in patients sedated with propofol, compared with non-propofol-based sedation (0.67 and 0.44). The incidence of cardiac arrest during and immediately after the procedure (recovery area) for all endoscopies was 3.92 per 10,000; of which, 72% were airway management related. About 90.0% of all peri-procedural cardiac arrests occurred in patients who received propofol.

CONCLUSIONS

The incidence of cardiac arrest and death is about 10 times higher in patients receiving propofol-based sedation compared with those receiving midazolam-fentanyl sedation. More than two thirds of these events occur during EGD and ERCP.

Safety of Non-anesthesia Provider-Administered Propofol (NAAP) Sedation in Advanced Gastrointestinal Endoscopic Procedures: Comparative Meta-Analysis of Pooled Results

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.

Feasibility of non-anesthesiologist-administered propofol sedation for emergency endoscopic retrograde cholangiopancreatography

Background. The safety of non-anesthesiologist-administered propofol (NAAP) sedation in emergent endoscopic retrograde cholangiopancreatography (ERCP) has not been fully clarified. Thus, the aim of this study was to assess the safety of NAAP sedation in emergent ERCP. Materials and Methods. We retrospectively analyzed 182 consecutive patients who had obstructive jaundice and who underwent ERCP under NAAP sedation. The patients were divided into Group A (with mild acute cholangitis or without acute cholangitis) and Group B (moderate or severe acute cholangitis). And technical safety and adverse events were assessed. Results. The adverse events were hypoxia (31 cases), hypotension (26 cases), and bradycardia (2 cases). There was no significant difference in the rate of each adverse event of hypoxia and bradycardia in either group. Although the rate of transient hypotension associated in Group B was higher than that in Group A, it was immediately improved with conservative treatment. Moreover, there were no patients who showed delayed awakening, or who developed other complications. Conclusions. In conclusion, NAAP sedation is feasible even in emergent ERCP. Although some transient adverse events (e.g., hypotension) were observed, no serious adverse events occurred. Thus, propofol can be used in emergent ERCP but careful monitoring is mandatory.