Sedation for upper gastrointestinal endoscopy: a comparative study of propofol and midazolam

Remimazolam Dosing for Gastroscopy: A Randomized Noninferiority Trial

BACKGROUND

Remimazolam, an ultra-short-acting benzodiazepine, may provide adequate sedation for endoscopy while causing less cardiovascular or respiratory disturbance than propofol. Although fixed-dose administration is suggested, body weight affects the volume of the central chamber and thus affects the sedation depth that can be achieved by the first dose. This study aimed to compare the efficacy and safety of different doses of remimazolam and propofol by body weight for sedation during gastroscopy.

METHODS

This multicenter, randomized, single-blind, parallel-controlled noninferiority trial recruited patients from five centers between March 2021 and July 2022. A total of 1,883 patients scheduled to undergo gastroscopy were randomized to groups receiving 0.15 mg/kg remimazolam, 0.2 mg/kg remimazolam, or 1.5 mg/kg propofol. The noninferiority margin was set to 5%. The primary outcome was the success rate of sedation. Adverse events were recorded to evaluate safety.

RESULTS

The sedation success rate of the 0.2 mg/kg remimazolam group was not inferior to that of the 1.5 mg/kg propofol group (98.7% vs. 99.4%; risk difference, -0.64%; 97.5% CI, -2.2 to 0.7%, meeting criteria for noninferiority). However, the sedation success rate of the 0.15 mg/kg remimazolam group was 88.5%, and that of the 1.5 mg/kg propofol group was 99.4% (risk difference, -10.8%; 97.5% CI, -14.0% to -8.0%), demonstrating inferiority. Simultaneously, the overall adverse events rate of remimazolam was lower than that of propofol, and the incidence of bradycardia, hypotension, subclinical respiratory depression, and hypoxia in the remimazolam groups was significantly lower than that in the propofol group.

CONCLUSIONS

This trial established the noninferior sedation success rate of remimazolam (0.2 mg/kg but not 0.15 mg/kg) compared with propofol (1.5 mg/kg), with a superior safety profile.

EDITOR’S PERSPECTIVE

Efficacy and safety of esketamine for sedation among patients undergoing gastrointestinal endoscopy: a systematic review and meta-analysis

BACKGROUND

Patients who undergo gastrointestinal endoscopy often require propofol-based sedation combined with analgesics. At present, the efficacy and safety of esketamine as an adjunct to propofol for sedation during endoscopic procedures in patients remains controversial. Moreover, there is no universal agreement regarding the appropriate dose of esketamine supplementation. This study aimed to assess the efficacy and safety of esketamine as an adjunct to propofol for sedation during endoscopic procedures in patients.

METHODS

Seven electronic databases and three clinical trial registry platforms were searched and the deadline was February 2023. Randomized controlled trials (RCTs) evaluating the efficacy of esketamine for sedation were included by two reviewers. Data from the eligible studies were combined to calculate the pooled risk ratio or standardized mean difference.

RESULTS

Eighteen studies with 1962 esketamine participants were included in the analysis. As an adjunct to propofol, the administration of esketamine reduced the recovery time compared to normal saline (NS). However, there was no significant difference between the opioids group and ketamine group. For propofol dosage, the administration of esketamine required a lower propofol dosage compared to the NS group and opioids group].For complications, the esketamine group had fewer complications compared to the NS group and opioid group in patients, but there were no significant differences between the esketamine group and ketamine group. Notably, the coadministration of esketamine was associated with a higher risk of visual disturbance compared to the NS group. In addition, we used subgroup analysis to investigate whether 0.2-0.5 mg/kg esketamine was effective and tolerable for patients.

CONCLUSION

Esketamine as an adjunct to propofol, is an appropriate effective alternative for sedation in participants undergoing gastrointestinal endoscopy. However, considering the possibility of its psychotomimetic effects, esketamine should be used with caution.

Academy of Medicine, Singapore clinical guideline on the use of sedation by non-anaesthesiologists during gastrointestinal endoscopy in the hospital setting

INTRODUCTION

In Singapore, non-anaesthesiologists generally administer sedation during gastrointestinal endoscopy. The drugs used for sedation in hospital endoscopy centres now include propofol in addition to benzodiazepines and opiates. The requirements for peri-procedural monitoring and discharge protocols have also evolved. There is a need to develop an evidence-based clinical guideline on the safe and effective use of sedation by non-anaesthesiologists during gastrointestinal endoscopy in the hospital setting.

METHODS

The Academy of Medicine, Singapore appointed an expert workgroup comprising 18 gastroenterologists, general surgeons and anaesthesiologists to develop guidelines on the use of sedation during gastrointestinal endoscopy. The workgroup formulated clinical questions related to different aspects of endoscopic sedation, conducted a relevant literature search, adopted Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology and developed recommendations by consensus using a modified Delphi process.

RESULTS

The workgroup made 16 recommendations encompassing 7 areas: (1) purpose of sedation, benefits and disadvantages of sedation during gastrointestinal endoscopy; (2) pre-procedural assessment, preparation and consent taking for sedation; (3) Efficacy and safety of drugs used in sedation; (4) the role of anaesthesiologist administered sedation during gastrointestinal endoscopy; (5) performance of sedation; (6) post-sedation care and discharge after sedation; and (7) training in sedation for gastrointestinal endoscopy for non-anaesthesiologists.

CONCLUSION

These recommendations serve to guide clinical practice during sedation for gastrointestinal endoscopy by non-anaesthesiologists in the hospital setting.

Comparison of clinical efficacy and safety between dexmedetomidine and propofol among patients undergoing gastrointestinal endoscopy: a meta-analysis

OBJECTIVE

To compare the clinical efficacy and safety of dexmedetomidine and propofol in patients who underwent gastrointestinal endoscopy.

METHODS

Relevant studies comparing dexmedetomidine and propofol among patients who underwent gastrointestinal endoscopy were retrieved from databases such as PubMed, Embase, and Cochrane Library.

RESULTS

Seven relevant studies (dexmedetomidine group, n = 238; propofol group, n = 239) met the inclusion criteria. There were no significant differences in the induction time (weighted mean difference [WMD] = 3.46, 95% confidence interval [CI] = -0.95-7.88, I2 = 99%) and recovery time (WMD = 2.74, 95% CI = -2.72-8.19, I2 = 98%). Subgroup analysis revealed no significant differences in the risks of hypotension (risk ratio [RR] = 0.56, 95% CI = 0.25-1.22) and nausea and vomiting (RR = 1.00, 95% CI = 0.46-2.22) between the drugs, whereas dexmedetomidine carried a lower risk of hypoxia (RR = 0.26, 95% CI = 0.11-0.63) and higher risk of bradycardia (RR = 3.01, 95% CI = 1.38-6.54).

CONCLUSIONS

Dexmedetomidine had similar efficacy and safety profiles as propofol in patients undergoing gastrointestinal endoscopy.

Propofol compared with bolus and titrated midazolam for sedation in outpatient colonoscopy: a prospective randomized double-blind study

BACKGROUND AND AIMS

The safest and most efficient method of sedation for outpatient colonoscopy remains unclear. This study aimed to compare the efficiency and safety of bolus administration of midazolam compared with titrated administration and propofol administration for patients undergoing outpatient colonoscopy.

METHODS

We randomly divided patients undergoing colonoscopy into the propofol group, bolus midazolam group, and titrated midazolam group. We compared total procedure time, induction time, recovery time, and discharge time among the 3 groups. We also compared patient satisfaction and the incidence of adverse events.

RESULTS

In total, 267 patients (89 in each study group) were enrolled during the study period. Patients in the propofol group had a shorter total procedure time (39.5 vs 59.4 vs 58.1 minutes; P < .001), induction time (4.6 vs 6.3 vs 7.6 minutes; P < .001), recovery time (11.5 vs 29.5 vs 29.2 minutes; P < .001), and discharge time (20.6 vs 34.9 vs 34.7 minutes; P < .001) than patients in the bolus midazolam group and titrated midazolam group. Patients in the propofol group reported higher degrees of satisfaction than patients in the bolus or titrated midazolam plus meperidine groups (9.9 vs 9.6 vs 9.6 [P = .007] and 4.9 vs 4.7 vs 4.8 [P = .008], respectively). Adverse events were not significantly different between groups.

CONCLUSIONS

In this randomized trial, propofol was superior to bolus or titrated midazolam in terms of endoscopy unit efficiency and patient satisfaction during outpatient colonoscopy. (Clinical trial registration number: KCT0002805.).

Recent Developments in Drugs for GI Endoscopy Sedation

Providing sedation for patients undergoing gastrointestinal (GI) endoscopy continues to be a debated topic in both anesthesia and gastroenterology circles. Sedation approaches are widely varied across the globe. While propofol administration is embraced by more endoscopists and patients, its administration evolves controversy. Whereas trained nurses and gastroenterologists are allowed to administer propofol for GI endoscopy sedation in Europe and Asia, it is the sole privilege of anesthesia providers in the USA. However, the costs of anesthesia providers are significant and threaten to derail the screening colonoscopy practice. Efforts were made by both drug and device manufacturers to find alternatives. Fospropofol was one such effort that did not live up to the expectations due to respiratory depressant properties that were similar to propofol. Use of a new tool to administer propofol in the form of Sedasys® was the next experiment that tried to find alternative to anesthesia providers. The device did not succeed due to inadequate sedation. The latest effort is remimazolam, a new benzodiazepine that has quicker recovery profile. In the interim, many drug combinations such as propofol-dexmedetomidine and propofol-ketamine are improving the safety without compromising the quality of sedation. This review attempts to discuss the new drug innovations and drug combinations of existing sedatives for the benefit of readers.

Low-dose midazolam and propofol use for conscious sedation during diagnostic endoscopy

To find the right sedation technique for different types of treatment methods and the right amount of sedatives so the chances of side effects happening can be reduced. This was a retrospective cohort analysis conducted on prospectively collected data. Patients who underwent esophagogastroduodenoscopy only (E group) were sub-divided into two subgroups: (a) Those who received 0.5 mg/kg of propofol (E-a), (b) Those who received 0.025 mg/kg of midazolam and 0.5 mg/kg of propofol (E-b). Patients who underwent esophagogastroduodenoscopy with colonoscopy (EC group) were also sub-divided into three subgroups: (a) Those who received 0.5 mg/kg of propofol (EC-a), (b) Those who received 0.025 mg/kg of midazolam and 0.5 mg/kg of propofol (EC-b), (c) Those who received 25 mg (12.5 mg if body weight < 50 kg or age > 70) of meperidine and 0.025 mg/kg of midazolam along with 0.5 mg/kg of propofol (EC-c). When the level of target was not reached, 10-20 mg of propofol was additionally injected. Sedation efficacy and safety were then compared among groups. E-b and EC-b decreased the overall amount of propofol and reduced side effect of temporary hypoxemia compared to E-a and EC-a. EC-b shortened patient recovery time compared to EC-c and reduced paradoxical reaction. In terms of the patient satisfaction and patient cooperation by endoscopists, there were no significant differences between EC-b and EC-c. Concomitant use of low dosages of both propofol and midazolam is found to be useful and safe when endoscopy needs to be performed.

Safety and efficacy of combined use of propofol and etomidate for sedation during gastroscopy: Systematic review and meta-analysis

BACKGROUND

Sedation with etomidate or propofol alone during gastroscopy has many side effects. A systematic review and meta-analysis were conducted to evaluate the safety and efficacy of the combined use of propofol and etomidate for sedation during gastroscopy.

METHODS

PubMed, Embase, Medline (via Ovid SP), Cochrane library databases, CINAHL (via EBSCO), China Biology Medicine disc (CBMdisc), Wanfang, VIP, and China National Knowledge Infrastructure (CNKI) databases were systematically searched. We included randomized controlled trials (RCTs) comparing the combined use of propofol and etomidate vs etomidate or propofol alone for sedation during gastroscopy. Data were pooled using the random-effects models or fixed-effect model based on heterogeneity.

RESULTS

Fifteen studies with 2973 participants were included in the analysis. Compared to propofol alone, the combined use of propofol and etomidate possibly increased recovery time (SMD = 0.14, 95% CI = 0.04-0.24; P = .005), and the risk for myoclonus (OR = 3.07, 95% CI = 1.73-5.44; P < .001), injection pain, and nausea and vomiting. Furthermore, compared to propofol alone, the combination of propofol and etomidate produced an apparent beneficial effect for mean arterial pressure (MAP) after anesthesia (SMD = 1.32, 95% CI = 0.38-2.26; P = .006), SPO2 after anesthesia (SMD = 0.99, 95% CI = 0.43-1.55; P < .001), apnea or hypoxemia (OR = 0.16, 95% CI = 0.08-0.33; P < .001), injection pain, and body movement. Further, compared to etomidate alone, the combination of propofol and etomidate reduced the risk for myoclonus (OR = 0.15, 95% CI = 0.11-0.22; P < .001), body movement, and nausea and vomiting.

CONCLUSION

The combination of propofol and etomidate might increase recovery time vs that associated with propofol, but it had fewer side effects on circulation and respiration in patients undergoing gastroscopy. The combined use of propofol and etomidate can improve and produce an apparent beneficial effect on the adverse effects of propofol or etomidate alone, and it was safer and more effective than propofol or etomidate alone.

Conscious sedation using propofol versus midazolam in cirrhotic patients during upper GI endoscopy: A comparative study

AIM

We aimed to assess the safety and efficacy of propofol versus midazolam in cirrhotic patients undergoing upper GI endoscopy.

METHODS

Ninety compensated cirrhotic patients (all met class I-III criteria according to the American Society of Anesthesia) were enrolled in this comparative study. They were classified into three groups according to scheduled pre-endoscopy sedation drugs; the midazolam group, which included 30 patients who received IV weight-dependent midazolam (0.05 mg/kg with additional doses of 1 mg every 2 min when necessary, up to a maximum dose of 0.1 mg/kg or 10 mg); the propofol group, which included 30 patients who received a propofol bolus dose according to age and weight (0.25 mg/kg with additional doses of 20-30 mg every 30-60 s when necessary, up to a maximum dose of 400 mg); and the combined group, which included 30 patients who received half a dose of midazolam and of propofol.

RESULTS

Prolonged postendoscopy recovery times were reported in the midazolam group, while shorter recovery times were reported in the propofol and combined groups. All patients in the propofol and combined groups gained consciousness shortly postendoscopy; however, only half of the midazolam group's patients gained consciousness after the standard recovery time (10-30 min). Highly significant differences were found among the three groups regarding consciousness level according to the Glasgow coma scale, as well as regarding the occurrence of hypoxia during endoscopy.

CONCLUSION

Considering safety and efficacy issues, propofol is better than midazolam in gastrointestinal endoscopy, especially in patients with liver cirrhosis.

The Comparison of Midazolam and Propofol in Gastrointestinal Endoscopy: A Systematic Review and Meta-analysis

INTRODUCTION

Midazolam and propofol are both used for sedation in gastrointestinal endoscopy. We conducted a systematic review and meta-analysis to compare the efficacy and safety of midazolam and propofol in gastrointestinal endoscopy.

MATERIALS AND METHODS

PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases were systematically searched. Randomized controlled trials assessing the effect of midazolam versus propofol on sedation in gastrointestinal endoscopy are included. Two investigators have independently searched for articles, extracted data, and assessed the quality of included studies. This meta-analysis was performed using the random-effect model.

RESULTS

Five randomized controlled trials involving 552 patients were included in the meta-analysis. Overall, compared with midazolam sedation during gastrointestinal endoscopy, propofol sedation results in higher endoscopist satisfaction scores during gastrointestinal endoscopy than midazolam [standard mean difference (Std. MD)=-0.71; 95% confidence interval (CI)=-1.05 to -0.37; P<0.0001), but the comparison shows no remarkable influence on patient satisfaction scores between midazolam and propofol (Std. MD=-0.34; 95% CI=-0.88 to 0.20; P=0.21), procedure time (Std. MD=0.14; 95% CI=-0.13 to 0.42; P=0.31), hypoxia [risk ratio (RR)=0.86; 95% CI=0.53-1.38; P=0.53), and bradycardia (RR=1.05; 95% CI=0.54-2.06; P=0.89). In addition, propofol shows higher incidence of hypotension than midazolam (RR=0.58; 95% CI=0.34-0.99; P=0.04).

CONCLUSIONS

When compared with midazolam sedation for gastrointestinal endoscopy, propofol sedation results in higher endoscopist satisfaction scores, but may increase the incidence of hypotension.

Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018

Supplemental Digital Content is available in the text.

Efficacy and safety of sedation during endoscopic submucosal dissection of gastric cancers using a comparative trial of propofol versus midazolam

BACKGROUND AND STUDY AIMS

Proper sedation is necessary for the safe and satisfactory completion of endoscopic submucosal dissection (ESD) for early gastric cancer. This study was conducted as a comparative trial of efficacy and safety, comparing propofol-based sedation and midazolam-based sedation during ESD of early gastric cancer patients.

PATIENTS AND METHODS

This study examined 64 lesions in 58 patients treated using ESD with midazolam plus pentazocine between July 2013 and January 2014 (group M) and 237 lesions in 216 patients treated by ESD using propofol plus pentazocine between February 2014 and December 2015 (group P). The two groups were compared in terms of the frequency of body movement during ESD as the primary outcome and in terms of the procedure time, en bloc resection rate, intraoperative change in cardiorespiratory dynamics, and postoperative awareness as the secondary outcomes. Body movement was defined as movement by a patient that required interruption of the procedure or restraint of the patient's body trunk, and addition of a sedative agent.

RESULTS

The median frequency of body movement during ESD was significantly lower in group P (0 times) than in group M (3 times) ( P  < 0.001). No significant difference was found for the mean procedure time (117 min in group P; 127 min in group M). Although no significant difference was found in the incidence of hypoxemia, bradycardia, or bradypnea, the incidence of hypotension was significantly higher in group P (31.5 %) than in group M (6.9 %) ( P  = 0.004). Patients in group P had significantly higher postoperative awareness immediately after ESD and at 1 hour after ESD ( P  = 0.002 and 0.022, respectively).

CONCLUSION

These results demonstrate the efficacy and safety of propofol-based sedation for gastric ESD.

Bilateral thoracic paravertebral nerve blocks for placement of percutaneous radiologic gastrostomy in patients with amyotrophic lateral sclerosis: a case series

BACKGROUND AND AIMS

To assess the efficacy of bilateral thoracic paravertebral nerve blocks (PVB) in providing procedural anesthesia and post-procedural analgesia for placement of percutaneous radiologic gastrostomy tubes (PRG) in patients with amyotrophic lateral sclerosis (ALS).

METHODS

We prospectively observed 10 patients with ALS scheduled for PRG placement that had bilateral thoracic PVBs at thoracic 7, 8, and 9 levels with administration of a mixture of 3 mL of 1% ropivacaine, 0.5 mg/mL dexamethasone, and 5 μg/mL epinephrine at each level. The success of the block was assessed after 10 minutes. PRG placement was done in the interventional radiology suite without sedation. All patients were followed up via phone 24 hours after the procedure.

RESULTS

All 10 patients had successful placement of PRG with PVBs as the primary anesthetic. Segmental anesthesia over the surgical site in all cases was successful with first attempt of the blocks. Three patients had significant hypotension after the block, requiring boluses of vasopressors and intravenous fluids. All patients reported high levels of satisfaction and sleep quality on the night of the procedure.

CONCLUSIONS

Bilateral thoracic PVBs provided satisfactory procedural anesthesia and post-procedural analgesia, and thus, seem promising as a safe alternative to sedation in ALS patients having PRG placement.

Similar Risk of Cardiopulmonary Adverse Events Between Propofol and Traditional Anesthesia for Gastrointestinal Endoscopy: A Systematic Review and Meta-analysis

BACKGROUND & AIMS

Even though propofol use for gastrointestinal endoscopic procedures has increased over the past decade, there is a perception that it causes a higher rate of cardiopulmonary adverse events. The aim of this study was to compare the sedation-related adverse events associated with use of propofol vs nonpropofol agents for endoscopic procedures. We also wanted to determine the influence of duration or complexity of the procedures and endoscopist-directed (gastroenterologist) vs non-gastroenterologist-directed sedation on the outcomes.

METHODS

A search was conducted using Medline, EMBASE, and the Cochrane controlled trials registry. The following cardiopulmonary adverse events were assessed: hypoxia, hypotension, and arrhythmias. The procedures were divided into 2 groups based on the procedure length: a nonadvanced endoscopic procedure group consisting of esophagogastroduodenoscopy, colonoscopy, and sigmoidoscopy, and an advanced endoscopic procedures group including endoscopic retrograde cholangiopancreatography, endoscopic ultrasonography, balloon enteroscopy, and endoscopic submucosal dissection. Pooled odds ratios for complications were calculated for all the procedures combined and then separately for the 2 groups. Random-effects models were used for 2-proportion comparisons.

RESULTS

Of the 2117 citations identified, 27 original studies qualified for this meta-analysis and included 2518 patients. Of these, 1324 received propofol, and 1194 received midazolam, meperidine, pethidine, remifentanil, and/or fentanyl. Most of the included studies were randomized trials of moderate quality and nonsignificant heterogeneity (Cochran Q, 26.07; P = .13). Compared with traditional sedative agents, the pooled odds ratio with the use of propofol for developing hypoxia for all the procedures combined was 0.82 (95% confidence interval [CI], 0.63-1.07), and for developing hypotension was 0.92 (95% CI, 0.64-1.32). In the nonadvanced endoscopic procedure group, those who received propofol were 39% less likely to develop complications than those receiving traditional sedative agents (odds ratio, 0.61; 95% CI, 0.38-0.99). There was no difference in the complication rate for the advanced endoscopic procedure group (odds ratio, 0.86; 95% CI, 0.56-1.34). A subgroup analysis did not show any difference in adverse events when propofol was administered by gastroenterologists or nongastroenterologists.

CONCLUSIONS

Propofol sedation has a similar risk of cardiopulmonary adverse events compared with traditional agents for gastrointestinal endoscopic procedures. Propofol use in simple endoscopic procedures was associated with a decreased number of complications. When used for gastrointestinal endoscopic procedures of a complex nature and longer duration, propofol was not associated with increased rates of hypoxemia, hypotension, or arrhythmias. Administration of propofol by gastroenterologists does not appear to increase the complication rates.

A comparison of propofol and midazolam/meperidine sedation in upper gastrointestinal endoscopy

INTRODUCTION

There is increasing interest in sedation for upper gastrointestinal endoscopy (UGE). Prospective randomized studies comparing sedation properties and complications of propofol and midazolam/meperidine in upper gastrointestinal endoscopy (UGE) are few.

AIM

To compare propofol and midazolam/meperidine sedation for UGE in terms of cardiopulmonary side effects, patient and endoscopist satisfaction and procedure-related times.

MATERIAL AND METHODS

This was a prospective, randomized, double-blind study of propofol versus midazolam and meperidine in 100 patients scheduled for diagnostic upper gastrointestinal endoscopy. The patients were divided into propofol and midazolam/meperidine groups. Randomization was generated by a computer. Cardiopulmonary side effects (hypotension, bradycardia, hypoxemia), procedure-related times (endoscopy time, awake time, time to hospital discharge), and patient and endoscopist satisfaction were compared between groups.

RESULTS

There was no significant difference between the groups with respect to the cost, endoscopy time, or demographic and clinical characteristics of the patients. Awake time and time to hospital discharge were significantly shorter in the propofol group (6.58 ±4.72 vs. 9.32 ±4.26 min, p = 0.030 and 27.60 ±7.88 vs. 32.00 ±10.54 min, p = 0.019). Hypotension incidence was significantly higher in the propofol group (12% vs. 0%, p = 0.027). The patient and endoscopist satisfaction was better with propofol.

CONCLUSIONS

Propofol may be preferred to midazolam/meperidine sedation, with a shorter awake and hospital discharge time and better patient and endoscopist satisfaction. However, hypotension risk should be considered with propofol, and careful evaluation is needed, particularly in cardiopulmonary disorders.

Sedation in the Ambulatory Endoscopy Center: Optimizing Safety, Expectations and Throughput

In the United States, sedation and analgesia are the standard of practice when endoscopic procedures are performed in the ambulatory endoscopy center. Over the last 30 years, there has been a dramatic shift of endoscopic procedures from the hospital outpatient department to ambulatory endoscopy centers. This article will discuss sedation and analgesia in the ambulatory endoscopy center as it relates to optimizing safety, patient expectations, and efficiency.

Basic principles and practice of gastric cancer screening using high-definition white-light gastroscopy: Eyes can only see what the brain knows

Endoscopic diagnosis of gastrointestinal tumors consists of the following processes: (i) detection; (ii) differential diagnosis; and (iii) quantitative diagnosis (size and depth) of a lesion. Although detection is the first step to make a diagnosis of the tumor, the lesion can be overlooked if an endoscopist has no knowledge of what an early-stage 'superficial lesion' looks like. In recent years, image-enhanced endoscopy has become common, but white-light endoscopy (WLI) is still the first step for detection and characterization of lesions in general clinical practice. Settings and practice of routine esophagogastroduodenoscopy (EGD) such as use of antispasmodics, number of endoscopic images taken, and observational procedure are customarily decided in each facility in each country and are not well standardized. Therefore, in the present article, we attempted to outline currently available evidence and actual Japanese practice on gastric cancer screening using WLI, and provide tips for detecting EGC during routine EGD which could become the basis of future research.

Efficacy of Conversational Hypnosis and Propofol in Reducing Adverse Effects of Endoscopy

Background:

As pain and nausea is usually associated with endoscopy procedure, its management is important to alleviate patients’ anxious in this regard.

Objectives:

The present study aimed to examine the effectiveness of conversational hypnosis in reducing anxiety and endoscopy-related complications as well as its role in increasing the satisfaction of patients exposed to endoscopic procedures.

Patients and Methods:

The participants of upper GI endoscopy procedure were randomly assigned to an experiment group (with conversational hypnosis intervention, n = 93) and a control group (n = 47). The participants’ hemodynamic indexes (HR, blood pressure, pulse oximetry), anxiety, satisfaction level, and complications resulted from the procedure were monitored and included in the self-administered questionnaire.

Results:

The results indicated that the participants in experiment group had a significant reduction of anxiety in the posttest. The adverse side effects such as vomiting, nausea, and hiccups in the experimental group was less than the control group, though this difference was not significant (P = 0.54).

Conclusions:

The results suggested that conversational hypnosis technique could reduce anxiety as well as the sedation process in invasive procedures such as endoscopy.

Morbidity and mortality of endoscopist-directed nurse-administered propofol sedation (EDNAPS) in a tertiary referral center

BACKGROUND AND STUDY AIMS

Endoscopist-Directed Nurse-Administered Propofol Sedation (EDNAPS) has been evaluated in community settings rather than tertiary referral centers.

PATIENTS AND METHODS

A hospital-wide prospectively collected database of Medical Emergency Team Calls (METCALL), emergency responses triggered by medically unstable patients, was reviewed. Responses that followed EDNAPS were extracted and compared with a prospectively entered database of all endoscopies performed using EDNAPS over the same period.

RESULTS

A total of 33,539 endoscopic procedures (16,393 gastroscopies, 17,146 colonoscopies) were performed on 27,989 patients using EDNAPS. Intravenous drugs included midazolam (0 - 5 mg), fentanyl (0 - 100 mcg), and propofol (10 - 420 mg). Of 23 METCALLs (18 gastroscopies and 5 colonoscopies), there were 16 with ASA scores of III or higher. Indications for gastroscopy were gastrointestinal (GI) hemorrhage (n = 11; 8 variceal, 3 nonvariceal), dysphagia (n = 5), PEG removal (n = 1), and dyspepsia (n = 1). Fifteen of 22 patients, including all of those who had a colonoscopy, made a full recovery and returned to the ward or were discharged home. In the gastroscopy group, seven were intubated and admitted to Intensive Care, of whom six were emergency cases for gastrointestinal bleeding (n = 4 variceal, n = 2 non variceal) and one in which the indication was PEG removal. Two deaths occurred in the intubated group.

CONCLUSIONS

In a tertiary referral center, EDNAPS for low-to-moderate risk (ASA ≤ 2) patients undergoing gastroscopy and colonoscopy is very safe. Gastroscopy is associated with greater anesthetic risk than colonoscopy and those with high ASA scores needing urgent endoscopy for upper gastrointestinal hemorrhage are at particular risk of cardiorespiratory decompensation.

Optimization of Deep Sedation with Spontaneous Respiration for Therapeutic Endoscopy Combining Propofol and Bispectral Index Monitoring

Background/Aims. This study aimed to establish optimal propofol anesthesia for therapeutic endoscopy, which has not been established. Methodology. We retrospectively investigated data on 89 patients who underwent upper-GI endoscopic submucosal dissection or endoscopic mucosal resection under anesthesia with propofol. Examined doses of propofol were changed according to efficacy and/or adverse events and classified into 5 periods. A bispectral index (BIS) monitor was used at Period 5 to decrease the incidence of adverse events caused by oversedation. The initial dose of propofol was administered after bolus injection of pethidine hydrochloride (0.5 mg/kg), and 1.0 mL of propofol was added every minute until the patients fell asleep. Continuous and bolus infusion were performed to maintain sedation. When the patient moved or an adverse event occurred, the maintenance dose examined was increased or decreased by 5 mL/h regardless of body weight. Results. Dose combinations (introduction : maintenance) and patient numbers for each period were as follows: Period 1 (n = 27), 0.5 mg/kg : 5 mg/kg/h; Period 2 (n = 11), 0.33 mg/kg : 3.3 mg/kg/h; Period 3 (n = 7), 0.5 mg/kg : 3.3 mg/kg/h; Period 4 (n = 14), 0.5 mg/kg : 2.5 mg/kg/h; Period 5 (n = 30), 0.5 mg/kg : 2.5 mg/kg/h, using BIS monitor. During Period 5, an adverse event occurred in 10.0% of patients, which was lower than that for Periods 1–4. Conclusions. Period 5 propofol anesthesia with BIS protocol could be safe and useful for therapeutic endoscopy under deep sedation with spontaneous respiration.

Efficacy and safety of a patient-positioning device (EZ-FIX) for endoscopic retrograde cholangiopancreatography

AIM

To assess the efficacy and safety of a patient-positioning device (EZ-FIX) for endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

A total of 105 patients were randomized to the EZ-FIX (n = 53) or non-EZ-FIX (n = 52) group in this prospective study. Midazolam and propofol, titrated to provide an adequate level of sedation during therapeutic ERCP, were administered by trained registered nurses under endoscopist supervision. Primary outcome measures were the total dose of propofol and sedative-related complications, including hypoxia and hypotension. Secondary outcome measures were recovery time and sedation satisfaction of the endoscopist, nurses, and patients.

RESULTS

There was no significant difference in the rate of hypoxia, but there was a statistical trend (EX-FIX group; n = 4, 7.55%, control group; n = 6, 11.53%, P = 0.06). The mean total dose of propofol was lower in the EZ-FIX group than in the non-EZ-FIX group (89.43 ± 49.8 mg vs 112.4 ± 53.8 mg, P = 0.025). In addition, the EZ-FIX group had a shorter mean recovery time (11.23 ± 4.61 mg vs 14.96 ± 5.12 mg, P < 0.001). Sedation satisfaction of the endoscopist and nurses was higher in the EX-FIX group than in the non-EZ-FIX group. Technical success rates of the procedure were 96.23% and 96.15%, respectively (P = 0.856). Procedure-related complications did not differ by group (11.32% vs 13.46%, respectively, P = 0.735).

CONCLUSION

Using EZ-FIX reduced the total dose of propofol and the recovery time, and increased the satisfaction of the endoscopist and nurses.

Guidelines for sedation in gastroenterological endoscopy

Recently, the need for sedation in gastrointestinal endoscopy has been increasing. However, the National Health Insurance Drug Price list in Japan does not include any drug specifically used for the sedation. Although benzodiazepines are the main medication, their use in cases of gastrointestinal endoscopy has not been approved. This has led the Japan Gastrointestinal Endoscopy Society to develop the first set of guidelines for sedation in gastrointestinal endoscopy on the basis of evidence-based medicine in collaboration with the Japanese Society for Anesthesiologists. The present guidelines comprise 14 statements, five of which were judged to be valid on the highest evidence level and three on the second highest level. The guidelines are not intended to strongly recommend the use of sedation for gastrointestinal endoscopy, but rather to indicate the policy as to the choice of appropriate procedures when such sedation is deemed necessary. In clinical practice, the final decision as to the use of sedation should be made by physicians considering patient willingness and physical condition.

Clinical impact of gastroenterologist-administered propofol during esophagogastroduodenoscopy: a randomized comparison at a single medical clinic

BACKGROUND

Although midazolam is widely used during endoscopic procedures by endoscopists, propofol has been recently favored for its rapid action and metabolism. The aim of this study is to compare the clinical advantages between propofol and midazolam use during screening esophagogastroduodenoscopy (EGD) for gastric cancer and post-procedure management at a medical clinic.

METHODS

One hundred six healthy patients aged 20-69 years requesting sedation for screening EGD from October 2012 to May 2013 at a single clinic in Japan were randomly assigned to propofol (n = 54) or midazolam (n = 52). Medications were given by bolus injection, and the dose was adjusted by body weight. Sedation level and tolerability during EGD and recovery time were assessed. Sedation level and tolerability were evaluated by American Society of Anesthesiologists responsiveness levels and four levels of the gag reflex, respectively. For safety purposes, endoscopists and nurses were trained in administering propofol and an anesthesiologist was on call at all times.

RESULTS

No statistically significant differences were found between the two groups in sedation level and patient tolerability. Full recovery time in the propofol group (4.7 min) was significantly shorter than that in the midazolam group (24 min, P < 0.01).

CONCLUSIONS

Regarding post-procedure management of patients in a medical clinic, propofol use might not necessitate a recovery room and excessive assessment tasks because of rapid recovery time without any prolonged reaction, which causes patient compliance. (

CLINICAL TRIAL REGISTRATION NUMBER

UMIN000009142.).

Prescribing patterns of the four most commonly used sedatives in endoscopic examination in Korea: propofol, midazolam, diazepam, and lorazepam

As the sedative use increases due to the effectiveness and relatively safe profile, the abuse potential is also increasing. This study was conducted to examine the usage of four sedative agents in endoscopic examination and to compare the propofol use with the other three sedatives. Using National Health Insurance claims data from 2008 to 2012, we identified the number of cases of conscious sedation during endoscopy using one or more of the following agents: propofol, midazolam, diazepam, and lorazepam. The general characteristics of patients and medical service providers were analyzed, and the regional and annual distributions of frequency of use were compared. We also identified patient cases with excessive number of endoscopic examinations. Among the total of 3,156,231 sedatives users, midazolam was the most commonly used agent (n=2,845,250, 90.1%). However, the largest increase in patient number, which increased from 11,410 in 2008 to 28,170 in 2012, was observed with propofol. While the majority of patients received an annual endoscopy, we identified several suspected abuse cases of patients receiving endoscopies repetitively as many as 114 times in five years. The rise of sedative use in endoscopic examinations and several patient cases of repeated sedative administration suggest a potential risk for abuse. Medical service providers should be cautious when using sedatives and carefully review each patient's medical history prior to the procedure.

Propofol versus midazolam for upper gastrointestinal endoscopy in cirrhotic patients: a meta-analysis of randomized controlled trials

BACKGROUND

Sedation during gastrointestinal endoscopy is often achieved using propofol or midazolam in general population. However, impaired protein synthesis, altered drug metabolism, and compromised hepatic blood flow in patients with liver cirrhosis might affect the pharmacokinetics of sedatives, placing cirrhotic patients undergoing endoscopy at a greater risk of adverse events. The objective of this study was to assess comparative efficacies and safety of propofol and midazolam in cirrhotic patients undergoing endoscopy.

METHODS

Randomized, controlled trials comparing propofol with midazolam in cirrhotic patients undergoing gastrointestinal endoscopy were selected. We performed the meta-analysis, using a random-effect model, the Review Manager, Version 5.2, statistical software package (Cochrane Collaboration, Oxford, UK) according to the PRISMA guidelines.

RESULTS

Five studies between 2003 and 2012, including 433 patients, were included. Propofol provided a shorter time to sedation (weight mean difference: -2.76 min, 95% confidence interval: -3.00 to -2.51) and a shorter recovery time (weight mean difference -6.17 min, 95% confidence interval: -6.81 to -5.54) than midazolam did. No intergroup difference in the incidence of hypotension, bradycardia, or hypoxemia was observed. Midazolam was associated with the deterioration of psychometric scores for a longer period than propofol.

CONCLUSION

This meta-analysis suggests that Propofol sedation for endoscopy provides more rapid sedation and recovery than midazolam does. The risk of sedation-related side effects for propofol does not differ significantly from that of midazolam. The efficacy of propofol in cirrhotic patients undergoing endoscopy is superior to those of midazolam.

Safety analysis of endoscopist-directed propofol sedation: a prospective, national multicenter study of 24 441 patients in German outpatient practices

BACKGROUND AND AIM

Since 2008, there exists a German S3-guideline allowing non-anesthesiological administration of propofol for gastrointestinal endoscopy. In this prospective, national, multicenter study, we evaluated the safety of endoscopist-administered propofol sedation (EDP) in German outpatient practices of Gastroenterology.

METHODS

In this multicenter survey of 53 ambulatory practices of Gastroenterology, we prospectively evaluated 24 441 patients that had received EDP. We recorded adverse events during the endoscopic procedure and additionally retrieved questionnaires investigating subjective parameters 24 h after the endoscopic procedure.

RESULTS

In 24 441 patients 13 793 colonoscopies, 6467 esophagogastroduodenoscopies, and 4181 double examinations were performed. In this study, 52.1% of the patients received propofol mono-sedation, and 47.9% received a combination of midazolam and propofol. Major adverse events occurred in four patients (0.016%) enrolled to this study (three mask ventilations and one laryngospasm). Minor adverse events were observed in 112 patients (0.46%) with hypoxemia being the most common minor event. All patients with adverse events recovered without persistent impairment. Minor adverse events occurred more frequently in patients sedated with propofol mono compared to propofol and midazolam (P < 0.0001) and correlated with increasing propofol dosages (P < 0.001; Pearson correlation coefficient r = 0.044). Twenty-four hours after the endoscopy, patients sedated with propofol plus midazolam stated a significantly reduced sensation of pain (P < 0.01) and improved symptoms of dizziness, nausea and vomiting (P < 0.001) compared to patients having received propofol mono-sedation.

CONCLUSION

Four years after the implementation of a German S3-Guideline for endoscopic sedation, we demonstrated that EDP is a safe procedure.

Target-controlled infusion of propofol versus intermittent bolus of a sedative cocktail regimen in deep sedation for gastrointestinal endoscopy: comparison of cardiovascular and respiratory parameters

OBJECTIVE

To investigate whether target-controlled infusion (TCI) with propofol, a method that has theoretically better control of drug concentration, produces less cardiovascular and respiratory suppression than an intermittent bolus of a sedative cocktail regimen in deep sedation for gastrointestinal endoscopy.

METHODS

In total 100 participants who had undergone esophagoduodenoscopy (EGD) and 120 who had undergone colonoscopy were prospectively and randomly enrolled to receive TCI with propofol or intermittent bolus of cocktail regimen containing midazolam, alfentanil and propofol until they were unresponsive to verbal commands. The target concentration was adjusted and the bolus of the cocktail regimen was added based on their responses. The nadir values of heart rate, blood pressure and oxygen saturation during and after the procedure were recorded.

RESULTS

The nadir systolic blood pressure during the endoscopy in the cocktail regimen group was significantly lower than that in the TCI with propofol group. In the cocktail regimen group, the incidence of hypotension during colonoscopy and that of bradycardia during EGD were higher than those in the TCI with propofol group. No participants in the TCI with propofol group experienced hypoxia during endoscopy. In the cocktail regimen group, six participants who had undergone EGD and six who had undergone colonoscopy showed transient hypoxic episodes during or after endoscopy.

CONCLUSION

TCI with propofol produced less cardiovascular and respiratory suppression than intermittent bolus of a sedative cocktail regimen in deep sedation for gastrointestinal endoscopy.

The use of propofol as a sedative agent in gastrointestinal endoscopy: a meta-analysis

OBJECTIVES

To assess the efficacy and safety of propofol sedation for gastrointestinal endoscopy, we conducted a meta-analysis of randomized controlled trials (RCTs) comparing propofol with traditional sedative agents.

METHODS

RCTs comparing the effects of propofol and traditional sedative agents during gastrointestinal endoscopy were found on MEDLINE, the Cochrane Central Register of Controlled Trials, and EMBASE. Cardiopulmonary complications (i.e., hypoxia, hypotension, arrhythmia, and apnea) and sedation profiles were assessed.

RESULTS

Twenty-two original RCTs investigating a total of 1,798 patients, of whom 912 received propofol only and 886 received traditional sedative agents only, met the inclusion criteria. Propofol use was associated with shorter recovery (13 studies, 1,165 patients; WMD -19.75; 95% CI -27.65, 11.86) and discharge times (seven studies, 471 patients; WMD -29.48; 95% CI -44.13, -14.83), higher post-anesthesia recovery scores (four studies, 503 patients; WMD 2.03; 95% CI 1.59, 2.46), better sedation (nine studies, 592 patients; OR 4.78; 95% CI 2.56, 8.93), and greater patient cooperation (six studies, 709 patients; WMD 1.27; 95% CI 0.53, 2.02), as well as more local pain on injection (six studies, 547 patients; OR 10.19; 95% CI 3.93, 26.39). Effects of propofol on cardiopulmonary complications, procedure duration, amnesia, pain during endoscopy, and patient satisfaction were not found to be significantly different from those of traditional sedative agents.

CONCLUSIONS

Propofol is safe and effective for gastrointestinal endoscopy procedures and is associated with shorter recovery and discharge periods, higher post-anesthesia recovery scores, better sedation, and greater patient cooperation than traditional sedation, without an increase in cardiopulmonary complications. Care should be taken when extrapolating our results to specific practice settings and high-risk patient subgroups.

Safety and efficacy of deep sedation with propofol alone or combined with midazolam administrated by nonanesthesiologist for gastric endoscopic submucosal dissection

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.

Intermittent manually controlled versus continuous infusion of propofol for deep sedation during interventional endoscopy: a prospective randomized trial

INTRODUCTION

Beside the traditional, intermittent bolus application of propofol, continuous propofol infusion via infusion pump is an alternative procedure for deep sedation during long-lasting interventional endoscopy. However, up to now, there are no randomized comparisons for gastrointestinal endoscopy.

METHODS

One hundred patients (ERCP: n = 60, EUS: n = 40) were randomly assigned to receive intermittent bolus application ("bolus group") or continuous infusion ("perfusor group") of propofol sedation after induction with 3 mg midazolam for deep sedation. Patients in the bolus group received an initial propofol dose according to body weight (bw <70 kg: 40 mg; bw ≥ 70 kg 60 mg). In the perfusor group, bw-adapted, continuous propofol infusion (6 mg/kg) via the Injectomat 2000 MC (Fresenius-Kabi) was administered after an initial bolus of 1 mg/kg. Vital signs, dose of propofol, patient cooperation (VAS 1-10), sedation depth, and the recovery time as well as the quality of recovery were evaluated.

RESULTS

Total propofol dose in the bolus group 305 ± 155 mg (100-570 mg) and in the perfusor group 343 ± 123 mg (126-590 mg, p = 0.5) were comparable. Oxygen saturation below 90% was seen in four patients of each group, with no need for assisted ventilation. Arterial blood pressure <90 mmHg was documented in two patients in the bolus group and seven patients in the perfusor group (p = 0.16). Patients' cooperation was rated as good in both groups (bolus group, 9.1 ± 0.9; perfusor group, 8.9 ± 1; p = 0.17). Recovery time was significantly shorter in the bolus group compared with the perfusor group (19 ± 5 versus 23 ± 6 min, p < 0.001) whereas the quality of recovery was nearly identical in both groups.

CONCLUSION

Both sedation regimens allow nearly identical good controllability of propofol sedation. However, recovery time was significantly slower and hypotension was tended to occur more often in the perfusor group.

Prospective description of coughing, hemodynamic changes, and oxygen desaturation during endoscopic sedation

BACKGROUND

Deep sedation is increasingly used for endoscopy. The impact of sedation level on hemodynamic status, oxygenation, and aspiration risk is incompletely described.

AIMS

To describe the incidence of intraprocedural cough, hemodynamic changes, oxygen desaturation, and their relationship to clinical factors and sedation level.

METHODS

Detailed prospective recordings of hemodynamic changes, oxygen desaturation, and cough during 757 nonemergent endoscopic procedures done under sedation using propofol, midazolam, and/or fentanyl.

RESULTS

Thirteen percent of patients had at least one cough and 3% had prolonged cough. Cough was more common in nonsmokers (P = 0.05), upper endoscopy (P < 0.0001), with propofol (P = 0.0008), longer procedures (P = 0.0001), and hiccups (P = 0.01). The association between supine positioning during colonoscopy and cough approached significance (P = 0.06). Oxygen desaturation was rare (4%) and associated only with deep sedation (P = 0.02). Mean systolic and diastolic blood pressure (BP) dropped by 7.3 and 5.6% respectively. Decreases in systolic BP were more common in whites (P = 0.03), males (P = 0.004), nonsmokers (P = 0.04), during colonoscopy (P < 0.0001), and in patients receiving midazolam and fentanyl (P = 0.01). Heart rate (HR) dropped >20% from baseline in 15% of patients and was more common during colonoscopy (P = 0.002). HR increased >20% in 20% of patients and was more common with coughing (P < 0.0001) and in younger patients (P = 0.0002). No patient required pharmacologic treatment of BP or HR.

CONCLUSIONS

We have described procedural predictors of cough that may help clinicians reduce the risk of aspiration during endoscopy. Hemodynamic changes during endoscopy are common but largely clinically insignificant.

Incidence of propofol injection pain and effect of lidocaine pretreatment during upper gastrointestinal endoscopy

BACKGROUND/AIMS

Propofol has been used in the past for sedation in upper gastrointestinal (GI) endoscopic procedures. This study aimed to measure the incidence of propofol injection pain and evaluate the effect of lidocaine on pain caused during sedative upper GI endoscopic examinations.

METHODS

Subjects scheduled to undergo sedative diagnostic upper GI endoscopy were randomly assigned to lidocaine and placebo groups. Pretreatment with a bolus of 1% lidocaine 2 ml or normal saline 2 ml into the largest dorsal vein of the non-dominant hand was followed by propofol administration. Pain intensity was estimated by an examiner blinded to the group assignment using a four-point verbal rating scale. A score of 1-3 was regarded as pain.

RESULTS

A total of 121 patients (males, 69; age, 58.6 ± 12.1 years) completed the study; 61 and 60 subjects were randomly assigned to the lidocaine and placebo groups, respectively. The incidence of pain during upper GI endoscopy was 60%. The lidocaine group showed a lower incidence of pain than the placebo group (37.7% vs. 60.0%, P = 0.018). The lidocaine group perceived significantly less pain than the placebo group (median pain score, 0 vs. 1, P = 0.008). Only lidocaine pretreatment was an independently associated factor against pain perception (OR, 0.380; 95% CI, 0.177-0.815; P = 0.013).

CONCLUSIONS

Pretreatment using lidocaine was found to be effective in reducing propofol injection-induced pain. However, its usefulness for GI endoscopic procedures in daily clinical practice needs further evaluation because of the low intensity of pain.

Diazepam during endoscopic submucosal dissection of gastric epithelial neoplasias

AIM: To investigate risk factors and adverse events related to high-dose diazepam administration during endoscopic submucosal dissection for gastric neoplasias.

METHODS: Between February 2002 and December 2009, a total of 286 patients with gastric epithelial neoplasia underwent endoscopic submucosal dissection in our hospital. To achieve moderate sedation, 5-7.5 mg of diazepam was administered intravenously by non-anesthesiologists. Intermittent additional administration of 2.5-5 mg diazepam was performed if uncontrollable body movement of the patient was observed. All patients were classified into groups based on the required diazepam dose: low-dose (≤ 17.5 mg, n = 252) and high-dose (> 17.5 mg, n = 79).

RESULTS: Differences between the low- and high-dose diazepam groups were observed in lifetime alcohol consumption (0.30 ± 0.48 vs 0.44 ± 0.52 tons, P = 0.032), body weight (58.4 ± 10.3 vs 62.0 ± 9.9 kg, P = 0.006), tumor size (15 ± 10 vs 23 ± 18 mm, P < 0.001), lesion location (P < 0.001) and the presence of ulcerative findings (14/238 vs 18/61, P < 0.001). Multivariate analysis identified all five variables as independently related to required diazepam dosage. In terms of adverse reactions to diazepam administration, paradoxical excitement was significantly more frequent in the high-dose diazepam group (P < 0.001).

CONCLUSION: Intermittent administration of diazepam enabled safe completion of gastric endoscopic submucosal dissection except in patients who were alcohol abusers or obese, or who showed complicated lesions.

Comparison of midazolam alone versus midazolam plus propofol during endoscopic submucosal dissection

Background/Aims

For proper sedation during endoscopic submucosal dissection (ESD), propofol has been widely used. This study aimed to compare the levels of sedation and tolerance of patients treated with midazolam (M group) and a combination of midazolam and propofol (MP group) during ESD.

Methods

A total of 44 consecutive patients undergoing ESD were randomly assigned to the two groups. In the M group, 2 mg of midazolam was given repeatedly to maintain after a loading dose of 5 mg. The MP group initially received 5 mg of midazolam and 20 mg of propofol. Then, we increased the dosage of propofol by 20 mg gradually.

Results

The average amount of midazolam was 12 mg in the M group. In the M group, 10 patients were given propofol additionally, since they failed to achieve proper sedation. The average amount of propofol was 181 mg in the MP group. Procedure time, vital signs and rates of complications were not significantly different between two groups. Movement of patients and discomfort were lower in the MP group.

Conclusions

During ESD, treatment with propofol and a low dose of midazolam for sedation provides greater satisfaction for endoscopists compared to midazolam alone.

Computer-assisted personalized sedation for upper endoscopy and colonoscopy: a comparative, multicenter randomized study

BACKGROUND

The SEDASYS System is an investigational computer-assisted personalized sedation system integrating propofol delivery with patient monitoring to enable endoscopist/nurse teams to safely administer propofol.

OBJECTIVE

To compare the safety and effectiveness of the SEDASYS System to the current standard of care for sedation during routine endoscopic procedures.

DESIGN

Nonblinded multicenter randomized comparative study.

SETTING

Four ambulatory surgery centers, 3 endoscopy centers, and 1 academic center in the United States.

PATIENTS

One thousand American Society of Anesthesiologists physical status class I to III adults undergoing routine colonoscopy or EGD.

INTERVENTIONS

Sedation with the SEDASYS System (SED) and sedation with each site's current standard of care (CSC; benzodiazepine/opioid combination).

MAIN OUTCOME MEASUREMENTS

Area under the curve of oxygen desaturation was the primary endpoint. Secondary endpoints included patient satisfaction, clinician satisfaction, level of sedation, and patient recovery time.

RESULTS

Four hundred ninety-six patients were randomized to SED and 504 to CSC. Area under the curve of oxygen desaturation was significantly lower for SED (23.6 s·%) than for CSC (88.0 s·%; P = .028). Patients were predominately minimally to moderately sedated in both groups. SED patients were significantly more satisfied than CSC patients (P = .007). Clinician satisfaction was greater with SED than with CSC (P < .001). SED patients recovered faster than CSC patients (P < .001). The incidence of adverse events was 5.8% in the SED group and 8.7% in the CSC group.

LIMITATIONS

Nonblinded.

CONCLUSIONS

The SEDASYS System could provide endoscopist/nurse teams a safe and effective on-label means to administer propofol to effect minimal to moderate sedation during routine colonoscopy and EGD.

Randomized controlled trial of patient-controlled sedation for colonoscopy: Entonox vs modified patient-maintained target-controlled propofol

AIM

Propofol sedation is often associated with deep sedation and decreased manoeuvrability. Patient-maintained sedation has been used in such patients with minimal side-effects. We aimed to compare novel modified patient-maintained target-controlled infusion (TCI) of propofol with patient-controlled Entonox inhalation for colonoscopy in terms of analgesic efficacy (primary outcome), depth of sedation, manoeuvrability and patient and endoscopist satisfaction (secondary outcomes).

METHOD

One hundred patients undergoing elective colonoscopy were randomized to receive either TCI propofol or Entonox. Patients in the propofol group were administered propofol initially to achieve a target concentration of 1.2 μg/ml and then allowed to self-administer a bolus of propofol (200 μg/kg/ml) using a patient-controlled analgesia pump with a handset. Entonox group patients inhaled the gas through a mouthpiece until caecum was reached and then as required. Sedation was initially given by an anaesthetist to achieve a score of 4 (Modified Observer's Assessment of Alertness and Sedation Scale), and colonoscopy was then started. Patients completed an anxiety score (Hospital Anxiety and Depression questionnaire), a baseline letter cancellation test and a pain score on a 100-mm visual analogue scale before and after the procedure. All patients completed a satisfaction survey at discharge and 24 h postprocedure.

RESULTS

The median dose of propofol was 174 mg, and the median number of propofol boluses was four. There was no difference between the two groups in terms of pain recorded (95% confidence interval of the difference -0.809, 5.02) and patient/endoscopist satisfaction. There was no difference between the two groups in either depth of sedation or manoeuvrability.

CONCLUSION

Both Entonox and the modified TCI propofol provide equally effective sedation and pain relief, simultaneously allowing patients to be easily manoeuvred during the procedures.

Predicting patient tolerance of endoscopy with conscious sedation

OBJECTIVE

To evaluate the adequacy of benzodiazepine/opiate sedation for endoscopic procedures and to identify patient and procedure characteristics that may predict poor procedural tolerance.

MATERIALS AND METHODS

A total of 2155 patients who underwent sedated gastroscopy, colonoscopy or flexible sigmoidoscopy between January and December 2007, participated in the prospective evaluation of procedural tolerance and the procedures were evaluated using three questionnaires completed by the patient, endoscopist and assisting nurse. Perception of procedural tolerance was scored using a 100-point visual analog scale (VAS), 0: very good to 100: very poorly. In order to identify patient and procedure characteristics predictive of poor procedural tolerance, we compared 10% of patients who tolerated the procedure least well with the remaining patients.

RESULTS

About 216 (10%) of 2155 patients gave a VAS score of >30, and were compared with the 1939 patients with a VAS <30. Patients who tolerated the procedure least well (VAS ≥30) were more likely female [odds ratio (OR) 2.8, 95% confidence interval 1.9-4.1], had colonoscopy (OR 2.9, 1.8-4.5) or had a training endoscopist perform the procedure (OR 3.2, 2.2-4.8). Patients with BMI ≥35 were also more likely to have a VAS ≥30 (p < 0.01). Sedation type and American Society of Anesthesiologists grade had no significant effect on patient tolerance.

CONCLUSIONS

A majority of patients tolerate endoscopic procedures well when benzodiazepine/opiate sedation is used. Accurately identifying the minority who tolerate these procedures less well remains difficult.

Sedation in digestive endoscopy: the Athens international position statements

BACKGROUND

Guidelines and practice standards for sedation in endoscopy have been developed by various national professional societies. No attempt has been made to assess consensus among internationally recognized experts in this field.

AIM

To identify areas of consensus and dissent among international experts on a broad range of issues pertaining to the practice of sedation in digestive endoscopy.

METHODS

Thirty-two position statements were reviewed during a 1 (1/2)-day meeting. Thirty-two individuals from 12 countries and four continents, representing the fields of gastroenterology, anaesthesiology and medical jurisprudence heard evidence-based presentations on each statement. Level of agreement among the experts for each statement was determined by an open poll.

RESULTS

The principle recommendations included the following: (i) sedation improves patient tolerance and compliance for endoscopy, (ii) whenever possible, patients undergoing endoscopy should be offered the option of having the procedure either with or without sedation, (iii) monitoring of vital signs as well as the levels of consciousness and pain/discomfort should be performed routinely during endoscopy, and (iv) endoscopists and nurses with appropriate training can safely and effectively administer propofol to low-risk patients undergoing endoscopic procedures.

CONCLUSIONS

While the standards of practice vary from country to country, there was broad agreement among participants regarding most issues pertaining to sedation during endoscopy.

Safe and effective sedation in endoscopic submucosal dissection for early gastric cancer: a randomized comparison between propofol continuous infusion and intermittent midazolam injection

PURPOSE

Endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) generally takes longer to perform than conventional endoscopy and usually requires moderate/deep sedation with close surveillance for patient safety. The aim of this study was to compare the safety profiles and recovery scores propofol continuous infusion and intermittent midazolam (MDZ) injection as sedation for ESD.

METHODS

Sixty EGC patients scheduled for ESDs between August and November 2008 were included in this prospective study and randomly divided into a propofol (P-group, 28 patients) and an MDZ (M-group, 32 patients) group using an odd-even system. The P-group received a 0.8 mg/kg induction dose and a 3 mg/kg/h maintenance dose of 1% propofol using an infusion pump. All patients received 15 mg pentazocine at the start of the ESD and at 60-min intervals thereafter. We recorded and analyzed blood pressure, oxygen saturation and heart rate during and following the procedure and evaluated post-anesthetic recovery scores (PARS) and subsequent alertness scores.

RESULTS

The propofol maintenance and total dose amounts were (mean +/- standard deviation) 3.7 +/- 0.6 mg/kg/h and 395 +/- 202 mg, respectively. The mean total dose of MDZ was 10.3 +/- 4.5 mg. There were no cases of de-saturation <90% or hypotension <80 mmHg in either group. Alertness scores 15 and 60 min after the procedures were significantly higher in the P-group (4.9/4.9) than in the M-group (4.6/4.5; p < 0.05). The mean PARS 15 and 30 min after the ESDs were significantly higher in the P-group (9.6/9.9) than in the M-group (8.6/9.2; p < 0.01).

CONCLUSION

Based on our results, the ESDs for EGC performed under sedation using propofol continuous infusion were as safe as those performed using intermittent MDZ injection. Propofol-treated patients had a quicker recovery profile than those treated with MDZ. We therefore recommend the use of continuous propofol sedation for ESD, but sedation guidelines for the use of propofol are necessary.

Endoscopy: consensus on approving propofol sedation by nonanesthesiologists

Propofol sedation by nonanesthesiologists is still a highly controversial issue despite the fact that numerous studies have approved this sedation regimen for gastrointestinal endoscopy. A new position statement from a collaboration of four different American gastroenterology and hepatology societies outlines the latest recommendations for nonanesthesiologist administration of propofol.

Estudo comparativo de eficácia e segurança entre propofol e midazolam durante sedação para colonoscopia

OBJETIVO: Comparar a segurança e a eficácia do propofol com a do midazolam na sedação profunda durante colonoscopias. MÉTODOS: Sessenta e seis pacientes foram submetidos à colonoscopias e estudados prospectivamente. Um total de 50 pacientes recebeu 3,25 mg.kg-1 de peso de propofol. No grupo controle de 16 pacientes foi administrado 2,05 mg.kg-1 de peso de midazolam. A dose de manutenção foi titulada de acordo com a necessidade. Os parâmetros cardiovasculares e respiratórios observados foram a saturação de oxigênio, pressão arterial sistólica e diastólica e frequência cardíaca. Após o procedimento foi realizado um questionário sobre intercorrências como dor, desconforto e satisfação após a colonoscopia, utilizando uma escala visual de zero a dez. Foi aplicado o teste t de Student para a análise estatística. RESULTADOS: A amostra foi similar com relação às variáveis idade, peso, sexo e condição física. Houve diferença estatística significativa para os parâmetros saturação de oxigênio do sangue e pressão arterial sistólica entre os dois grupos. Não houve diferença estatística significativa para os parâmetros pressão arterial diastólica e pulso. Apesar das diferenças nos parâmetros cardiovasculares e respiratórios, não houve repercussões hemodinâmicas significativas. Não houve diferença estatística no parâmetro dor e satisfação. Os pacientes que apresentaram agitação (25%) no grupo midazolam, relataram mais desconforto (p=0,038). CONCLUSÃO: As variações nos parâmetros cardiovasculares e respiratórios, mesmo com diferenças significativas entre os grupos, não causaram repercussões clínicas significativas nos dois grupos, caracterizando a segurança na sedação profunda. A sedação com midazolam ou propofol não está associada a níveis de dor e satisfação diferentes entre os dois grupos. O grupo midazolan referiu significativamente mais desconforto que o grupo propofol.

Comparison of differing sedation practice for upper endoscopic ultrasound using expert observational analysis of the procedural sedation

AIM

To compare the quality between 2 commonly used sedation practices for upper endoscopic ultrasound (EUS) by using expert observational analysis of the sedation practice.

METHODS

After institutional review board approval, 50 adults undergoing EUS had videotape observation of the procedural sedation: 25 received benzodiazepine/opiate administered by the endoscopy team as per the standard protocol at our institution, and 25 received propofol administered by a dedicated anesthesiologist. Quantitative analysis of the video was performed using the Dartmouth Operative Conditions Scale (DOCS). The DOCS is a tool previously developed to quantify the adequacy of procedural sedation through an objective measurement of the patient state during the sedation process. In this study, the DOCS was used in a novel way to compare the quality of sedation provided by different sedation protocols. Data were collected on patient demographics, patient and provider satisfaction, efficiency, side effects, and safety measures.

RESULTS

Videotape analysis using the DOCS revealed that 52% (13/25) of the standard group exhibited an uncontrolled patient state (significant undersedation and/or oversedation) on 1 or more occasion during their EUS procedure compared with 28% (7/25) of the propofol group. Patients in the standard group spent 7.1% of the procedure in an uncontrolled patient state, whereas patients in the propofol group experienced an uncontrolled state approximately 1.0% of the procedure time. Overall efficiency as measured by time in both the procedure room and in recovery was superior in the propofol group. These patients spent 12 less minutes on average in the procedure room and were ready for discharge in about half the time (56 minutes versus 109 minutes). The propofol group experienced significantly less in-hospital and at-home nausea and vomiting and felt back to baseline status more quickly. Finally, patient satisfaction was improved in the propofol group: 60% felt the procedure was better than anticipated versus 21% in the standard group.

CONCLUSIONS

Expert videotape analysis of the patient state during procedural sedation allows direct comparison of sedation methodologies using small numbers of patients. In our institution, endoscopist-directed sedation using a midazolam/narcotic combination for EUS proved inferior to sedation using propofol given by an anesthesiologist. Specifically, a midazolam/narcotic combination provided less effective intraprocedural conditions, was less efficient both before and after the procedure, and was less satisfactory to patients as compared with propofol. Results of this type of analysis can be used to drive appropriate system redesign and improve patient care.

Combined sedation with midazolam/propofol for gastrointestinal endoscopy in elderly patients

Background

Although gastrointestinal endoscopy with sedation is increasingly performed in elderly patients, data on combined sedation with midazolam/propofol are very limited for this age group.

Methods

We retrospectively analyzed 454 endoscopic procedures in 347 hospitalized patients ≥ 70 years who had received combined sedation with midazolam/propofol. 513 endoscopic procedures in 397 hospitalized patients < 70 years during the observation period served as controls. Characteristics of endoscopic procedures, co-morbidity, complications and mortality were compared.

Results

Elderly patients had a higher level of co-morbidity and needed lower mean propofol doses for sedation. We observed no major complication and no difference in the number of minor complications. The procedure-associated mortality was 0%; the 28-day mortality was significantly higher in the elderly (2.9% vs. 1.0%).

Conclusions

In this study on elderly patients with high level co-morbidity, a favourable safety profile was observed for a combined sedation with midazolam/propofol with a higher sensitivity to propofol in the elderly.