Dexmedetomidine versus midazolam for gastrointestinal endoscopy: a meta-analysis

Determining factors for dexmedetomidine sedation in endoscopic submucosal dissection for early-stage gastric cancer

Background and Aim

Although no specific sedation recommendations exist in early-stage gastric cancer (ESGC) for endoscopic submucosal dissection (ESD), dexmedetomidine (DEX) is useful along with benzodiazepines and analgesics. Furthermore, DEX is used for endoscopic treatment requiring lengthy sedation. However, it is unclear which patients should be administered DEX. We examined the factors that determine when DEX should be added for sedation during ESD for ESGC.

Methods

Of 316 patients undergoing ESD for ESGC at our hospital between January 2017 and December 2020, we examined 310 receiving intravenous anesthesia. Preoperative patient factors and treatment outcomes were retrospectively examined according to the sedation method.

Results

Among patients with ESGC undergoing ESD at our hospital, DEX was more frequently used alongside sedation in men, those undergoing gastrectomy, those with a lesion diameter ≥20 mm, and those with preoperative ulcers. In the standard group, patients whose treatment duration exceeded 120 min typically had a lesion diameter ≥20 mm, preoperative ulcers, lesions located outside the L region, and were treated by junior physicians.

Conclusion

It is important to evaluate specific preoperative factors (lesion diameter ≥20 mm, preoperative ulcers, lesion located outside the L region, and having a junior physician as the treating physician) in patients undergoing ESD for ESGC to determine whether the combined use of DEX in sedation is necessary.

Efficacy and safety of sedation with dexmedetomidine in adults undergoing gastrointestinal endoscopic procedures: systematic review and meta-analysis of randomized controlled trials

Background: The sedative role of dexmedetomidine (DEX) in gastrointestinal endoscopic procedures is unclear. We performed this systematic review and meta-analysis to assess the efficacy and safety of sedation with DEX during gastrointestinal endoscopic procedures with a view to providing evidence-based references for clinical decision-making. Methods: The PubMed, Embase, Cochrane Library, Web of Science, and ClinicalTrials.gov databases were searched for randomized controlled trials (RCTs) that compared DEX with different sedatives comparators (such as propofol, midazolam, and ketamine) for sedation in a variety of adult gastrointestinal endoscopic procedures from inception to 1 July 2022. Standardized mean difference (SMD) and weighted mean difference (WMD) with 95% confidence interval (CI) or pooled risk ratios (RR) with 95% CI were used for continuous outcomes or dichotomous outcomes, respectively, and a random-effect model was selected regardless of the significance of the heterogeneity. Results: Forty studies with 2,955 patients were assessed, of which 1,333 patients were in the DEX group and 1,622 patients were in the control (without DEX) group. The results suggested that the primary outcomes of sedation level of DEX are comparable to other sedatives, with similar RSS score and patient satisfaction level, and better in some clinical outcomes, with a reduced risk of body movements or gagging (RR: 0.60; 95% CI: 0.37 to 0.97; p = 0.04; I2 = 68%), and a reduced additional requirement for other sedatives, and increased endoscopist satisfaction level (SMD: 0.41; 95% CI: 0.05 to 0.77; p = 0.03; I2 = 86%). In terms of secondary outcomes of adverse events, DEX may benefit patients in some clinical outcomes, with a reduced risk of hypoxia (RR:0.34; 95% CI: 0.20 to 0.55; p < 0.0001; I2 = 52%) and cough (RR: 0.25; 95% CI: 0.12 to 0.54; p = 0.0004; I2 = 0%), no significant difference in the risk of hypotension, while an increased risk of bradycardia (RR: 3.08; 95% CI: 2.12 to 4.48; p < 0.00001; I2 = 6%). Conclusion: This meta-analysis indicates that DEX is a safe and effective sedative agent for gastrointestinal endoscopy because of its benefits for patients in some clinical outcomes. Remarkably, DEX is comparable to midazolam and propofol in terms of sedation level. In conclusion, DEX provides an additional option in sedation for gastrointestinal endoscopic procedures. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/#searchadvanced.

Dexmedetomidine is safe and effective for reducing intraprocedural pain in colorectal endoscopic submucosal dissection

Objectives

Endoscopic submucosal dissection (ESD) is effective for the resection of colorectal intramucosal lesions. This study was performed to examine the safety and effectiveness of using dexmedetomidine (DEX) in the anesthesia regimen of patients with colorectal lesions undergoing ESD.

Methods

We retrospectively examined 287 consecutive patients who underwent ESD for colorectal lesions in our institution from January 2015 to December 2021. Outcomes including the frequency of intraprocedural pain and adverse events were compared between the DEX and no DEX groups. Moreover, univariate and multivariate analyses were conducted for each clinical factor of intraprocedural pain. Intraprocedural pain was defined as patient-reported abdominal pain or body movement during the procedure.

Results

The incidence of intraprocedural pain was significantly lower in the DEX than in the no DEX group (7% vs. 17%, p = 0.02). The incidence of hypotension was also significantly higher in the DEX group (7% vs. 0%, p = 0.01), but no cerebrovascular or cardiac ischemic events occurred. In the univariate analyses, the diameter of the resected specimen, procedure time, no use of DEX, and total midazolam dose was associated with intraprocedural pain. The midazolam dose and DEX administration were significantly negatively correlated and the diameter of resected specimen and procedure time were significantly positively correlated. Multivariate logistic regression showed that no use of DEX was independently associated with intraprocedural pain (p = 0.02).

Conclusions

Adding DEX to the anesthesia regimen in patients undergoing colorectal ESD appears to be safe and effective for reducing intraprocedural pain.

What Is the Role of Dexmedetomidine in Modern Anesthesia and Critical Care?

Dexmedetomidine's unique sedative properties have led to its widespread use. Dexmedetomidine has a beneficial pharmacologic profile including analgesic sparing effects, anxiolysis, sympatholysis, organ-protective effects against ischemic and hypoxic injury, and sedation which parallels natural sleep. An understanding of predictable side effects, effects of age-related physiologic changes, and pharmacokinetic and pharmacodynamic effects of dexmedetomidine is crucial to maximize its safe administration in adults and children. This review focuses on the growing body of literature examining advances in applications of dexmedetomidine in children and adults.

Efficacy of dexmedetomidine versus midazolam when combined with butorphanol for sedation and analgesia during burn dressing changes: A randomized clinical trial

Objective: The aim of this study was to compare dexmedetomidine-butorphanol (DB) and midazolam-butorphanol (MB) combinations for sedation, and analgesia in burn patients undergoing dressing changes.

Methods: A total of 56 ASA I–II burn patients were included in this single-center randomized clinical trial. The ages of these patients were between 20 and 60 years. TBSA ranged from 10% to 50%. They were randomized to group DB and group MB during dressing change. In the DB group, each patient received a bolus dose of dexmedetomidine (0.5 μg kg−1) and intermittent boluses of butorphanol (20 μg kg−1). In the MB group, each patient received a bolus dose of midazolam (0.05 mg kg−1) and intermittent boluses of butorphanol (20 μg kg−1). The primary outcomes were sedation scores and pain scores. The second outcomes were vital signs, side effects, and butorphanol consumption.

Results: The sedation scores of these two groups did not differ significantly (p &gt; 0.05), and the pain scores of these groups were not significantly different (p &gt; 0.05). More patients had hypotension in the DB group than in the MB group (6 versus 0, p = 0.01), but the number of patients who had respiratory depression was higher in the MB group compared with the DB group (4 versus 0, p = 0.038). Butorphanol consumption in the MB group was higher than in the DB group (p = 0.025).

Conclusion: Dexmedetomidine is comparable to midazolam when combined with butorphanol in burn patients during dressing change. Compared with midazolam, it has the advantage of opioid-sparing effect.

Clinical Trial Registration: [http://www.chictr.org.cn/showproj.aspx&amp;proj=130622], identifier [ChiCTR2100049325].

New sedatives and analgesic drugs for gastrointestinal endoscopic procedures

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.

Safety and efficacy of pentazocine–midazolam combination for pain and anxiety relief in radiofrequency ablation therapy for hepatocellular carcinoma

Background and Aim

Radiofrequency ablation (RFA) therapy is frequently used as first‐line treatment for small hepatocellular carcinoma (HCC). RFA is often associated with pain; however, no definitive solution has been established for its relief. We retrospectively analyzed the safety and efficacy of the combination of pentazocine and midazolam to relieve pain experienced by HCC patients undergoing RFA.

Methods

We studied 77 patients with 98 HCCs treated with RFA between January 2015 and August 2019. Patients were divided into two groups: the sedative‐free group, which included those who received pentazocine alone, and the pentazocine–midazolam group, which included those who received a combination of pentazocine and midazolam. The degrees of analgesia and sedation were evaluated using the numerical rating scale (NRS) and the Richmond Agitation‐Sedation Scale (RASS), respectively. Other parameters such as treatment time, awakening time, midazolam dosage, vital signs, local recurrence rate, and time to recurrence were also examined.

Results

The median NRS score and RASS score were significantly lower in the pentazocine–midazolam group. Ninety‐five percent of patients in the pentazocine–midazolam group had no memory of the RFA session. The treatment time and awakening time were prolonged for the pentazocine–midazolam group. No significant differences in oxygen saturation, recurrence rates, and time to local recurrence were observed between groups.

Conclusion

A combination of pentazocine and midazolam is safe and effective for pain and anxiety relief experienced by patients undergoing RFA for local treatment of HCC.

Lack of influence of dexmedetomidine on rat glomus cell response to hypoxia, and on mouse acute hypoxic ventilatory response

Background and Aims

There is a lack of basic science data on the effect of dexmedetomidine on the hypoxic chemosensory reflex with both depression and stimulation suggested. The primary aim of this study was to assess if dexmedetomidine inhibited the cellular response to hypoxia in rat carotid body glomus cells, the cells of the organs mediating acute hypoxic ventilatory response (AHVR). Additionally, we used a small sample of mice to assess if there was any large influence of subsedative doses of dexmedetomidine on AHVR.

Material and Methods

In the primary study, glomus cells isolated from neonatal rats were used to study the effect of 0.1 nM (n = 9) and 1 nM (n = 13) dexmedetomidine on hypoxia-elicited intracellular calcium [Ca2%]i influx using ratiometric fluorimetry. Secondarily, whole animal unrestrained plethysmography was used to study AHVR in a total of 8 age-matched C57BL6 mice, divided on successive days into two groups of four mice randomly assigned to receive sub-sedative doses of 5, 50, or 500 μg.kg-1 dexmedetomidine versus control in a crossover study design (total n = 12 exposures to drug with n = 12 controls).

Results

There was no effect of dexmedetomidine on the hypoxia-elicited increase in [Ca2%]i in glomus cells (a mean ± SEM increase of 95 ± 32 nM from baseline with control hypoxia, 124 ± 41 nM with 0.1 nM dexmedetomidine; P = 0.514). In intact mice, dexmedetomidine had no effect on baseline ventilation during air-breathing (4.01 ± 0.3 ml.g-1.min-1 in control and 2.99 ± 0.5 ml.g-1.min-1 with 500 μg.kg-1 dexmedetomidine, the highest dose; P = 0.081) or on AHVR (136 ± 19% increase from baseline in control, 152 ± 46% with 500 μg.kg-1 dexmedetomidine, the highest dose; P = 0.536).

Conclusion

Dexmedetomidine had no effect on the cellular responses to hypoxia. We conclude that it unlikely acts via inhibition of oxygen sensing at the glomus cell. The respiratory chemoreflex effects of this drug remain an open question. In our small sample of intact mice, hypoxic chemoreflex responses and basal breathing were preserved.

Dexmedetomidine combined with midazolam infusion guided by bispectral index during bronchoscopy

BACKGROUND

Conscious sedation guided by bispectral index (BIS) during bronchoscopy has been proved to be a feasible approach. This study aimed to investigate the safety and efficacy of dexmedetomidine combined with midazolam for undergoing conscious sedation during bronchoscopy.

METHODS

The trial was registered prior to patient enrollment at the Chinese Clinical Trial Registry. Patients were randomized into DEX group (dexmedetomidine combined with midazolam) and FEN group (fentanyl combined with midazolam). Bronchoscopy was performed under awake sedation titrated to a BIS level of 60-80. The primary endpoint was the incidence of hypoxia, the secondary endpoint was the incidence of bradycardia and hypotension, effect of sedation including satisfaction degree (VAS) of the operators and patients and patients' willingness to undergo bronchoscopy again.

RESULTS

A total of 222 cases in DEX group and 211 cases in FEN group completed the study. The incidence of hypoxia and tachycardia in DEX group was lower than that in FEN group (8.1% vs 14.7%, 10.4% vs 19.0%, p < 0.05), and the incidence of hypotension and bradycardia in DEX group was higher than that in FEN group (6.8% vs 0, 15.3% vs 8.1%, p < 0.05). Midazolam dosage was significantly lower in the DEX group than in the FEN group, and the duration of surgery was significantly longer in the DEX group. The differences in intraoperative discomfort of VAS score, satisfaction VAS score, and willingness rate to undergo bronchoscopy again were not statistically significant between the two groups. In addition, the proportion of "procedural interference by patient movement" in DEX group was higher than that in FEN group.

CONCLUSIONS

The conscious sedation regimen of dexmedetomidine combined with midazolam monitored by BIS is considered to be safe and effective during bronchoscopy. The occurrence of hypoxia and tachycardia was less, and the fluctuation of blood pressure and heart rate was mild, but the proportion of bradycardia in dexmedetomidine group was higher than that in fentanyl combined with midazolam group.

Risk Factors for Prolonged Hospital Stay after Endoscopy

Background/Aims

The recovery room used after endoscopy has limited capacity, and an efficient flow of the endoscopy unit is desired. We investigated the duration of hospital stay after endoscopy and the risk factors for prolonged hospital stay among outpatients.

Methods

We retrospectively studied consecutive patients who underwent esophagogastroduodenoscopy or colonoscopy at the Toyoshima Endoscopy Clinic. We collected data on age, sex, body weight, midazolam and pethidine dosage, respiratory depression during endoscopy, and duration of hospital stay after endoscopy (scope out to check out). Risk factors for prolonged hospital stay (>100 minutes) were identified using multiple logistic regression analysis.

Results

We enrolled 3,898 patients, including 3,517 (90.2%) patients tested under sedation and 381 (9.8%) patients tested without sedation. Overall, 442 (11.3%) patients had prolonged stay (>100 min). The mean time difference between sedation group and non-sedation group was 44.2 minutes for esophagogastroduodenoscopy and 39.1 minutes for colonoscopy. Age (odds ratio [OR], 1.025; 95% confidence interval [CI], 1.014−1.036), female sex (OR, 1.657; 95% CI, 1.220−2.249), and midazolam dose (OR, 1.019; 95% CI, 1.013−1.026) were independently associated with prolonged hospital stay after esophagogastroduodenoscopy, with similar results for colonoscopy.

Conclusions

Old age, female sex, and midazolam dose were independent risk factors for prolonged hospital stay after endoscopy.

Guidelines for sedation in gastroenterological endoscopy (second edition)

Sedation in gastroenterological endoscopy has become an important medical option in routine clinical care. Here, the Japan Gastroenterological Endoscopy Society and the Japanese Society of Anesthesiologists together provide the revised "Guidelines for sedation in gastroenterological endoscopy" as a second edition to address on-site clinical questions and issues raised for safe examination and treatment using sedated endoscopy. Twenty clinical questions were determined and the strength of recommendation and evidence quality (strength) were expressed according to the "MINDS Manual for Guideline Development 2017." We were able to release up-to-date statements related to clinical questions and current issues relevant to sedation in gastroenterological endoscopy (henceforth, "endoscopy"). There are few reports from Japan in this field (e.g., meta-analyses), and many aspects have been based only on a specialist consensus. In the current scenario, benzodiazepine drugs primarily used for sedation during gastroenterological endoscopy are not approved by national health insurance in Japan, and investigations regarding expense-related disadvantages have not been conducted. Furthermore, including the perspective of beneficiaries (i.e., patients and citizens) during the creation of clinical guidelines should be considered. These guidelines are standardized based on up-to-date evidence quality (strength) and supports on-site clinical decision-making by patients and medical staff. Therefore, these guidelines need to be flexible with regard to the wishes, age, complications, and social conditions of the patient, as well as the conditions of the facility and discretion of the physician.

Comparison of dexmedetomidine-propofol and ketamine-propofol administration during sedation-guided upper gastrointestinal system endoscopy

BACKGROUND

Dexmedetomidine and ketamine popular sedative agents that result in minimal respiratory depression and the presence of analgesic activity. We aimed to compare the effectiveness and safety of a dexmedetomidine-propofol combination and a ketamine-propofol combination during upper gastrointestinal system endoscopy.

METHODS

The study commenced after receiving approval from the local ethics committee. Patients between 18 and 60 years in the American Society of Anesthesiologists (ASA) I and II groups were included. Patients who had severe organ disease, who had allergies to the study drugs, and who refused to participate were excluded. Cases were randomized into a dexmedetomidine-propofol group (Group D, n = 30) and a ketamine-propofol group (Group K, n = 30). Cardiac monitoring, peripheral oxygen saturation, and bispectral index (BIS) monitoring were performed. Group D received 1 mg/kg dexmedetomidine + 0.5 mg/kg propofol intravenous (IV) bolus, 0.5 μg/kg/h dexmedetomidine + 0.5 mg/kg/h propfol infusion. Group K received 1 mg/kg ketamine + 0.125 mL/kg propofol iv bolus, 0.25 mg/kg/h ketamine + 0.125 mL/kg/h propfol infusion. Patients were followed up with a Ramsay Sedation Scale (RSS) of ≥4. Means, standard deviations, lowest and highest frequency values, and ratio values were used for descriptive statistics, and the SPSS 22.0 program was used for statistical analyses.

RESULTS

In Group K, recovery time and mean blood pressure (MBP) values were significantly shorter. Furthermore, coughing rate, pulse, and BIS values were higher than in Group D (P < .05). Although there were no significant differences between the groups in terms of endoscopic tolerance and endoscopist satisfaction, we observed that the dexmedetomidine group experienced more comfortable levels of sedation.

CONCLUSION

Dexmedetomidine-propofol and ketamine-propofol combinations may be suitable and safe for endoscopy sedation due to their different properties. It was observed that the dexmedetomidine-propfol combination was superior in terms of sedation depth and that the ketamine-propofol combination was superior in terms of early recovery. As a result, we suggest the dexmedetomidine-propofol combination for upper gastrointestinal system endoscopy sedation due to hemodynamic stability and minimal adverse effects.

Long-Term Outcomes of Endoscopic Submucosal Dissection for Superficial Esophageal Squamous Cell Carcinoma

In this review, we summarize up-to-date reports with 5-year survival after endoscopic submucosal dissection (ESD) for superficial esophageal squamous cell carcinoma. In ESD for the depth of the epithelium (m1) or lamina propria (m2), the 5-year cause-specific survival and 5-year overall survival rates were reported to be 98-100%, and 85-95%, respectively. In cases with submucosal invasion or vascular involvement, additional prophylactic treatment such as chemoradiotherapy or surgery was recommended, and the 5-year cause-specific survival and 5-year overall survival rates were reported to be 85-100%, and 56-84%, respectively. Additional treatment might be too invasive for the elderly or patients with severe comorbidities. The risk of additional therapy should be balanced against the risk of lymph node metastasis, considering the life expectancy of such patients.

Dexmedetomidine or midazolam in combination with propofol for sedation in endoscopic retrograde cholangiopancreatography: a randomized double blind prospective study

Introduction

Interventional endoscopic procedures, such as endoscopic retrograde cholangiopancreatography (ERCP), often require sedation during the procedure. The most commonly used drugs for this purpose are midazolam and propofol, which are used as sedative and hypnotic agents with minimal analgesic potential.

Aim

To compare the analgesic sedative effects of midazolam-propofol and dexmedetomidine-propofol combinations and their influence on hemodynamic and respiratory variables in patients undergoing ERCP.

Material and methods

Forty adult patients aged 20-78 and undergoing ERCP were randomized to two groups. Patients were premedicated with midazolam (0.05 mg/kg 10 min before the procedure) in group M and with dexmedetomidine (1 μg/kg for 10 min) in group D. Propofol was used for maintenance. The sedation level was monitored using the bispectral index (BIS) to maintain a score between 70 and 80. Hemodynamic and respiratory variables, recovery time and adverse events were recorded.

Results

The hemodynamic and respiratory variables were similar in both groups. Total propofol consumption was significantly lower in the dexmedetomidine group (208.5 ±80.0 vs. 154.5 ±66.7 mg; p = 0.011). The recovery period was shorter in group D (time to achieve the Aldrete score 9 was 9.4 ±2.1 vs. 6.6 ±1.1 min; p < 0.001). Changes in hemodynamic and respiratory variables and adverse events were not different between the two groups.

Conclusions

We found a shorter recovery time and comparable sedative and adverse effects with the dexmedetomidine-propofol combination compared with the midazolam-propofol combination. Dexmedetomidine in combination with propofol may be a safe and useful alternative for sedation for ERCP patients.

Additional Mosapride to Proton Pump Inhibitor for Gastroesophageal Reflux Disease: A Meta-Analysis

BACKGROUND AND AIM

In gastroesophageal reflux disease (GERD), the additive effect of mosapride to a proton pump inhibitor (PPI) is still controversial. This meta-analysis integrated randomized controlled trials (RCTs) in which mosapride combined with a PPI was compared with a PPI alone in GERD treatment.

METHODS

RCTs were systematically searched with the PubMed, Cochrane library, Web of Science, and the Igaku-Chuo-Zasshi database. We combined the data from the RCTs with a random effects model, calculated the standardized mean difference (SMD) and pooled the risk difference (RD) with 95% confidence intervals (CIs).

RESULTS

We included nine RCTs in the present meta-analysis. In the mosapride combined with PPI group, the improvement of the symptom score was significantly greater than that in the PPI alone group without significant heterogeneity (SMD: -0.28, 95% CI: -0.45 to -0.12, p = 0.0007). In the mosapride combined with PPI group, the symptom score after treatment was significantly lower than that in the PPI alone group (SMD: -0.24, 95% CI: -0.42 to -0.06, p = 0.007).

CONCLUSIONS

Mosapride combined with a PPI significantly improved the reflux symptom score compared with that of PPI alone.

Dexmedetomidine is safe and reduces the additional dose of midazolam for sedation during endoscopic retrograde cholangiopancreatography in very elderly patients

Background

Endoscopic retrograde cholangiopancreatography (ERCP) often requires deep sedation. Dexmedetomidine, a highly selective α2-adrenoceptor agonist with sedative activity and minimal effects on respiration, has recently been widely used among patients in the intensive care unit. However, its use in endoscopic procedures in very elderly patients is unclear. In this study, we retrospectively investigated the safety and efficacy of dexmedetomidine sedation during ERCP.

Methods

The study included 62 very elderly patients (aged over 80 years) who underwent ERCP from January 2014, with sedation involving dexmedetomidine (i.v. infusion at 3.0 μg/kg/h over 10 min followed by continuous infusion at 0.4 μg/kg/h) along with midazolam. For comparison, the study included 78 patients who underwent ERCP before January 2014, with midazolam alone. We considered additional administration of midazolam as needed to maintain a sedation level of 3–4, according to the Ramsay sedation scale. The outcome measures were amount of midazolam, adverse events associated with sedation, and hemodynamics.

Results

The incidence of decreased SpO₂ and median dose of additional midazolam were significantly lower in the dexmedetomidine group than in the conventional group. The minimum systolic blood pressure and minimum heart rate during and after examination was significantly lower in the dexmedetomidine group than in the conventional group. However, serious acute heart failure or arrhythmia was not noted.

Conclusions

Dexmedetomidine can decrease the incidence of respiratory complications and the total dose of other sedative agents. It can be used as an alternative to conventional methods with midazolam for adequate sedation during ERCP in very elderly patients.

Comparison of upper airway patency in patients with mild obstructive sleep apnea during dexmedetomidine or propofol sedation: a prospective, randomized, controlled trial

Background

In addition to propofol, dexmedetomidine is a suitable alternative for intraoperative sedation in procedures requiring regional anesthesia. To date, however, little is known about the influences of each drug on upper airway patency. Accordingly, the authors investigated differences between dexmedetomidine and propofol sedation in the occurrence of upper airway obstruction and requirements for airway intervention in patients with mild obstructive sleep apnea.

Methods

Patients with an apnea/hypopnea index of 5–14/h according to Watch-PAT 200 analysis were enrolled in this study. Spinal anesthesia was routinely performed for surgery. Intraoperative sedation was initiated using either dexmedetomidine or propofol infusion at a level of modified observer’s assessment of alertness/sedation scale 3. The primary outcome was the proportion of patients exhibiting signs of upper airway obstruction. A sign of upper airway obstruction was defined as no detection of end-tidal carbon dioxide for at least 10 s despite respiratory efforts.

Results

A total of 50 patients were included in the final analysis (dexmedetomidine [n = 26]; propofol [n = 24]). During the intraoperative sedation period, there was a significantly lower proportion of patients exhibiting signs of upper airway obstruction in the dexmedetomidine group than in the propofol group (11.5% vs. 41.7%, P = 0.035). An artificial airway was inserted in 1 patients (3.8%) and 5 patient (20.8%) in the dexmedetomidine and propofol groups, respectively (P = 0.093).

Conclusion

Dexmedetomidine sedation was associated with a lower incidence of upper airway obstruction than propofol sedation in patients with mild obstructive sleep apnea.

Trial registration number

Clinical trials.gov (NCT02993718): Retrospectively registered.

Dexmedetomidine for conscious sedation with colorectal endoscopic submucosal dissection: a prospective double-blind randomized controlled study

Objective

Conscious sedation for colorectal endoscopic submucosal dissection (ESD) has not been standardized, and there are no studies of sedation for colorectal ESD.

Methods

We conducted a prospective double-blind randomized controlled trial to clarify the usefulness of DEX during colorectal ESD. In total 80 patients with colorectal ESD from April 2016 to May 2017 were assigned to the placebo group or the DEX group (40 cases each). The primary outcome was patient satisfaction (visual analogue scale: VAS). Secondary outcomes were evaluated for 13 factors, including patient pain level (VAS), endoscopist satisfaction (VAS), objective patient pain level viewed from the endoscopist’s perspective (VAS), rate of patient response, rate of side effects, etc., from the patient’s and endoscopist’s perspectives.

Results

Patient satisfaction was 8.4 and 9.1 (P = 0.018) in the placebo group and the DEX group, respectively. Secondary outcomes of patient pain level, endoscopist satisfaction, objective patient pain level from the endoscopist’s perspective for the placebo and DEX groups were 1.2 and 0.4 (P = 0.045), 8.2 and 9.3 (P < 0.001), and 1.2 and 0.5 (P = 0.002), respectively. All of these were significantly positive results (more comfortable and less pain) in the DEX group. The rate of a patient response was 100% in all cases. The side effects (hypoxia/bradycardia/hypotension) were 0%/0%/0% and 7.5%/7.5%/5% (P = 0.030). However, these rates were less than the reported side effect occurrence rate, and no additional medication was needed.

Conclusion

DEX enables conscious sedation, and is useful not only for patient and endoscopist satisfaction but also for pain relief. DEX is an effective sedation method for colorectal ESD.

Propofol for gastrointestinal endoscopy

Most gastrointestinal endoscopic procedures are now performed with sedation. Moderate sedation using benzodiazepines and opioids continues to be widely used, but propofol sedation is becoming more popular because its unique pharmacokinetic properties make endoscopy almost painless, with a very predictable and rapid recovery process. There is controversy as to whether propofol should be administered only by anesthesia professionals. According to published values, endoscopist-directed propofol has a lower mortality rate than endoscopist-delivered benzodiazepines and opioids, and a comparable rate to general anesthesia by anesthesiologists. Rapid recovery has a major impact on patient satisfaction, post-procedure education and the general flow of the endoscopy unit. According to estimates, the absolute economic benefit of endoscopist-directed propofol implementation in a screening setting is probably substantial, with 10-year savings of $3.2 billion in the USA. Guidelines concerning the use of propofol emphasize the need for adequate training and certification in sedation by non-anesthetists.

Pethidine dose and female sex as risk factors for nausea after esophagogastroduodenoscopy

Nausea and vomiting after esophagogastroduodenoscopy have not been studied in detail. The aim of this study was to evaluate the risk factors for post-endoscopic nausea. We performed a case-control study at the Toyoshima Endoscopy Clinic. Eighteen patients with post-endoscopic nausea and 190 controls without post-endoscopic nausea were analyzed. We conducted univariate and multivariate logistic regression analyses with respect to patient age; sex; body height; body weight; the use of psychotropic drugs as baseline medications; and the dosing amounts of midazolam, pethidine, flumazenil and naloxone. On univariate analysis, post-endoscopic nausea was significantly related with patient age (odds ratio = 0.946); female sex (odds ratio = 10.85); body weight (odds ratio = 0.975); and the dose per kg body weight of pethidine (odds ratio = 53.03), naloxone (odds ratio = 1.676), and flumazenil (odds ratio = 1.26). On multivariate analysis, the dose per kg body weight of pethidine (odds ratio = 21.67, p = 0.004) and female sex (odds ratio = 13.12, p = 0.047) were the factors independently associated with post-endoscopic nausea. The prevalence of nausea after esophagogastroduodenoscopy was 0.49% (18/3,654). In conclusion, post-endoscopic nausea was associated with the dose of pethidine and female sex.

Can sedation using a combination of propofol and dexmedetomidine enhance the satisfaction of the endoscopist in endoscopic submucosal dissection?

BACKGROUND AND STUDY AIMS

 The aim of this pilot randomized controlled trial was to evaluate and compare the satisfaction of the endoscopist along with the effectiveness and safety of sedation between sedation protocol using a combination of propofol (PF) and dexmedetomidine (DEX) (Combination group) and sedation protocol using PF alone (PF group) during gastric endoscopic submucosal dissection (ESD).

PATIENTS AND METHODS

Fifty-eight patients with gastric neoplasias scheduled for gastric ESD were enrolled and randomly assigned to the two groups. The satisfaction scores of the endoscopists and the parameters for the effectiveness and safety of sedation were evaluated by comparisons between the two groups.

RESULTS

The satisfaction scores of the endoscopists, which were measured using a visual analogue scale, were significantly higher in the Combination group than in the PF group (88 vs. 69, P  = 0.003). The maintenance dose of PF was lower in the Combination group than in the PF group (2 mg/kg/h vs. 5 mg/kg/h, P  < 0.001), and the number of rescue PF injections was fewer in the Combination group than in the PF group (2 times vs. 6 times, P  < 0.001). The incidence of bradycardia (defined as a pulse rate ≤ 45 bpm) in the Combination group was higher than that in the PF group (37.9 % vs. 10.3 %, P  = 0.029).

CONCLUSIONS

This study suggests that gastroenterologist-directed sedation using a combination of PF and DEX during gastric ESD can enhance the satisfaction levels of endoscopists by providing stable sedation with an acceptable safety profile.

Dexmedetomidine provides less body motion and respiratory depression during sedation in double-balloon enteroscopy than midazolam

Objectives:

Patients undergoing double-balloon enteroscopy require sedatives such as midazolam; however, patient’s body motion often hampers the outcome of double-balloon enteroscopy. Recently, dexmedetomidine has been used for endoscopic sedation and was reported to effectively reduce body motion. This study aimed to evaluate the efficacy and safety of sedation with dexmedetomidine in double-balloon enteroscopy (UMIN ID000015785).

Methods:

A prospective, observational study was conducted in 81 patients who underwent 111 double-balloon enteroscopy from July to December 2015 (dexmedetomidine group). The medical records of 112 patients who underwent 166 double-balloon enteroscopy with midazolam and pentazocine sedation from January 1 to October 31, 2014, were used for comparison (midazolam group). After propensity score matching, 182 double-balloon enteroscopy (91 double-balloon enteroscopy for each group) were analyzed.

Results:

There were 13 cases (11.7%) with body movements in the dexmedetomidine group. Comparison of the two groups matched by propensity score showed that the dexmedetomidine group had less body movement (12.1% vs 34.1%, p = 0.001) and less respiratory depression (50.5% vs 68.1%, p = 0.023). Hypotension (8.8% vs 4.4%, p = 0.232) and bradycardia (2.2% vs 0%, p = 0.497) were not significantly different in the two groups.

Conclusion:

Using dexmedetomidine for conscious sedation can reduce body motion and respiratory depression compared to our previous records.

Effect of dexmedetomidine in the prophylactic endoscopic injection sclerotherapy for oesophageal varices: a study protocol for prospective interventional study

Background

Dexmedetomidine (DEX) is a novel, highly selective α2-adrenoceptor agonist that elicits sedative, amnestic, sympatholytic and analgesic effects in patients. Several Japanese investigators have reported the clinical usefulness of DEX for sedation in endoscopic therapies for gastrointestinal malignancies; however, there have been limited data regarding the usefulness and safety of DEX for sedation during endoscopic procedures for oesophageal varices (OVs), such as endoscopic injection sclerotherapy (EIS). In this prospective, single-arm interventional study, we aimed to elucidate these issues.

Methods

Patients who require two or more sessions of prophylactic EIS for the treatment of OVs will be enrolled in this prospective interventional study. EIS procedures include two methods: (1) sedation during endoscopic procedures will be performed using conventional methods (pentazocine (PNZ) and midazolam (MDZ)), and (2) sedation during endoscopic procedures will be performed using PNZ, low-dose MDZ and DEX. These two methods were randomly assigned in the first and second EIS. The effect and safety of these two procedures with respect to patient sedation are to be compared with the degree of sedation evaluated using the Bispectral Index monitoring system (Aspect Medical Systems, Norwood, Massachusetts, USA).

Ethics and dissemination

This study received approval from the Institutional Review Board at Hyogo College of Medicine (approval no. 2324). The authors are committed to publishing the study results as widely as possible in peer-reviewed journals, and to ensuring that appropriate recognition is provided to everyone who is working on this study.

Trial registration number

UMIN000026688; Pre-results.

Dexmedetomidine vs propofol for gastrointestinal endoscopy: A meta-analysis

Background and aim

Several randomized controlled trials have compared sedation with dexmedetomidine and propofol in gastrointestinal endoscopy, with contradictory results. We conducted a meta-analysis of data from randomized controlled trials that compared dexmedetomidine with propofol.

Methods

We searched PubMed, the Cochrane library, and the Igaku-chuo-zasshi database for randomized trials eligible for inclusion in our meta-analysis. We identified six eligible randomized trials from the database search, and compared the effect of propofol versus dexmedetomidine with respect to: (a) patient's satisfaction level, (b) body movement or gagging, (c) cardiopulmonary complications, and (d) change in heart rate. Data from eligible studies were combined to calculate pooled risk difference (RD) or weighted mean difference (WMD).

Results

Compared to propofol, dexmedetomidine significantly decreased the patient's satisfaction level (WMD: -0.678, 95% confidence interval (CI): -1.149 to -0.207, p = 0.0048), and there was no significant heterogeneity among the trial results. The pooled RD for developing body movement or gagging when using dexmedetomidine was 0.107 (95% CI: -0.09 to 0.305, p = 0.288), with no significant differences. Compared with propofol, the pooled RD for hypotension, hypoxia, and bradycardia with dexmedetomidine sedation were -0.029 (95% CI: -0.11 to 0.05), -0.080 (95% CI: -0.178 to 0.018), and 0.022 (95% CI: -0.027 to 0.07), respectively, with no significant differences. Compared to propofol, dexmedetomidine significantly decreased the heart rate (WMD: -10.41, 95% CI: -13.77 to -7.051, p ≤ 0.0001), without significant heterogeneity.

Conclusions

In gastrointestinal endoscopy, patient satisfaction level was higher in propofol administration, when compared to dexmedetomidine. The risk of complications was similar.

Effect of prophylactic clipping in colorectal endoscopic resection: A meta-analysis of randomized controlled studies

BACKGROUND AND AIM

The efficacy of clipping for preventing delayed bleeding after colorectal endoscopic resection is still controversial. To assess the efficacy of prophylactic clipping, we conducted a meta-analysis of randomized controlled trials.

METHODS

We searched PubMed, the Cochrane library, and the Igaku-chuo-zasshi database for randomized trials eligible for inclusion in our meta-analysis. We identified seven eligible randomized trials from the database search, and compared the effect of clipping versus non-clipping with respect to delayed bleeding and perforation. Data from eligible studies were combined to calculate pooled odds ratios (ORs).

RESULTS

Postoperative bleeding was observed in 41 of 1526 cases (2.7%) without clipping and in 32 of 1533 cases (2.1%) with clipping (OR 0.76, 95% CI: 0.39-1.47, p = 0.414). There was no significant heterogeneity among the trial results (I-Square = 26.7%, p = 0.22). In the subgroup analysis based on small tumor size (<20 mm) and large tumor size (≥20 mm), there were no significant differences. Compared with non-clipping, the pooled OR of developing perforation with clipping was 1.00 (95% CI: 0.14-7.25), indicating no significant difference between the two groups.

CONCLUSIONS

Prophylactic clipping did not decrease the occurrence of delayed bleeding after colorectal endoscopic resection. Clipping could be of interest in patients with a high risk of bleeding (anticoagulation) or large lesions, but with the available trials data to prove this are scarce.

Feasibility of deep sedation with a combination of propofol and dexmedetomidine hydrochloride for esophageal endoscopic submucosal dissection

BACKGROUND AND AIM

The aim of the present study was to evaluate the efficacy and safety of sedation with a combination of propofol (PF) and dexmedetomidine (DEX) compared with sedation with benzodiazepines in esophageal endoscopic submucosal dissection (ESD).

METHODS

We retrospectively reviewed clinical data for 40 consecutive patients who had undergone esophageal ESD at the Yokohama City University Hospital between July 2012 and August 2014. Of these patients, 20 were sedated with benzodiazepines (conventional group) and another 20 patients were sedated with a combination of PF and DEX (combination group). Parameters for efficacy and safety of sedation were evaluated by comparisons between the two groups.

RESULTS

Median procedural times in the combination group were shorter than those in the conventional group (61 min vs. 89 min, P = 0.03), and the percentage of patients who showed restlessness in the combination group was significantly lower than that in the conventional group (25% vs. 65%, P = 0.025). Incidences of hypotension and bradycardia in the combination group were higher than those in the conventional group (60% vs. 15%, P = 0.008, and 60% vs. 15%, P = 0.008, respectively).

CONCLUSION

This retrospective study suggests that a combination of PF and DEX may provide stable deep sedation with less body movement than benzodiazepines during esophageal ESD.

Effects of different doses of dexmedetomidine on heart rate and blood pressure in intensive care unit patients

The aim of the present study was to observe and compare the sedative effect of different doses of DEX on heart rate (HR) and blood pressure (BP) in critically ill patients admitted to intensive care units (ICUs). The study included patients that were retained in ICUs and required sedation between January and March 2014. Patients were excluded if they had a BP of >200 mmHg, a HR of <60 bpm or were in a state of shock. The included patients were randomized into three groups: Group A, 1.0 µg/kg/10 min DEX; group B, 0.5 µg/kg/10 min DEX; and group C, 0.4 µg/kg/h DEX. After receiving these initial designated doses of DEX via an intravenous (IV) infusion pump for 10 min, the patients were maintained continuously at an identical dose of 0.4 µg/kg/h DEX. Ramsay score, HR, systolic blood pressure (SBP), diastolic blood pressure (DBP), breathing rate (BR) and peripheral capillary oxygen saturation (SpO₂) were recorded prior to the IV pump infusion and at 2, 4, 6, 8, 10, 60, 120, 180 and 240 min following infusion. Patients in groups A and B achieved sedation more rapidly compared with those in group C (P<0.05). HR decreased more significantly at 8 and 60 min after the initial IV pump infusion with DEX in groups A and B compared with group C (P<0.05). SBP decreased significantly at 10 min after IV pump infusion in group A compared with groups B and C (P<0.05). No significant difference existed in the SBP reduction trend between the three groups during the maintenance period. Therefore, the routine dose of DEX (0.4 µg/kg/h) provides an ideal sedative effect in ICU patients. The recommended loading dose for a more rapid sedation is 0.5 µg/kg/h. High loading doses of DEX via IV pump infusion should be avoided in elderly individuals, patients with acute exacerbation of chronic obstructive pulmonary disease and anemic patients, in whom combination medication, such as midazolam or propofol, may be considered when necessary.

Timing of oral refeeding in acute pancreatitis: A systematic review and meta-analysis

BACKGROUND AND AIM

The optimal timing of oral refeeding in acute pancreatitis is unclear. This study aimed to perform a systematic review with meta-analysis of randomized controlled trials (RCTs) that compared early oral refeeding with standard oral refeeding in acute pancreatitis.

METHODS

PubMed, the Cochrane library, and the Igaku-Chuo-Zasshi database were searched in order to identify RCTs eligible for inclusion in the systematic review. The weighted mean differences (WMDs) or odds ratios (ORs) with 95% confidence intervals (CIs) were calculated.

RESULTS

Five eligible RCTs were included. Compared with standard oral refeeding, early oral refeeding significantly decreased the length of hospital stay (WMD: -2.22, 95%CI: -3.37 to -1.08, p = 0.0001). Although there was heterogeneity (I²= 56%, p = 0.06), subgroup analysis of the refeeding criteria (immediate group and hungry group) eliminated the heterogeneity. There was no significant difference between the early refeeding group and standard refeeding groups with respect abdominal pain and distension (OR 1.14; 95%CI 0.65-1.99 and OR 1.53; 95%CI 0.81-2.90).

CONCLUSIONS

Compared with standard oral refeeding, early oral refeeding safely reduced the length of hospital stay in patients with acute pancreatitis.

Effects of preoperative proton pump inhibitor administration on bleeding after gastric endoscopic submucosal dissection: A systematic review and meta-analysis

BACKGROUND AND AIM

The efficacy of using proton pump inhibitors (PPIs) prior to gastric endoscopic submucosal dissection (ESD) to reduce gastric bleeding remains controversial. This study aimed to systematically review the literature to evaluate the efficacy of preoperative PPI use to reduce post-ESD bleeding.

METHODS

PubMed, the Cochrane library, and the Igaku-Chuo-Zasshi database were searched to identify randomized trials eligible for inclusion in the systematic review. Data from four studies (406 patients) were combined to calculate a pooled risk difference (RD) for developing post-ESD bleeding.

RESULTS

Compared with patients who received no premedication, the pooled RD for post-ESD bleeding in patients who received preoperavive PPI was -0.027 (95% confidence interval: -0.070-0.017, p = 0.228), without significant heterogeneity. Preoperavive PPI use significantly increased gastric pH (weighted mean difference: 1.289, 95% CI: 0.227-2.352, p = 0.0174).

CONCLUSIONS

This systematic review and meta-analysis showed that premedication with PPI had no advantage for the prevention of post-ESD bleeding, despite increasing gastric pH.

Effects of carbon dioxide insufflation in balloon-assisted enteroscopy: A systematic review and meta-analysis

BACKGROUND AND AIM

The efficacy of CO2 insufflation during balloon-assisted enteroscopy remains controversial. This study aimed to perform a systematic review with meta-analysis of randomized controlled trials (RCTs) in which CO2 insufflation was compared with air insufflation in balloon-assisted enteroscopy.

METHODS

PubMed, the Cochrane library, and the Igaku-Chuo-Zasshi database were searched to identify RCTs eligible for inclusion in the systematic review. Data from the eligible studies were combined to calculate the pooled odds ratios (ORs) or weighted mean differences (WMDs) with 95% confidence intervals (CIs).

RESULTS

Four RCTs (461 patients) were identified. Compared with air insufflation, CO2 insufflation significantly increased intubation depth of oral enteroscopy (WMD: 55.2, 95% CI: 10.77-99.65, p = 0.015). However, there was significant heterogeneity. The intubation depth of anal enteroscopy showed no significant difference between the CO2 group and the air group. CO2 insufflation significantly reduced abdominal pain compared with air insufflation (WMD: -2.463, 95% CI: -4.452 to -0.474, p = 0.015), without significant heterogeneity. The PaCO2 or end-tidal CO2 level showed no significant difference between the CO2 group and air group.

CONCLUSIONS

Compared with air insufflation, CO2 insufflation during balloon-assisted enteroscopy caused less post-procedural pain without CO2 retention.