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Allen D, Hanumantharao SN, McDonell R, Irvine KA, Sahbaie P, Clark D, Blum P. Preclinical characterization of the efficacy and safety of biologic N-001 as a novel pain analgesic for post-operative acute pain treatment. Sci Rep 2023; 13:11778. [PMID: 37479740 PMCID: PMC10362049 DOI: 10.1038/s41598-023-38618-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 07/11/2023] [Indexed: 07/23/2023] Open
Abstract
Inhibition of actin remodeling in nerves modulates action potential propagation and therefore could be used to treat acute pain. N-001 is a novel protein analgesic engineered from several C. Botulinum toxins. N-001 targets sensory neurons through ganglioside GT1b binding and ADP-ribosylates G-actin reducing actin remodeling. The activity and efficacy of N-001 was evaluated previously in vitro and in a mouse inflammatory pain model. To assess the relevance of N-001 for treatment of acute post-surgical pain, the current study evaluated the efficacy of N-001 in a mouse hind-paw incision model by peri-incisional and popliteal nerve block administration combined with mechanical testing. N-001 provided relief of pain-like behavior over 3 days and 2 days longer than the conventional long-acting anesthetic bupivacaine. Preclinical safety studies of N-001 indicated the drug produced no toxic or adverse immunological reactions over multiple doses in mice. These results combined with past targeting results encourage further investigation of N-001 as an analgesic for post-operative pain management with the potential to function as a differential nociceptor-specific nerve block.
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Affiliation(s)
- Derek Allen
- Neurocarrus Inc, Monterey, CA, USA
- Microbiology and Environmental Toxicology, University of California-Santa Cruz, Santa Cruz, CA, USA
- School of Biological Sciences, University of Nebraska-Lincoln, Lincoln, NE, USA
| | | | - Rylie McDonell
- School of Biological Sciences, University of Nebraska-Lincoln, Lincoln, NE, USA
| | | | - Peyman Sahbaie
- Stanford University School of Medicine, Stanford, CA, USA
| | - David Clark
- Stanford University School of Medicine, Stanford, CA, USA
- VA Palo Alto Health Care, Palo Alto, CA, USA
| | - Paul Blum
- Neurocarrus Inc, Monterey, CA, USA.
- Microbiology and Environmental Toxicology, University of California-Santa Cruz, Santa Cruz, CA, USA.
- School of Biological Sciences, University of Nebraska-Lincoln, Lincoln, NE, USA.
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Zaver HB, Ghoz H, Malviya B, Bali A, Antwi S, Moyer AM, Bi Y. Pilot Study: Personalized Medicine in Endoscopy, Can Pharmacogenomics Predict Response to Conscious Sedation? J Pers Med 2023; 13:1107. [PMID: 37511720 PMCID: PMC10381361 DOI: 10.3390/jpm13071107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 06/26/2023] [Accepted: 07/04/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Adequate response to moderate (conscious) sedation varies significantly between individuals. Polymorphisms in genes encoding drug metabolizing enzymes can lead to inter-individual variability in drug efficacy, potentially influencing sedation requirements during endoscopic procedures. OBJECTIVES The aim of this study was to assess the potential role of inter-individual variation in inherited polymorphisms of drug-metabolizing enzymes, cytochrome P450 (CYP450), specifically CYP3A4 and CYP3A5, in sedation requirements for outpatient endoscopic procedures. METHODS A retrospective analysis of sedation requirements and pharmacogenomics data in 106 unique patients who received outpatient esophagogastroduodenoscopy (EGD), colonoscopy, or both between December 2011 and February 2019 was conducted. Patients were divided into two groups based on their sedation requirements during endoscopy (high vs. normal sedation). RESULTS Patients with reduced a CYP2C19 metabolism (poor + intermediate metabolizers) (odds ratio [OR] = 0.38, 95% confidence interval [CI]: 0.16-0.91, p = 0.03), poor CYP3A5 metabolism (OR = 0.25, 95% CI: 0.095-0.65, p = 0.0046), and poor UGT1A1 (OR = 2.76, 95% CI: 1.07-7.13, p = 0.08) had higher odds of requiring normal sedation compared to those with CYP2C19 increased metabolism, CYP3A5 intermediate metabolism, and UGT1A1 intermediate metabolism. CONCLUSION Information about inter-individual variation in (CYP450) genes may be useful for determining the sedation requirements for outpatient endoscopic procedures. We found that patients with reduced CYP2C19 metabolism, poor CYP3A5 metabolism, and poor UGT1A1 metabolism were more likely to require normal sedation requirements during outpatient endoscopic procedures.
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Affiliation(s)
- Himesh B. Zaver
- Department of Internal Medicine, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Hassan Ghoz
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL 32224, USA (Y.B.)
| | - Balkishan Malviya
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL 32224, USA (Y.B.)
| | - Aman Bali
- Department of Internal Medicine, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Samuel Antwi
- Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, FL 32224, USA;
| | - Ann M. Moyer
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA;
| | - Yan Bi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL 32224, USA (Y.B.)
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Dhir A, Jain K. Sedation for endoscopic procedures: Treading a tightrope. Indian J Gastroenterol 2023; 42:153-155. [PMID: 37166699 DOI: 10.1007/s12664-023-01375-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Affiliation(s)
- Ankita Dhir
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh, 160 012, India
- Department of Anaesthesia, Max Super Speciality Hospital, Phase6, Mohali, 160 055, India
| | - Kajal Jain
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh, 160 012, India.
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Fatima H, Imperiale T. Safety Profile of Endoscopist-directed Balanced Propofol Sedation for Procedural Sedation: An Experience at a Hospital-based Endoscopy Unit. J Clin Gastroenterol 2022; 56:e209-e215. [PMID: 34739402 DOI: 10.1097/mcg.0000000000001630] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 09/27/2021] [Indexed: 12/10/2022]
Abstract
BACKGROUND Nurse-administered propofol sedation was restricted to anesthesiologists in 2009, a practice that has contributed to spiraling health care costs in the United States. AIM The aim of this study was to evaluate the safety of endoscopist-directed balanced propofol sedation (EDBPS). MATERIALS AND METHODS We identified patients undergoing endoscopy with EDBPS from January 1, 2017, to June 20, 2017, and abstracted their medical records. Adverse events (AEs) included: hypoxia (oxygen saturation < 90%); hypotension [(a) systolic blood pressure < 90 mm Hg, (b) systolic blood pressure decline of >50 mm Hg, (c) decline in mean arterial pressure of >30%]; bradycardia (heart rate of < 40 beats/min). Logistic regression identified factors independently associated with AEs. RESULTS A total of 1897 patients received EDBPS during the study period [mean age: 55 y (SD=11.4 y); 56.4% women]. Patients received median doses of 50 µg fentanyl, 2 mg of midazolam, and a mean propofol dose of 160±99 mg. There were no major complications (upper 95% confidence interval, 0.19%). Overall, 334 patients (17.6%) experienced a clinically insignificant AE: 65 (3.4%) experienced transient hypoxia, 277 patients (14.6%) experienced hypotension, 2 had transient bradycardia. In bivariate analysis, older age was associated with risk for hypotension, propofol dose was associated with transient hypoxemia, and procedure duration was associated with both hypotension and transient hypoxia. In multivariate analysis, only procedure length was associated with AEs (odds ratio scale 10; odds ratio=1.07; 95% confidence interval, 1.05-1.09, P<0.001). CONCLUSIONS EDBPS is safe for endoscopic sedation. Given the higher cost of anesthesia-administered propofol, endoscopists should reinstate EDBPS by revising institutional sedation policies.
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Affiliation(s)
- Hala Fatima
- Division of Gastroenterology/Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN
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Yoo SW, Ki MJ, Kim D, Oh YJ, Lee J. The effect of an eye mask on midazolam requirement for sedation during spinal anesthesia: a randomized controlled trial. BMC Anesthesiol 2021; 21:232. [PMID: 34563112 PMCID: PMC8464090 DOI: 10.1186/s12871-021-01451-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 08/08/2021] [Indexed: 11/12/2022] Open
Abstract
Background Midazolam is frequently used for sedation during spinal anesthesia. However, external environmental factors, such as bright surgical lights, may hamper patient relaxation, which may lead to an increase in the dose of midazolam required and the likelihood of adverse drug effects. We investigated whether using an eye mask to block the external environment could reduce midazolam requirements during spinal anesthesia. Methods Participants aged 18–‒80 years, scheduled for elective surgery under spinal anesthesia, were randomly divided into a masked group (wearing eye masks during surgery, n = 20) and a control group (no mask, n = 18). The sedation level was assessed using a modified Observer Assessment of Alertness and Sedation (MOAA/S) scale. Midazolam (1 mg) was incrementally administered every 5 min until moderate sedation (MOAA/S score of 3) was achieved. The bispectral index (BIS) was monitored, and the onset and maintenance times of a BIS < 80 were recorded. Results The two groups had similar demographic characteristics. The midazolam requirements were significantly lower in the masked group than in the control group (2.8 mg vs. 3.7 mg, P = 0.024). However, the onset and maintenance times for a BIS < 80 were similar. In addition, there were no significant differences in the incidence of side effects or patient satisfaction between the two groups. Conclusions Blocking the external environment with an eye mask during spinal anesthesia can reduce the requirement for sedatives, such as midazolam. Trial registration The trial was retrospectively registered with the Clinical Research Information Service (No. KCT0005528, 15/10/2020) entitled “Can we reduce an amount of sleeping pills just by blocking light?”.
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Affiliation(s)
- Seon Woo Yoo
- Department of Anesthesiology and Pain Medicine, Jeonbuk National University Medical School and Hospital, 20, Geonji-ro, Deokjin-gu, Jeonju, 54907, South Korea.,Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, South Korea
| | - Min-Jong Ki
- Department of Anesthesiology and Pain Medicine, Jeonbuk National University Medical School and Hospital, 20, Geonji-ro, Deokjin-gu, Jeonju, 54907, South Korea.,Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, South Korea
| | - Dal Kim
- Department of Anesthesiology and Pain Medicine, Jeonbuk National University Medical School and Hospital, 20, Geonji-ro, Deokjin-gu, Jeonju, 54907, South Korea
| | - Yu Jin Oh
- Department of Anesthesiology and Pain Medicine, Jeonbuk National University Medical School and Hospital, 20, Geonji-ro, Deokjin-gu, Jeonju, 54907, South Korea
| | - Jeongwoo Lee
- Department of Anesthesiology and Pain Medicine, Jeonbuk National University Medical School and Hospital, 20, Geonji-ro, Deokjin-gu, Jeonju, 54907, South Korea. .,Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, South Korea.
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Romito JW, Turner ER, Rosener JA, Coldiron L, Udipi A, Nohrn L, Tausiani J, Romito BT. Baclofen therapeutics, toxicity, and withdrawal: A narrative review. SAGE Open Med 2021; 9:20503121211022197. [PMID: 34158937 PMCID: PMC8182184 DOI: 10.1177/20503121211022197] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 05/13/2021] [Indexed: 12/11/2022] Open
Abstract
Baclofen is an effective therapeutic for the treatment of spasticity related to multiple sclerosis, spinal cord injuries, and other spinal cord pathologies. It has been increasingly used off-label for the management of several disorders, including musculoskeletal pain, gastroesophageal reflux disease, and alcohol use disorder. Baclofen therapy is associated with potential complications, including life-threatening toxicity and withdrawal syndrome. These disorders require prompt recognition and a high index of suspicion. While these complications can develop following administration of either oral or intrathecal baclofen, the risk is greater with the intrathecal route. The management of baclofen toxicity is largely supportive while baclofen withdrawal syndrome is most effectively treated with re-initiation or supplementation of baclofen dosing. Administration of other pharmacologic adjuncts may be required to effectively treat associated withdrawal symptoms. This narrative review provides an overview of the historical and emerging uses of baclofen, offers practical dosing recommendations for both oral and intrathecal routes of administration, and reviews the diagnosis and management of both baclofen toxicity and withdrawal.
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Affiliation(s)
- Jia W Romito
- Department of Anesthesiology and Pain
Management, The University of Texas Southwestern Medical Center, Dallas, TX,
USA
- Department of Neurological Surgery, The
University of Texas Southwestern Medical Center, Dallas, TX, USA
- Department of Neurology, The University
of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Emily R Turner
- Department of Anesthesiology and Pain
Management, The University of Texas Southwestern Medical Center, Dallas, TX,
USA
| | - John A Rosener
- Department of Anesthesiology and Pain
Management, The University of Texas Southwestern Medical Center, Dallas, TX,
USA
| | - Landon Coldiron
- Department of Anesthesiology and Pain
Management, The University of Texas Southwestern Medical Center, Dallas, TX,
USA
| | - Ashutosh Udipi
- Department of Anesthesiology and Pain
Management, The University of Texas Southwestern Medical Center, Dallas, TX,
USA
| | - Linsey Nohrn
- Department of Anesthesiology and Pain
Management, The University of Texas Southwestern Medical Center, Dallas, TX,
USA
| | - Jacob Tausiani
- Department of Anesthesiology and Pain
Management, The University of Texas Southwestern Medical Center, Dallas, TX,
USA
| | - Bryan T Romito
- Department of Anesthesiology and Pain
Management, The University of Texas Southwestern Medical Center, Dallas, TX,
USA
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Almohaish S, Sandler M, Brophy GM. Time Is Brain: Acute Control of Repetitive Seizures and Status Epilepticus Using Alternative Routes of Administration of Benzodiazepines. J Clin Med 2021; 10:jcm10081754. [PMID: 33920722 PMCID: PMC8073514 DOI: 10.3390/jcm10081754] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 04/13/2021] [Accepted: 04/13/2021] [Indexed: 12/15/2022] Open
Abstract
Time plays a major role in seizure evaluation and treatment. Acute repetitive seizures and status epilepticus are medical emergencies that require immediate assessment and treatment for optimal therapeutic response. Benzodiazepines are considered the first-line agent for rapid seizure control. Thus, various routes of administration of benzodiazepines have been studied to facilitate a quick, effective, and easy therapy administration. Choosing the right agent may vary based on the drug and route properties, patient’s environment, caregiver’s skills, and drug accessibility. The pharmacokinetic and pharmacodynamic aspects of benzodiazepines are essential in the decision-making process. Ultimately, agents and routes that give the highest bioavailability, fastest absorption, and a modest duration are preferred. In the outpatient setting, intranasal and buccal routes appear to be equally effective and more rapidly administered than rectal diazepam. On the other hand, in the inpatient setting, if available, the IV route is ideal for benzodiazepine administration to avoid any potential absorption delay. In this article, we will provide an overview and comparison of the various routes of benzodiazepine administration for acute control of repetitive seizures and status epilepticus.
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Affiliation(s)
- Sulaiman Almohaish
- Department of Pharmacotherapy and Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, VA 23298, USA; (S.A.); (M.S.)
- College of Clinical Pharmacy, King Faisal University, Al-Ahsa 3198, Saudi Arabia
| | - Melissa Sandler
- Department of Pharmacotherapy and Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, VA 23298, USA; (S.A.); (M.S.)
- Department of Physical Medicine and Rehabilitation, School of Medicine, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Gretchen M. Brophy
- Department of Pharmacotherapy and Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, VA 23298, USA; (S.A.); (M.S.)
- Correspondence: ; Tel.: +1-(804)-828-1201
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Hong GW, Lee JK, Lee JH, Bong JH, Choi SH, Cho H, Nam JH, Jang DK, Kang HW, Kim JH, Lim YJ, Koh MS, Lee JH. Comparison of Fentanyl versus Meperidine in Combination with Midazolam for Sedative Colonoscopy in Korea. Clin Endosc 2020; 53:562-567. [PMID: 32615653 PMCID: PMC7548153 DOI: 10.5946/ce.2020.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 04/22/2020] [Indexed: 12/22/2022] Open
Abstract
Background/Aims Combination of midazolam and opioids is used widely for endoscopic sedation. Compared with meperidine, fentanyl is reportedly associated with rapid recovery, turnover rate of endoscopy room, and quality of endoscopy. We compared fentanyl with meperidine when combined with midazolam for sedative colonoscopy.
Methods A retrospective, cross-sectional, 1:2 matching study was conducted. Induction and recovery time were compared as the primary outcomes. Moreover, cecal intubation time, withdrawal time, total procedure time of colonoscopy, paradoxical reaction, adenoma detection rate, and adverse effect of midazolam or opioids were assessed as the secondary outcomes.
Results A total of 129 subjects (43 fentanyl vs. 86 meperidine) were included in the analysis. The fentanyl group showed significantly more rapid induction time (4.5±2.7 min vs. 7.5±4.7 min, p<0.001), but longer recovery time (59.5±25.6 min vs. 50.3±10.9 min, p=0.030) than the meperidine group. In multivariate analysis, the induction time of the fentanyl group was 3.40 min faster (p<0.001), but the recovery time was 6.38 min longer (p=0.046) than that of the meperidine group. There was no difference in withdrawal time and adenoma detection rate between the two groups.
Conclusions The fentanyl group had more rapid sedation induction time but longer recovery time than the meperidine group.
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Affiliation(s)
- Gwan Woo Hong
- Department of Internal Medicine, Dongguk University Ilsan Hospital, College of Medicine, Dongguk University, Goyang, Korea
| | - Jun Kyu Lee
- Department of Internal Medicine, Dongguk University Ilsan Hospital, College of Medicine, Dongguk University, Goyang, Korea
| | - Jung Hyeon Lee
- Department of Internal Medicine, Dongguk University Ilsan Hospital, College of Medicine, Dongguk University, Goyang, Korea
| | - Ji Hun Bong
- Department of Internal Medicine, Dongguk University Ilsan Hospital, College of Medicine, Dongguk University, Goyang, Korea
| | - Sung Hun Choi
- Department of Internal Medicine, Dongguk University Ilsan Hospital, College of Medicine, Dongguk University, Goyang, Korea
| | - Hyeki Cho
- Department of Internal Medicine, Dongguk University Ilsan Hospital, College of Medicine, Dongguk University, Goyang, Korea
| | - Ji Hyung Nam
- Department of Internal Medicine, Dongguk University Ilsan Hospital, College of Medicine, Dongguk University, Goyang, Korea
| | - Dong Kee Jang
- Department of Internal Medicine, Dongguk University Ilsan Hospital, College of Medicine, Dongguk University, Goyang, Korea
| | - Hyoun Woo Kang
- Department of Internal Medicine, Dongguk University Ilsan Hospital, College of Medicine, Dongguk University, Goyang, Korea
| | - Jae Hak Kim
- Department of Internal Medicine, Dongguk University Ilsan Hospital, College of Medicine, Dongguk University, Goyang, Korea
| | - Yun Jeong Lim
- Department of Internal Medicine, Dongguk University Ilsan Hospital, College of Medicine, Dongguk University, Goyang, Korea
| | - Moon Soo Koh
- Department of Internal Medicine, Dongguk University Ilsan Hospital, College of Medicine, Dongguk University, Goyang, Korea
| | - Jin Ho Lee
- Department of Internal Medicine, Dongguk University Ilsan Hospital, College of Medicine, Dongguk University, Goyang, Korea
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Efficacy of Sedation by Midazolam in Association With Meperidine or Fentanyl and Role of Patient Distress During Elective Colonoscopy. Gastroenterol Nurs 2020; 43:258-263. [PMID: 32433429 DOI: 10.1097/sga.0000000000000456] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Meperidine and fentanyl are opioids currently used in addition to midazolam for sedation and analgesia during colonoscopy in Italy. The aim of the study was to assess the impact of patients' psychological state before elective colonoscopy on the efficacy of the sedation regimens. Eighty outpatients who underwent an elective colonoscopy were included in our study. The Hospital Anxiety and Depression Scale questionnaire was self-administered to evaluate basal anxiety and depression state. The rate of baseline discomfort was evaluated by a standard 100-mm visual analog scale. Sedation was obtained alternatively with a midazolam-meperidine or midazolam-fentanyl combination. There were no statistically significant differences between the fentanyl and meperidine groups on body mass index, age, and gender composition. Patients in the meperidine group reported less pain during colonoscopy than patients in the fentanyl group. There were statistically significant positive correlations in the meperidine group with the distress, anxiety, and depression. Our study has pointed out greater effectiveness of the midazolam plus meperidine regimen, equal recovery times, and no significant differences in the duration of the endoscopic examinations. The evaluation of patients' psychological status seems to predict the efficacy of sedation when the nociceptive component of pain is well controlled.
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Sedation in Pediatric Bronchoscopy: Propofol versus Fentanyl. Indian Pediatr 2020. [DOI: 10.1007/s13312-020-1836-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Abstract
Editor’s Perspective
What We Already Know about This Topic
What This Article Tells Us That Is New
Background
Enhanced recovery protocols employ various approaches to minimize detrimental side effects of anesthetizing agents. The authors tested the hypothesis that adding low-dose dexmedetomidine to propofol for anesthesia in ambulatory colonoscopies, compared with propofol alone, would lower the propofol requirement, improve the intra-procedure hemodynamic state, and not increase time-to-discharge.
Methods
In this noninferiority, double-blind, randomized controlled trial, patients having colonoscopies received total IV anesthesia either with propofol and placebo (n = 50), or propofol and a bolus dose of dexmedetomidine, 0.3 μg/kg (n = 51). Additional propofol was administered to maintain a Bispectral Index score of 60. Following the procedure, readiness for discharge was assessed regularly using the Modified Post Anesthetic Discharge Scoring System until discharge criteria were met. The primary outcome was the percentage of patients meeting discharge criteria within 30 min from procedure end-time.
Results
Twenty-six of 51 (51%) patients receiving propofol-dexmedetomidine were ready for discharge by 30 min from procedure end time, compared with 44 of 50 (88%) receiving propofol (P < 0.001). Propofol consumption was lower in subjects receiving propofol–dexmedetomidine (140 μg · kg-1 · min-1) compared to those receiving propofol (180 μg · kg-1 · min-1) with P = 0.011. The lowest mean arterial pressure decreased further from baseline in those receiving propofol–dexmedetomidine (−30%; mean decrease −30 ±10.5 mmHg) compared to propofol (−21%; mean decrease, −22 ± 14.2 mmHg) with P = 0.003. There was no difference in incidence of bradycardia, with sustained bradycardia occurring in 3 of 51 (6%) patients receiving propofol–dexmedetomidine compared to 1 of 50 (2%) patients receiving propofol (P = 0.62). No apnea episodes requiring positive-pressure ventilation occurred in either group.
Conclusions
For anesthesia in ambulatory colonoscopy, combining low-dose dexmedetomidine with propofol delayed discharge readiness and provoked hypotension compared to propofol alone.
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Akbulut UE, Kartal S, Dogan U, Akcali GE, Kalayci S, Kirci H. Propofol with and without Midazolam for Diagnostic Upper Gastrointestinal Endoscopies in Children. Pediatr Gastroenterol Hepatol Nutr 2019; 22:217-224. [PMID: 31110954 PMCID: PMC6506432 DOI: 10.5223/pghn.2019.22.3.217] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 12/11/2018] [Accepted: 12/11/2018] [Indexed: 12/15/2022] Open
Abstract
PURPOSE Various publications on the use of sedation and anesthesia for diagnostic procedures in children have demonstrated that no ideal agent is available. Although propofol has been widely used for sedation during esophagogastroduodenoscopy in children, adverse events including hypoxia and hypotension, are concerns in propofol-based sedation. Propofol is used in combination with other sedatives in order to reduce potential complications. We aimed to analyze whether the administration of midazolam would improve the safety and efficacy of propofol-based sedation in diagnostic esophagogastroduodenoscopies in children. METHODS We retrospectively reviewed the hospital records of children who underwent diagnostic esophagogastroduodenoscopies during a 30-month period. Demographic characteristics, vital signs, medication dosages, induction times, sedation times, recovery times, and any complications observed, were examined. RESULTS Baseline characteristics did not differ between the midazolam-propofol and propofol alone groups. No differences were observed between the two groups in terms of induction times, sedation times, recovery times, or the proportion of satisfactory endoscopist responses. No major procedural complications, such as cardiac arrest, apnea, or laryngospasm, occurred in any case. However, minor complications developed in 22 patients (10.7%), 17 (16.2%) in the midazolam-propofol group and five (5.0%) in the propofol alone group (p=0.010). CONCLUSION The sedation protocol with propofol was safe and efficient. The administration of midazolam provided no additional benefit in propofol-based sedation.
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Affiliation(s)
- Ulas Emre Akbulut
- Department of Pediatric Gastroenterology Hepatology and Nutrition, University of Health Sciences, Antalya Education and Research Hospital, Antalya, Turkey
| | - Seyfi Kartal
- Department of Anesthesiology and Intensive Care Medicine, University of Health Sciences, Kanuni Training and Research Hospital, Trabzon, Turkey
| | - Ufuk Dogan
- Department of Anesthesiology and Intensive Care Medicine, University of Health Sciences, Kanuni Training and Research Hospital, Trabzon, Turkey
| | - Gulgun Elif Akcali
- Department of Anesthesiology and Intensive Care Medicine, University of Health Sciences, Kanuni Training and Research Hospital, Trabzon, Turkey
| | - Serap Kalayci
- Department of Anesthesiology and Intensive Care Medicine, University of Health Sciences, Kanuni Training and Research Hospital, Trabzon, Turkey
| | - Hulya Kirci
- Department of Pediatric Gastroenterology Hepatology and Nutrition, University of Health Sciences, Kanuni Training and Research Hospital, Trabzon, Turkey
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Kayaaltı S, Kayaaltı Ö. Safety of applying midazolam-ketamine-propofol sedation combination under the supervision of endoscopy nurse with patient-controlled analgesia pump in colonoscopy. World J Clin Cases 2018; 6:1146-1154. [PMID: 30613673 PMCID: PMC6306640 DOI: 10.12998/wjcc.v6.i16.1146] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 11/09/2018] [Accepted: 11/23/2018] [Indexed: 02/05/2023] Open
Abstract
AIM To compare the results of midazolam-ketamine-propofol sedation performed by an endoscopy nurse and anaesthetist during colonoscopy in terms of patient satisfaction and safety. METHODS American Statistical Association (ASA) I-II 60 patients who underwent colonoscopy under sedation were randomly divided into two groups: sedation under the supervision of an anaesthetist (SSA) and sedation under the supervision of an endoscopy nurse (SSEN). Both groups were initially administered 1 mg midazolam, 50 mg ketamine and 30-50 mg propofol. Continuation of sedation was performed by the anaesthetist in the SSA group and the nurse with a patient-controlled analgesia (PCA) pump in the SSEN group. The total propofol consumption, procedure duration, recovery times, pain using the visual analogue scale (VAS) and satisfaction score of the patients, and side effects were recorded. In addition, the patients were asked whether they remembered the procedure and whether they would prefer the same method in the case of re-endoscopy. RESULTS Total propofol consumption in the SSEN group was significantly higher (P < 0.05) than that in the SSA group. When the groups were compared in terms of VAS score, recovery time, patient satisfaction, recall of the procedure, re-preference for the same method in case of re-endoscopy, and side effects, there were no significant differences (P > 0.05) between the two groups. No long-term required intervention side effects were observed in either group. CONCLUSION Colonoscopy sedation in ASA I-II patients can be safely performed by an endoscopy nurse using PCA pump with the incidence of side effects and patient satisfaction levels similar to sedation under anaesthetist supervision.
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Affiliation(s)
- Selda Kayaaltı
- Division of Anaesthesiology and Reanimation, Develi Public Hospital, Develi, Kayseri 38400, Turkey
| | - Ömer Kayaaltı
- Computer Technology, Kayseri University, Develi Huseyin Sahin Vocational College, Develi, Kayseri 38400, Turkey
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Pastis NJ, Yarmus LB, Schippers F, Ostroff R, Chen A, Akulian J, Wahidi M, Shojaee S, Tanner NT, Callahan SP, Feldman G, Lorch DG, Ndukwu I, Pritchett MA, Silvestri GA. Safety and Efficacy of Remimazolam Compared With Placebo and Midazolam for Moderate Sedation During Bronchoscopy. Chest 2018; 155:137-146. [PMID: 30292760 DOI: 10.1016/j.chest.2018.09.015] [Citation(s) in RCA: 126] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 08/20/2018] [Accepted: 09/05/2018] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND While the complexity of flexible bronchoscopy has increased, standard options for moderate sedation medications have not changed in three decades. There is a need to improve moderate sedation while maintaining safety. Remimazolam was developed to address shortcomings of current sedation strategies. METHODS A prospective, double-blind, randomized, multicenter, parallel group trial was performed at 30 US sites. The efficacy and safety of remimazolam for sedation during flexible bronchoscopy were compared with placebo and open-label midazolam. RESULTS The success rates were 80.6% in the remimazolam arm, 4.8% in the placebo arm (P < .0001), and 32.9% in the midazolam arm. Bronchoscopy was started sooner in the remimazolam arm (mean, 6.4 ± 5.82 min) compared with placebo (17.2 ± 4.15 min; P < .0001) and midazolam (16.3 ± 8.60 min). Time to full alertness after the end of bronchoscopy was significantly shorter in patients treated with remimazolam (median, 6.0 min; 95% CI, 5.2-7.1) compared with those treated with placebo (13.6 min; 95% CI, 8.1-24.0; P = .0001) and midazolam (12.0 min; 95% CI, 5.0-15.0). Remimazolam registered superior restoration of neuropsychiatric function compared with placebo and midazolam. Safety was comparable among all three arms, and 5.6% of the patients in the remimazolam group had serious treatment-emergent adverse events as compared with 6.8% in the placebo group. CONCLUSIONS Remimazolam administered under the supervision of a pulmonologist was effective and safe for moderate sedation during flexible bronchoscopy. In an exploratory analysis, it demonstrated a shorter onset of action and faster neuropsychiatric recovery than midazolam.
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Affiliation(s)
- Nicholas J Pastis
- Division of Pulmonary and Critical Care, Medical University of South Carolina, Charleston, SC.
| | - Lonny B Yarmus
- Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, MD
| | | | | | - Alexander Chen
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO
| | - Jason Akulian
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina, Chapel Hill, NC
| | - Momen Wahidi
- Pulmonary and Critical Care Medicine, Duke University Medical Center, Durham, NC
| | - Samira Shojaee
- Division of Pulmonary Disease and Critical Care Medicine, Virginia Commonwealth University, Richmond, VA
| | - Nichole T Tanner
- Division of Pulmonary and Critical Care, Medical University of South Carolina, Charleston, SC
| | - Sean P Callahan
- Division of Pulmonary and Critical Care, Greenville Health System, Greenville, SC
| | | | - Daniel G Lorch
- Pulmonary Associates of Brandon Clinical Research, Brandon, FL
| | - Ikeadi Ndukwu
- LaPorte County Institute for Clinical Research, Michigan City, IN
| | - Michael A Pritchett
- Pulmonary and Critical Care Medicine, FirstHealth Moore Regional Hospital, and Pinehurst Medical Clinic, Pinehurst, NC
| | - Gerard A Silvestri
- Division of Pulmonary and Critical Care, Medical University of South Carolina, Charleston, SC
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Nishizawa T, Suzuki H. Propofol for gastrointestinal endoscopy. United European Gastroenterol J 2018; 6:801-805. [PMID: 30023057 PMCID: PMC6047291 DOI: 10.1177/2050640618767594] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 03/05/2018] [Indexed: 12/12/2022] Open
Abstract
Most gastrointestinal endoscopic procedures are now performed with sedation. Moderate sedation using benzodiazepines and opioids continues to be widely used, but propofol sedation is becoming more popular because its unique pharmacokinetic properties make endoscopy almost painless, with a very predictable and rapid recovery process. There is controversy as to whether propofol should be administered only by anesthesia professionals. According to published values, endoscopist-directed propofol has a lower mortality rate than endoscopist-delivered benzodiazepines and opioids, and a comparable rate to general anesthesia by anesthesiologists. Rapid recovery has a major impact on patient satisfaction, post-procedure education and the general flow of the endoscopy unit. According to estimates, the absolute economic benefit of endoscopist-directed propofol implementation in a screening setting is probably substantial, with 10-year savings of $3.2 billion in the USA. Guidelines concerning the use of propofol emphasize the need for adequate training and certification in sedation by non-anesthetists.
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Affiliation(s)
- Toshihiro Nishizawa
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
- Department of Gastroenterology and Hepatology, Keio University School of Medicine, Tokyo, Japan
| | - Hidekazu Suzuki
- Department of Gastroenterology and Hepatology, Keio University School of Medicine, Tokyo, Japan
- Fellowship Training Center and Medical Education Center, Keio University School of Medicine, Tokyo, Japan
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16
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Procedural sedation by advanced care paramedics for emergency gastrointestinal endoscopy. CAN J EMERG MED 2018; 21:235-242. [PMID: 29759099 DOI: 10.1017/cem.2018.372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES At the QEII Health Sciences Centre Emergency Department (ED) in Halifax, Nova Scotia, advanced care paramedics (ACPs) perform procedural sedation and analgesia (PSA) for many indications, including orthopedic procedures. We have begun using ACPs as sedationists for emergent upper gastrointestinal (UGI) endoscopy. This study compares ACP-performed ED PSA for UGI endoscopy and orthopedic procedures in terms of adverse events, airway intervention, vasopressor requirement, and PSA medication use. METHODS A data set was built from an ED PSA quality control database matching 61 UGI endoscopy PSAs to 183 orthopedic PSAs by propensity scores calculated using age, gender, and the American Society of Anesthesiologists (ASA) classification. Outcomes assessed were hypotension (systolic BP30 sec), vomiting, arrhythmias, death, airway intervention, vasopressor requirement, and PSA medication use. RESULTS UGI endoscopy patients experienced hypotension more frequently than orthopedic patients (OR=4.11, CI: 2.05-8.22) and required airway repositioning less often (OR=0.24, CI: 0.10-0.59). They received ketamine more frequently (OR=15.7, CI: 4.75-67.7) and fentanyl less often (OR=0.30, CI: 0.15-0.63) than orthopedic patients. Four endoscopy patients received phenylephrine, and one required intubation. No patient died in either group. CONCLUSIONS In ACP-led sedation for UGI endoscopy and orthopedic procedures, adverse events were rare with the notable exception of hypotension, which was more frequent in the endoscopy group. Only endoscopy patients required vasopressor treatment and intubation. We provide preliminary evidence that ACPs can manage ED PSA for emergent UGI endoscopy, although priorities must shift from pain control to hemodynamic optimization.
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17
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Kim EH, Park JC, Shin SK, Lee YC, Lee SK. Effect of the midazolam added with propofol-based sedation in esophagogastroduodenoscopy: A randomized trial. J Gastroenterol Hepatol 2018; 33:894-899. [PMID: 29048708 DOI: 10.1111/jgh.14026] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Revised: 10/11/2017] [Accepted: 10/12/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM Although propofol has been widely used for sedation during esophagogastroduodenoscopy (EGD), adverse events including hypoxia and hypotension may be a concern in the propofol-based sedation. We aimed to analyze whether administration of midazolam would improve safety and efficacy of propofol-based sedation in EGD. METHODS One hundred twenty patients who were scheduled to undergo diagnostic EGD were randomly assigned to either midazolam plus propofol (MP) or propofol alone groups. In the MP group, 2 mg of midazolam and 10 mg of propofol were given initially. In the propofol alone group, 40-60 mg of propofol was given initially. In both groups, 20 mg of propofol was given repeatedly to maintain moderate sedation as needed. Vital signs including oxygen saturation were monitored every 2 min. After the patients fully recovered, satisfaction score was investigated from endoscopists, nurses, and patients, respectively. RESULTS The baseline characteristics did not differ between the MP and propofol alone groups. The mean required doses of propofol was (mean ± standard deviation) 0.3 ± 0.3 and 0.8 ± 0.2 mg/kg in the MP and propofol alone groups, respectively (P < 0.001). In addition, sedation-related adverse events and recovery time did not differ between the two groups. The proportion of satisfactory did not differ between the two groups (MP vs propofol alone; proportion; patient, 95.0% vs 93.3%, P > 0.999; endoscopist, 73.3% vs 80.0%, P = 0.064; nurse, 73.3% vs 76.7%, P = 0.551). CONCLUSION Adding midazolam to propofol did not reduced the safety and efficacy, and sedation using propofol alone could be suitable for sedation during diagnostic EGD.
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Affiliation(s)
- Eun Hye Kim
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jun Chul Park
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Kwan Shin
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Chan Lee
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Kil Lee
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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18
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Lin OS. Sedation for routine gastrointestinal endoscopic procedures: a review on efficacy, safety, efficiency, cost and satisfaction. Intest Res 2017; 15:456-466. [PMID: 29142513 PMCID: PMC5683976 DOI: 10.5217/ir.2017.15.4.456] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 08/03/2017] [Accepted: 08/03/2017] [Indexed: 02/07/2023] Open
Abstract
Most gastrointestinal endoscopic procedures are now performed with sedation. Moderate sedation using benzodiazepines and opioids continue to be widely used, but propofol sedation is becoming more popular because its unique pharmacokinetic properties make endoscopy almost painless, with a very predictable and rapid recovery process. There is controversy as to whether propofol should be administered only by anesthesia professionals (monitored anesthesia care) or whether properly trained non-anesthesia personnel can use propofol safely via the modalities of nurse-administered propofol sedation, computer-assisted propofol sedation or nurse-administered continuous propofol sedation. The deployment of non-anesthesia administered propofol sedation for low-risk procedures allows for optimal allocation of scarce anesthesia resources, which can be more appropriately used for more complex cases. This can address some of the current shortages in anesthesia provider supply, and can potentially reduce overall health care costs without sacrificing sedation quality. This review will discuss efficacy, safety, efficiency, cost and satisfaction issues with various modes of sedation for non-advanced, non-emergent endoscopic procedures, mainly esophagogastroduodenoscopy and colonoscopy.
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Affiliation(s)
- Otto S Lin
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
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19
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Impact of pharmaceutical care on pain and agitation in a medical intensive care unit in Thailand. Int J Clin Pharm 2017; 39:573-581. [PMID: 28357623 DOI: 10.1007/s11096-017-0456-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Accepted: 03/21/2017] [Indexed: 10/19/2022]
Abstract
Background Currently, a lack of pharmaceutical care exists concerning pain and agitation in medical intensive care units (MICU) in Thailand. Pharmaceutical care focusing on analgesics/sedatives would improve clinical outcomes. Objective To investigate the impact of pharmaceutical care of pain and agitation on ICU length of stay (LOS), hospital LOS, ventilator days and mortality. Setting The MICU of a university hospital. Method A before/after study was conducted on mechanically ventilated patients receiving analgesics/sedatives. Medical chart reviews and data collection were conducted in the retrospective group (no pharmacists involved). In the prospective group, pharmacists involved with the critical care team helped select analgesics/sedatives for individual patients. Main outcome measure ICU LOS Results In total, 90 and 66 patients were enrolled in retrospective and prospective groups, respectively. The median duration of ICU LOS was reduced from 10.00 (2.00-72.00) in the retrospective group to 6.50 days (2.00-30.00) in the prospective group (p = 0.002). The median hospital stay was reduced from 30.50 days (2.00-119.00) in the retrospective group to 17.50 days (2.00-110.00) in the prospective group (p < 0.001). Also, the median ventilator days was reduced from 14.00 days (2.00-90.00) to 8.50 days (1.00-45.00), p = 0.008. Mortality was 53.03% in the prospective group and 46.67% in the retrospective group (p = 0.432). Conclusion Pharmacist participation in a critical care team resulted in a significant reduction in the duration of ICU LOS, hospital LOS and ventilator days, but not mortality.
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20
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Southerland JH, Brown LR. Conscious Intravenous Sedation in Dentistry: A Review of Current Therapy. Dent Clin North Am 2016; 60:309-346. [PMID: 27040288 DOI: 10.1016/j.cden.2015.11.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Several sedation options are used to minimize pain, anxiety, and discomfort during oral surgery procedures. Minimizing or eliminating pain and anxiety for dental care is the primary goal for conscious sedation. Intravenous conscious sedation is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate as well as cardiovascular function. Patients must retain their protective airway reflexes, and respond to and understand verbal communication. The drugs and techniques used must therefore carry a broad margin of safety.
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Affiliation(s)
- Janet H Southerland
- Department of Oral and Maxillofacial Surgery, Meharry Medical College School of Dentistry, 1005 Dr. DB Todd Jr. Boulevard, Nashville, TN 37208, USA.
| | - Lawrence R Brown
- Dadeland Oral Surgery Associates, 8950 S.W. 74th Court, Suite 1610, Miami Florida 33156; Baptist Hospital Of Miami, 8900 North Kendall Drive, Miami Florida 33176
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21
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Vet NJ, Kleiber N, Ista E, de Hoog M, de Wildt SN. Sedation in Critically Ill Children with Respiratory Failure. Front Pediatr 2016; 4:89. [PMID: 27606309 PMCID: PMC4995367 DOI: 10.3389/fped.2016.00089] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Accepted: 08/09/2016] [Indexed: 01/08/2023] Open
Abstract
This article discusses the rationale of sedation in respiratory failure, sedation goals, how to assess the need for sedation as well as effectiveness of interventions in critically ill children, with validated observational sedation scales. The drugs and non-pharmacological approaches used for optimal sedation in ventilated children are reviewed, and specifically the rationale for drug selection, including short- and long-term efficacy and safety aspects of the selected drugs. The specific pharmacokinetic and pharmacodynamic aspects of sedative drugs in the critically ill child and consequences for dosing are presented. Furthermore, we discuss different sedation strategies and their adverse events, such as iatrogenic withdrawal syndrome and delirium. These principles can guide clinicians in the choice of sedative drugs in pediatric respiratory failure.
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Affiliation(s)
- Nienke J Vet
- Intensive Care, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands; Department of Pediatrics, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands
| | - Niina Kleiber
- Intensive Care, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands; Department of Pediatric Surgery, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands; Department of Pediatrics, CHU Sainte-Justine, Montreal, QC, Canada
| | - Erwin Ista
- Intensive Care, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands; Department of Pediatrics, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands
| | - Matthijs de Hoog
- Intensive Care, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands; Department of Pediatrics, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands
| | - Saskia N de Wildt
- Intensive Care, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands; Department of Pediatric Surgery, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands; Department of Pharmacology and Toxicology, Radboud University, Nijmegen, Netherlands
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22
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Jensen JT, Hornslet P, Konge L, Møller AM, Vilmann P. High efficacy with deep nurse-administered propofol sedation for advanced gastroenterologic endoscopic procedures. Endosc Int Open 2016; 4:E107-11. [PMID: 26793779 PMCID: PMC4713185 DOI: 10.1055/s-0041-107899] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Whereas data on moderate nurse-administered propofol sedation (NAPS) efficacy and safety for standard endoscopy is abundant, few reports on the use of deep sedation by endoscopy nurses during advanced endoscopy, such as Endoscopic Retrograde Cholangiopancreatography (ERCP) and Endoscopic Ultrasound (EUS) are available and potential benefits or hazards remain unclear. The aims of this study were to investigate the efficacy of intermittent deep sedation with propofol for a large cohort of advanced endoscopies and to provide data on the safety. PATIENTS AND METHODS All available data from patients sedated with intermittent deep NAPS for ERCP, EUS or double balloon enteroscopy (DBE, since the method was implemented in May 2007 through December 2012 were included for evaluation in a retrospective case-control design. RESULTS Data from 1899 patients undergoing 1899 procedures were included for evaluation. All but one procedure were completed with intermittent deep NAPS. The mean propofol dose was 397 mg (SD: 232.4) and the infusion rate was 23.9 mg/kg. The frequency of hypoxia was 4.3 % and 20 patients needed assisted ventilation (1.1 %). Anesthesiologic support was requested eight times (0.4 %). One patient was intubated due to suspected aspiration. CONCLUSIONS Intermittent deep NAPS for advanced endoscopies in selected patients provided an almost 100 % success rate. However, the rate of hypoxia, hypotension and respiratory support was high compared with previously published data, but the method was still assessed as safe.
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Affiliation(s)
- Jeppe Thue Jensen
- Gastro unit D, Department of endoscopy, Copenhagen University Hospital Herlev, Denmark
| | - Pernille Hornslet
- Gastro unit D, Department of endoscopy, Copenhagen University Hospital Herlev, Denmark
| | - Lars Konge
- Copenhagen Academy for Medical Education and Simulation, University of Copenhagen and the Capital Region of Denmark, Denmark
| | - Ann Merete Møller
- Department of Anaesthesiology, Copenhagen University Hospital Herlev, Denmark
| | - Peter Vilmann
- Gastro unit D, Department of endoscopy, Copenhagen University Hospital Herlev, Denmark
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Abstract
Sedation allows patients to tolerate unpleasant endoscopic procedures by relieving anxiety, discomfort, or pain. It also reduces a patient's risk of physical injury during endoscopic procedures, while providing the endoscopist with an adequate setting for a detailed examination. Sedation is therefore considered by many endoscopists to be an essential component of gastrointestinal endoscopy. Endoscopic sedation by nonanesthesiologists is a worldwide practice and has been proven effective and safe. Moderate sedation/analgesia is generally accepted as an appropriate target for sedation by nonanesthesiologists. This focused review describes the general principles of endoscopic sedation, the detailed pharmacology of sedatives and analgesics (focused on midazolam, propofol, meperidine, and fentanyl), and the multiple regimens available for use in actual practice.
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Affiliation(s)
- Sung-Hoon Moon
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
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24
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Park JM, Kim JH. Assessment and Treatment of Pain in Adult Intensive Care Unit Patients. Korean J Crit Care Med 2014. [DOI: 10.4266/kjccm.2014.29.3.147] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Jun-Mo Park
- Department of Anesthesiology and Pain Medicine, Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu, Korea
| | - Ji Hyun Kim
- Department of Anesthesiology and Pain Medicine, Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu, Korea
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Tas A, Mıstanoglu V, Darcın S, Kececioglu M. Tramadol versus fentanyl during propofol-based deep sedation for uterine dilatation and curettage: a prospective study. J Obstet Gynaecol Res 2013; 40:749-53. [PMID: 24320560 DOI: 10.1111/jog.12259] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Accepted: 08/03/2013] [Indexed: 11/29/2022]
Abstract
AIM Dilatation and curettage (D&C) is a common day-care procedure in obstetrics and gynecology, with patients discharged after a brief hospital stay on the same day of the surgery. Although it has a short duration, severe pain occurs during the procedure. Therefore, this surgical procedure requires an anesthetic to provide adequate analgesia, rapid onset, and rapid recovery. The main objective of the present study was to compare the analgesic effectiveness and safety of tramadol with those of fentanyl during D&C. METHODS The study comprised 100 women with American Society of Anesthesiologists classification I-II who were scheduled for a D&C procedure. Baseline anesthesia was maintained with 1 mg/kg propofol, and the patients were then randomly allocated to receive tramadol 1 mg/kg (Group T, n = 50) or fentanyl 1 μg/kg (Group F, n = 50). Hemodynamic variables, sedation, pain, the Aldrete recovery score, and side-effects were recorded. RESULTS SpO₂ levels in Group F in the 5th min and at the end of the procedure were significantly lower than those in Group T (P = 0.024 and 0.021, respectively). CONCLUSION Tramadol provides similar analgesic efficacy to fentanyl. Furthermore, tramadol may provide better respiratory stability in patients undergoing a D&C procedure.
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Affiliation(s)
- Ayca Tas
- Department of Anesthesiology, Dr Faruk Sukan Maternity and Child Hospital, Konya, Turkey
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26
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McGovern PC, Wible M, Korth-Bradley JM, Quintana A. Pancreatitis in tigecycline Phase 3 and 4 clinical studies. J Antimicrob Chemother 2013; 69:773-8. [PMID: 24216769 PMCID: PMC3922153 DOI: 10.1093/jac/dkt427] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Objectives To examine the incidence of pancreatitis among subjects enrolled in the tigecycline clinical trial programme, summarize cases and examine concomitant use of other pancreatitis-causing medications. Methods Subject data from Phase 3 and 4 comparative tigecycline studies were included in the analysis; investigator-reported adverse events of ‘pancreatitis’, ‘necrotizing pancreatitis’ or ‘pancreas disorder’ were reviewed. Data were summarized and cases were reported. No statistical comparisons were made. The incidence of overall pancreatitis with 95% CIs was calculated. The Wilson score method was used to calculate CIs. Results Nineteen subjects with investigator-determined pancreatitis were identified from the programme database, which included 3788 subjects treated with tigecycline and 3646 subjects treated with a comparator. There were 9 cases identified among the tigecycline-treated subjects [9 of 3788 (0.24%; 95% CI, 0.11–0.45)] and 10 cases among the comparator-treated subjects [10 of 3646 (0.27%; 95% CI, 0.13–0.50)]. The demographic characteristics of the subjects with pancreatitis were similar between treatment groups. The median duration of tigecycline therapy was 8.0 days compared with 11.0 days of comparator treatment. Concomitant or prior exposure to a Badalov class I medication was evident in the majority of subjects who developed pancreatitis. A numerically higher number of tigecycline-treated subjects were exposed to furosemide prior to the onset of pancreatitis than comparator-treated subjects. Conclusions Pancreatitis was uncommon in subjects treated with tigecycline, with an occurrence of <1%. Concomitant medications known to cause pancreatitis should be considered when prescribing tigecycline, but may not identify those at risk of developing pancreatitis.
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Affiliation(s)
| | | | | | - Alvaro Quintana
- Medicines Development Group, Pfizer Inc., Collegeville, PA, USA
- Corresponding author. Tel: +1-484-865-2027; Fax: +1-484-865-6462; E-mail:
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27
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Dzeletovic I, Harrison ME, Crowell MD, Ramirez FC, Yows CR, Harris LA, Pasha SF, Gurudu SR, Leighton JA, Heigh RI. Impact of fentanyl in lieu of meperidine on endoscopy unit efficiency: a prospective comparative study in patients undergoing EGD. Gastrointest Endosc 2013; 77:883-7. [PMID: 23472999 DOI: 10.1016/j.gie.2013.01.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Accepted: 01/01/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND Turnaround time is an important component of endoscopy unit efficiency. Any reduction in the total time from patient arrival in the endoscopy room to departure from the recovery area may translate into better endoscopy unit efficiency. OBJECTIVE To evaluate the effects on endoscopy unit efficiency of a change in narcotic choice for moderate sedation in patients undergoing EGD at an ambulatory surgery center. DESIGN Prospective, comparative, quality-improvement project. SETTING Endoscopy unit of a tertiary-care academic medical center. PATIENTS We enrolled consecutive patients (n = 1963) who underwent outpatient EGD by 1 of 5 endoscopists between November 2008 and November 2010. INTERVENTION Moderate sedation with midazolam plus fentanyl versus meperidine. MAIN OUTCOME MEASUREMENTS Sedation-dependent endoscopy unit efficiency and total procedure time (induction-to-intubation, intubation-to-extubation, and extubation-to-discharge). RESULTS Fentanyl was associated with reduced total procedure time by 10.1 minutes resulting from both shorter induction-to-intubation time and extubation-to-discharge time (P < .001). The mean (± SD) sedation-dependent endoscopy unit efficiency was 3.2 (± 1.9) procedures per hour for the meperidine group and 3.9 (± 2.7) procedures per hour for the fentanyl group (P = .012); this would translate into possibly increasing the endoscopy suite efficiency by 22%. Based on dosage equivalency conversion, equal doses of fentanyl and meperidine were used. No sedation-related complications or need for reversal agents were recorded. LIMITATIONS No randomization was performed. CONCLUSION Compared with meperidine, fentanyl in combination with midazolam was associated with significantly shorter total procedure time. By improving the turnaround time, sedation-dependent endoscopy unit efficiency may be improved by 22%.
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Affiliation(s)
- Ivana Dzeletovic
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona 85259, USA
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Mohanasundaram U, Ho LA, Kuschner WG, Chitkara RK, Canfield J, Canfield LM, Krishna G. The Diagnostic Yield of Navigational Bronchoscopy Performed with Propofol Deep Sedation. ACTA ACUST UNITED AC 2013. [DOI: 10.5402/2013/824693] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Objective. To describe the diagnostic yield of electromagnetic navigation bronchoscopy (ENB) utilizing propofol for procedural deep sedation. Methods. We conducted a structured retrospective analysis of the medical records of patients who underwent ENB with propofol for the evaluation of pulmonary nodules and masses. We analyzed the relationships between lesion size and location, variance (CT-to-body divergence), and positron emission tomography findings on diagnostic yield. Diagnoses were established by histopathological evaluation and clinical-radiographic followup. Results. 41 patients underwent ENB during the study period. The overall diagnostic yield was 89% (42 of 47 target lesions). Among the 42 positive specimens, the diagnoses were squamous cell carcinoma (n=10), adenocarcinoma (n=14), small cell carcinoma (n=2), adenocarcinoma in situ (n=2), coccidioidomycosis (n=1), and inflammatory processes (n=13). Average lesion size was 3.01±0.21 cm and variance 3.6±0.15 mm. The diagnostic yield was greater when the lesion size was >4 cm (100%) and when variance was ≤4 mm (91% versus 87%, P=0.003). Conclusion. The diagnostic yield of ENB utilizing propofol for procedural deep sedation at our center was excellent. ENB with deep sedation may result in superior diagnostic yield compared with ENB performed with moderate sedation.
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Affiliation(s)
- Uma Mohanasundaram
- Division of Pulmonary and Critical Care Medicine, Stanford University Medical Center, Stanford, CA 94305, USA
- Pulmonary Section, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA 94304, USA
| | - Lawrence A. Ho
- Division of Pulmonary and Critical Care Medicine, Stanford University Medical Center, Stanford, CA 94305, USA
- Pulmonary Section, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA 94304, USA
| | - Ware G. Kuschner
- Division of Pulmonary and Critical Care Medicine, Stanford University Medical Center, Stanford, CA 94305, USA
- Pulmonary Section, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA 94304, USA
| | - Rajinder K. Chitkara
- Division of Pulmonary and Critical Care Medicine, Stanford University Medical Center, Stanford, CA 94305, USA
- Pulmonary Section, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA 94304, USA
| | - James Canfield
- Pulmonary Section, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA 94304, USA
| | - Lourdes M. Canfield
- Pulmonary Section, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA 94304, USA
| | - Ganesh Krishna
- Division of Pulmonary and Critical Care Medicine, Stanford University Medical Center, Stanford, CA 94305, USA
- Pulmonary Section, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA 94304, USA
- Palo Alto Medical Foundation, Palo Alto, 701 E. El Camino Real, Mountain View, CA 94040, USA
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Tanaka N, Horiuchi A, Nakayama Y, Katsuyama Y, Isobe M, Aoyama T, Tanaka E, Ohmori S. Safety and effectiveness of low-dose propofol sedation during and after esophagogastroduodenoscopy in child A and B cirrhotic patients. Dig Dis Sci 2013. [PMID: 23179158 DOI: 10.1007/s10620-012-2483-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Effective and safe sedation for patients with liver cirrhosis is problematic. AIM To examine the safety and effectiveness of low-dose propofol sedation during and after esophagogastroduodenoscopy (EGD) in cirrhotic patients. METHODS Study 1 was a prospective study in cirrhotic patients who underwent diagnostic EGD under propofol sedation. Propofol was given by bolus injection with an age-adjusted standard protocol consisting of 40 mg for patients <70 years, 30 mg for patients aged 70-89 years; additional injections of 20 mg propofol were given up to a maximum of 120 mg. The principal parameter was the occurrence of adverse events within 24 h after EGD. Secondary parameters included successful procedures, complications, and full recovery within 60 min. In Study 2, the residual effects of propofol were evaluated using a driving simulator and blood propofol concentrations in a subset of cirrhotic patients undergoing EGD and compared with healthy individuals. The principal parameter was driving ability. RESULTS Study 1: Consecutive cirrhotic patients were entered and all 163 successfully completed EGD. The mean dose of propofol was 46 mg (range 30-120 mg). No complications occurred. Full recovery had occurred in 100 % 60 min after the procedure. No adverse events occurred within 24 h after EGD. Study 2: There were no significant differences in blood propofol levels between cirrhotic patients (n = 21) and healthy individuals (n = 20) after sedation. In cirrhotic patients, there was no deterioration in driving ability as compared with healthy individuals. CONCLUSION Low-dose propofol sedation provided safe and effective sedation for EGD in cirrhotic patients with rapid recovery.
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Affiliation(s)
- Naoki Tanaka
- Department of Metabolic Regulation, Institute on Aging and Adaptation, Shinshu University Graduate School of Medicine, Shinshu, Japan
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Porhomayon J, Nader ND, El-Solh AA, Hite M, Scott J, Silinskie K. Pre- and post-intervention study to assess the impact of a sedation protocol in critically ill surgical patients. J Surg Res 2013; 184:966-72.e4. [PMID: 23622725 DOI: 10.1016/j.jss.2013.03.065] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Revised: 02/08/2013] [Accepted: 03/20/2013] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Sedation and pain management for mechanically ventilated critically ill surgical patients pose many challenges for the intensivist. Even though daily interruption of sedatives and opioids is appropriate in medical intensive care unit (ICU) patients, it may not be feasible in the surgical patients with pain from surgical incision or trauma. Therefore we developed an analgesia/sedation based protocol for the surgical ICU population. METHODS We performed a two-phase prospective observational control study. We evaluated a prescriber driven analgesia/sedation protocol (ASP) in a 12-bed surgical ICU. The pre-ASP group was sedated as usual (n = 100) and the post-ASP group was managed with the new ASP (n = 100). Each phase of the study lasted for 5 mo. Comparisons between the two groups were performed by χ(2) or Fisher's exact test for categorical variables and the Mann-Whitney test for nonparametric variables. A P value <0.05 was statistically significant. RESULTS We found a significant reduction in the use of fentanyl (P < 0.001) and midazolam (P = 0.001). We achieved sedation goals of 86.8% in the post-ASP group compared to 74.4% in the pre-ASP (P < 0.001). Mean mechanical ventilations days in pre- and post-ASP group were 5.9 versus 3.8 (P = 0.033). CONCLUSION In our cohort of critically ill surgery patients implementation of an ASP resulted in reduced use of continuously infused benzodiazepines and opioids, a decline in cumulative benzodiazepine and analgesic dosages, and a greater percentage of Richmond Agitation Sedation Scale scores at goal. We also showed reduced mechanical ventilation days.
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Affiliation(s)
- Jahan Porhomayon
- VA Western New York Healthcare System & Rochester General Hospital, Division of Critical Care Medicine, Department of Anesthesiology & Surgery, State University of New York at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York.
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Hsu WH, Wang SSW, Shih HY, Wu MC, Chen YY, Kuo FC, Yang HY, Chiu SL, Chu KS, Cheng KI, Wu DC, Lu IC. Low effect-site concentration of propofol target-controlled infusion reduces the risk of hypotension during endoscopy in a Taiwanese population. J Dig Dis 2013; 14:147-52. [PMID: 23216875 DOI: 10.1111/1751-2980.12020] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Target-controlled infusion (TCI) of propofol is an effective way of delivering propofol during endoscopy. However, the ideal effect-site concentration (Ce) of propofol has not yet been defined in an Asian population. This study aimed to determine the ideal Ce of propofol in painless gastrointestinal endoscopy in a Taiwanese population. METHODS A total of 121 consecutive patients undergoing diagnostic endoscopy were recruited for this study. The endoscopic procedure was carried out within 1 h. TCI of propofol was utilized during the procedure. All patients received the same regimen to induce conscious sedation, including a bolus of midazolam (0.04 mg/kg) and fentanyl (0.5 μg/kg). The Ce of propofol was calculated using the Schneider model. Patients were randomly assigned to either the low Ce group (1.5-2.5 μg/mL) or high Ce group (3.0-4.0 μg/mL). Their cardiovascular and respiratory events were monitored during the procedure and the patients' post-procedure satisfaction was evaluated. RESULTS The mean requirement for propofol was 232.02 mg in the low Ce group and 329.56 mg in the high Ce group, respectively (P < 0.0001). No unexpected event was observed in either group. However, more episodes of hypotension were observed in the high Ce group (P = 0.026). The post-procedure satisfaction rate between the two groups was comparable. CONCLUSION A low Ce of propofol TCI (1.5-2.5 μg/mL) achieved adequate anesthesia, reduced the risk of hypotension, and attained a high satisfaction rate in a Taiwanese population undergoing diagnostic painless endoscopy.
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Affiliation(s)
- Wen-Hung Hsu
- Division of Internal Medicine, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung, Taiwan, China
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Abstract
Critically ill patients are routinely provided analgesia and sedation to prevent pain and anxiety, permit invasive procedures, reduce stress and oxygen consumption, and improve synchrony with mechanical ventilation. Regional preferences, patient history, institutional bias, and individual patient and practitioner variability, however, create a wide discrepancy in the approach to sedation of critically ill patients. Untreated pain and agitation increase the sympathetic stress response, potentially leading to negative acute and long-term consequences. Oversedation, however, occurs commonly and is associated with worse clinical outcomes, including longer time on mechanical ventilation, prolonged stay in the intensive care unit, and increased brain dysfunction (delirium and coma). Modifying sedation delivery by incorporating analgesia and sedation protocols, targeted arousal goals, daily interruption of sedation, linked spontaneous awakening and breathing trials, and early mobilization of patients have all been associated with improvements in patient outcomes and should be incorporated into the clinical management of critically ill patients. To improve outcomes, including time on mechanical ventilation and development of acute brain dysfunction, conventional sedation paradigms should be altered by providing necessary analgesia, incorporating propofol or dexmedetomidine to reach arousal targets, and reducing benzodiazepine exposure.
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Chun SY, Kim KO, Park DS, Kim SY, Park JW, Baek IH, Kim JH, Park CK. Safety and efficacy of deep sedation with propofol alone or combined with midazolam administrated by nonanesthesiologist for gastric endoscopic submucosal dissection. Gut Liver 2012; 6:464-70. [PMID: 23170151 PMCID: PMC3493727 DOI: 10.5009/gnl.2012.6.4.464] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Accepted: 06/22/2012] [Indexed: 12/26/2022] Open
Abstract
Background/Aims Endoscopic submucosal dissection (ESD) is accepted as a treatment for gastric neoplasms and usually requires deep sedation. The aim of this study was to evaluate the safety and efficacy profiles of deep sedation induced by continuous propofol infusion with or without midazolam during ESD. Methods A total of 135 patients scheduled for ESDs between December 2008 and June 2010 were included in this prospective study and were randomly assigned to one of two groups: the propofol group or the combination group (propofol plus midazolam). Results The propofol group reported only one case of severe hypoxemia with no need of mask ventilation or intubation. Additionally, 18 cases of mild hypotension were observed in the propofol group, and 11 cases were observed in the combination group. The combination group had a lower mean total propofol dose (378 mg vs 466 mg, p<0.012), a longer mean recovery time (10.5 minutes vs 7.9 minutes, p=0.027), and a lower frequency of overall adverse events (32.8% vs 17.6%, p=0.042). Conclusions Deep sedation induced by continuous propofol infusion was shown to be safe during ESD. The combination of continuous propofol infusion and intermittent midazolam injection can decrease the total dose and infusion rate of propofol and the overall occurrence of adverse events.
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Affiliation(s)
- Seung Yeon Chun
- Department of Internal Medicine, Hallym University College of Medicine, Anyang, Korea
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Abstract
Endoscopic procedures are common and sedation is frequently used to minimize anxiety and discomfort, reduce the potential for physical injury during the procedure, and improve overall patient tolerability and satisfaction. In this article, the authors review the variety of options for sedation and analgesia available to the gastroenterologist or surgical endoscopist.
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Affiliation(s)
- Travis F Wiggins
- Department of Gastroenterology, Ochsner Clinic Foundation, New Orleans, Louisiana
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Abstract
Sedation is the drug-induced reduction of a patient's consciousness. The aim of sedation in endoscopic procedures is to increase the patient's comfort and to improve endoscopic performance, especially in therapeutic procedures. The most commonly used sedation regimen for conscious sedation in gastrointestinal endoscopy is still the combination of benzodiazepines with opioids. However, the use of propofol has increased enormously in the past decade and several studies show advantages of propofol over the traditional regimes in terms of faster recovery time. It is important to be aware that the complication rate of endoscopies increases when sedation is used; therefore, a thorough risk evaluation before the procedure and monitoring during the procedure must be performed. In addition, properly trained staff and emergency equipment should be available. The best approach to sedation in endoscopy is to choose a sedation regimen for the individual patient, tailored according to the clinical risk assessment and the anxiety level of the patient, as well as to the type of planned endoscopic procedure.
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Correia LM, Bonilha DQ, Gomes GF, Brito JR, Nakao FS, Lenz L, Rohr MRS, Ferrari AP, Libera ED. Sedation during upper GI endoscopy in cirrhotic outpatients: a randomized, controlled trial comparing propofol and fentanyl with midazolam and fentanyl. Gastrointest Endosc 2011; 73:45-51, 51.e1. [PMID: 21184869 DOI: 10.1016/j.gie.2010.09.025] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2010] [Accepted: 09/14/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND Patients with liver cirrhosis frequently undergo diagnostic or therapeutic upper GI endoscopy (UGIE), and the liver disease might impair the metabolism of drugs usually administered for sedation. OBJECTIVE AND SETTING To compare sedation with a combination of propofol plus fentanyl and midazolam plus fentanyl in cirrhotic outpatients undergoing UGIE. DESIGN A prospective, randomized, controlled trial was conducted between February 2008 and February 2009. MAIN OUTCOMES MEASUREMENTS Efficacy (proportion of complete procedures using the initial proposed sedation scheme), safety (occurrence of sedation-related complications), and recovery time were measured. RESULTS Two hundred ten cirrhotic patients referred for UGIE were randomized to 2 groups: midazolam group (0.05 mg/kg plus fentanyl 50 μg intravenously) or propofol group (0.25 mg/kg plus fentanyl 50 μg intravenously). There were no differences between groups regarding age, sex, weight, etiology of cirrhosis, and Child-Pugh or American Society of Anesthesiologists classification. Sedation with propofol was more efficacious (100% vs 88.2%; P < .001) and had a shorter recovery time than sedation with midazolam (16.23 ± 6.84 minutes and 27.40 ± 17.19 minutes, respectively; P < .001). Complication rates were similar in both groups (14% vs 7.3%; P = .172). LIMITATIONS Single-blind study; sample size. CONCLUSION Both sedation schemes were safe in this setting. Sedation with propofol plus fentanyl was more efficacious with a shorter recovery time compared with midazolam plus fentanyl. Therefore, the former scheme is an alternative when sedating cirrhotic patients undergoing UGIE.
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Affiliation(s)
- Lucianna Motta Correia
- Disciplina de Gastroenterologia Clínica, Universidade Federal de São Paulo, São Paulo, Brasil
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Kauling ALC, Locks GDF, Brunharo GM, da Cunha VJL, de Almeida MCS. Conscious sedation for upper digestive endoscopy performed by endoscopists. Rev Bras Anestesiol 2010; 60:577-83, 320-3. [PMID: 21146053 DOI: 10.1016/s0034-7094(10)70072-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2010] [Accepted: 06/06/2010] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Conscious sedation in the ambulatory setting albeit common is not risk-free. The present study aimed at evaluating the blood pressure, heart rate and peripheral oxygen saturation in patients submitted to conscious sedation for upper digestive endoscopy performed by endoscopists. METHODS A total of 105 patients of both sexes were selected, aged 18 and older, physical status ASA I to III, submitted to upper digestive endoscopy under conscious sedation. The patients were monitored through noninvasive blood pressure measurements, pulse oximetry and heart rate recorded before, during and after the examination. The sedation was carried out with midazolam or meperidine. RESULTS The variations in oxygen saturation, blood pressure and heart rate throughout time were not statistically significant. However, an incidence of hypoxia of 41.9% was observed; 53.3% of the cases presented arterial hypotension and 25.6% presented tachycardia. Obese patients were more prone to hypoxia and hypotension than those non obese. CONCLUSIONS The occurrence of hypoxia and arterial hypotension is common in upper digestive endoscopic examinations under conscious sedation when midazolam and meperidine are associated. Obese patients demonstrated to be more susceptible to hypoxemia and arterial hypotension.
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Abstract
GOALS This double-blind, multicenter study evaluated the safety and efficacy of intravenous fospropofol (6.5 mg/kg vs. 2 mg/kg) for moderate sedation in patients undergoing colonoscopy. METHODS In all, 314 patients >or=18 years (American Society of Anesthesiologists PS1 to PS3) were randomized to receive fospropofol 2 mg/kg, fospropofol 6.5- mg/kg, or midazolam 0.02 mg/kg, after pretreatment with intravenous fentanyl 50 mcg. Supplemental doses of study medication were permitted to achieve a Modified Observer's Assessment of Alertness/Sedation scale score <or=4 and to enable the investigator to begin a procedure. The study end points included sedation success, recovery, memory retention, physician satisfaction, and safety. RESULTS Sedation success was higher in the fospropofol 6.5 mg/kg versus 2 mg/kg group (87% vs. 26%; P<0.001) and was 69% in the midazolam group. Patients in the 6.5-mg/kg group were significantly less likely to remember being awake during the procedure (51% vs. 100% in the 2-mg/kg group, P<0.001; 60% for the midazolam group). Patients in the fospropofol groups had similar memory retention (70% and 82% for the 6.5 mg/kg and 2 mg/kg groups, respectively) compared with 41% for the midazolam group. Mean physician satisfaction scores were higher in the fospropofol 6.5-mg/kg group (7.7) than the 2-mg/kg group (4.5), P<0.001. Most adverse events were mild to moderate in intensity; the most common treatment-related adverse events were paresthesias (68% vs. 60%) and pruritus (16% vs. 26%) in the fospropofol 6.5 and 2 mg/kg groups, respectively. CONCLUSIONS The fospropofol 6.5-mg/kg dosing regimen was well tolerated and effective for sedation during colonoscopy and was associated with higher rates of sedation success, memory retention, and physician satisfaction than the fospropofol 2-mg/kg dose.
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Addition of Low-Dose Ketamine to Propofol-Fentanyl Sedation for Gynecologic Diagnostic Laparoscopy: Randomized Controlled Trial. J Minim Invasive Gynecol 2010; 17:325-30. [DOI: 10.1016/j.jmig.2010.01.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2009] [Revised: 01/14/2010] [Accepted: 01/21/2010] [Indexed: 11/21/2022]
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Cruz FSF, Carregaro AB, Raiser AG, Zimmerman M, Lukarsewski R, Steffen RPB. Total intravenous anesthesia with propofol and S(+)-ketamine in rabbits. Vet Anaesth Analg 2010; 37:116-22. [DOI: 10.1111/j.1467-2995.2009.00513.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Thomson A, Andrew G, Jones DB. Optimal sedation for gastrointestinal endoscopy: review and recommendations. J Gastroenterol Hepatol 2010; 25:469-78. [PMID: 20370725 DOI: 10.1111/j.1440-1746.2009.06174.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Sedation practices for endoscopy vary widely. The present review focuses on the commonly used regimens in endoscopic sedation and the associated risks and benefits together with the appropriate safety measures and monitoring practices. In addition, alternatives and additions to intravenous sedation are discussed. Personnel requirements for endoscopic sedation are reviewed; there is evidence presented to indicate that non-anesthetists can administer sedative drugs, including propofol, safely and efficaciously in selected cases. The development of endoscopic sedation as a multi-disciplinary field is highlighted with the formation of the Australian Tripartite Endoscopy Sedation Committee. This comprises representatives of the Australian and New Zealand College of Anaesthetists, the Gastroenterological Society of Australia and the Royal Australasian College of Surgeons. Possible future directions in this area are also briefly summarized.
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Affiliation(s)
- Andrew Thomson
- Gastroenterology and Hepatology Unit, The Canberra Hospital and the Australian National University, Australia.
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Robertson DJ, Jacobs DP, Mackenzie TA, Oringer JA, Rothstein RI. Clinical trial: a randomized, study comparing meperidine (pethidine) and fentanyl in adult gastrointestinal endoscopy. Aliment Pharmacol Ther 2009; 29:817-23. [PMID: 19154568 DOI: 10.1111/j.1365-2036.2009.03943.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND There is little evidence to guide choice between meperidine (pethidine) and fentanyl for sedation for gastrointestinal endoscopy. AIM To compare meperidine with fentanyl in terms of procedure time and analgesia. METHODS Single centre randomized controlled trial. Patients received narcotic doses and midazolam at the discretion of the attending endoscopist who was unaware of narcotic assignment. Endoscopy and recovery times were then recorded. The main outcome was total procedure time, defined as endoscopy time plus recovery time. Patient discomfort was assessed prior to discharge via visual analogue scale (VAS). RESULTS In total, 55 patients were randomized to meperidine [44 colonoscopy and 11 esophagogastroduodenoscopy (EGD)] and 56 to fentanyl (45 colonoscopy and 11 EGD). Total procedure time was shorter for those receiving fentanyl (mean = 87.7 min) than for those receiving meperidine (mean = 102.9 min) (P = 0.05). The difference between the groups was explained by a shorter mean recovery time in the fentanyl group (63.0 min) than in the meperidine group (76.2 min) (P = 0.07). Based on post procedure pain scores, examinations with meperidine (mean = 1.99) were less painful when compared with those receiving fentanyl (mean = 2.86, P = 0.03). CONCLUSIONS Fentanyl shortened total procedure time by reducing recovery time. A simple change in narcotic choice could increase endoscopy unit efficiency.
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Affiliation(s)
- D J Robertson
- VA Medical Center, White River Junction, VT 05009, USA.
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González-Huix Lladó F. ¿La sedación necesaria para la realización de una endoscopia debe ser realizada exclusivamente por un anestesista o puede ser realizada con seguridad y eficacia por médicos no anestesistas o personal de enfermería especializado? GASTROENTEROLOGIA Y HEPATOLOGIA 2009; 32:65-7. [DOI: 10.1016/j.gastrohep.2008.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2008] [Accepted: 06/30/2008] [Indexed: 12/28/2022]
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Silvestri GA, Vincent BD, Wahidi MM, Robinette E, Hansbrough JR, Downie GH. A Phase 3, Randomized, Double-Blind Study To Assess the Efficacy and Safety of Fospropofol Disodium Injection for Moderate Sedation in Patients Undergoing Flexible Bronchoscopy. Chest 2009; 135:41-47. [DOI: 10.1378/chest.08-0623] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
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Poon CM, Leung TL, Wong CW, Chan YL, Leung TC, Leong HT. Safety of nurse-administered propofol sedation using PCA pump for outpatient colonoscopy in Chinese patients: a pilot study. Asian J Surg 2008; 30:239-43. [PMID: 17962125 DOI: 10.1016/s1015-9584(08)60032-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND To determine the safety and effectiveness of nurse-administered propofol sedation using patient-controlled analgesia (PCA) pump in outpatient colonoscopy in a Chinese population. METHODS From April to June 2005, 50 consecutive ASA class I or II patients aged 18-65 undergoing outpatient colonoscopy in an endoscopy centre of a regional hospital were prospectively recruited in this study. After a loading dose of 40-60 mg intravenous propofol, a mixture containing 14.3 mg propofol and 35 microg alfentanil were delivered via a patient-controlled syringe pump as bolus dose by an endoscopy nurse under the supervision of an endoscopist during the procedure. Lockout time was set to be zero. We aimed to achieve conscious sedation, with an Observers Scale for Sedation and Alertness (OSSA) score of 3. The primary outcome measure was complications from sedation, which included hypotension, bradycardia and desaturation. Other outcome measures included onset time, patients pain score, endoscopists and nurses satisfaction on the level of sedation, patients satisfaction regarding the procedure (measured by 10 cm visual analogue scale), and their willingness to repeat the procedure. RESULTS The mean lowest systolic blood pressure and mean arterial pressure (MAP) were 103.2 +/- 12.4 mmHg and 78.3 +/- 11.0 mmHg, respectively. The mean percentage drop in MAP was 15.7 +/- 11.9%. Six patients (12.2%) developed transient hypotension. Three patients (6.1%) had bradycardia. There was no episode of desaturation. The median onset time to reach OSSA score of 3 was 1 minute (range, 0.5-20.5). The OSSA score of 3 could be maintained throughout the procedure. The mean loading dose of propofol was 48.9 +/- 6.7 mg. The mean total dosages of propofol and alfentanil given were 124.2 +/- 38.1 mg and 184.3 +/- 93.7 mug, respectively. Endoscopists, endoscopy nurses and patients were highly satisfied with the sedation. The median pain score was 1 (range, 0-10; 0 = no pain, 10 = very painful), and the mean recovery time was 2.8 +/- 2.8 minutes. Most patients (93.9%) were willing to repeat the procedure. CONCLUSION Nurse-administered propofol sedation using PCA pump is safe and effective in sedation and pain control in outpatient colonoscopy in a healthy Chinese population.
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Affiliation(s)
- Chi-Ming Poon
- Department of Surgery, North District Hospital, Sheung Shui, Hong Kong SAR
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Gastrointestinal Endoscopy. Crit Care Med 2008. [DOI: 10.1016/b978-032304841-5.50020-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Lubarsky DA, Candiotti K, Harris E. Understanding modes of moderate sedation during gastrointestinal procedures: a current review of the literature. J Clin Anesth 2007; 19:397-404. [PMID: 17869995 DOI: 10.1016/j.jclinane.2006.11.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2006] [Revised: 11/08/2006] [Accepted: 11/09/2006] [Indexed: 12/26/2022]
Abstract
Recommendations for routine screening for colorectal cancer with colonoscopy are likely to substantially increase the demand for provision of sedation for these procedures. Because of this burgeoning caseload and associated economic constraints, it is unlikely that anesthesiologists will be available for all such procedures, particularly those involving average-risk patients. Thus, sedative agents that can be safely administered by nonanesthesiologists, appropriately trained in monitoring and managing the patient's airway, are desperately needed. New concepts in sedation for colonoscopy include enhanced mechanisms for drug delivery such as patient-controlled sedation/analgesia and target-controlled infusion, along with the development of new drugs such as a modified cyclodextrin-based formulation of propofol and fospropofol disodium (Aquavan Injection), a water-soluble prodrug of propofol.
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Affiliation(s)
- David A Lubarsky
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL 33136, USA.
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Martínez J, Casellas JA, Aparicio JR, Garmendia M, Amorós A. [Safety of propofol administration by the staff of a gastrointestinal endoscopy unit]. GASTROENTEROLOGIA Y HEPATOLOGIA 2007; 30:105-9. [PMID: 17374321 DOI: 10.1157/13100070] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Deep sedation controlled by the staff of gastrointestinal endoscopy units is currently controversial. In the last few years, numerous studies have provided data supporting the safety of propofol use in these techniques. We present a large series of patients who underwent gastroscopy or colonoscopy under endoscopist-controlled deep sedation. A total of 875 procedures (297 gastroscopies and 578 colonoscopies) were included. In all procedures intravenous propofol with or without intravenous midazolam was administered. In gastroscopies, complications attributable to the sedation were found in only 6.7% of the patients, mostly due to desaturation, which was resolved without the need for intubation. In colonoscopies, complications were found in 11.2%, the most frequent being bradycardia and desaturation, none of which were serious. No association was found between the presence of complications and the propofol dose administered. In the group of patients undergoing colonoscopy, simultaneous midazolam administration allowed reduction of the propofol dose required to achieve deep sedation. In conclusion, propofol shows a good safety profile and excellent tolerance in patients undergoing gastroscopy and colonoscopy and can be administrated by the endoscopy team. At least in the case of colonoscopy, the associated use of midazolam allows the propofol dose to be decreased, thus, theoretically, reducing the drug's adverse effects.
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Affiliation(s)
- Juan Martínez
- Unidad de Endoscopia Digestiva, Hospital General Universitario de Alicante, España.
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Abstract
PURPOSE OF REVIEW This review provides an update on the management of upper gastrointestinal bleeding with special attention to patient preparation, sedation, hemostatic techniques, and postprocedure care. RECENT FINDINGS In a large multicenter clinical trial, nurse-administered propofol sedation had a complication rate of less than 0.2%. The optimal management for an ulcer with adherent clot was confirmed by a meta-analysis to be clot removal and endoscopic treatment of the underlying lesion. A number of prospective studies have demonstrated that capsule endoscopy is the most sensitive imaging modality for identifying lesions in the small bowel and that double-balloon enteroscopy is the least invasive modality available for the management of these lesions. SUMMARY This update describes many recent advances in the diagnosis and management of upper gastrointestinal bleeding. However, clearly, much work needs to be done in this field. Since propofol is not available for use in all endoscopy units, is there a better alternative for deep sedation? Rebleeding occurs in 20% of patients after endoscopic therapy, and so can we provide better outcomes with newer technologies (endoscopic suturing devices)? Finally, what is the best management for Helicobacter pylori-negative, nonsteroidal antiinflammatory drug-negative ulcer patients?
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Affiliation(s)
- Noel B Martins
- University of Massachusetts Medical School, Worcester, Massachusetts, USA
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