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Ichijima R, Ikehara H, Yamaguchi D, Nagata Y, Ogura K, Esaki M, Minoda Y, Ono H, Maeda Y, Kiriyama S, Sumiyoshi T, Kanmura Y, Gotoda T. Randomized controlled trial of remimazolam compared with placebo in Japanese patients undergoing upper gastrointestinal endoscopy: Phase III investigator-initiated clinical trial. Dig Endosc 2024. [PMID: 38403959 DOI: 10.1111/den.14758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 01/09/2024] [Indexed: 02/27/2024]
Abstract
OBJECTIVES To assess the effectiveness of remimazolam against normal saline (placebo) as a sedative agent for endoscopy in a multicenter, randomized, double-blind, investigator-initiated phase III controlled trial. METHODS We included 48 Japanese patients undergoing upper gastrointestinal endoscopy. For the procedure, an initial remimazolam dose of 3 mg and additional doses of 1 mg were administered, as determined in the phase II clinical study. The primary study end-point was the successful sedation rate during gastrointestinal endoscopy, determined as a Modified Observer's Assessment of Alertness/Sedation score ≤4 before the start of endoscopy, the completion of gastrointestinal endoscopy, and two or fewer additional doses per 6 min. RESULTS The successful endoscopy sedation rates were 91.9% and 9.1% in the remimazolam and placebo groups, respectively (P < 0.01). The time from the end of endoscopy to arousal was 0.0 (0.0-0.0) min for both groups. The number of additional doses required to achieve sedation was lower in the remimazolam group than that in the placebo group (P < 0.01). CONCLUSIONS Remimazolam demonstrated a significantly higher sedation effect during upper gastrointestinal endoscopy in Japanese patients with safe and fast recovery compared with placebo.
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Affiliation(s)
- Ryoji Ichijima
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
- Department of Gastroenterology, Kiriyama Clinic, Gunma, Japan
| | - Hisatomo Ikehara
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
- Department of Gastroenterology, Internal Medicine, Kitasato University School of Medicine, Kanagawa, Japan
| | - Daisuke Yamaguchi
- Department of Gastroenterology, National Hospital Organization Ureshino Medical Center, Saga, Japan
| | - Yasuhiko Nagata
- Department of Gastroenterology, Nagata Surgery and Gastroenterological Clinic, Tokyo, Japan
| | - Kanako Ogura
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
- Department of Gastroenterology, Nagata Surgery and Gastroenterological Clinic, Tokyo, Japan
| | - Mitsuru Esaki
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yosuke Minoda
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hiroyuki Ono
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Yuki Maeda
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | | | | | - Yuichi Kanmura
- Department of Anesthesiology, Fujimoto General Hospital, Miyazaki, Japan
| | - Takuji Gotoda
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
- Department of Gastroenterology, Cancer Institute Hospital, Tokyo, Japan
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Oue K, Oda A, Shimizu Y, Takahashi T, Kamio H, Sasaki U, Imamura S, Imado E, Mukai A, Doi M, Sakuma M, Ono S, Aikawa T, Yoshida M. Efficacy and safety of remimazolam besilate for sedation in outpatients undergoing impacted third molar extraction: a prospective exploratory study. BMC Oral Health 2023; 23:774. [PMID: 37865761 PMCID: PMC10589926 DOI: 10.1186/s12903-023-03538-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 10/12/2023] [Indexed: 10/23/2023] Open
Abstract
BACKGROUND Dental treatments often cause anxiety, fear, and stress in patients. Intravenous sedation is widely used to alleviate these concerns, and various agents are employed for sedation. However, it is important to find safer and more effective sedation agents, considering the adverse effects associated with current agents. This study aimed to investigate the efficacy and safety of remimazolam besilate (hereinafter called "remimazolam") and to determine the optimal dosages for sedation in outpatients undergoing dental procedures. METHODS Thirty-one outpatients aged 18-65 years scheduled for impacted third molar extraction were included in the study. Remimazolam was administered as a single dose of 0.05 mg/kg followed by a continuous infusion at a rate of 0.35 mg/kg/h, with the infusion rate adjusted to maintain a sedation level at a Modified Observer's Assessment of Alertness/Sedation (MOAA/S) score of 2-4. The primary endpoint was the sedation success rate with remimazolam monotherapy, and the secondary endpoints included induction time, recovery time, time until discharge, remimazolam dose, respiratory and circulatory dynamics, and frequency of adverse events. RESULTS The sedation success rate with remimazolam monotherapy was 100%. The remimazolam induction dose was 0.08 (0.07-0.09) mg/kg, and the anesthesia induction time was 3.2 (2.6-3.9) min. The mean infusion rate of remimazolam during the procedure was 0.40 (0.38-0.42) mg/kg/h. The time from the end of remimazolam administration to awakening was 8.0 (6.7-9.3) min, and the time from the end of remimazolam administration to discharge was 14.0 (12.5-15.5) min. There were no significant respiratory or circulatory effects requiring intervention during sedation. CONCLUSIONS Continuous intravenous administration of remimazolam can achieve optimal sedation levels without significantly affecting respiratory or circulatory dynamics. The study also provided guidance on the appropriate dosage of remimazolam for achieving moderate sedation during dental procedures. Additionally, the study findings suggest that electroencephalogram monitoring can be a reliable indicator of the level of sedation during dental procedural sedation with remimazolam. TRIAL REGISTRATION The study was registered in the Japan Registry of Clinical Trials (No. jRCTs061220052) on 30/08/2022.
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Affiliation(s)
- Kana Oue
- Division of Oral and Maxillofacial Surgery and Oral Medicine, Department of Dental Anesthesiology, Hiroshima University Hospital, Kasumi 1-2-3, Minami-ku, Hiroshima, Japan.
| | - Aya Oda
- Division of Oral and Maxillofacial Surgery and Oral Medicine, Department of Dental Anesthesiology, Hiroshima University Hospital, Kasumi 1-2-3, Minami-ku, Hiroshima, Japan
| | - Yoshitaka Shimizu
- Department of Dental Anesthesiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Kasumi 1-2-3, Minami-ku, Hiroshima, Japan
| | - Tamayo Takahashi
- Division of Oral and Maxillofacial Surgery and Oral Medicine, Department of Dental Anesthesiology, Hiroshima University Hospital, Kasumi 1-2-3, Minami-ku, Hiroshima, Japan
| | - Hisanobu Kamio
- Division of Oral and Maxillofacial Surgery and Oral Medicine, Department of Dental Anesthesiology, Hiroshima University Hospital, Kasumi 1-2-3, Minami-ku, Hiroshima, Japan
| | - Utaka Sasaki
- Division of Oral and Maxillofacial Surgery and Oral Medicine, Department of Dental Anesthesiology, Hiroshima University Hospital, Kasumi 1-2-3, Minami-ku, Hiroshima, Japan
| | - Serika Imamura
- Division of Oral and Maxillofacial Surgery and Oral Medicine, Department of Dental Anesthesiology, Hiroshima University Hospital, Kasumi 1-2-3, Minami-ku, Hiroshima, Japan
| | - Eiji Imado
- Division of Oral and Maxillofacial Surgery and Oral Medicine, Department of Dental Anesthesiology, Hiroshima University Hospital, Kasumi 1-2-3, Minami-ku, Hiroshima, Japan
| | - Akari Mukai
- Department of Dental Anesthesiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Kasumi 1-2-3, Minami-ku, Hiroshima, Japan
| | - Mitsuru Doi
- Department of Dental Anesthesiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Kasumi 1-2-3, Minami-ku, Hiroshima, Japan
| | - Miyuki Sakuma
- Department of Oral and Maxillofacial Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Kasumi 1-2-3, Minami-ku, Hiroshima, Japan
| | - Shigehiro Ono
- Department of Oral and Maxillofacial Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Kasumi 1-2-3, Minami-ku, Hiroshima, Japan
| | - Tomonao Aikawa
- Department of Oral and Maxillofacial Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Kasumi 1-2-3, Minami-ku, Hiroshima, Japan
| | - Mitsuhiro Yoshida
- Division of Oral and Maxillofacial Surgery and Oral Medicine, Department of Dental Anesthesiology, Hiroshima University Hospital, Kasumi 1-2-3, Minami-ku, Hiroshima, Japan
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Su M, Zhu Y, Liu S, Song L, Qu J, Zhang Y, Zhang Q. Median effective dose (ED 50) of esketamine combined with propofol for children to inhibit response of gastroscope insertion. BMC Anesthesiol 2023; 23:240. [PMID: 37464290 PMCID: PMC10354894 DOI: 10.1186/s12871-023-02204-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 07/11/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND Propofol is the most commonly used drug for procedural sedation during gastroscopy. However, independent use of propofol can lead to increased dosage and additional side effects. Esketamine was found to be exceptional in combination with propofol for painless gastroscopy. No studies have calculated the median effective dose (ED50) of esketamine combined with propofol in pediatric painless gastroscopy. Here, we designed a research to study the ED50 of esketamine combined with propofol using the Dixon and Massey up-and-down sequential method for inhibiting the response of gastroscope insertion. METHODS Children who met the inclusion and exclusion criteria were included in this study. Propofol and esketamine were used as anesthetics for painless gastroscopy in children. To explore the ED50, the initial propofol dose was set at 3 mg/kg in all children. The first child was given an esketamine dose of 0.1 mg/kg, followed by 30 s of slow bolus injection propofol. If anesthesia induction failed (coughing or body movement of children during gastroscope insertion), the esketamine dose was elevated in the next child, with a interval difference of 0.05 mg/kg. Otherwise, if the anesthesia induction was successful, the next dosage was reduced by 0.05 mg/kg. The study was stopped if nine crossover inflection points were reached. The ED50 of esketamine was calculated using probit regression, and the blood pressure, pulse oxygen saturation, heart rate, recovery time, and side effects were recorded in all children. RESULTS A total of 26 children were included in this study. The ED50 of esketamine combined with 3 mg/kg propofol was 0.143 mg/kg (95% CI 0.047-0.398 mg/kg). The total consumption of propofol was 16.04 ± 5.37 mg. The recovery time was 16.38 ± 8.70 min. Adverse effects recorded were delayed awakening in two cases and increased oral secretions of another child during the examination inducing cough and hypoxemia (86% was the lowest). DISCUSSION The ED50 of esketamine was 0.143 mg/kg when combined with 3 mg/kg propofol for successful sedation in pediatric gastroscope insertion. This sub-anaesthetic dose of esketamine was safe and efficacious with few complications in pediatric painless gastroscopy. TRIAL REGISTRATION The study was registered at the Chinese Clinical Trial Registry ( www.chictr.org.cn ; registration number: ChiCTR2100052830 on 06/11/2021).
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Affiliation(s)
- Ming Su
- Binzhou Medical University Hospital, Binzhou, China
| | - Yichao Zhu
- Binzhou Medical University Hospital, Binzhou, China
| | - Shupeng Liu
- Binzhou Medical University Hospital, Binzhou, China
| | - Lijuan Song
- Binzhou Medical University Hospital, Binzhou, China
| | - Jiangtao Qu
- Binzhou Medical University Hospital, Binzhou, China
| | - Yong Zhang
- Binzhou Medical University Hospital, Binzhou, China
| | - Quanyi Zhang
- Binzhou Medical University Hospital, Binzhou, China.
- Department of Anesthesiology, Binzhou Medical University Hospital, Huanghe-Str.2, Binzhou, China.
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Long YQ, Wang D, Chen S, Xu Y, Feng CD, Ji FH, Cheng H, Peng K. Effect of balanced opioid-free anaesthesia on postoperative nausea and vomiting after video-assisted thoracoscopic lung resection: protocol for a randomised controlled trial. BMJ Open 2022; 12:e066202. [PMID: 36414282 PMCID: PMC9685244 DOI: 10.1136/bmjopen-2022-066202] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Opioid-free anaesthesia (OFA) may reduce opioid-related side effects such as postoperative nausea and vomiting (PONV) and hyperalgesia. This study aims to investigate the effects of balanced OFA on PONV and pain outcomes in patients undergoing video-assisted thoracoscopic surgery (VATS). METHODS AND ANALYSIS This randomised controlled trial will be conducted at the First Affiliated Hospital of Soochow University in Suzhou, China. A total of 120 adults scheduled for VATS lung resection will be randomly assigned with a 1:1 ratio to either an OFA group or a control group, stratified by sex (n=60 in each group). Patients will receive balanced anaesthesia with esketamine, dexmedetomidine and sevoflurane (the OFA group), or sufentanil and sevoflurane (the control group). All patients will receive PONV prophylaxis with intraoperative dexamethasone and ondansetron. Multimodal analgesia consists of intraoperative flurbiprofen axetil, ropivacaine infiltration at the end of surgery and postoperative patient-controlled sufentanil. The primary outcome is the incidence of PONV within 48 hours after surgery. Secondary outcomes are nausea, vomiting, need for antiemetic therapy, pain scores at rest and while coughing, postoperative sufentanil consumption, need for rescue analgesia, length of post-anaesthesia care unit stay, length of postoperative hospital stay, and 30-day and 90-day post-surgical pain and mortality. Safety outcomes are hypotension, bradycardia, hypertension, tachycardia, interventions for haemodynamic events, level of sedation, headache, dizziness, nightmare and hallucination. All analyses will be performed in the modified intention-to-treat population. ETHICS AND DISSEMINATION Ethics approval was obtained from the Ethics Committee of the First Affiliated Hospital of Soochow University (2022-042). All patients will provide written informed consent. The results of this study will be published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER Chinese Clinical Trial Registry (ChiCTR2200059710).
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Affiliation(s)
- Yu-Qin Long
- Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anaesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Dan Wang
- Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anaesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Shaomu Chen
- Thoracic Surgery, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Yu Xu
- Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Anesthesiology, Suzhou Xiangcheng People's Hospital, Suzhou, China
| | - Chang-Dong Feng
- Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anaesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Fu-Hai Ji
- Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anaesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Hao Cheng
- Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anaesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Ke Peng
- Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anaesthesiology, Soochow University, Suzhou, Jiangsu, China
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Song N, Shan XS, Yang Y, Zheng Z, Shi WC, Yang XY, Li Y, Tan AP, Liu H, Peng K, Ji FH. Low-Dose Esketamine as an Adjuvant to Propofol Sedation for Same-Visit Bidirectional Endoscopy: Protocol for a Multicenter Randomized Controlled Trial. Int J Gen Med 2022; 15:4733-4740. [PMID: 35571286 PMCID: PMC9091685 DOI: 10.2147/ijgm.s365068] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 04/29/2022] [Indexed: 11/23/2022] Open
Abstract
Background Same-visit bidirectional endoscopy (esophagogastroduodenoscopy and colonoscopy) is widely performed under sedation. At present, the optimal sedation regimen remains unclear. This study aims to test the hypothesis that a low-dose esketamine added to propofol sedation reduces hemodynamic and respiratory adverse events in these procedures. Methods In this multicenter, randomized, double-blind, placebo-controlled trial, 660 adult patients scheduled for same-visit bidirectional endoscopy under sedation from 3 teaching hospitals in China will be recruited. Patients will be randomly allocated, in a 1:1 ratio, to an esketamine group or a normal saline group (n = 330 in each group), stratified by study center. All patients will receive intravenous propofol 0.5 mg/kg and sufentanil 0.1 μg/mL for induction of sedation, followed by intravenous esketamine 0.15 mg/kg or the same volume of normal saline. Propofol will be titrated to the target sedation levels during the procedures. The primary endpoint is a composite of desaturation (peripheral oxygen saturation < 90%) and hypotension (systolic blood pressure <80 mmHg or decrease >30% of baseline). Secondary endpoints include desaturation, hypotension, total dose of propofol, pain scores and fatigue scores on the 0-10 numerical rating scale, dizziness or headache, hallucination or nightmare, nausea or vomiting, endoscopist satisfaction, and patient satisfaction. All analyses will be intention-to-treat. Discussion We expect that a low-dose esketamine adjunct to propofol-based sedation will improve cardiorespiratory stability in patients undergoing same-visit bidirectional endoscopy, providing reference for clinical sedation practice during these procedures. Trial Registration Chinese Clinical Trial Registry (Identifier: ChiCTR-ChiCTR2200055938).
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Affiliation(s)
- Nan Song
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, People’s Republic of China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, People’s Republic of China
| | - Xi-Sheng Shan
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, People’s Republic of China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, People’s Republic of China
| | - Yi Yang
- Department of Anesthesiology, the People’s Hospital of SND, Suzhou, Jiangsu, People’s Republic of China
| | - Zhong Zheng
- Department of Anesthesiology, Taicang First People’s Hospital, Taicang, Jiangsu, People’s Republic of China
| | - Wen-Cheng Shi
- Department of Anesthesiology, Taicang First People’s Hospital, Taicang, Jiangsu, People’s Republic of China
| | - Xiao-Yan Yang
- Department of Anesthesiology, the People’s Hospital of SND, Suzhou, Jiangsu, People’s Republic of China
| | - Yang Li
- Department of Anesthesiology, the People’s Hospital of SND, Suzhou, Jiangsu, People’s Republic of China
| | - Ai-Ping Tan
- Department of Anesthesiology, the People’s Hospital of SND, Suzhou, Jiangsu, People’s Republic of China
| | - Hong Liu
- Department of Anesthesiology and Pain Medicine, University of California Davis Health System, Sacramento, CA, USA
| | - Ke Peng
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, People’s Republic of China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, People’s Republic of China
| | - Fu-Hai Ji
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, People’s Republic of China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, People’s Republic of China
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Ang TL, Seet E, Goh YC, Ng WK, Koh CJ, Lui HF, Li JW, Oo AM, Lim KBL, Ho KS, Chew MH, Quan WL, Tan DMY, Ng KH, Goh HS, Cheong WK, Tseng P, Ling KL. Academy of Medicine, Singapore clinical guideline on the use of sedation by non-anaesthesiologists during gastrointestinal endoscopy in the hospital setting. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2022; 51:24-39. [PMID: 35091728 DOI: 10.47102/annals-acadmedsg.2021306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
INTRODUCTION In Singapore, non-anaesthesiologists generally administer sedation during gastrointestinal endoscopy. The drugs used for sedation in hospital endoscopy centres now include propofol in addition to benzodiazepines and opiates. The requirements for peri-procedural monitoring and discharge protocols have also evolved. There is a need to develop an evidence-based clinical guideline on the safe and effective use of sedation by non-anaesthesiologists during gastrointestinal endoscopy in the hospital setting. METHODS The Academy of Medicine, Singapore appointed an expert workgroup comprising 18 gastroenterologists, general surgeons and anaesthesiologists to develop guidelines on the use of sedation during gastrointestinal endoscopy. The workgroup formulated clinical questions related to different aspects of endoscopic sedation, conducted a relevant literature search, adopted Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology and developed recommendations by consensus using a modified Delphi process. RESULTS The workgroup made 16 recommendations encompassing 7 areas: (1) purpose of sedation, benefits and disadvantages of sedation during gastrointestinal endoscopy; (2) pre-procedural assessment, preparation and consent taking for sedation; (3) Efficacy and safety of drugs used in sedation; (4) the role of anaesthesiologist administered sedation during gastrointestinal endoscopy; (5) performance of sedation; (6) post-sedation care and discharge after sedation; and (7) training in sedation for gastrointestinal endoscopy for non-anaesthesiologists. CONCLUSION These recommendations serve to guide clinical practice during sedation for gastrointestinal endoscopy by non-anaesthesiologists in the hospital setting.
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Affiliation(s)
- Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
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Gotoda T, Akamatsu T, Abe S, Shimatani M, Nakai Y, Hatta W, Hosoe N, Miura Y, Miyahara R, Yamaguchi D, Yoshida N, Kawaguchi Y, Fukuda S, Isomoto H, Irisawa A, Iwao Y, Uraoka T, Yokota M, Nakayama T, Fujimoto K, Inoue H. Guidelines for sedation in gastroenterological endoscopy (second edition). Dig Endosc 2021; 33:21-53. [PMID: 33124106 DOI: 10.1111/den.13882] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 10/12/2020] [Accepted: 10/21/2020] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Takuji Gotoda
- Japanese Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Takuji Akamatsu
- Japanese Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Seiichiro Abe
- Japanese Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Yousuke Nakai
- Japanese Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Waku Hatta
- Japanese Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Naoki Hosoe
- Japanese Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Yoshimasa Miura
- Japanese Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Ryoji Miyahara
- Japanese Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Naohisa Yoshida
- Japanese Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Shinsaku Fukuda
- Japanese Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Hajime Isomoto
- Japanese Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Atsushi Irisawa
- Japanese Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Yasushi Iwao
- Japanese Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Toshio Uraoka
- Japanese Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Takeo Nakayama
- Department of Health Informatics, Kyoto University School of Public Health, Kyoto, Japan
| | - Kazuma Fujimoto
- Japanese Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Haruhiro Inoue
- Japanese Gastroenterological Endoscopy Society, Tokyo, Japan
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The Comparison of Midazolam and Propofol in Gastrointestinal Endoscopy: A Systematic Review and Meta-analysis. Surg Laparosc Endosc Percutan Tech 2018; 28:153-158. [PMID: 29738382 DOI: 10.1097/sle.0000000000000532] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Midazolam and propofol are both used for sedation in gastrointestinal endoscopy. We conducted a systematic review and meta-analysis to compare the efficacy and safety of midazolam and propofol in gastrointestinal endoscopy. MATERIALS AND METHODS PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases were systematically searched. Randomized controlled trials assessing the effect of midazolam versus propofol on sedation in gastrointestinal endoscopy are included. Two investigators have independently searched for articles, extracted data, and assessed the quality of included studies. This meta-analysis was performed using the random-effect model. RESULTS Five randomized controlled trials involving 552 patients were included in the meta-analysis. Overall, compared with midazolam sedation during gastrointestinal endoscopy, propofol sedation results in higher endoscopist satisfaction scores during gastrointestinal endoscopy than midazolam [standard mean difference (Std. MD)=-0.71; 95% confidence interval (CI)=-1.05 to -0.37; P<0.0001), but the comparison shows no remarkable influence on patient satisfaction scores between midazolam and propofol (Std. MD=-0.34; 95% CI=-0.88 to 0.20; P=0.21), procedure time (Std. MD=0.14; 95% CI=-0.13 to 0.42; P=0.31), hypoxia [risk ratio (RR)=0.86; 95% CI=0.53-1.38; P=0.53), and bradycardia (RR=1.05; 95% CI=0.54-2.06; P=0.89). In addition, propofol shows higher incidence of hypotension than midazolam (RR=0.58; 95% CI=0.34-0.99; P=0.04). CONCLUSIONS When compared with midazolam sedation for gastrointestinal endoscopy, propofol sedation results in higher endoscopist satisfaction scores, but may increase the incidence of hypotension.
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Kim EH, Park JC, Shin SK, Lee YC, Lee SK. Effect of the midazolam added with propofol-based sedation in esophagogastroduodenoscopy: A randomized trial. J Gastroenterol Hepatol 2018; 33:894-899. [PMID: 29048708 DOI: 10.1111/jgh.14026] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Revised: 10/11/2017] [Accepted: 10/12/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM Although propofol has been widely used for sedation during esophagogastroduodenoscopy (EGD), adverse events including hypoxia and hypotension may be a concern in the propofol-based sedation. We aimed to analyze whether administration of midazolam would improve safety and efficacy of propofol-based sedation in EGD. METHODS One hundred twenty patients who were scheduled to undergo diagnostic EGD were randomly assigned to either midazolam plus propofol (MP) or propofol alone groups. In the MP group, 2 mg of midazolam and 10 mg of propofol were given initially. In the propofol alone group, 40-60 mg of propofol was given initially. In both groups, 20 mg of propofol was given repeatedly to maintain moderate sedation as needed. Vital signs including oxygen saturation were monitored every 2 min. After the patients fully recovered, satisfaction score was investigated from endoscopists, nurses, and patients, respectively. RESULTS The baseline characteristics did not differ between the MP and propofol alone groups. The mean required doses of propofol was (mean ± standard deviation) 0.3 ± 0.3 and 0.8 ± 0.2 mg/kg in the MP and propofol alone groups, respectively (P < 0.001). In addition, sedation-related adverse events and recovery time did not differ between the two groups. The proportion of satisfactory did not differ between the two groups (MP vs propofol alone; proportion; patient, 95.0% vs 93.3%, P > 0.999; endoscopist, 73.3% vs 80.0%, P = 0.064; nurse, 73.3% vs 76.7%, P = 0.551). CONCLUSION Adding midazolam to propofol did not reduced the safety and efficacy, and sedation using propofol alone could be suitable for sedation during diagnostic EGD.
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Affiliation(s)
- Eun Hye Kim
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jun Chul Park
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Kwan Shin
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Chan Lee
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Kil Lee
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Nishizawa T, Suzuki H, Hosoe N, Ogata H, Kanai T, Yahagi N. Dexmedetomidine vs propofol for gastrointestinal endoscopy: A meta-analysis. United European Gastroenterol J 2017; 5:1037-1045. [PMID: 29163971 DOI: 10.1177/2050640616688140] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 12/12/2016] [Indexed: 12/21/2022] Open
Abstract
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.
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Affiliation(s)
- Toshihiro Nishizawa
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan.,Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Hidekazu Suzuki
- Medical Education Center, Keio University School of Medicine, Tokyo, Japan
| | - Naoki Hosoe
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo, Japan
| | - Haruhiko Ogata
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo, Japan
| | - Takanori Kanai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Naohisa Yahagi
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
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