Conscious sedation: is there a need for improvement?

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Sedation, analgesia, and cardiorespiratory function in colonoscopy using midazolam combined with fentanyl or propofol

BACKGROUND AND AIMS

The use of sedatives during colonoscopy remains controversial because of its safety concerns. We compared cardiorespiratory function and sedative and analgesic effects in sedative colonoscopy, using combinations of midazolam with either fentanyl or propofol.

METHODS

Eligible patients (n = 480) received 1.0-2.0 mg midazolam alone (n = 160), midazolam combined with either 50-100 mg fentanyl intramuscularly (n = 160), or 0.5-2.5 mg/kg propofol intravenously, as premedication for sedative colonoscopy. Pulse rate, blood pressure, and saturation of peripheral oxygen (SpO(2)) were monitored. Levels of sedation and analgesia were semi-quantitatively scored using visual analog scales, and amnesia profiles were qualitatively evaluated.

RESULTS

Combining midazolam with either fentanyl or propofol resulted in acceptable sedative and analgesic effects compared to treatment with midazolam alone (P < 0.001), with the combination with propofol giving more favorable results. More patients receiving the propofol combination became amnestic to the procedure than patients receiving the fentanyl combination. However, midazolam combined with propofol disturbed the pulse rate (P < 0.05) and blood pressure (P < 0.001) more significantly than a combination with fentanyl, or midazolam alone.

CONCLUSION

The combination of midazolam with either fentanyl or propofol allowed patients to undergo colonoscopy under comparable sedative and analgesic conditions. The combination with fentanyl had a significantly lower effect on pulse rate and blood pressure. The combination with propofol produced superior amnestic effects.

Systematic review: the use of nitrous oxide gas for lower gastrointestinal endoscopy

BACKGROUND

Nitrous oxide gas (N(2)O) has been proposed as an alternative to intravenous (i.v.) analgesia in patients undergoing lower gastrointestinal endoscopy.

AIM

To perform a systematic review of randomized studies where N(2)O was compared against control in patients undergoing either flexible sigmoidoscopy or colonoscopy.

METHODS

Electronic databases were searched; reference lists were checked and letters were sent to authors requesting data. Methodological quality was assessed. Data were tabulated on the duration and difficulty of the procedure, quality of sedation and speed of patient recovery.

RESULTS

A total of 11 studies were identified containing 623 patients. No differences were seen between groups for duration, difficulty of procedure or complications. Patient-reported pain was similar for N(2)O when undergoing flexible sigmoidoscopy vs. no sedation and when undergoing colonoscopy vs. i.v. sedation. Differences in delivery of N(2)O were identified. In all studies, N(2)O was associated with a more rapid recovery than i.v. sedation.

CONCLUSION

For patients undergoing colonoscopy, N(2)O provides comparable analgesia to i.v. sedation. The rapid psychomotor recovery with N(2)O enables quicker patient discharge and removes the need for a patient to be chaperoned. Benefit was not seen from N(2)O in patients undergoing flexible sigmoidoscopy possibly because it was delivered on demand rather than continuously.

Methods of sedation in pediatric endoscopy: a survey of NASPGHAN members

The performance of endoscopy in children generally requires the concomitant administration of sedation to ensure the patient's safety, comfort, and cooperation throughout the procedures. New pharmacological agents, increased procedural volume, variable access to anesthesia support, and improvement in endoscopic technique have contributed to vast differences in sedation regimens for gastrointestinal procedures in patients of all ages. To better understand variation in practice patterns among pediatric gastroenterologists, the NASPGHAN Endoscopy and Procedures Committee surveyed 103 NASPGHAN members during a recent NASPGHAN national meeting. The results of this survey confirm that sedation practices vary widely and reflect continued uncertainty regarding optimal sedation regimens for pediatric endoscopy.

Understanding modes of moderate sedation during gastrointestinal procedures: a current review of the literature

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.

Target-controlled infusion during monitored anesthesia care in patients undergoing EUS: propofol alone versus midazolam plus propofol. A prospective double-blind randomised controlled trial

BACKGROUND

It has been speculated that midazolam may be effective in reducing the required dose of propofol during sedation.

AIM

To evaluate the sparing effect of midazolam during target-controlled propofol infusion.

METHODS

Two hundred-seventy patients undergoing upper endoscopic ultrasound were randomised to receive sedation with propofol plus placebo (group A) or plus midazolam (group B). Outcome parameters were the procedure duration, the discharge time and the satisfaction of patients, operator and nurse about the quality of sedation.

RESULTS

The mean propofol dose administered was 364+/-207 mg in group A and 394+/-204 mg in group B. Mean procedure duration (group A: 32+/-17 min, group B: 35+/-22 min) and discharge time (group A: 39+/-30 min, group B: 38+/-24 min) were similar in both groups. No severe complications were observed. The quality of sedation was judged satisfactory for all patients by both the endoscopist and the nurse assistant without any difference between the two groups. No patient remembered the procedure or reported it as unpleasant.

CONCLUSIONS

Target-controlled propofol infusion provides safe and effective sedation; premedication with low dose of midazolam does not reduce the total amount of propofol administered. Further studies are needed to compare propofol alone with propofol co-administered with opioid.

[Sedation in upper gastrointestinal endoscopy. Analysis of tolerance, complications and cost-effectiveness]

INTRODUCTION AND AIM

Sedation of patients is an important complement to endoscopic procedures. The aim of this study was to analyze tolerance, complications and cost-effectiveness in patients undergoing diagnostic upper gastrointestinal endoscopy.

PATIENTS AND METHOD

A total of 357 patients were prospectively studied: 138 non-sedated, 116 sedated with midazolam and 103 sedated with midazolam and meperidine. Subjective tolerance, tolerance perceived by the endoscopist, complications, and cost-effectiveness were evaluated. The Chi-square test was used for the statistical analysis. P-values of less than 0.05 were considered statistically significant.

RESULTS

Subjective tolerance was greater in patients sedated with midazolam and meperidine than in the other groups (p < 0.05). Tolerance perceived by the endoscopist was greater in the group sedated with both drugs than in the group sedated with midazolam (p < 0.05). Subjective tolerance was better in sedated men and women but there was no association between sedation and perceived tolerance according to sex. Subjective tolerance was better in sedated patients older than 70 years than in those younger than 40 years (p < 0.05). Complications were more frequent in sedated patients and the most frequent complication in all the groups studied was mild desaturation; there was a significant difference between the group sedated with midazolam and meperidine and the non-sedated group (p < 0.05). Non-sedation had the best cost-effectiveness ratio but sedation with midazolam and meperidine was the most effective alternative.

CONCLUSION

From the point of view of the endoscopist, endoscopy can be performed without sedation, although subjective tolerance is greater in patients sedated with midazolam and meperidine. Non-sedation is more cost-effectiveness than sedation but if sedation is required midazolam and meperidine achieve better results in terms of effectiveness than midazolam alone.

Anxiety during the performance of colonoscopies: modification using music therapy

BACKGROUND AND STUDY AIMS

Colonoscopies are usually performed using pharmacological sedation. This process entails certain risks. In the search for alternative methods, some studies have analysed the effect music can have on patients during the procedure when used as a complement to sedation. We present a prospective, randomized study in which we assess the anxiolytic action music has when it is administered during a single colonoscopy.

PATIENTS AND METHODS

We included 118 patients who were scheduled for ambulatory colonoscopies. They were randomly assigned to the control group (n = 55) and the experimental group (n = 63). We determined their levels of anxiety using the State-Trait Anxiety Inventory Test (STAI) form, which they filled in before and after the examination. Patients listened to music through personal headphones.

RESULTS

The score on the STAI form before the examination was 25.25 +/- 10.49 and 28.16 +/- 11.43 in the control and experimental groups, respectively (P > 0.05). The decrease of the score on the STAI scale after the colonoscopy in the control and experimental groups was 6.27 (95% confidence interval, 3.26-9.28) and 11.35 (95% confidence interval, 8.64-14.05), respectively (P < 0.01).

CONCLUSIONS

Listening to music during ambulatory colonoscopies decreases the level of anxiety that is inherent to the process without other anxiolytic methods.

Is routine sedation or topical pharyngeal anesthesia beneficial during upper endoscopy?

BACKGROUND

Upper endoscopy is an invasive procedure. However, the benefits of routinely administered sedative medication or topical pharyngeal anesthesic are controversial. The aim of this study was to clarify their effects on patient tolerance and difficulty of upper endoscopy.

METHODS

A total of 252 patients scheduled for diagnostic upper endoscopy were randomly assigned to 4 groups: (1) sedation with midazolam and placebo pharyngeal spray (midazolam group), (2) placebo sedation and lidocaine pharyngeal spray (lidocaine group), (3) placebo sedation and placebo pharyngeal spray (placebo group), and (4) no intravenous cannula/pharyngeal spray (control group). The endoscopist and the patient assessed the procedure immediately after the examination. Another questionnaire was sent to the patients 2 weeks later.

RESULTS

Patients in the midazolam group rated the examination easier and less uncomfortable compared with those in the other groups. The differences were especially evident in the questionnaires completed 2 weeks after the examination ( p < 0.001). Lidocaine did not significantly improve patient tolerance. However, endoscopists found the procedure easier in patients in the lidocaine group compared with the midazolam ( p < 0.01) and control groups ( p < 0.01) but not the placebo group.

CONCLUSIONS

Routine administration of midazolam for sedation increased patient tolerance for upper endoscopy. However, endoscopists found intubation to be more difficult in sedated vs. non-sedated patients. Topical pharyngeal anesthesia did not enhance patient tolerance, but it did make upper endoscopy technically easier compared with endoscopy in patients sedated with midazolam without topical pharyngeal anesthesia, and in patients who had no sedation or pharyngeal anesthesia, but not in patients who received placebo sedation and placebo pharyngeal anesthesia.

Target-controlled propofol infusion during monitored anesthesia in patients undergoing ERCP

BACKGROUND

A target-controlled infusion system automatically adjusts the rate of infusion of propofol to maintain a desired (target) concentration. The aim of this study was to determine whether administration of propofol with a target-controlled infusion system could improve the sedation of patients undergoing ERCP.

METHODS

A total of 205 consecutive patients undergoing ERCP were sedated by using a propofol target-controlled infusion system by an anesthesiologist. The target plasma concentration of propofol ranged from 2 to 5 microg/mL. A bolus dose of fentanyl (50-100 mcg) was administered if signs of insufficient analgesia were observed at the maximum target concentration of propofol allowed. The technical difficulty of ERCP was graded on a scale from 1 (least difficult) to 5 (most difficult).

RESULTS

The mean dosages of propofol and fentanyl administered were 465 (245) mg and 59 (23) mcg, respectively. The total dose of propofol administered and the mean duration of ERCP were related to the degree of difficulty of the procedure. No severe complication was observed; mean time to discharge was 31 (12) minutes. Time to discharge was not influenced by the difficulty of ERCP or by the total dose of propofol administered.

CONCLUSIONS

A target-controlled infusion system for administration of propofol provides safe and effective sedation during ERCP. Further studies are needed to determine the cost-effectiveness and the safety profile for infusion of propofol with a target-controlled infusion system by a nonanesthesiologist during ERCP.

Importance of psychiatric intervention in intolerances in endoscopic procedures

Despite the fact that pre-medication, in a number of different drug combinations, has been used for a long time in endoscopy units, and has been subject to extended clinical studies, it is still not possible to claim that it has attained an ideal state with regard to patient tolerance to endoscopy procedures. In this clinical study, we have investigated the effects of psychological intervention in addition to medication, which we used on patients with intolerance to endoscopy. Intolerance was very high in all endoscopic procedures (15.8% total). It was observed that average midazolam doses were significantly higher in intolerant than in tolerant patients. It was found that in patients who had received psychiatric intervention, the decrease in midazolam dose was statistically significant in a subsequent endoscopy procedure.

Meperidine: a critical review

Meperidine was initially synthesized as an anticholinergic agent but was soon discovered to have analgesic properties. Although meperidine's anticholinergic effects were demonstrated in vivo, the anticholinergic effects on the biliary and renal tracts have not been demonstrated in vivo. Studies have clearly demonstrated that meperidine is no more efficacious in treating biliary or renal tract spasm than comparative mu opioids. The initial studies demonstrating the analgesic efficacy of meperidine were mostly case reports and not double-blind, randomized, controlled trials in specific populations. Subsequent comparative studies failed to demonstrate any advantages of meperidine over comparable doses of other analgesics. Meperidine was portrayed in practice and teaching as having unique clinical advantages. The analgesic effects of meperidine are not pronounced, and, in addition, meperidine use is complicated by unique side effects including serotonergic crisis and normeperidine toxicity. Meperidine's poor efficacy, toxicity, and multiple drug interactions have resulted in a movement to replace meperidine with more efficacious and less toxic opioid analgesics.