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Dong SA, Guo Y, Liu SS, Wu LL, Wu LN, Song K, Wang JH, Chen HR, Li WZ, Li HX, Zhang L, Yu JB. A randomized, controlled clinical trial comparing remimazolam to propofol when combined with alfentanil for sedation during ERCP procedures. J Clin Anesth 2023; 86:111077. [PMID: 36764022 DOI: 10.1016/j.jclinane.2023.111077] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 01/09/2023] [Accepted: 02/03/2023] [Indexed: 02/11/2023]
Abstract
STUDY OBJECTIVE In many countries, the combination of propofol and opioid is used as the preferred sedative regime during ERCP. However, the most serious risks of propofol sedation are oxygen deficiency and hypotension. Compared to midazolam, remimazolam has a faster onset and offset of hypnotic effect, as well as cardiorespiratory stability, and to achieve widespread acceptance for procedural sedation, remimazolam must replace propofol which is the most commonly used for procedural sedation. The objective of this study was to compare the safety and efficacy profiles of the remimazolam and propofol when combined with alfentanil for sedation during ERCP procedures. DESIGN A randomized, controlled, single-center trial. SETTING The Endoscopic Centre of Tianjin Nankai Hospital, China. PATIENTS 518 patients undergoing elective ERCP under deep sedation. INTERVENTIONS Patients scheduled for ERCP were randomly assigned to be sedated with either a combination of remimazolam-alfentanil or propofol-alfentanil. MEASUREMENTS The primary outcome was the prevalence of hypoxia, which was defined as SpO2 < 90% for >10 s. Other outcomes were the need for airway maneuver, procedure, and sedation-related outcomes and side effects (e.g., nausea, vomiting, and cardiovascular adverse events). MAIN RESULTS A total of 518 patients underwent randomization. Of these, 250 were assigned to the remimazolam group and 255 to the propofol group. During ERCP, 9.6% of patients in the remimazolam group showed hypoxia, while in the propofol group, 15.7% showed hypoxia (p = 0.04). The need for airway maneuvering due to hypoxia was significantly greater in the propofol group (p = 0.04). Furthermore, patients sedated with remimazolam had a lower percentage of hypotension than patients sedated with propofol (p < 0.001). Patients receiving remimazolam sedation expressed higher satisfaction scores and were recommended the same sedation for the next ERCP. The procedure time in the remimazolam group was much longer than in the propofol group due to the complexity of the patient's disease, which resulted in a longer sedation time. CONCLUSION During elective ERCP, patients administered with remimazolam showed fewer respiratory depression events under deep sedation with hemodynamic advantages over propofol when administered in combination with alfentanil.
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Affiliation(s)
- Shu-An Dong
- Department of Anesthesiology and Critical Care Medicine, Tianjin Nankai Hospital, Tianjin Medical University, No. 6, Changjiang Road, Tianjin, China
| | - Yan Guo
- Department of Anesthesiology and Critical Care Medicine, Tianjin Nankai Hospital, Tianjin Medical University, No. 6, Changjiang Road, Tianjin, China
| | - Sha-Sha Liu
- Department of Anesthesiology and Critical Care Medicine, Tianjin Nankai Hospital, Tianjin Medical University, No. 6, Changjiang Road, Tianjin, China
| | - Li-Li Wu
- Department of Anesthesiology and Critical Care Medicine, Tianjin Nankai Hospital, Tianjin Medical University, No. 6, Changjiang Road, Tianjin, China
| | - Li-Na Wu
- Department of Anesthesiology and Critical Care Medicine, Tianjin Nankai Hospital, Tianjin Medical University, No. 6, Changjiang Road, Tianjin, China
| | - Kai Song
- Department of Anesthesiology and Critical Care Medicine, Tianjin Nankai Hospital, Tianjin Medical University, No. 6, Changjiang Road, Tianjin, China
| | - Jing-Hua Wang
- Department of Epidemiology, Tianjin Neurological Institute and Department of Neurology, Tianjin Medical University General Hospital, No. 154, Anshan Road, Tianjin, China
| | - Hui-Rong Chen
- Department of Anesthesiology and Critical Care Medicine, Tianjin Nankai Hospital, Tianjin Medical University, No. 6, Changjiang Road, Tianjin, China
| | - Wei-Zhi Li
- Department of Gastrointestinal Surgery, Tianjin Nankai Hospital, Tianjin Medical University, No. 6, Changjiang Road, Tianjin, China
| | - Huan-Xi Li
- Department of Hepatobiliary Surgery, Tianjin Nankai Hospital, Tianjin Medical University, No. 6, Changjiang Road, Tianjin, China
| | - Li Zhang
- Department of Hepatobiliary Surgery, Tianjin Nankai Hospital, Tianjin Medical University, No. 6, Changjiang Road, Tianjin, China
| | - Jian-Bo Yu
- Department of Anesthesiology and Critical Care Medicine, Tianjin Nankai Hospital, Tianjin Medical University, No. 6, Changjiang Road, Tianjin, China.
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Seleem WM, El Hossieny KM, Abd-Elsalam S. Evaluation of Different Sedatives for Colonoscopy. Curr Drug Saf 2020; 15:20-24. [PMID: 31362661 DOI: 10.2174/1574886314666190726154238] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 07/12/2019] [Accepted: 07/15/2019] [Indexed: 01/25/2023]
Abstract
Background & Aims:
Sedation and analgesia are important elements of endoscopic
examinations; sedation for colonoscopy aims to relieve patient discomfort and anxiety, improve the
outcome of the examination, diminish the patient’s memory of the event and achieve comfortable
and technically successful endoscopic procedure.
Methods:
Our prospective study was carried out on 150 patients who were referred for colonoscopy;
they were divided into two groups based on the pre-endoscopic sedation given for them: propofol
fentanyl or propofol ketamine. Detailed histories, thorough physical examinations, and routine
laboratory investigations were performed for all patients, along with monitoring of their vital signs and
oxygen saturation levels (before, during and after colonoscopy), to assess safety, efficacy, recovery
times, complications of the sedative drugs, comfort of the patients and endoscopists.
Results:
There was no statistically significant difference between the two groups in terms of age,
sex and Body Mass Indexes (BMI). With respect to their Mean Arterial Blood Pressures (MAPs)
and heart rates, there was high hemodynamic stability in the propofol ketamine group, and both the
groups were efficacious, although the propofol fentanyl group had shorter recovery times than the
propofol ketamine group (3±1.7 minutes and 4±2.8 minutes, respectively). However, nausea, vomiting
and hypoxia were common in the propofol fentanyl group, while hallucinations were common
in the propofol ketamine group. In propofol fentanyl group; there was a significant decrease in the
heart rate more common in females (with age range 39-58 years) during and after colonoscopy
[p value 0.01].
Conclusion:
Sedation with propofol ketamine during colonoscopy was found to be safe and
efficacious to achieve hemodynamic stability with fewer complications than propofol fentanyl.
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Affiliation(s)
- Waseem M. Seleem
- Gastroenterology Unit, Internal Medicine Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Khadeja M. El Hossieny
- Anaesthesia and Intensive Care Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Sherief Abd-Elsalam
- Tropical Medicine Department, Faculty of Medicine, Tanta University, Tanta, Egypt
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Fogarty M, Orr JA, Sakata D, Brewer L, Johnson K, Fang JC, Kuck K. A comparison of ventilation with a non-invasive ventilator versus standard O 2 with a nasal cannula for colonoscopy with moderate sedation using propofol. J Clin Monit Comput 2019; 34:1215-1221. [PMID: 31760586 DOI: 10.1007/s10877-019-00426-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 11/17/2019] [Indexed: 12/27/2022]
Abstract
The aim of this study was to test the effects of CPAP on moderately sedated patients undergoing colonoscopy. Our hypothesis was that CPAP can reduce the incidence and duration of obstructive apnea and hemoglobin oxygen desaturation in patients undergoing procedural sedation for colonoscopy. Two groups of consenting adult patients scheduled to undergo routine colonoscopy procedures and sedated with propofol and fentanyl were monitored in this study: control and intervention. Patients in the intervention group were connected via a facemask to a ventilator that delivered supplemental oxygen (100%) through a standard air-cushion mask. The mask had a built-in leak to facilitate CO2 clearance during CPAP. Patients in the control group received 2-10 L/min of oxygen via nasal cannula or non-rebreather mask. Subjects in the control group were collected in a prior study and used as historical controls. The primary outcome measures were the number of apneic events and the cumulative duration of apneic events. An apneic event was defined as a period longer than 10 s without respiration. The secondary outcome was the area under the curve (AUC) for the arterial oxygen saturation less than 90% versus time during sedative and analgesic administration (time (s) below threshold multiplied by percent below threshold). A desaturation event was defined as a period of time during which arterial oxygen saturation was less than 90%. 29 patients were enrolled in the intervention group and 156 patients were previously enrolled in the control group as part of an earlier study. The median number of apneic events in the control group was 7 compared to 0 in the intervention group. The intervention group experienced apnea less than 1% of the total procedure time compared to 17% in the control group (p < 0.001). There were no desaturation events observed in the 29 patients in the intervention group. In contrast, 27 out of 156 patients in the control group experienced a desaturation event. Average AUC of patients in the control group was 70%-s (time (s) * oxygen saturation below < 90%) (95% CI 32.34-108.60%) whereas the average AUC in intervention group patients was 0%-s (% time (s) * oxygen saturation < 90%) (95% CI 0-0%), p = 0.01. This preliminary study found that CPAP via a tight-fitting mask may be an effective tool to reduce the incidence and duration of obstructive apneic events as well as hemoglobin oxygen desaturation during lower endoscopy procedures that use propofol and fentanyl for sedation.Clinical Trial Registration ClinicalTrials.gov ID: NCT02623270. https://clinicaltrials.gov/ct2/show/NCT02623270 .
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Affiliation(s)
- Mike Fogarty
- Department of Anesthesiology and Bioengineering, University of Utah, Salt Lake City, UT, USA.
| | - Joseph A Orr
- Department of Anesthesiology and Bioengineering, University of Utah, Salt Lake City, UT, USA
| | - Derek Sakata
- Department of Anesthesiology, University of Utah, Salt Lake City, UT, USA
| | - Lara Brewer
- Department of Anesthesiology and Bioengineering, University of Utah, Salt Lake City, UT, USA
| | - Ken Johnson
- Department of Anesthesiology, University of Utah, Salt Lake City, UT, USA
| | - John C Fang
- Department of Gastroenterology, University of Utah, Salt Lake City, UT, USA
| | - Kai Kuck
- Department of Anesthesiology and Bioengineering, University of Utah, Salt Lake City, UT, USA
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Bahrami Gorji F, Amri P, Shokri J, Alereza H, Bijani A. Sedative and Analgesic Effects of Propofol-Fentanyl Versus Propofol-Ketamine During Endoscopic Retrograde Cholangiopancreatography: A Double-Blind Randomized Clinical Trial. Anesth Pain Med 2016; 6:e39835. [PMID: 27853681 PMCID: PMC5106556 DOI: 10.5812/aapm.39835] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Revised: 07/31/2016] [Accepted: 08/10/2016] [Indexed: 12/20/2022] Open
Abstract
Background Endoscopic retrograde cholangiopancreatography (ERCP) is a painful procedure that requires analgesia and sedation. Objectives In this study, we compared the analgesic and sedative effects of propofol-ketamine versus propofol-fentanyl in patients undergoing ERCP. Methods In this clinical trial, 72 patients, aged 30 - 70 years old, who were candidates for ERCP were randomly divided into two groups. Before the start of ERCP, both groups received midazolam 0.5 - 1 mg. The intervention group (PK) received ketamine 0.5 mg/kg, and the control group (PF) received fentanyl 50 - 100 micrograms. All patients received propofol 0.5 mg/kg in a loading dose followed by 75 mcg/kg/minute in an infusion. The patients, the anesthesiologist, and the endoscopist were unaware of the medication regimen. Sedation and analgesia quality (based on a VAS), blood pressure, respiratory rate, heart rate, arterial oxygen saturation, recovery time (based on Aldrete scores), and endoscopist and patient satisfation were recorded. Results The sedative effects were equal in the two groups (P > 0.05), but the analgesic effects were higher in the PF group than in the PK group (P < 0.05). The PK group had higher blood pressure levels in the eighth minute. Respiratory rate, heart rate, and arterial oxygen saturation showed no significant differences between the groups (P > 0.05). Endoscopist satisfaction, patient satisfaction, and recovery time showed no significant differences between the two groups (P > 0.05). Conclusions The results showed that the sedative effect of propofol-ketamine was equal to the propofol-fentanyl combination during ERCP. To prevent respiratory and hemodynamic complications during ERCP, the propofol-ketamine combination should be used in patients with underlying disease.
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Affiliation(s)
- Fakhroddin Bahrami Gorji
- Student Committee Research, The Clinical Research Development Unit of Roohani Hospital, Babol University of Medical Sciences, Babol, Iran
| | - Parviz Amri
- Department of Intensive Care, Babol University of Medical Sciences, Babol, Iran
- Corresponding author: Parviz Amri, Department of Intensive Care, Babol University of Medical Sciences, Babol, Iran. Tel: +98-1112238301, E-mail:
| | - Javad Shokri
- Department of Gastroenterology, Babol University of Medical Sciences, Babol, Iran
| | - Hakimeh Alereza
- Vice Chancellor, Babol University of Medical Sciences, Babol, Iran
| | - Ali Bijani
- Social Determinants of Health Research Center, Babol University of Medical Sciences, Babol, Iran
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