Sedation in endoscopy: when and how

Effects of Bispectral Index-controlled Use of Magnesium on Propofol Consumption and Sedation Level in Patients Undergoing Colonoscopy

Objective

The aim of this study is to investigate the effects of bispectral index-controlled use of magnesium on propofol consumption, periprocedural hemodynamic response and patient comfort.

Material

A total of 60 patients were enrolled in the study. In Group 1 (magnesium), a single dose 50 mg/kg magnesium sulfate diluted with 100 mL 0.9% NaCl was administered 10 minutes before the beginning of the procedure. Initially bolus dose of 0.5 mg/kg propofol was applied. The maintenance dose of propofol was 60 mcg/kg/min. During the procedure, the propofol infusion was increased by titration until the bispectral index (BIS) value of 70 was achieved. In Group 2 (saline), 100 ml 0.9% NaCl was administered 10 minutes before the beginning of the procedure. The bolus and maintenance doses of propofol, and target BIS values were the same as those in Group 1.

Results

When BIS values were compared between the groups, the initial BIS values in the magnesium group (Group 1) were significantly higher than those of the saline group (Group 2) (p<0.05). The time to reach BIS 70 was significantly shorter in the magnesium group (p<0.05). Propofol consumption was greater in Group 2 than in Group 1 (p<0.05). The time to reach BIS 70 was significantly shorter in Group 1 (p<0.05). No significant difference was found between the groups in terms of patient- and endoscopist-satisfaction (p<0.05).

Conclusion

The use of magnesium in addition to propofol may be an efficient and reliable option to reduce the drug consumption during colonoscopic interventions.

Sedation with propofol in digestive endoscopy administered by gastroenterologists. Experience in a Venezuelan hospital

OBJECTIVES

propofol is a rapid acting hypnotic that is becoming the drug of choice for sedation in digestive endoscopy worldwide. There is some controversy with regard to the use of propofol by physicians who are not anesthesiologists. We present our experience of the administration of propofol by endoscopist and nursing personnel.

METHODS

this was a retrospective study of sedation in endoscopy. Propofol was exclusively used and administered by the endoscopist who performed the procedure and the nursing staff. All patients included were of a low and moderate surgical risk (ASA I, II and III). No complementary medication was used such as benzodiazepines or opiates.

RESULTS

a total of 70,696 digestive endoscopy procedures performed between 2002 and 2017 were included in the study. Propofol was administered in an induction bolus of 10 to 50 mg, continuing with intermittent boluses of 10 to 20 mg, according to the patients' response. The incidence of complications was very low, assisted ventilation with a mask was required on 78 (0.11%) occasions. Only one case required endotracheal intubation and two patients had significant hypotension that required the administration of ephedrine. The average recovery time of all neuropsychomotor functions after the procedure was 15 minutes; 98% of patients reported a good or excellent level of tolerance and clearly remembered the details of the interview one hour after the procedure.

CONCLUSIONS

the use of propofol as a sedative in digestive endoscopy is a safe and effective technique, provided that it is administered and controlled by the endoscopist and nursing staff in properly selected patients. This allows gastroenterologists to achieve adequate sedation.

Negative impact of sedation on esophagogastric junction evaluation during esophagogastroduodenoscopy

AIM: To compare the esophagogastric junction (EGJ) areas observed in sedated and non-sedated patients during esophagogastroduodenoscopy (EGD).

METHODS: Data were collected prospectively from consecutive patients who underwent EGD for various reasons. The patients were divided into three groups according to the sedation used: propofol, midazolam, and control (no sedation). The EGJ was observed during both insertion and withdrawal of the endoscope. The extent of the EGJ territory observed was classified as excellent, good, fair, or poor. In addition, the time the EGJ was observed was estimated.

RESULTS: The study included 103 patients (50 males; mean age 58.44 ± 10.3 years). An excellent observation was achieved less often in the propofol and midazolam groups than in the controls (27.3%, 28.6% and 91.4%, respectively, P < 0.001). There was a significant difference in the time at which EGJ was observed among the groups (propofol 20.7 ± 11.7 s vs midazolam 16.3 ± 7.3 s vs control 11.6 ± 5.8 s, P < 0.001). Multivariate analysis showed that sedation use was the only independent risk factor for impaired EGJ evaluation (propofol, OR = 24.4, P < 0.001; midazolam, OR = 25.3, P < 0.001). Hiccoughing was more frequent in the midazolam group (propofol 9% vs midazolam 25.7% vs control 0%, P = 0.002), while hypoxia (SaO2 < 90%) tended to occur more often in the propofol group (propofol 6.1% vs midazolam 0% vs control 0%, P = 0.101).

CONCLUSION: Sedation during EGD has a negative effect on evaluation of the EGJ.

Comparison between the recovery time of alfentanil and fentanyl in balanced propofol sedation for gastrointestinal and colonoscopy: a prospective, randomized study

Background

There is increasing interest in balanced propofol sedation (BPS) titrated to moderate sedation (conscious sedation) for endoscopic procedures. However, few controlled studies on BPS targeted to deep sedation for diagnostic endoscopy were found. Alfentanil, a rapid and short-acting synthetic analog of fentanyl, appears to offer clinically significant advantages over fentanyl during outpatient anesthesia.

It is reasonable to hypothesize that low dose of alfentanil used in BPS might also result in more rapid recovery as compared with fentanyl.

Methods

A prospective, randomized and double-blinded clinical trial of alfentanil, midazolam and propofol versus fentanyl, midazolam and propofol in 272 outpatients undergoing diagnostic esophagogastroduodenal endoscopy (EGD) and colonoscopy for health examination were enrolled. Randomization was achieved by using the computer-generated random sequence. Each combination regimen was titrated to deep sedation. The recovery time, patient satisfaction, safety and the efficacy and cost benefit between groups were compared.

Results

260 participants were analyzed, 129 in alfentanil group and 131 in fentanyl group. There is no significant difference in sex, age, body weight, BMI and ASA distribution between two groups. Also, there is no significant difference in recovery time, satisfaction score from patients, propofol consumption, awake time from sedation, and sedation-related cardiopulmonary complications between two groups. Though deep sedation was targeted, all cardiopulmonary complications were minor and transient (10.8%, 28/260). No serious adverse events including the use of flumazenil, assisted ventilation, permanent injury or death, and temporary or permanent interruption of procedure were found in both groups. However, fentanyl is New Taiwan Dollar (NT$) 103 (approximate US$ 4) cheaper than alfentanil, leading to a significant difference in total cost between two groups.

Conclusions

This randomized, double-blinded clinical trial showed that there is no significant difference in the recovery time, satisfaction score from patients, propofol consumption, awake time from sedation, and sedation-related cardiopulmonary complications between the two most common sedation regimens for EGD and colonoscopy in our hospital. However, fentanyl is NT$103 (US$ 4) cheaper than alfentanil in each case.

Trial registration

Institutional Review Board of Buddhist Tzu Chi General Hospital (IRB097-18) and Chinese Clinical Trial Registry (ChiCTR-TRC-12002575)