Propofol sedation with a target-controlled infusion pump and bispectral index monitoring system in elderly patients during a complex upper endoscopy procedure

Effect of moderate versus deep sedation on recovery following outpatient gastroscopy in older patients: a randomized controlled trial

BACKGROUND

Although gastrointestinal endoscopy with sedation is increasingly performed in older patients, the optimal level of sedation remains open to debate. In this study, our objective was to compare the effects of moderate sedation (MS) and deep sedation (DS) on recovery following outpatient gastroscopy in elderly patients.

METHODS

In this randomized, partially blinded, controlled trial, we randomly divided 270 patients older than 60 years who were scheduled for elective outpatient gastroscopy into the MS or DS group based on the Modified Observer's Assessment of Alertness/Sedation (MOAA/S) scale. The primary outcome was the duration of stay in the post-anesthesia care unit (PACU). Secondary outcomes included the duration of the total hospital stay, frequency of retching, bucking, and body movements during the examination, endoscopist and patient satisfaction, and sedation-associated adverse events during the procedure.

RESULTS

A total of 264 patients completed the study, of whom 131 received MS and 133 received DS. MS was associated with a shorter PACU stay [16.15 ± 9.01 min vs. 20.02 ± 11.13 min, P < 0.01] and total hospital stay [27.32 ± 9.86 min vs. 30.82 ± 12.37 min, P < 0.05], lesser hypoxemia [2.3% (3/131) vs. 12.8% (17/133), P < 0.01], use of fewer vasoactive drugs (P < 0.001), and more retching (P < 0.001). There was no difference in the incidence of bucking and body movements or endoscopist and patient satisfaction between the two groups.

CONCLUSION

Compared to deep sedation, moderate sedation may be a preferable choice for American Society of Anesthesiologists (ASA) Grade I-III elderly patients undergoing outpatient gastroscopies, as demonstrated by shorter PACU stays and total hospital stays, lower sedation-associated adverse events, and similar levels of endoscopist and patient satisfaction.

Propofol sedation in routine endoscopy: A case series comparing target controlled infusion vs manually controlled bolus concept

BACKGROUND

Many studies have addressed safety and effectiveness of non-anaesthesiologist propofol sedation (NAPS) for gastrointestinal (GI) endoscopy Target controlled infusion (TCI) is claimed to provide an optimal sedation regimen by avoiding under- or oversedation.

AIM

To assess safety and performance of propofol TCI sedation in comparison with nurse-administered bolus-sedation.

METHODS

Fouty-five patients undergoing endoscopy under TCI propofol sedation were prospectively included from November 2016 to May 2017 and compared to 87 patients retrospectively included that underwent endoscopy with NAPS. Patients were matched for age and endoscopic procedure. We recorded time of sedation and endoscopy, dosage of medication and adverse events.

RESULTS

There was a significant reduction in dose per time of propofol administered in the TCI group, compared to the NAPS group (8.2 ± 2.7 mg/min vs 9.3 ± 3.4 mg/min; P = 0.046). The time needed to provide adequate sedation levels was slightly but significantly lower in the control group (5.3 ± 2.7 min vs 7.7 ± 3.3 min; P < 0.001), nonetheless the total endoscopy time was similar in both groups. No differences between TCI and bolus-sedation was observed for mean total-dosage of propofol rate as well as adverse events.

CONCLUSION

This study indicates that sedation using TCI for GI endoscopy reduces the dose of propofol necessary per minute of endoscopy. This may translate into less adverse events. However, further and randomized trials need to confirm this trend.

The efficacy of non-anesthesiologist-administered propofol sedation with a target-controlled infusion system during double-balloon endoscopic retrograde cholangiopancreatography

BACKGROUND

The sedation method used during double-balloon endoscopic retrograde cholangiopancreatography (DB-ERCP) differs among countries and/or facilities, and there is no established method. This study aimed to evaluate the efficacy of non-anesthesiologist-administered propofol (NAAP) sedation using a target-controlled infusion (TCI) system during DB-ERCP.

METHODS

This retrospective study was conducted between May 2017 and December 2020 at an academic center. One hundred and fifty-six consecutive patients who underwent DB-ERCP were sedated by gastroenterologists using diazepam (n = 77) or propofol with a TCI system (n = 79), depending on the period. The primary endpoint was a comparison of poor sedation rates between the two groups. Poor sedation was defined as a condition requiring the use of other sedative agents or discontinuation of the procedure. Secondary endpoints were sedation-related adverse events and risk factors for poor sedation.

RESULTS

Poor sedation occurred significantly more often in the diazepam sedation group (diazepam sedation, n = 12 [16%] vs. propofol sedation, n = 1 [1%]; P = 0.001). Vigorous body movements (3 or 4) (diazepam sedation, n = 40 [52%] vs. propofol sedation, n = 28 [35%]; P = 0.038) and hypoxemia (< 85%) (diazepam sedation, n = 7 [9%] vs. propofol sedation, n = 1 [1%]; P = 0.027) occurred significantly more often in the diazepam sedation group. In the multivariate analysis, age < 70 years old (OR, 10.26; 95% CI, 1.57-66.98; P = 0.015), BMI ≥ 25 kg/m2 (OR, 11.96; 95% CI, 1.67-85.69; P = 0.014), and propofol sedation (OR, 0.06; 95% CI, 0.01-0.58; P = 0.015) were associated factors for poor sedation.

CONCLUSIONS

NAAP sedation with the TCI system during DB-ERCP was safer and more effective than diazepam sedation.

Efficacy and safety analysis of midazolam combined with dezocine sedation and analgesia colonoscopy in patients with inflammatory bowel disease: a prospective single-center open study

Objective: Colonoscopy plays an important role in the diagnosis, prognosis prediction, assessment of disease activity and severity, and treatment of inflammatory bowel disease (IBD)-related complications. However, some patients refuse to undergo colonoscopy due to perceived pain and other discomfort, their diagnosis and treatment are affected. Therefore, we conducted a prospective study to explore the efficacy and safety of midazolam combined with dezocine for sedation in IBD patients undergoing colonoscopy. Methods: 224 patients were divided into sedative-colonoscopy-group (SCG, n = 93), anesthesia-colonoscopy-group (ACG, n = 90) and ordinary-colonoscopy-group (OCG, n = 41). The vital signs (blood pressure, pulse, respiration and blood oxygen saturation), pain degree during colonoscopy, satisfaction and complication rates of the three groups were compared. Results: Before colonoscopy, there was no significant difference among the vital signs of the three groups. The vital signs of the ACG were significantly lower than those of the SEG and the OCG (p < 0.05), and the difference was not significant between the SCG and OCG during colonoscopy. The colonoscopy pain score in the SCG was lower than that in the OCG (0.79 ± 1.09 vs. 2.98 ± 1.27, p < 0.001). The satisfaction score of the SCG (9.26 ± 1.16) was not significantly different from that of the ACG (9.42 ± 1.41) but was higher than that of the OCG (6.63 ± 1.13) (p < 0.001). The total complication rate of the ACG was 45.56% (41/90), which was significantly higher than that of the SCG [20.43% (19/93)] and the OCG [19.51% (8/41)]. Colon perforation, abnormal blood pressure fluctuation and hypoxemia were significantly more common in the ACG than in the SCG and the OCG (p < 0.05). However, there was no significant difference in the incidence of complications between the SCG and OCG. Conclusion: Compared with ordinary-colonoscopy, colonoscopy performed under midazolam and dezocine sedation is more comfortable for patients, thereby increasing satisfaction and compliance. Colonoscopy that is performed under midazolam and dezocine is similar to colonoscopy that is anesthesia with propofol in terms of comfort, satisfaction and compliance and similar to ordinary-colonoscopy in terms of safety. Considering the shortage of anesthesiologists, the application of midazolam combined with dezocine for digestive endoscopy is worthy of clinical promotion.

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.

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

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

Efficacy and safety of midazolam combined with dezocine for sedation and analgesia in digestive endoscopy: A prospective open single-center study

Objective: Digestive endoscopy is an important means of diagnosing and treating gastrointestinal diseases and a tool for screening and monitoring early gastrointestinal tumors. Digestive endoscopy can be performed using midazolam combined with dezocine for sedation and analgesia. This study explored the efficacy and safety of midazolam combined with dezocine. Methods: A total of 135 patients undergoing digestive endoscopy in the Department of Gastrointestinal Endoscopy of the Sixth Affiliated Hospital, Sun Yat-sen University, from June 2021 to September 2021, were enrolled and non-blindly and non-randomly divided into a sedation-endoscopy-group (SEG, n = 45), anesthesia-endoscopy-group (AEG, n = 44), and ordinary-endoscopy-group (OEG, n = 46). Vital signs, levels of sedation and analgesia, the degree of pain during colonoscopy, satisfaction, and the incidence of complications were compared among the three groups. Results: There were no statistically significant differences in vital signs (blood pressure, pulse, respiration, and blood oxygen saturation) among the three groups before endoscopy (p > 0.05). The AEG reported no pain during colonoscopy, and the pain score during colonoscopy for the SEG was lower than that for the OEG (1.11 ± 1.21 vs. 3.00 ± 1.16, p < 0.001). The scores for satisfaction were 8.84 ± 1.30 points in the SEG, 8.95 ± 1.10 points in the AEG, and 6.37 ± 0.90 points in the OEG; the differences were statistically significant (p < 0.001). The total incidence of complications in the AEG was 38.64% (17/44), which was significantly higher than that in the SEG [13.33% (6/45)] and OEG [13.04% (6/46)] (p < 0.001). In the SEG, the overall incidence of complications in women was significantly higher than that in men (p = 0.027). Conclusion: Digestive endoscopy using midazolam combined with dezocine for sedation makes patients more comfortable, more satisfied and more compliant than the ordinary endoscopy. Additionally, it is comparable to endoscopy under general anesthesia with propofol with regard to comfort, satisfaction, and patient compliance and comparable to the ordinary endoscopy with regard to safety. Considering the shortage of anesthesiologists, the application of midazolam combined with dezocine in digestive endoscopy is worthy of clinical popularization. This study has been registered in the Hospital Ethics Committee of the Sun Yat-sen University Sixth Affiliated Hospital (Ethical Number: 2021ZSLYEC-182).

Efficacy of capnographic and bispectral index monitoring on trans-oral therapeutic endoscopy: A prospective observational study

BACKGROUND AND AIM

Oral therapeutic and invasive endoscopy requires deep sedation to reduce patient distress due to prolonged examination and procedures. The usefulness of capnography and bispectral index (BIS) monitoring in the early hypoxia detection in oral therapeutic and invasive endoscopy has yet to be evaluated. This study aimed to investigate the clinical impact of capnography and BIS monitoring on hypoxic events during oral therapeutic and invasive endoscopic procedures.

METHODS

This is a prospective observational study. Trans-oral non-intubated therapeutic and/or invasive endoscopic procedures were performed with conventional monitoring (pulse oximetry, pulse, and blood pressure) as well as additional monitoring (BIS and end-tidal CO₂ concentration). Hypoxia is defined as oxygen saturation of <90% that lasts >15 s. The clinical impact of capnography and BIS monitoring on hypoxic events during oral therapeutic and invasive endoscopic procedures were investigated with the risk factors for hypoxia in each patient.

RESULTS

Patients with hypoxia had significantly more apneas detected using capnography than other patients. The multivariate analysis revealed the detected apnea by capnography as an independent risk factor for hypoxia (odds ratio: 3.48[95% confidence interval: 1.24-9.78], P = 0.02). The BIS was not significantly different as a risk factor for hypoxia; however, per-event analysis revealed significantly decreased BIS values over time in 3 min before hypoxic events.

CONCLUSIONS

Apnea detected by capnography was an independent predictor of hypoxia. The BIS value was not associated with hypoxia events; however, it showed a significant downward trend before hypoxia events.

Resting State Functional Connectivity Analysis During General Anesthesia: A High-Density EEG Study

The depth of anesthesia monitoring is helpful to guide administrations of general anesthetics during surgical procedures,however, the conventional 2-4 channels electroencephalogram (EEG) derived monitors have their limitations in monitoring conscious states due to low spatial resolution and suboptimal algorithm. In this study, 256-channel high-density EEG signals in 24 subjects receiving three types of general anesthetics (propofol, sevoflurane and ketamine) respectively were recorded both before and after anesthesia. The raw EEG signals were preprocessed by EEGLAB 14.0. Functional connectivity (FC) analysis by traditional coherence analysis (CA) method and a novel sparse representation (SR) method. And the network parameters, average clustering coefficient (ACC) and average shortest path length (ASPL) before and after anesthesia were calculated. The results show SR method find more significant FC differences in frontal and occipital cortices, and whole brain network (p<0.05). In contrast, CA can hardly obtain consistent ASPL in the whole brain network (p>0.05). Further, ASPL calculated by SR for whole brain connections in all of three anesthesia groups increased, which can be a unified EEG biomarker of general anesthetics-induced loss of consciousness (LOC). Therefore FC analysis based on SR analysis has better performance in distinguishing anesthetic-induced LOC from awake state.

National trends in nonoperating room anesthesia: procedures, facilities, and patient characteristics

PURPOSE OF REVIEW

Nonoperating room anesthesia (NORA) continues to increase in popularity and scope. This article reviews current and new trends in NORA, trends in anesthesia management in nonoperating room settings, and the evolving debates surrounding these trends.

RECENT FINDINGS

National data suggests that NORA cases will continue to rise relative to operating room (OR) anesthesia and there will continue to be a shift towards performing more interventional procedures outside of the OR. These trends have important implications for the safety of interventional procedures as they become increasingly more complex and patients continue to be older and more frail. In order for anesthesia providers and proceduralists to be prepared for this future, rigorous standards must be set for safe anesthetic care outside of the OR.Although the overall association between NORA and patient morbidity and mortality remains unclear, focused studies point toward trends specific to each non-OR procedure type. Given increasing patient and procedure complexity, anesthesiology teams may see a larger role in the interventional suite. However, the ideal setting and placement of anesthesia staff for interventional procedures remain controversial. Also, the impact of COVID-19 on the growth and utilization of non-OR anesthesia remains unclear, and it remains to be seen how the pandemic will influence the delivery of NORA procedures in postpandemic settings.

SUMMARY

NORA is a rapidly growing field of anesthesia. Continuing discussions of complication rates and mortality in different subspecialty areas will determine the need for anesthesia care and quality improvement efforts in each setting. As new noninvasive procedures are developed, new data will continue to shape debates surrounding anesthesia care outside of the operating room.

Anesthetic strategy for obese patients during gastroscopy: deep sedation or conscious sedation? A prospective randomized controlled trial

OBJECTIVE

This paper aims to compare the incidence of SpO₂ values < 95% and < 90% of the obese patients between conscious sedation and deep sedation and whether conscious sedation was superior to the deep sedation for obese patients during diagnostic gastroscopy.

METHODS

Obese patients undergoing diagnostic gastroscopy were randomly assigned to two different intervention groups: group CS (conscious sedation) or group DS (deep sedation). Group CS patients were managed by conscious sedation [Modified Observer Assessment of Alertness/Sedation (MOAA/S) at 4-5] protocol, and group DS patients were managed by deep sedation (MOAA/S at ≤ 2) protocol. Propofol and sufentanil (0.1 and 0.05 mg/kg) were, respectively, infused for sedation and analgesia in CS and DS protocols. The primary endpoints were to compare the incidence of SpO₂ values < 95% and < 90% of the patients between the two groups. The incidence of successful sedation, satisfaction scores of patients and endoscopist were assessed as secondary endpoints.

RESULTS

115 obese patients (59 in group CS and 56 in group DS) were enrolled in this study. The incidences of SpO₂ < 95% and < 90% in group CS (42.4% and 6.8%) were significantly lower than those in group DS (69.6% and 19.6%, with P = 0.003 and 0.041, respectively). The incidence of successful sedation was similar between groups (86.4% vs 89.3%, P = 0.641). Patient satisfaction scores and endoscopist satisfaction scores were both similar between groups (P = 0.548 and 0.171).

CONCLUSION

Conscious sedation with propofol and sufentanil (0.1 mg/kg) reduced the incidence of hypoxic events without affecting gastroscopy procedure and satisfaction compared with the deep sedation for obese patients during diagnostic gastroscopy.

TRIAL REGISTRATION

ChiCTR-1900024894; registration date, July 31, 2019. http://www.chictr.org.cn .

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.

Propofol sedation with a target-controlled infusion pump in elderly patients undergoing ERCP

BACKGROUND AND AIMS

Advanced age is an important risk factor for adverse events (AEs) during propofol sedation for endoscopic procedures. This study aimed to evaluate the safety and efficacy of nonanesthesiologist-administered propofol (NAAP) sedation with a target-controlled infusion (TCI) system in elderly patients during ERCP.

METHODS

This study retrospectively analyzed 482 patients who underwent ERCP under propofol sedation with a TCI system at Iwakuni Medical Center between January 2014 and October 2016. Patients were divided into 3 groups according to their age: group A, <70 years (n = 130); group B, ≥70 and <85 years (n = 224); and group C, ≥85 years (n = 125). We compared the propofol dose and AEs during ERCP.

RESULTS

The median total infusion dose and minimum and maximum target blood concentrations of propofol were 336 mg, 2.2 μg/mL, and 2.2 μg/mL in group A; 184 mg, 1.0 μg/mL, and 1.4 μg/mL in group B; and 99 mg, .6 μg/mL, and 1.0 μg/mL in group C, respectively, with older groups requiring a lower dose (P < .0001). Hypotension was observed in 23 patients (4.8%), with no significant difference between groups (group A, 2.3%; group B, 6.3%; group C, 4.8%; P = .24). Hypoxemia was observed in 16 patients (3.3%), with no significant difference between groups (group A, 3.1%; group B, 4.9%; group C, .8%; P = .17). All AEs were immediately resolved, and no procedures were aborted.

CONCLUSIONS

NAAP sedation with a TCI system during ERCP may be acceptable in elderly patients with a lower dose of propofol than that used in younger patients.

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.

The Effect of Adding Midazolam to Propofol Intravenous Sedation to Suppress Gag Reflex During Dental Treatment

We retrospectively investigated the efficacy and safety of propofol administration alone and in combination with midazolam for gag reflex suppression during dental treatment under intravenous sedation. We included 56 patients with an overactive gag reflex who were to undergo dental treatment under intravenous sedation. They were divided into propofol (P group, n = 22) and midazolam with propofol (MP group, n = 34) groups. The P group received propofol alone, while the MP group received midazolam (0.04 mg/kg) prior to target-controlled infusion (TCI) of propofol (titrated for adequate sedation). The patients' anesthetic records were evaluated for vital sign changes, adverse cardiovascular or respiratory event frequency, the number of forced treatment interruptions, and the TCI-predicted cerebral propofol concentration at gag reflex suppression (posterior tongue stimulation with a dental mirror). No significant differences were observed between the 2 groups preoperatively. There were no cases of forced interruptions or significant respiratory compromise in either group. Cardiovascular adverse event frequency was lower in the MP group than in the P group (all p < .05). Our results suggest that propofol, when combined with midazolam, minimized cardiovascular effects compared with propofol alone when used to suppress the gag reflex in patients during dental treatment under intravenous sedation.

Efficacy of Endoscopic Submucosal Dissection of Esophageal Neoplasms under General Anesthesia

Background/Aims

Evidence that general anesthesia (GA) reduces the operative time of esophageal endoscopic submucosal dissection (ESD) is currently insufficient. This study aims to evaluate the efficacy and safety of esophageal ESD under GA.

Methods

A total of 227 lesions from 198 consecutive patients with superficial esophageal neoplasms treated by ESD at 3 Japanese institutions between April 2011 and September 2017 were included in this retrospective study. For ESD, GA and deep sedation (DS) were used in 102 (51.5%, GA group) and 96 patients (48.5%, DS group), respectively.

Results

There were no statistically significant differences in age, sex, or comorbidities between the groups. In the GA group, the tumor size was larger (21 [3–77] mm vs. 14 [3–63] mm, p<0.001), luminal circumference was larger (≥2/3; 13.9% vs. 5.4%, p=0.042), procedure time was shorter (28 [5–202] min vs. 40 [8–249] min, p<0.001), and submucosal dissection speed was faster (25.2 [7.8–157.2] mm² /min vs. 16.2 [2.4–41.3] mm² /min, p<0.001). The rates of intraoperative perforation and aspiration pneumonia were lower in the GA group, but the difference did not achieve statistical significance (p=0.242 and p=0.242).

Conclusions

GA shortens the procedure time of esophageal ESD.

Dexmedetomidine for conscious sedation with colorectal endoscopic submucosal dissection: a prospective double-blind randomized controlled study

Objective

Conscious sedation for colorectal endoscopic submucosal dissection (ESD) has not been standardized, and there are no studies of sedation for colorectal ESD.

Methods

We conducted a prospective double-blind randomized controlled trial to clarify the usefulness of DEX during colorectal ESD. In total 80 patients with colorectal ESD from April 2016 to May 2017 were assigned to the placebo group or the DEX group (40 cases each). The primary outcome was patient satisfaction (visual analogue scale: VAS). Secondary outcomes were evaluated for 13 factors, including patient pain level (VAS), endoscopist satisfaction (VAS), objective patient pain level viewed from the endoscopist’s perspective (VAS), rate of patient response, rate of side effects, etc., from the patient’s and endoscopist’s perspectives.

Results

Patient satisfaction was 8.4 and 9.1 (P = 0.018) in the placebo group and the DEX group, respectively. Secondary outcomes of patient pain level, endoscopist satisfaction, objective patient pain level from the endoscopist’s perspective for the placebo and DEX groups were 1.2 and 0.4 (P = 0.045), 8.2 and 9.3 (P < 0.001), and 1.2 and 0.5 (P = 0.002), respectively. All of these were significantly positive results (more comfortable and less pain) in the DEX group. The rate of a patient response was 100% in all cases. The side effects (hypoxia/bradycardia/hypotension) were 0%/0%/0% and 7.5%/7.5%/5% (P = 0.030). However, these rates were less than the reported side effect occurrence rate, and no additional medication was needed.

Conclusion

DEX enables conscious sedation, and is useful not only for patient and endoscopist satisfaction but also for pain relief. DEX is an effective sedation method for colorectal ESD.

Impact of postoperative analgesia with dezocine plus ropivacaine versus fentanyl plus ropivacaine on stress response and immune function in patients with gastric cancer

AIM

To investigate the effect of postoperative analgesia with dezocine combined with ropivacaine and fentanyl combined with ropivacaine on stress response and immune function in patients with gastric cancer.

METHODS

Eighty-eight patients with gastric cancer who underwent surgery from November 2016 to October 2017 at Tongji Hospital were randomly divided into an observation group and a control group, with 44 cases in each group. The patients in the observation group were given dexrazoxane 30 mg + 0.75% ropivacaine 20 mL + 100 mL 0.9% sodium chloride injection for analgesia; the control group was given fentanyl 8 μg + 0.75% ropivacaine 20 mL + 100 mL 0.9% sodium chloride injection. The analgesic effects at 4, 12, 24, and 48 h after operation were compared between the two groups. Serum levels of interleukin (IL)-6, IL-2, tumor necrosis factor α (TNF-α), monocyte chemotactic protein-1 (MCP-1), and high mobility group box-1 (HMGB-1), plasma levels of endothelin (ET) and AngⅡ, and the levels of CD3⁺, CD4⁺, CD8⁺ T cells, and natural killer cells (NK) in immune cells were compared in the two groups before and after surgery. Adverse reactions within 48 h after surgery such as dizziness, nausea, and respiratory depression were recorded.

RESULTS

Visual acuity scores in the observation group at 4, 12, 24, and 48 h after operation were significantly lower than those in the control group (t = 4.636, 4.399, 7.084, 11.022, P < 0.05). Serum levels of IL-6, TNF-α, MCP-1, and HMGB-1 in the observation group at 24 and 48 h after operation were significantly lower than those in the control group, and the levels of IL-2 in the observation group were significantly higher than those in the control group (t_{24 h} = 14.544, 18.041, 17.154, 14.143, 15.797, t_{48 h} = 17.016, 18.838, 9.389, 17.821, 19.497, P < 0.05). Plasma levels of ET and Ang Ⅱ in the observation group at 24 and 48 h after operation were significantly lower than those in the control group (t_{24 h} = 3.900, 2.784, t_{48 h} = 2.816, 2.122, P < 0.05). The levels of CD3⁺, CD4⁺ T cells, and NK cells in immune cells in the observation group at 24 h after operation were significantly higher than those in the control group (t = 5.767, 2.716, 2.978, P < 0.05). There was no significant difference in CD8+ T cells between the two groups before and after operation (t = 0.316, P > 0.05). Within 48 h after operation, the incidence of adverse reactions in the observation group was significantly lower than that in the control group (11.36% vs 29.55%, χ² = 4.469, P < 0.05).

CONCLUSION

Postoperative analgesia with dezocine plus ropivacaine is effective in patients with gastric cancer, which can reduce stress response and inflammatory cytokines and improve immune function.

Comparison of propofol with midazolam in endoscopic submucosal dissection for esophageal squamous cell carcinoma: a randomized controlled trial

BACKGROUND

Interruption of sedation due to a poor response to modified neuroleptanalgesia (m-NLA) with midazolam often occurs during endoscopic submucosal dissection (ESD) for esophageal squamous cell carcinoma (ESCC) because most patients have a history of heavy alcohol intake. Recently, propofol has been used feasibly and safely during endoscopic procedures. The aim of this study was to clarify the efficacy and safety of propofol compared with that of midazolam during ESD for ESCC.

METHODS

This was a single-blind, randomized controlled trial in a single center. Patients with ESCC scheduled for ESD were included in the study. Patients were randomly assigned to one of two groups: the propofol group and the midazolam group. The main outcome was the incidence of discontinuation of the procedure due to a poor response to sedation. Secondary outcomes included risk factors for a poor response to sedation.

RESULTS

Between April 2014 and October 2015, 132 patients (n = 66 per group) who underwent ESD for ESCC were enrolled in this study. The incidence of discontinuation due to a poor response to sedation in the propofol and midazolam groups was 0% (0/66) and 37.9% (25/66), respectively (p < 0.01). Multivariate analyses revealed that use of midazolam [Odds ratio (OR), 7.61; 95% confidence interval (CI), 2.64-21.92; p < 0.01] and age (OR, 0.93; 95% CI, 0.86-0.98; p < 0.01) were risk factors for a poor response to sedation.

CONCLUSIONS

Our study indicates that, compared with midazolam, propofol is a more efficient sedative for m-NLA during ESD for ESCC.

Training and Competency in Sedation Practice in Gastrointestinal Endoscopy

The practice of endoscopic sedation requires a thorough understanding of preprocedural assessment, sedation pharmacology, intraprocedure monitoring, adverse event management, and postprocedural care. The training process has become increasingly standardized and entails knowledge and practice-based components. The use of propofol in particular requires a higher level of structured training owing to its narrow therapeutic window. Simulation has increased opportunities for practice-based training in a controlled environment. After completion of training, the endoscopist must demonstrate competence in theoretical understanding and technical ability to administer sedation. Although individual institutions have certification processes, there is a lack of validated, standardized methods to confirm competence.