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Huang B, Li NP, Tan GK, Liang N. Effectiveness and safety of remimazolam combined with alfentanil in hysteroscopic examination: A prospective, randomized, single-blind trial. Medicine (Baltimore) 2024; 103:e37627. [PMID: 38608088 PMCID: PMC11018237 DOI: 10.1097/md.0000000000037627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Accepted: 02/26/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Remimazolam is a novel, ultrashort-acting benzodiazepine. This study aimed to compare the efficacy and safety of remimazolam and propofol for hysteroscopic examination, to determine the optimal dose of remimazolam combined with alfentanil for painless hysteroscopy, and to calculate its median effective dose (ED50). METHODS Step 1: A total of 208 patients undergoing hysteroscopic examination were prospectively included in this study. Patients were randomized into 4 groups: 0.2 mg/kg remimazolam (group A), 0.25 mg/kg remimazolam besylate (group B), 0.3 mg/kg remimazolam (group C), and 2 mg/kg propofol (group D), with 52 patients in each group. One minute after losing consciousness, patients received an intravenous injection of alfentanil at 5 µg/kg, followed by a continuous infusion of alfentanil at 0.5 µg/kg/min. If patients showed frowning, movement, or MOAA/S > 1, sedatives were added: 0.05 mg/kg/dose of remimazolam for groups A, B, and C, and 0.5 mg/kg/dose of propofol for group D. Step 2: Dixon's up-and-down method was used to calculate the ED50 of remimazolam combined with alfentanil during hysteroscopic examination. MAIN RESULTS The sedation success rates of the remimazolam groups were 88.46%, 94.23%, and 98.08%, respectively, compared to 96.15% in the propofol group, with no significant difference (P = .175). MAP in groups A and B was higher than in group D (P < .05), and significantly higher in group C than in group D (P = .0016). SpO2 values in groups A, B, and C were higher than in group D at T2 to T3 (P < .001). HR in groups A, B, and C was significantly higher than in group D (P < .001). The ED50 of remimazolam combined with alfentanil in hysteroscopy was 0.244 mg/kg, 95%CI (0.195-0.22) and ED95 was 0.282 mg/kg, 95%CI (0.261-1.619). CONCLUSION In hysteroscopy, the sedative effect of remimazolam is like that of propofol, with 0.25 mg/kg remimazolam showing better safety and efficacy, and less impact on the respiratory and circulatory systems. Additionally, under the influence of alfentanil, the ED50 of remimazolam in hysteroscopy is 0.244 mg/kg, with no severe adverse reactions observed.
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Affiliation(s)
- Bei Huang
- The Affiliated Nanhua Hospital, Hengyang Medical School, University of South China, Hengyang, Hunan, China
- The Affiliated Nanhua Hospital, Department of Anesthesiology, Hengyang Medical School, University of Suth China, Hengyang, Hunan, China
| | - Nan-Ping Li
- The Affiliated Nanhua Hospital, Hengyang Medical School, University of South China, Hengyang, Hunan, China
- The Affiliated Nanhua Hospital, Department of Anesthesiology, Hengyang Medical School, University of Suth China, Hengyang, Hunan, China
| | - Gang-Kai Tan
- The Affiliated Nanhua Hospital, Hengyang Medical School, University of South China, Hengyang, Hunan, China
- The Affiliated Nanhua Hospital, Department of Anesthesiology, Hengyang Medical School, University of Suth China, Hengyang, Hunan, China
| | - Na Liang
- The Affiliated Nanhua Hospital, Department of Anesthesiology, Hengyang Medical School, University of Suth China, Hengyang, Hunan, China
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Hong JT, Park SW. Etomidate versus propofol for sedation in gastrointestinal endoscopy: A systematic review and meta-analysis of outcomes. Medicine (Baltimore) 2023; 102:e32876. [PMID: 36820568 PMCID: PMC9907930 DOI: 10.1097/md.0000000000032876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
Abstract
BACKGROUND Propofol is increasingly being used for sedation in gastrointestinal endoscopy; however, owing to its side effects, an alternative drug is needed. We aimed to compare the safety, satisfaction, and efficacy outcomes of etomidate versus propofol in patients undergoing gastrointestinal endoscopy, including advanced endoscopic procedures. METHODS We systematically searched Embase, PubMed, Cochrane Central Register of Controlled Trials, CINAHL (via EBSCO), China National Knowledge Infrastructure, and Web of Science (1946-April 2020) databases for randomized controlled trials of gastrointestinal endoscopy (upper gastrointestinal endoscopy, colonoscopy, and advanced endoscopy) using etomidate or propofol as sedatives. We pooled odds ratios (ORs) for the safety profile and patient and anesthesiologist satisfaction using mixed-effects conditional logistic models and standardized mean differences for efficiency outcomes using random-effects models. RESULTS Twenty-four studies involving 3875 patients were included. Compared with propofol, etomidate resulted in significantly reduced apnea (OR: 0.22; 95% confidence interval [CI]: 0.13-0.37; P < .001), hypoxemia (OR: 0.43; 95% CI: 0.35-0.54; P < .001), hypotension (OR: 0.20; 95% CI: 0.11-0.36; P < .001), and bradycardia (OR: 0.52; 95% CI: 0.30-0.91; P = .02) but led to increased myoclonus (OR: 8.54; 95% CI: 5.20-14.01; P < .001) and lowered anesthesiologist satisfaction (OR: 0.60; 95% CI: 0.39-0.91; P = .02). CONCLUSION Etomidate may be a good alternative to propofol for gastrointestinal endoscopy, especially advanced endoscopy. Etomidate appears to be safe as an inducer for hemodynamically unstable patients or older adult patients undergoing gastrointestinal endoscopy.
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Affiliation(s)
- Ji Taek Hong
- Department of Internal Medicine, Ewha Woman’s University College of Medicine, Seoul, Korea
- * Correspondence: Ji Taek Hong, Department of Internal Medicine, Ewha Woman’s University College of Medicine, Seoul 07985, Korea (e-mail: )
| | - Sung-Wook Park
- Department of Internal Medicine, Nasaret International Hospital, Incheon, Korea
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Lee JM, Park Y, Park JM, Park HJ, Bae JY, Seo SY, Lee JH, Chon HK, Chung JW, Choi HH, Lee JK, Kim BW. New sedatives and analgesic drugs for gastrointestinal endoscopic procedures. Clin Endosc 2022; 55:581-587. [PMID: 36031764 PMCID: PMC9539299 DOI: 10.5946/ce.2021.283] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 03/02/2022] [Indexed: 11/25/2022] Open
Abstract
Procedural sedation has become increasingly common in endoscopy. Sedatives and analgesics induce anxiolysis and amnesia. In addition, an appropriate level of sedation is necessary for safe procedures including therapeutic endoscopy. Midazolam and propofol are the most commonly used drugs in sedative endoscopy. In recent years, the need to ascertain the safety and effectiveness of sedation has increased in practice. Therefore, new sedatives and analgesic drugs for optimal sedative endoscopy, have recently emerged. This article reviews the characteristics of sedatives and analgesics, and describes their clinical use in gastrointestinal endoscopy.
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Affiliation(s)
- Jae Min Lee
- Department of Internal Medicine, Korea University Anam Hospital, Seoul, Korea
| | - Yehyun Park
- Department of Internal Medicine, Ewha Womans University Seoul Hospital, Seoul, Korea
| | - Jin Myung Park
- Department of Internal Medicine, Kangwon National University Hospital, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Hong Jun Park
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jun Yong Bae
- Department of Internal Medicine and Digestive Disease Center, Seoul Medical Center, Seoul, Korea
| | - Seung Young Seo
- Department of Internal Medicine and Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Korea
| | - Jee Hyun Lee
- Department of Pediatrics, Seoul Metropolitan Children's Hospital, Seoul, Korea
| | - Hyung Ku Chon
- Department of Internal Medicine, Wonkwang University Hospital, Wonkwang University School of Medicine, Iksan, Korea
| | - Jun-Won Chung
- Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Hyun Ho Choi
- Department of Internal Medicine, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea
| | - Jun Kyu Lee
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Byung-Wook Kim
- Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
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Sneyd JR, Absalom AR, Barends CRM, Jones JB. Hypotension during propofol sedation for colonoscopy: an exploratory analysis. Br J Anaesth 2021; 128:610-622. [PMID: 34916051 PMCID: PMC9008870 DOI: 10.1016/j.bja.2021.10.044] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 10/11/2021] [Accepted: 10/17/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Intraoperative and postoperative hypotension occur commonly and are associated with organ injury and poor outcomes. Changes in arterial blood pressure (BP) during procedural sedation are not well described. METHODS Individual patient data from five trials of propofol sedation for colonoscopy and a clinical database were pooled and explored with logistic and linear regression. A literature search and focused meta-analysis compared the incidence of hypotension with propofol and alternative forms of procedural sedation. Hypotensive episodes were characterised by the original authors' definitions (typically systolic BP <90 mm Hg). RESULTS In pooled individual patient data (n=939), 36% of procedures were associated with episodes of hypotension. Longer periods of propofol sedation and larger propofol doses were associated with longer-lasting and more-profound hypotension. Amongst 380 patients for whom individual BP measurements were available, 107 (28%) experienced systolic BP <90 mm Hg for >5 min, and in 89 (23%) the episodes exceeded 10 min. Meta-analysis of 18 RCTs identified an increased risk ratio for the development of hypotension in procedures where propofol was used compared with the use of etomidate (two studies; n=260; risk ratio [RR] 2.0 [95% confidence interval: 1.37-2.92]; P=0.0003), remimazolam (one study; n=384; RR 2.15 [1.61-2.87]; P=0.0001), midazolam (14 studies; n=2218; RR 1.46 [1.18-1.79]; P=0.0004), or all benzodiazepines (15 studies; n=2602; 1.67 [1.41-1.98]; P<0.00001). Hypotension was less likely with propofol than with dexmedetomidine (one study; n=60; RR 0.24 [0.09-0.62]; P=0.003). CONCLUSIONS Hypotension is common during propofol sedation for colonoscopy and of a magnitude and duration associated with harm in surgical patients.
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Affiliation(s)
- J Robert Sneyd
- Faculty of Medicine and Dentistry, University of Plymouth, Plymouth, UK.
| | - Anthony R Absalom
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Clemens R M Barends
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Jordan B Jones
- College of Osteopathic Medicine, Rocky Vista University, Ivins, UT, USA
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Liu X, Ding B, Shi F, Zhang Y, Liu L, Sha Y, Zhao T. The Efficacy and Safety of Remimazolam Tosilate versus Etomidate-Propofol in Elderly Outpatients Undergoing Colonoscopy: A Prospective, Randomized, Single-Blind, Non-Inferiority Trial. Drug Des Devel Ther 2021; 15:4675-4685. [PMID: 34819721 PMCID: PMC8606755 DOI: 10.2147/dddt.s339535] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 11/07/2021] [Indexed: 02/02/2023] Open
Abstract
Objective The optimal sedation regime during endoscopy remains controversial, especially for elderly outpatients. In this study, we compared the efficacy and safety between remimazolam tosilate (RT) and etomidate-propofol (EP) in elderly outpatients undergoing colonoscopy. Methods A total of 260 elderly outpatients undergoing sedative colonoscopy were randomized into two groups. Patients in the RT group received a 0.075-mg/kg maintenance dose of remimazolam following an initial dose of 0.15 mg/kg, whereas patients in the EP group (10 mL:20 mg etomidate plus 10 mL:100 mg propofol) received a 0.05-mL/kg maintenance dose following an initial dose of 0.1 mL/kg to maintain a Modified Observer’s Assessment of Alertness/Sedation score of ≤3 during the procedure. The primary endpoint was the success of the procedure. Secondary endpoints included time metrics, hemodynamics, consumption of fentanyl, etomidate, propofol, and remimazolam, intraoperative body movement, patient and endoscopist satisfaction scores, supplemental dose of sedative and fentanyl, and incidence and severity of adverse events. Results The procedure success rate was 96.52% in the RT group and 100% in the EP group. The difference in procedure success rate between the RT and EP groups was −3.48% (95% confidence interval: −6.81%, −0.15%). Four patients in the RT group required rescue midazolam. Compared with patients in the RT group, the onset time of the EP group was significantly lower (p < 0.05), whereas time to fully alert (p = 0.001), ready for discharge (p = 0.001), and hospital discharge (p = 0.002) were all significantly higher in the EP group. However, there were no significant differences in procedure time (p = 0.846) or cecal intubation time (p = 0.320) between the two groups. Although the frequency of intraoperative body movement was higher in the RT group, the difference was not significant (p = 0.508). There were no significant differences in patients’ demographic and baseline characteristics, supplemental doses of sedative and fentanyl, or patient and endoscopist satisfaction scores (p > 0.05). Muscular tremor and pain on injection were recorded more frequently in the EP group (p < 0.05). However, there were no significant differences in hypoxia, respiratory depression, or incidence of postoperative nausea and vomiting. The severity of adverse events was all mild (grade 1) across both groups. Conclusion RT may have non-inferior efficacy and a higher safety profile than EP in elderly outpatients undergoing colonoscopy, which suggests that RT may be more suitable for elderly outpatients undergoing colonoscopy.
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Affiliation(s)
- Xianwen Liu
- Department of Anaesthesiology, Liaocheng People's Hospital, Liaocheng, Shandong, People's Republic of China
| | - Baofeng Ding
- Department of Anaesthesiology, Liaocheng Second People's Hospital, Liaocheng, Shandong, People's Republic of China
| | - Fu Shi
- Department of Anaesthesiology, Liaocheng People's Hospital, Liaocheng, Shandong, People's Republic of China
| | - Yang Zhang
- Department of Anaesthesiology, Liaocheng People's Hospital, Liaocheng, Shandong, People's Republic of China
| | - Lei Liu
- Department of Anaesthesiology, Liaocheng People's Hospital, Liaocheng, Shandong, People's Republic of China
| | - Yongwei Sha
- Department of Anaesthesiology, Guanxian Central Hospital, Liaocheng, Shandong, People's Republic of China
| | - Tonghang Zhao
- Department of Anaesthesiology, Liaocheng People's Hospital, Liaocheng, Shandong, People's Republic of China
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Jung JH, Hyun B, Lee J, Koh DH, Kim JH, Park SW. Neurologic Safety of Etomidate-Based Sedation during Upper Endoscopy in Patients with Liver Cirrhosis Compared with Propofol: A Double-Blind, Randomized Controlled Trial. J Clin Med 2020; 9:jcm9082424. [PMID: 32751161 PMCID: PMC7466000 DOI: 10.3390/jcm9082424] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 07/17/2020] [Accepted: 07/24/2020] [Indexed: 12/12/2022] Open
Abstract
(1) Background: Although etomidate-based sedation is an effective and safe protocol in endoscopic procedures, there is a lack of evidence regarding the safety of etomidate in patients with liver cirrhosis (LC). This study aimed to compare the neurologic safety and efficacy of etomidate and propofol for endoscopic sedation in patients with LC. (2) Methods: From December 2017 to December 2019, consecutive cirrhotic patients who underwent sedative endoscopy using either etomidate or propofol were randomly recruited. The primary endpoint was the number connection test (NCT), and the secondary endpoints included factors for the safety of sedatives during endoscopy. (3) Results: 63 patients were enrolled in each of the etomidate and propofol groups. The NCT times were significantly lower in the etomidate group than in the propofol group. Furthermore, severe or very severe degree of encephalopathy was higher in the propofol group but was not significantly different. Pharmacological properties and the overall incidence of respiratory and cardiovascular events did not differ significantly between the groups. (4) Conclusion: Etomidate-based sedation exacerbates neither subclinical nor overt hepatic encephalopathy. It guarantees efficacies similar to those of propofol regarding rapid sedation, fast recovery, and early discharge, with no increased risk of adverse respiratory or cardiovascular events in patients with LC.
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Lee JM, Min G, Keum B, Lee JM, Kim SH, Choi HS, Kim ES, Seo YS, Jeen YT, Chun HJ, Lee HS, Um SH, Kim CD. Using Etomidate and Midazolam for Screening Colonoscopies Results in More Stable Hemodynamic Responses in Patients of All Ages. Gut Liver 2020; 13:649-657. [PMID: 30970436 PMCID: PMC6860030 DOI: 10.5009/gnl18514] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 12/27/2018] [Accepted: 01/03/2019] [Indexed: 12/16/2022] Open
Abstract
Background/Aims Recent studies have demonstrated that etomidate is a safe sedative drug with noninferior sedative effects. In our recent study, we revealed that etomidate/midazolam was more hemodynamically stable than propofol/midazolam in elderly patients undergoing colonoscopies. We aimed to investigate whether compared with propofol/midazolam, etomidate/midazolam causes fewer cardiopulmonary adverse events with noninferior efficacy for screening colonoscopies in patients of all ages. Methods In this single-center, randomized, double-blind study, we prospectively enrolled 200 patients. The patients were divided into etomidate and propofol groups. The primary outcome was the occurrence of cardiopulmonary adverse events. The secondary outcomes were the proportion of patients with fluctuations in vital signs (oxygen desaturation and transient hypotension), adverse events interrupting the procedure, and sedation-related outcomes. Results Adverse cardiopulmonary events were more common in the propofol group than the etomidate group (65.0% vs 51.0%, respectively; p=0.045). Forty-six patients (46.0%) in the propofol group and 29 (29.0%) in the etomidate group experienced fluctuations in their vital signs (p=0.013). The proportions of patients experiencing adverse events that interrupted the procedure, including myoclonus, were not significantly different between the two groups (etomidate: 20.0% vs propofol: 11.0%; p=0.079). Both groups had similar sedation-related outcomes. Multivariate analysis revealed that compared with the propofol groups, the etomidate group had a significantly lower risk of fluctuations in vital signs (odds ratio, 0.427; 95% confidence interval, 0.230 to 0.792; p=0.007). Conclusions Compared with using propofol/midazolam, using etomidate/midazolam for screening colonoscopies results in more stable hemodynamic responses in patients of all ages; therefore, we recommend using etomidate/midazolam for colonoscopies in patients with cardiovascular risk factors.
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Affiliation(s)
- Jung Min Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Wonkwang University Sanbon Medical Center, Gunpo, Korea.,Division of Gastroenterology and Hepatology, Department of Internal Medicine, Institute of Digestive Disease and Nutrition, Korea University Anam Hospital, Seoul, Korea
| | - Geeho Min
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Institute of Digestive Disease and Nutrition, Korea University Anam Hospital, Seoul, Korea
| | - Bora Keum
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Institute of Digestive Disease and Nutrition, Korea University Anam Hospital, Seoul, Korea
| | - Jae Min Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Institute of Digestive Disease and Nutrition, Korea University Anam Hospital, Seoul, Korea
| | - Seung Han Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Institute of Digestive Disease and Nutrition, Korea University Anam Hospital, Seoul, Korea
| | - Hyuk Soon Choi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Institute of Digestive Disease and Nutrition, Korea University Anam Hospital, Seoul, Korea
| | - Eun Sun Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Institute of Digestive Disease and Nutrition, Korea University Anam Hospital, Seoul, Korea
| | - Yeon Seok Seo
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Institute of Digestive Disease and Nutrition, Korea University Anam Hospital, Seoul, Korea
| | - Yoon Tae Jeen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Institute of Digestive Disease and Nutrition, Korea University Anam Hospital, Seoul, Korea
| | - Hoon Jai Chun
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Institute of Digestive Disease and Nutrition, Korea University Anam Hospital, Seoul, Korea
| | - Hong Sik Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Institute of Digestive Disease and Nutrition, Korea University Anam Hospital, Seoul, Korea
| | - Soon Ho Um
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Institute of Digestive Disease and Nutrition, Korea University Anam Hospital, Seoul, Korea
| | - Chang Duck Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Institute of Digestive Disease and Nutrition, Korea University Anam Hospital, Seoul, Korea
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Yoldas H, Yildiz I, Karagoz I, Sit M, Ogun MN, Demirhan A, Bilgi M. Effects of Bispectral Index-controlled Use of Magnesium on Propofol Consumption and Sedation Level in Patients Undergoing Colonoscopy. Medeni Med J 2019; 34:380-386. [PMID: 32821465 PMCID: PMC7433725 DOI: 10.5222/mmj.2019.99705] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 11/10/2019] [Indexed: 12/16/2022] Open
Abstract
Objective The aim of this study is to investigate the effects of bispectral index-controlled use of magnesium on propofol consumption, periprocedural hemodynamic response and patient comfort. Material A total of 60 patients were enrolled in the study. In Group 1 (magnesium), a single dose 50 mg/kg magnesium sulfate diluted with 100 mL 0.9% NaCl was administered 10 minutes before the beginning of the procedure. Initially bolus dose of 0.5 mg/kg propofol was applied. The maintenance dose of propofol was 60 mcg/kg/min. During the procedure, the propofol infusion was increased by titration until the bispectral index (BIS) value of 70 was achieved. In Group 2 (saline), 100 ml 0.9% NaCl was administered 10 minutes before the beginning of the procedure. The bolus and maintenance doses of propofol, and target BIS values were the same as those in Group 1. Results When BIS values were compared between the groups, the initial BIS values in the magnesium group (Group 1) were significantly higher than those of the saline group (Group 2) (p<0.05). The time to reach BIS 70 was significantly shorter in the magnesium group (p<0.05). Propofol consumption was greater in Group 2 than in Group 1 (p<0.05). The time to reach BIS 70 was significantly shorter in Group 1 (p<0.05). No significant difference was found between the groups in terms of patient- and endoscopist-satisfaction (p<0.05). Conclusion The use of magnesium in addition to propofol may be an efficient and reliable option to reduce the drug consumption during colonoscopic interventions.
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Affiliation(s)
- Hamit Yoldas
- Bolu Abant Izzet Baysal University Faculty of Medicine, Department of Anesthesiology and Reanimation, Bolu, Turkey
| | - Isa Yildiz
- Bolu Abant Izzet Baysal University Faculty of Medicine, Department of Anesthesiology and Reanimation, Bolu, Turkey
| | - Ibrahim Karagoz
- Bolu Abant Izzet Baysal University Faculty of Medicine, Department of Anesthesiology and Reanimation, Bolu, Turkey
| | - Mustafa Sit
- Bolu Abant Izzet Baysal University Faculty of Medicine, Department of General Surgery, Bolu, Turkey
| | - Muhammed Nur Ogun
- Bolu Abant Izzet Baysal University Faculty of Medicine, Department of Neurology, Bolu, Turkey
| | - Abdullah Demirhan
- Bolu Abant Izzet Baysal University Faculty of Medicine, Department of Anesthesiology and Reanimation, Bolu, Turkey
| | - Murat Bilgi
- Bolu Abant Izzet Baysal University Faculty of Medicine, Department of Anesthesiology and Reanimation, Bolu, Turkey
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Adinehmehr L, Shetabi H, Moradi Farsani D, Salehi A, Noorbakhsh M. Comparison of the Sedation Quality of Etomidate, Propofol, and Midazolam in Combination with Fentanyl During Phacoemulsification Cataract Surgery: A Double-Blind, Randomized, Controlled, Clinical Trial. Anesth Pain Med 2019; 9:e87415. [PMID: 31341824 PMCID: PMC6616865 DOI: 10.5812/aapm.87415] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 03/23/2019] [Accepted: 03/28/2019] [Indexed: 02/06/2023] Open
Abstract
Background According to the favorable effects of combination therapy to provide better sedation during phacoemulsification and lack of any studies investigating the sedative effect of etomidate, propofol, and midazolam in combination with fentanyl during the procedure. Objectives The current study aimed at comparing the sedative properties of the mentioned three combination therapies in this field. Methods The current double-blind, randomized, controlled clinical trial was conducted on patients referred for elective phacoemulsification surgery under sedation. They were randomly allocated to the three groups to receive fentanyl plus one of the following medications: Propofol, midazolam, and etomidate. Demographic characteristics, medical condition, and hemodynamic parameters before, during, and after surgery, sedation level, anesthetic complications, sedation-related adverse events, and patients' and surgeons' satisfaction were evaluated and recorded by the anesthesiologist and compared in the three studied groups. Results In the current study, out of 150 enrolled patients, 98 completed the study. Frequency of different levels of Ramsay scores was not significantly different between the groups (P = 0.41). Frequency of Ramsay scores 3 and 4 was 92%, 79.4%, and 88.2% in etomidate, midazolam and propofol groups, respectively (P = 0.32). The median recovery time was significantly higher in the midazolam group than the propofol group (P = 0.04); intergroup comparisons indicated that the patients' mean score of satisfaction in the propofol group was significantly higher than that of the etomidate group (P = 0.006). Conclusions The current study findings indicated that though the quality of sedation during phacoemulsification cataract surgery was acceptable in the three agents and the results had no significantly differences among the groups, and considering other factors including recovery time, hemodynamic evaluation, sedation-related complications, and patients' satisfication scores, it is suggested that propofol was superior to the other two agents.
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Affiliation(s)
- Leili Adinehmehr
- Anesthesiology and Critical Care Department, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hamidreza Shetabi
- Anesthesiology and Critical Care Department, Isfahan University of Medical Sciences, Isfahan, Iran
- Corresponding Author: Anesthesiology Department, Al Zahra Medical Center, Isfahan University of Medical Sciences, Sofeh Blvd., Isfahan, Iran.
| | - Darioush Moradi Farsani
- Anesthesiology and Critical Care Department, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ali Salehi
- Ophthalmology Department, Isfahan University of Medical Sciences, Isfahan, Iran
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Han SJ, Lee TH, Yang JK, Cho YS, Jung Y, Chung IK, Park SH, Park S, Kim SJ. Etomidate Sedation for Advanced Endoscopic Procedures. Dig Dis Sci 2019; 64:144-151. [PMID: 30054843 DOI: 10.1007/s10620-018-5220-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 07/18/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND STUDY AIM Although propofol is widely used for sedation for endoscopic procedures, concerns remain regarding cardiopulmonary adverse events. Etomidate has little effect on the cardiovascular and respiratory systems, but patient satisfaction analysis is lacking. We compared the efficacy and safety of balanced propofol and etomidate sedation during advanced endoscopic procedures. METHODS As a randomized noninferiority trial, balanced endoscopic sedation was achieved using midazolam and fentanyl, and patients were randomly assigned to receive propofol (BPS) or etomidate (BES) as add-on drug. The main outcomes were sedation efficacy measured on a 10-point visual analog scale (VAS) and safety. RESULTS In total, 186 patients (94 in the BPS group and 92 in the BES group) were evaluated. BES did not show noninferiority in terms of overall patient satisfaction, with a difference in VAS score of -0.35 (97.5 % confidence interval -1.03 to ∞, p = 0.03). Among endoscopists and nurses, BES showed noninferiority to BPS, with differences in VAS scores of 0.06 and 0.08, respectively. Incidence of cardiopulmonary adverse events was lower in the BES group (27.7 versus 14.1 %, p = 0.023). Hypoxia occurred in 5.3 and 1.1 % of patients in the BPS and BES group (p = 0.211). Myoclonus occurred in 12.1 % (11/92) in the BES group. BES had lower risk of overall cardiopulmonary adverse events (odds ratio 0.401, p = 0.018). CONCLUSIONS BES was not noninferior to BPS in terms of patient satisfaction. However, BES showed better safety outcomes in terms of cardiopulmonary adverse events.
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Affiliation(s)
- Su Jung Han
- Division of Gastroenterology, Department of Internal Medicine, Digestive Disease Center, Cheonan Hospital, Soonchunhyang University School of Medicine, 31, Sooncheonhyang 6-gil, Dongnam-gu, Cheonan-si, Chungcheongnam-do, 31151, Republic of Korea
| | - Tae Hoon Lee
- Division of Gastroenterology, Department of Internal Medicine, Digestive Disease Center, Cheonan Hospital, Soonchunhyang University School of Medicine, 31, Sooncheonhyang 6-gil, Dongnam-gu, Cheonan-si, Chungcheongnam-do, 31151, Republic of Korea.
| | - Jae Kook Yang
- Division of Gastroenterology, Department of Internal Medicine, Digestive Disease Center, Cheonan Hospital, Soonchunhyang University School of Medicine, 31, Sooncheonhyang 6-gil, Dongnam-gu, Cheonan-si, Chungcheongnam-do, 31151, Republic of Korea
| | - Young Sin Cho
- Division of Gastroenterology, Department of Internal Medicine, Digestive Disease Center, Cheonan Hospital, Soonchunhyang University School of Medicine, 31, Sooncheonhyang 6-gil, Dongnam-gu, Cheonan-si, Chungcheongnam-do, 31151, Republic of Korea
| | - Yunho Jung
- Division of Gastroenterology, Department of Internal Medicine, Digestive Disease Center, Cheonan Hospital, Soonchunhyang University School of Medicine, 31, Sooncheonhyang 6-gil, Dongnam-gu, Cheonan-si, Chungcheongnam-do, 31151, Republic of Korea
| | - Il-Kwun Chung
- Division of Gastroenterology, Department of Internal Medicine, Digestive Disease Center, Cheonan Hospital, Soonchunhyang University School of Medicine, 31, Sooncheonhyang 6-gil, Dongnam-gu, Cheonan-si, Chungcheongnam-do, 31151, Republic of Korea
| | - Sang-Heum Park
- Division of Gastroenterology, Department of Internal Medicine, Digestive Disease Center, Cheonan Hospital, Soonchunhyang University School of Medicine, 31, Sooncheonhyang 6-gil, Dongnam-gu, Cheonan-si, Chungcheongnam-do, 31151, Republic of Korea
| | - Suyeon Park
- Department of Statistics, Soonchunhyang University School of Medicine, Seoul, Republic of Korea
| | - Sun-Joo Kim
- Division of Gastroenterology, Department of Internal Medicine, Digestive Disease Center, Cheonan Hospital, Soonchunhyang University School of Medicine, 31, Sooncheonhyang 6-gil, Dongnam-gu, Cheonan-si, Chungcheongnam-do, 31151, Republic of Korea
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Choi GJ, Kang H, Baek CW, Jung YH, Ko JS. Etomidate versus propofol sedation for electrical external cardioversion: a meta-analysis. Curr Med Res Opin 2018; 34:2023-2029. [PMID: 30175627 DOI: 10.1080/03007995.2018.1519501] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To compare the efficacy and safety of etomidate vs propofol sedation for electrical cardioversion. METHODS The authors searched the MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials, Google Scholar, Koreamed, and KMBASE databases to identify all randomized controlled trials that compared etomidate and propofol sedation for cardioversion in adult patients. Induction and recovery time, success rate, number of shocks, and cumulative energy were evaluated. Adverse effects, including respiratory and cardiovascular complications, myoclonus, and nausea and vomiting, were also assessed. RESULTS A total of nine studies, involving a total of 430 patients, were included. Induction and recovery time, success rate, number of shocks, and cumulative energy were similar. The incidences of hypotension and respiratory depression were significantly higher in the propofol group than in the etomidate group (risk ratio [RR] = 0.11, 95% confidence interval (CI) = 0.02-0.74, I2 = 0%; RR = 0.50, 95% CI = 0.32-0.77, I2 = 47%, respectively). The incidences of myoclonus and nausea or vomiting were significantly higher in the etomidate group than in the propofol group (RR = 8.89, 95% CI = 4.59-17.23, I2 = 9%; RR = 5.13, 95% CI = 1.72-15.31, I2 = 31%, respectively). CONCLUSIONS Issues affecting efficacy, including induction and recovery time, success rate, number of shocks, and cumulative energy, were comparable between etomidate and propofol sedation. Regarding safety issues, propofol sedation resulted in hypotension and respiratory depression more frequently; however, initiation of positive pressure ventilation was comparable. Etomidate sedation caused myoclonus and nausea or vomiting more frequently.
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Affiliation(s)
- Geun Joo Choi
- a Department of Anesthesiology and Pain Medicine , Chung-Ang University College of Medicine , Seoul , Republic of Korea
| | - Hyun Kang
- a Department of Anesthesiology and Pain Medicine , Chung-Ang University College of Medicine , Seoul , Republic of Korea
| | - Chong Wha Baek
- a Department of Anesthesiology and Pain Medicine , Chung-Ang University College of Medicine , Seoul , Republic of Korea
| | - Yong Hun Jung
- a Department of Anesthesiology and Pain Medicine , Chung-Ang University College of Medicine , Seoul , Republic of Korea
| | - Jin Soo Ko
- b Department of Plastic Surgery , National Police Hospital , Seoul , Korea
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Efficacy and safety of etomidate-based sedation compared with propofol-based sedation during ERCP in low-risk patients: a double-blind, randomized, noninferiority trial. Gastrointest Endosc 2018; 87:174-184. [PMID: 28610897 DOI: 10.1016/j.gie.2017.05.050] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 05/25/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Etomidate is a short-acting intravenous hypnotic with a safety profile that is superior to alternative drugs such as propofol. However, there is a lack of evidence on the safety of etomidate in ERCP. The objective of this study was to compare efficacy and safety profiles of etomidate and propofol for endoscopic sedation. METHODS This single-center, randomized, double-blind, noninferiority trial included patients with American Society of Anesthesiologists (ASA) physical status I to II who had been scheduled for ERCP. All patients received .05 mg/kg midazolam intravenously as pretreatment before receiving etomidate or propofol. Either etomidate or propofol was then administered according to group allocation. The primary endpoint was an overall respiratory event. A noninferiority margin of 10% was assumed. RESULTS Sixty-three and 64 patients were enrolled in the etomidate and propofol groups, respectively. Respiratory events were identified in 10 patients (15.6%) in the etomidate group and 16 patients (25.4%) on the propofol group, with a rate difference of -9.8% (1-sided 97.5% confidence interval, -∞ to 4.2%). The overall incidence of cardiovascular events tended to be higher in the etomidate group (67.2% vs 50.8%, P = .060). In particular, tachycardia (heart rate > 100 beats/min) was more common in the etomidate group than in the propofol group (64.1% vs 34.9%, P = .001). Transient hypotension tended to be less common in the etomidate group (6.3 vs 15.9%, P = .084). CONCLUSIONS Etomidate-based sedation during ERCP was noninferior to propofol-based sedation in terms of the overall incidence of respiratory events in patients with ASA physical status I to II. (International Clinical Trials Registry Platform number: KCT0001926.).
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Kim MG, Park SW, Kim JH, Lee J, Kae SH, Jang HJ, Koh DH, Choi MH. Etomidate versus propofol sedation for complex upper endoscopic procedures: a prospective double-blinded randomized controlled trial. Gastrointest Endosc 2017; 86:452-461. [PMID: 28284883 DOI: 10.1016/j.gie.2017.02.033] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 02/23/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Although a growing body of evidence demonstrates that propofol-induced deep sedation can be effective and performed safely, cardiopulmonary adverse events have been observed frequently. Etomidate is a new emerging drug that provides hemodynamic and respiratory stability, even in high-risk patient groups. The objective of this study was to compare safety and efficacy profiles of etomidate and propofol for endoscopic sedation. METHODS A total of 128 patients undergoing EUS were randomized to receive either etomidate or propofol blinded administered by a registered nurse. The primary outcome was the proportion of patients with any cardiopulmonary adverse events. RESULTS Overall cardiopulmonary adverse events were identified in 22 patients (34.38%) of the etomidate group and 33 patients (51.56%) of the propofol group, without significant difference (P = .074). However, the incidence of oxygen desaturation (4/64 [6.25%] vs 20/64 [31.25%]; P =.001) and respiratory depression (5/64 [7.81%] vs 21/64 [32.81%]; P =.001) was significantly lower in the etomidate group than in the propofol group. The frequency of myoclonus was significantly higher in the etomidate group (22/64 [34.37%]) compared with the propofol group (8/64 [12.50%]) (P =.012). Repeated measure analysis of variance revealed significant effects of sedation group and time on systolic blood pressure (etomidate group greater than propofol group). Physician satisfaction was greater in the etomidate group than in the propofol group. CONCLUSIONS Etomidate administration resulted in fewer respiratory depression events and had a better sedative efficacy than propofol; however, it was more frequently associated with myoclonus and increased blood pressure during endoscopic procedures. (Clinical trial registration number: KCT0001701.).
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Affiliation(s)
- Mi Gang Kim
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
| | - Se Woo Park
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
| | - Jae Hyun Kim
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
| | - Jin Lee
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
| | - Sea Hyub Kae
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
| | - Hyun Joo Jang
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
| | - Dong Hee Koh
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
| | - Min Ho Choi
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
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Vargo JJ. Etomidate: Coming to an endoscopy unit near you? Gastrointest Endosc 2017; 86:462-463. [PMID: 28826547 DOI: 10.1016/j.gie.2017.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 04/09/2017] [Indexed: 02/08/2023]
Affiliation(s)
- John J Vargo
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio, USA
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Shen Y, Cai MH, Ji W, Bai J, Huang Y, Sun Y, Lin L, Niu J, Zhang MZ. Unrepaired Tetralogy of Fallot-related Pathophysiologic Changes Reduce Systemic Clearance of Etomidate in Children. Anesth Analg 2017; 123:722-30. [PMID: 27537760 DOI: 10.1213/ane.0000000000001477] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Pathophysiologic changes in children with congenital heart disease may alter the effect of drugs by influencing the pharmacokinetics (PK). Considering the limited literature that describes the PK of etomidate in pediatric patients, especially in those with tetralogy of Fallot (TOF), our aim was to characterize the PK of etomidate and explore the effects of TOF. METHODS Twenty-nine pediatric patients (15 with TOF and 14 with normal cardiac anatomy) scheduled to undergo elective surgery under general anesthesia were recruited in the study. All children received etomidate 60 μg/kg/min intravenously until a bispectral index of ≤50 was reached for 5 seconds during anesthesia induction. Arterial blood samples were drawn and analyzed. Population analysis was performed by using NONMEM to define PK characteristics. The estimates were standardized to a 70-kg adult using a per-kilogram model. RESULTS Data consisting of 244 samples from 29 children with a mean age of 236 days (range, 86-360 days) were used, including a TOF group with a mean age of 250 days (range, 165-360 days) and a normal cardiac anatomy group with a mean age of 221 days (range, 86-360 days). A 3-compartment disposition model was best fitted to describe the PK of etomidate. The introduction of TOF as a covariate for systemic clearance (Cl1) improved the model and resulted in a significant reduction of objective function (Δobjective function = -7.33; P = .0068), which means that TOF was a significant covariate of Cl1, and the etomidate Cl1 in children with TOF (1.67 × (weight [WT]/70 kg) L/min) was lower than those with normal cardiac anatomy (2.28 × (WT/70 kg) L/min). Other PK parameter values were as follows: V1 = 8.05 × (WT/70 kg) L; V2 = 13.7 × (WT/70 kg) L; V3 = 41.3 × (WT/70 kg) L; Cl2 = 3.35 × (WT/70 kg) L/min; Cl3 = 0.563 × (WT/70 kg) L/min. CONCLUSIONS A decreased systemic clearance for etomidate in children with TOF resulted in a lower required infusion rate and variation with time to achieve the same plasma concentration and maintain an equivalent target concentration or have longer sedation and recovery times after bolus or continuous infusion than normal children.
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Affiliation(s)
- Yang Shen
- From the *Pediatric Clinical Pharmacology Laboratory, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China; and †Department of Anesthesiology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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The Comparison of Etomidate and Propofol Anesthesia in Patients Undergoing Gastrointestinal Endoscopy: A Systematic Review and Meta-Analysis. Surg Laparosc Endosc Percutan Tech 2017; 27:1-7. [PMID: 28079763 DOI: 10.1097/sle.0000000000000373] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Etomidate and propofol played an important role in the sedation of patients undergoing gastrointestinal endoscopy. We conducted a systematic review and meta-analysis to compare their efficacy and safety. MATERIALS AND METHODS PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases were systematically searched. Randomized controlled trials assessing the effect of etomidate versus propofol for the anesthesia of patients undergoing gastrointestinal endoscopy were included. Two investigators independently searched articles, extracted data, and assessed the quality of included studies. The primary outcomes were anesthesia duration and recovery time. Meta-analysis was performed using random-effect model. RESULTS Six randomized controlled trials involving 1115 patients were included in the meta-analysis. Overall, compared with propofol, etomidate resulted in comparable anesthesia duration [standard mean difference (Std. MD)=-0.03; 95% confidence interval (CI), -0.16 to 0.10; P=0.66], recovery time (Std. MD=0.25; 95% CI, -0.42 to 0.92; P=0.47), mean arterial pressure at intubation (Std. MD=0.44; 95% CI, -0.26 to 1.15; P=0.21), heart pulse at intubation (Std. MD=0.93; 95% CI, -0.69 to 2.55; P=0.26), SPO2 at intubation (Std. MD=-0.52; 95% CI, -1.04 to 0.01; P=0.05), patient satisfaction [odds risk (OR)=0.42; 95% CI, 0.11-1.66; P=0.22], hypotension (OR=0.14; 95% CI, 0.02-1.22; P=0.07), changes of heart rate (OR=0.97; 95% CI, 0.61-1.53; P=0.88), nausea-vomiting (OR=2.02; 95% CI, 0.73-5.57; P=0.17), and the reduction in apnea or hyoxemia (OR=0.39; 95% CI, 0.24-0.64; P=0.0002), and injection pain (OR=0.03; 95% CI, 0.01-0.08; P<0.00001), but the increase in myoclonus (OR=8.54; 95% CI, 3.14-23.20; P<0.0001). CONCLUSIONS Between etomidate and propofol, no significant difference was revealed regarding anesthesia duration, recovery time, mean arterial pressure at intubation, heart pulse at intubation, SPO2 at intubation, patient satisfaction, hypotension, changes of heart rate and nausea-vomiting. Compared with propofol, etomidate showed reduced apnea or hyoxemia, and injection pain, but with an increased myoclonus.
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Kochhar GS, Gill A, Vargo JJ. On the Horizon: The Future of Procedural Sedation. Gastrointest Endosc Clin N Am 2016; 26:577-92. [PMID: 27372779 DOI: 10.1016/j.giec.2016.03.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Sedation plays an integral part in endoscopy. By achieving patient comfort, it allows for a better examination and enhances patient satisfaction. Various medications have been used, propofol being the current favorite. With emphasis on patient safety and quality of endoscopy, various new medications in different combinations are being used to achieve adequate sedation and not escalate the cost of the procedure. With the advent of newer medications and newer modalities to administer these medications, there is need for more specialized training for the endoscopist to feel comfortable while using these medications.
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Affiliation(s)
- Gursimran S Kochhar
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Anant Gill
- Saraswathi Institute of Medical Sciences, Anwarpur, Uttar Pradesh, India
| | - John J Vargo
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic, Cleveland Clinic Foundation, A-30, 9500 Euclid Avenue, Cleveland, OH, USA.
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Abstract
Context: Electrical cardioversion is a short painful procedure to regain normal sinus rhythm requiring anaesthesia for haemodynamic stability, sedation, analgesia and early recovery. Aims: To compare propofol and etomidate as sedatives during cardioversion. Settings and Design: Single centred, prospective and randomized single blind study comprising 60 patients. Subjects and Methods: Patients more than 18 years, American Society of Anesthesiologists I/II/III grades undergoing elective cardioversion, randomly divided to receive propofol 1 mg/kg intravenous (IV) bolus followed by 0.5 mg/kg (Group P, n = 30) or etomidate (Group E, n = 30) 0.1 mg/kg followed by 0.05 mg/kg. All patients received IV fentanyl (1 μg/kg) before procedure. Heart rate, blood pressure (BP) (systolic BP [SBP], diastolic BP [DBP], mean arterial pressure), respiratory rate, Aldrete recovery score (ARS) and Ramsay sedation score (RSS) were assessed at 1, 2, 5, 10, 15, 20 and 30 min post cardioversion. Incidence of hypotension, respiratory depression and side effects were compared. Statistical analysis used: Student's unpaired t-test, Chi-square test and Mann–Whitney test. P < 0.05 was taken as significant. Results: Group P showed significant fall in SBP, DBP, and mean BP at 2 min after cardioversion. Hypotension (33.3% Group P vs. 16.65% Group E) occurred more with propofol (P < 0.05). Group E showed better ARS at 1, 2, 5, 10, 15 and 20 min. Time required to attain RSS = 2 (659.1 s Group P and 435.7 s Group E) indicated longer recovery with propofol. Left atrial size (35.5-42.5 mm) did not affect success rate of cardioversion (80% Group P vs. 83.3% Group E). Incidence of myoclonus (Group E 26.67% vs. Group P 0%) showed significant difference. Conclusions: Etomidate/fentanyl is superior over propofol/fentanyl during cardioversion for quick recovery and haemodynamic stability.
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Affiliation(s)
- Pushkar M Desai
- Department of Anesthesiology, Seth GSMC and KEM Hospital, Parel, Mumbai, Maharashtra, India
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Zhou X, Li BX, Chen LM, Tao J, Zhang S, Ji M, Wu MC, Chen M, Zhang YH, Gan GS, Song XY. Etomidate plus propofol versus propofol alone for sedation during gastroscopy: a randomized prospective clinical trial. Surg Endosc 2016; 30:5108-5116. [DOI: 10.1007/s00464-016-4861-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 03/05/2016] [Indexed: 01/26/2023]
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Qin B, Hu H, Cao B, Zhu Z. Effects of continuous infusion of etomidate at various dose rates on adrenal function in dogs. BMC Anesthesiol 2016; 16:2. [PMID: 26743223 PMCID: PMC4705599 DOI: 10.1186/s12871-015-0171-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Accepted: 12/30/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Etomidate is a commonly used sedative in intravenous anesthesia. The aim of this study was to compare the effects of various etomidate doses administered by continuous infusion on adrenal function in dogs under general anesthesia. METHODS Thirty-six healthy adult male dogs were randomly divided into six groups. Sodium pentobarbital alone was administered to the control group (group C); five experimental groups (E1, E2, E3, E4, and E5) were also given etomidate at doses of 10, 15, 20, 25, and 30 μg · kg(-1) · min(-1), respectively, to maintain anesthesia. Heart rate (HR), mean arterial pressure (MAP), and bispectral index (BIS) were monitored. Serum cortisol, aldosterone, adrenaline, and noradrenaline levels were measured, and HR, MAP, and BIS values recorded, before intubation (T0), and at 1 h, 2 h, and 3 h after intubation (T1-3). RESULTS Cortisol and aldosterone levels in groups E1-5 decreased as the doses and times of continuous infusion of etomidate increased. The cortisol level was significantly decreased compared with baseline at T3 in group E1 and at T1-3 in groups E2-5 (P < 0.05). Compared with the corresponding levels in group C, cortisol levels were significantly lower than T0 values at T3 in group E1 and at T1-3 in groups E2-5 (P < 0.05). The aldosterone level was significantly lower at T3 in group E2 and at T1-3 in groups E3-5 (P < 0.05). Significant reductions in cortisol levels at T2-3 in group E2 and at T1-3 in groups E3-5 compared with group C were also observed (P < 0.05). The plasma adrenaline and noradrenaline levels, HR, MAP, and BIS in groups E1-5 were within the normal range at the different times and with the different doses (P > 0.05). CONCLUSIONS Cortisol and aldosterone levels decreased with time and continuous infusion of etomidate; there were no significant changes in adrenaline and noradrenaline levels, HR, MAP, and BIS in any group.
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Affiliation(s)
- Bangyong Qin
- Department of Anesthesiology, Affliated Hospital of Zunyi Medical College, No. 149 Dalian Road, Zunyi, Guizhou Province, 563003, China.
| | - Hongzhuan Hu
- Department of Anesthesiology, Affliated Hospital of Zunyi Medical College, No. 149 Dalian Road, Zunyi, Guizhou Province, 563003, China
| | - Baofeng Cao
- Department of Anesthesiology, Affliated Hospital of Zunyi Medical College, No. 149 Dalian Road, Zunyi, Guizhou Province, 563003, China
| | - Zhaoqiong Zhu
- Department of Anesthesiology, Affliated Hospital of Zunyi Medical College, No. 149 Dalian Road, Zunyi, Guizhou Province, 563003, China
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Song JC, Lu ZJ, Jiao YF, Yang B, Gao H, Zhang J, Yu WF. Etomidate Anesthesia during ERCP Caused More Stable Haemodynamic Responses Compared with Propofol: A Randomized Clinical Trial. Int J Med Sci 2015; 12:559-65. [PMID: 26180512 PMCID: PMC4502060 DOI: 10.7150/ijms.11521] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 05/25/2015] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Propofol may result in hypotension and respiratory depression, while etomidate is considered to be a safe induction agent for haemodynamically unstable patients because of its low risk of hypotension. We hypothesized that etomidate anesthesia during ERCP caused more stable haemodynamic responses compared with propofol. The primary endpoint was to compare the haemodynamic effects of etomidate vs. propofol in ERCP cases. The secondary endpoint was overall survival. METHODS A total of 80 patients undergoing ERCP were randomly assigned to an etomidate or propofol group. Patients in the etomidate group received etomidate induction and maintenance during ERCP, and patients in the propofol group received propofol induction and maintenance. Cardiovascular parameters and procedure-related time were measured and recorded during ERCP. RESULTS The average percent change to baseline in MBP was -8.4±7.8 and -14.4±9.4 with P = 0.002, and in HR was 1.8±16.6 and 2.4±16.3 with P = 0.874 in the etomidate group and the propofol group, respectively. MBP values in the etomidate group decreased significantly less than those in the propofol group (P<0.05). The ERCP duration and recovery time in both groups was similar. There was no significant difference in the survival rates between groups ( p = 0.942). CONCLUSIONS Etomidate anesthesia during ERCP caused more stable haemodynamic responses compared with propofol.
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Affiliation(s)
- Jin-Chao Song
- 1. Department of Anesthesiology, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Zhi-Jie Lu
- 1. Department of Anesthesiology, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Ying-Fu Jiao
- 1. Department of Anesthesiology, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Bin Yang
- 2. Department of Anesthesiology, Shanghai first people's hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hao Gao
- 1. Department of Anesthesiology, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Jinmin Zhang
- 1. Department of Anesthesiology, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Wei-Feng Yu
- 1. Department of Anesthesiology, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
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Tuncali B, Pekcan YO, Celebi A, Zeyneloglu P. Addition of low-dose ketamine to midazolam-fentanyl-propofol-based sedation for colonoscopy: a randomized, double-blind, controlled trial. J Clin Anesth 2015; 27:301-6. [PMID: 25801162 DOI: 10.1016/j.jclinane.2015.03.017] [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: 03/21/2014] [Revised: 01/25/2015] [Accepted: 03/04/2015] [Indexed: 10/23/2022]
Abstract
STUDY OBJECTIVE To evaluate the effects of low-dose ketamine on midazolam-fentanyl-propofol-based sedation for outpatient colonoscopy. DESIGN Prospective, randomized, double-blinded, placebo-controlled trial. SETTING Gastroenterology unit at a practice and clinical research center. SUBJECTS Ninety-seven healthy American Society of Anesthesiology physical status 1 volunteers. INTERVENTIONS Subjects were randomized to receive midazolam (0.02 mg/kg), fentanyl (1 μg/kg), and ketamine (0.3 mg/kg) and midazolam (0.02 mg/kg), fentanyl (1 μg/kg), and placebo (0.9% sodium chloride) in group K and group C, respectively. In both groups, incremental doses of propofol were used to maintain a Ramsay sedation score of 3 to 4. MEASUREMENTS Values of heart rate, blood pressure, oxygen saturation, and respiratory rate were measured. Procedure times, recovery times, drug doses used, complications associated with the sedation, and physician and patient satisfaction were also recorded. MAIN RESULTS In group K, mean amount of propofol used and mean induction time (P < .001), the need for the use of jaw thrust maneuver and mask ventilation, and the incidence of disruptive movements were significantly lower (P < .05) and gastroenterologist satisfaction at the beginning of the procedure was significantly superior (P < .05). Mean systolic blood pressures at 4, 6, 8, and 10 minutes (P < .01); diastolic blood pressures at 4, 6, and 8 minutes (P < .05); respiratory rates at 4, 6, 8, 10, 15, 20, and 25 minutes (P < .01); and oxygen saturation at 6, 8, 10, 15, and 20 minutes (P < .05) were significantly lower in group C. Patient satisfaction scores, recovery times, and discharge times were similar. No patient in either group experienced unpleasant dreams or hallucination in the postanesthesia care unit and on the first postoperative day. CONCLUSIONS Addition of low-dose ketamine to midazolam-fentanyl-propofol-based sedation for outpatient colonoscopy resulted in more rapid and better quality of sedation, less propofol consumption, more stable hemodynamic status, and less adverse effects with similar recovery times in adult patients.
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Affiliation(s)
- Bahattin Tuncali
- Department of Anesthesiology, Baskent University Zubeyde Hanim Practice and Research Centre, Izmir, Turkey.
| | - Yonca Ozvardar Pekcan
- Department of Anesthesiology, Baskent University Zubeyde Hanim Practice and Research Centre, Izmir, Turkey
| | - Arzu Celebi
- Department of Gastroenterology, Baskent University Zubeyde Hanim Practice and Research Centre, Izmir, Turkey
| | - Pinar Zeyneloglu
- Department of Anesthesiology, Medical Faculty of Baskent University, Ankara, Turkey
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Ma YH, Li YW, Ma L, Cao CH, Liu XD. Anesthesia for stem cell transplantation in autistic children: A prospective, randomized, double-blind comparison of propofol and etomidate following sevoflurane inhalation. Exp Ther Med 2015; 9:1035-1039. [PMID: 25667673 PMCID: PMC4316962 DOI: 10.3892/etm.2015.2176] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2014] [Accepted: 12/17/2014] [Indexed: 12/21/2022] Open
Abstract
The objective of the present study was to comparatively investigate the feasibility and safety of etomidate and propofol use following sevoflurane inhalation in autistic children during the intrathecal transplantation of stem cells. The patients selected were 60 autistic children with American Society of Anesthesiologists physical status I, who were aged between two and 12 years and scheduled for stem cell transplantation. The children received an inhalation induction of 8% sevoflurane, followed by intravenous injection of etomidate (0.2 mg/kg) in group E and propofol (2 mg/kg) in group P (n=30/group). Supplemental doses of 0.1 mg/kg etomidate or 1 mg/kg propofol were used until a deep sedation was obtained. The heart rate (HR), mean arterial pressure, oxygen saturation, respiratory rate, Ramsay sedation score (RSS) and recovery time were monitored continuously. Following anesthesia, blood pressure and HR measurements were significantly decreased in group P compared with the baseline (P<0.01) and group E values at the same time-points (P<0.05). The occurrence of adverse effects, such as respiratory depression, bradycardia, hypotension and pain on injection, was significantly higher in group P than that in group E, whereas the incidence of myoclonus in group E was significantly higher than that in group P (P<0.01). No significant differences in anesthesia induction, surgery duration, recovery time, RSS and physician satisfaction were observed between the two groups. In conclusion, sevoflurane-etomidate combinations resulted in more stable hemodynamic responses and relatively fewer adverse effects compared with propofol injection following sevoflurane inhalation and may therefore be more suitable for the induction of short-term anesthesia in autistic children during stem cell transplantation.
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Affiliation(s)
- Yu-Heng Ma
- Department of Anesthesiology, Second Artillery General Hospital of PLA, Beijing 100088, P.R. China
| | - Yong-Wang Li
- Department of Anesthesiology, Second Artillery General Hospital of PLA, Beijing 100088, P.R. China
| | - Li Ma
- Department of Gynecology and Obstetrics, Second Artillery General Hospital of PLA, Beijing 100088, P.R. China
| | - Cai-Hong Cao
- Department of Anesthesiology, Second Artillery General Hospital of PLA, Beijing 100088, P.R. China
| | - Xiang-Dong Liu
- Department of Anesthesiology, Second Artillery General Hospital of PLA, Beijing 100088, P.R. China
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Abstract
Although propofol has been the backbone for sedation in gastrointestinal endoscopy, both anesthesiologists and endoscopists are faced with situations where an alternative is needed. Recent national shortages forced many physicians to explore these options. A midazolam and fentanyl combination is the mainstay in this area. However, there are other options. The aim of this review is to explore these options. The future would be, invariably, to move away from propofol. The reason is not in any way related to the drawbacks of propofol as a sedative. The mandate that requires an anesthesia provider to administer propofol has been a setback in many countries. New sedative drugs like Remimazolam might fill this void in the future. In the meantime, it is important to keep an open eye to the existing alternatives.
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Affiliation(s)
- Basavana Gouda Goudra
- Department of Clinical Anesthesiology and Critical Care, Perelman School of Medicine, 680 Dulles Building, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Preet Mohinder Singh
- Department of Anesthesia, All India Institute of Medical Sciences, New Delhi, India
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Türk HŞ, Aydoğmuş M, Ünsal O, Köksal HM, Açik ME, Oba S. Sedation-analgesia in elective colonoscopy: propofol-fentanyl versus propofol-alfentanil. Rev Bras Anestesiol 2014; 63:352-7. [PMID: 23931250 DOI: 10.1016/j.bjan.2012.07.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Accepted: 07/19/2012] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Sedation-analgesia is recommended for comfortable colonoscopy procedures, which are invasive and can be painful. This study aimed to compare the combinations of propofol-alfentanil and propofol-fentanyl for sedation-analgesia in elective colonoscopy patients. METHODS This prospective and randomized study was planned in ASA I-II groups and included 80 patients between the ages of 18 and 65 years. Sedation-analgesia induction was performed as 1 μg.kg-1 fentanyl, 1 mg.kg-1 propofol in the propofol-fentanyl group (Group PF) and 10 μg.kg-1 alfentanil, 1 mg.kg-1 propofol in the propofol-alfentanil group (Group PA). Patients’ scores were limited to 3-4 values on the Ramsey Sedation Scale (RSS) by 0.5 mg.kg-1 bolus additional doses of propofol in sedation-analgesia maintenance. We recorded demographical data, heart rate, mean arterial pressure (MAP), oxygen saturation of hemoglobin (SpO2), RSS value, colonoscopy time, total dose of propofol, complications, recovery time, and discharge time, as well as colonoscopist and patient satisfaction scores. RESULTS MAP at the 15th minute in Group PA was signifi cantly higher than in Group PF (p = 0.037). Group PA’s beginning mean heart rate was higher than the mean heart rate at subsequent readings (p = 0.012, p = 0.002). The mean total propofol dose of Group PA was signifi cantly higher than the total dose of Group PF (p = 0.028). The mean recovery time of Group PA was signifi cantly longer than that of Group PF (p = 0.032). CONCLUSION Fentanyl provides better operative conditions and reduces the need for additional propofol doses. These advantages cause a shorter recovery time. Therefore, propofol-fentanyl is superior to the propofol-alfentanil for sedation-analgesia in colonoscopy.
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Affiliation(s)
- Hacer Şebnem Türk
- Şişli Etfal Training and Research Hospital, Department of Anesthesiology and Intensive Care Medicine, Istanbul, Turkey.
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Sedation-analgesia in elective colonoscopy: propofol-fentanyl versus propofol-alfentanil. Braz J Anesthesiol 2013; 63:352-7. [PMID: 24565243 DOI: 10.1016/j.bjane.2012.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Accepted: 07/19/2012] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Sedation-analgesia is recommended for comfortable colonoscopy procedures, which are invasive and can be painful. This study aimed to compare the combinations of propofol-alfentanil and propofol-fentanyl for sedation-analgesia in elective colonoscopy patients. METHODS This prospective and randomized study was planned in ASA I-II groups and included 80 patients between the ages of 18 and 65 years. Sedation-analgesia induction was performed as 1 μg.kg(-1) fentanyl, 1mg.kg(-1) propofol in the propofol-fentanyl group (Group PF) and 10 μg.kg(-1) alfentanil, 1mg.kg(-1) propofol in the propofol-alfentanil group (Group PA). Patients' scores were limited to 3-4 values on the Ramsey Sedation Scale (RSS) by 0.5mg.kg(-1) bolus additional doses of propofol in sedation-analgesia maintenance. We recorded demographical data, heart rate, mean arterial pressure (MAP), oxygen saturation of hemoglobin (SpO2), RSS value, colonoscopy time, total dose of propofol, complications, recovery time, and discharge time, as well as colonoscopist and patient satisfaction scores. RESULTS MAP at the 15(th) minute in Group PA was significantly higher than in Group PF (p = 0.037). Group PA's beginning mean heart rate was higher than the mean heart rate at subsequent readings (p = 0.012, p = 0.002). The mean total propofol dose of Group PA was significantly higher than the total dose of Group PF (p = 0.028). The mean recovery time of Group PA was significantly longer than that of Group PF (p = 0.032). CONCLUSION Fentanyl provides better operative conditions and reduces the need for additional propofol doses. These advantages cause a shorter recovery time. Therefore, propofol-fentanyl is superior to the propofol-alfentanil for sedation-analgesia in colonoscopy.
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Sedation for short hemato-oncologic invasive procedures in children: comparison of propofol-remifentanil and propofol-fentanyl. J Pediatr Hematol Oncol 2013; 35:112-7. [PMID: 23412587 DOI: 10.1097/mph.0b013e318279cbda] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Short hemato-oncologic procedures are often painful in children, and sedation should be performed outside the operating room. AIM : The study aims to compare the effects of remifentanil with those of fentanyl administered during short hemato-oncologic interventions in children. MATERIALS AND METHODS A prospective, randomized study was planned for 29 ASA I to III children (aged, 2 to 18 y) to undergo a total of 60 short oncologic interventions. The patients were placed into 2 groups: propofol-remifentanil (group PR) and propofol-fentanyl (group PF). Group PR was first administered propofol (2 mg/kg) and then remifentanil bolus (0.5 μg/kg). Group PF was first administered propofol (2 mg/kg) and then fentanyl bolus (0.5 μg/kg). Systolic arterial pressure, diastolic arterial pressure, mean arterial pressure, respiratory rate, peripheral oxygen saturation, and heart rate were recorded every 3 minutes during the intervention and every 5 minutes after the operation. Postanesthetic recovery scores, eye-opening time to speech, and recovery time were recorded. RESULTS Comparison of diastolic arterial pressure in groups at minute 3 of the procedure showed significant difference (P<0.05). Eye-opening to speech (P=0.043) and recovery times (P=0.002) were shorter in group PR. CONCLUSIONS During short hemato-oncologic interventions in children, the PR combination is a suitable one for early recovery.
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Current World Literature. Curr Opin Anaesthesiol 2010; 23:532-8. [DOI: 10.1097/aco.0b013e32833c5ccf] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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