Propofol infusion for sedation in outpatient oral surgery. A comparison with diazepam

Randomised Comparative Study on Propofol and Diazepam as a Sedating Agent in Day Care Surgery

OBJECTIVE

The study was conducted to assess the usefulness by qualitative comparison between the two intravenous sedative drugs, Diazepam and Propofol and to provide sedation in apprehensive and uncooperative patients undergoing day care oral surgical procedures.

METHODS

The present study was conducted on 20 adult patients, 10 in each group (Propofol and Diazepam) irrespective of age and sex. Intravenous sedation of Propofol compared with Diazepam in terms of onset of action, recovery, and anterograde amnesia, patient co-operation, surgeon's convenience and side effects and other parameters.

RESULTS

Propofol was found to be the superior sedating agent compared to Diazepam, having rapid onset and predictability of action, profoundness of amnesia and a faster recovery period, offering advantages of early patient discharge and better patient compliance.

CONCLUSION

Propofol was found to be an ideal sedating agent in day care oral surgical procedures.

A survey of the opinions of consultant anaesthetists in Scotland of sedation carried out by dentists

OBJECTIVES

To elicit the attitudes and opinions of consultant anaesthetists working in Scotland, with regard to conscious sedation carried out by dental practitioners.

METHOD

A questionnaire was designed to gauge opinion of consultant anaesthetists in Scotland on the practice of conscious sedation by dentists. The questionnaire was sent to 353 consultant anaesthetists working in 49 hospitals within the 15 health boards in Scotland.

RESULTS

Of the 366 questionnaires sent, 249 were returned of which 235 were valid. This gave a response rate of 64%. In general, those questioned felt that the provision of sedation in a hospital setting was more appropriate than in general dental practice. A majority (65%) thought that it was unrealistic for anaesthetists to provide all sedation for dental treatment, although many (58%) felt that anaesthetists should take more responsibility in this area. Again, a majority (60%) agreed that dentists should be trained to use sedation techniques for their patients but a significant number (63%) disagreed with the practice of operator/sedationist.

CONCLUSION

It is of concern to the dental profession that a significant number of anaesthetists do not feel that it is appropriate for dentists to be administering even the most simple methods of sedation. At present there are no clear, recognised guidelines as to the level of formal training required for the practice of conscious sedation by dentists. It is in the interests of the dental profession and the public to ensure that those choosing to practice sedation do so safely by following recognised guidelines in the training and practice of sedation.

Low-dose propofol infusion for sedation during local anesthesia

The safety and efficacy of lose-dose propofol for sedation were investigated on 90 consenting patients who had undergone surgical procedures with local anesthesia. After being premedicated with intravenous midazolam 0.05 mg.kg(-1), all patients were randomly divided into two groups and received intravenously either a loading dose of propofol 0.8 mg.kg(-1) followed by a continuous infusion of propofol 30 microg.kg(-1)min(-1) (propofol group) or an equivalent volume of saline (placebo group) during operation. Study groups were compared with respect to the level of sedation, hemodynamic variables, oxygen saturation, and the incidence of intraoperative side effects. In addition, the discharge time and the satisfaction of both patients and surgeons with this sedative technique were assessed. Propofol reduced patients' discomfort and lowered their arterial pressure and heart rate during the infiltration of local anesthetics. It also promoted an adequate level of sedation without clinically significant oxygen desaturation in the intraoperative period. Surgeons and patients in the propofol group showed a higher level of satisfaction than those in the placebo group. There was no significant difference between the two groups with regard to the incidence of adverse effects and the discharge time. In conclusion, it was found that the use of low-dose propofol infusion was a safe and effective sedative technique for local anesthesia.

Propofol anesthesia for outpatient oral and maxillofacial surgery

Propofol is a sedative-hypnotic intravenous anesthetic agent that has gained wide use in outpatient oral and maxillofacial surgery since its clinical introduction in 1985. Propofol has several therapeutic advantages that make it an excellent choice for use in all phases of general anesthesia and conscious sedation. It is associated with minimal side effects, a controllable anesthetic state, and rapid recovery. This review of propofol discusses its pharmacologic character, administration, and side effects and presents anesthetic drug interaction information and comparisons.

Neuroleptanesthesia: current status

PURPOSE

To review the current status and possible future of neuroleptanalgesia/anesthesia, techniques that may be nearly extinct.

SOURCE

Articles from 1966 to present were obtained from the Current Science and Medline databases. Search terms include neurolepananalgesia/anesthesia, conscious sedation, droperidol, benzodiazepines, propofol, ketamine, and opioids. Information and abstracts obtained from meetings on this topic helped complete the collection of information.

PRINCIPAL FINDINGS

Droperidol/fentanyl may still be clinically indicated in the management of surgical seizure therapy for electrocorticography. However, the high incidence of post-operative sedation and restlessness discourage its use for other surgical or diagnostic procedures. Many surgical interventions, once thought ideally suited for neuroleptic agents, now meet better success with newer medications. The use of midazolam and/or propofol, in association with newer opioids, provides ideal anesthetic combinations.

CONCLUSION

The advantages of newer anesthetic agents have redefined the clinical indications for neuroleptanesthesia. In routine modern anesthesia, anxiolysis, sedation, and/or analgesia is better provided, with quicker recovery, by the new pharmacokinetic and pharmacodynamic characteristics of recent medications than by the neuroleptic component of neuroleptanesthesia.

What is new in monitored anesthesia care?

The use of monitored anesthesia care (MAC) techniques is increasing in popularity because recovery profiles seem to be improved compared with general and regional anesthesia. This article describes the conceptual basis for MAC and reviews the current MAC practices.

Two methods of administration of propofol for dental sedation

Propofol was used for intravenous sedation in a group of 19 healthy fit young patients undergoing third molar extractions. We compared two ways of giving the drug, patient-controlled and operator-controlled, in a crossover trial. There were no differences between the two methods. The psychomotor functions returned to normal by 60 min, there was a high incidence of partial or complete amnesia and both methods were acceptable to 18/19 patients. There were only minimal changes in the respiratory function, and oxygen saturation remained normal. The only problem noted was mild pain on injection in 4 patients.

The use of propofol for sedation in the emergency department

OBJECTIVE

To evaluate the effectiveness of propofol and fentanyl when used by emergency physicians (EPs) for systemic sedation and analgesia in the ED.

METHODS

Over an eight-month period, a convenience sample of consenting patients at an urban teaching hospital ED who required sedation for painful procedures were enrolled in a descriptive study of therapeutic propofol sedation. After receiving 2 micrograms/kg of fentanyl i.v. the patients received a continuous infusion of propofol at 0.21 mg/kg/min i.v. to the desired level of sedation. A maintenance infusion of 3-6 mg/kg/hr was administered during the remainder of the procedure. Sedation time, total procedure time, and recovery time were recorded and the presence of side effects was noted. The patients and the physicians rated their satisfaction with the technique on a 100-mm visual analog scale. The patients were contacted at 24 hours for follow-up information.

RESULTS

Twenty patients (aged 19-62 years) received propofol infusion for procedures that included ten abscess incision and drainages, eight orthopedic reductions, one chest tube placement, and one wound exploration. The mean (+/- SD) total dose of propofol was 200 +/- 160 mg. The mean time to onset of sedation was 6.6 +/- 3.2 min, the mean procedure interval was 9.6 +/- 6.3 min, and the mean interval until recovery was 6.1 +/- 4.1 min. The median patient satisfaction score was 97 mm (range 40-100 mm); the median rating by physicians was 88 mm (range 4-100 mm). Side effects were noted in six patients: three had pain on injection, one had pain on injection and brief (< 1 min) hypotension (systolic blood pressure = 80 mm Hg), and two had apnea (< 30 sec). Seven patients had some recall of the procedure immediately afterwards, but only five had any recall at 24 hours. All 20 patients stated they would be willing to receive the same sedation again for a future procedure.

CONCLUSION

Propofol appears to be an effective agent to provide systemic sedation and analgesia when used in conjunction with fentanyl for procedures in the ED. Given its rapidity of onset and elimination, it may become a useful agent to EPs for i.v. sedation in the ED.

Intra-operative patient-controlled sedation and patient attitude to control. A crossover comparison of patient preference for patient-controlled propofol and propofol by continuous infusion

Intra-operative patient controlled sedation with propofol (bolus dose 18 mg over 5.4 s; lockout period 1 min) has been compared to continuous propofol infusion (3.6 mg.kg-1.h-1) in a randomised crossover study of 38 ASA 1 or 2 day surgery patients undergoing two-stage bilateral extraction of third molar teeth under local anaesthesia (76 procedures). Mean (SD) propofol used (mg.kg-1) was less with patient-controlled sedation (2.39 (1.28) than with the infusion (2.58 (0.84)) but the difference was not statistically significant. There were only minor differences between the methods in postoperative recovery of cognitive function and no differences for patient cooperation and surgeon's satisfaction with sedation. Patient-controlled sedation was preferred by 19 patients, continuous infusion by 10, with nine indifferent. Preferences, expressed as mild, moderate or strong, were significantly stronger for patient-controlled sedation (p < 0.05). Sedation was no deeper than eyelid closure with response to command in all 76 procedures. This level was reached in all 38 infusion cases but in only 26 cases with patient-controlled sedation, where 12 patients remained less sedated (p < 0.01). Patient-controlled sedation with propofol provided safe sedation and was strongly preferred over the infusion by a large proportion of patients.

[Use of Diprivan in ENT and stomatology]

Irrespective of the type of surgery, patient monitoring, including ECG-automated non-invasive blood pressure measurements, SpO2, FIO2 and capnography, is compulsory. Sedation: no initial bolus injection of propofol; continuous infusion of propofol at a rate of 1 to 4 mg.kg-1.h-1, using a syringe pump, combined with a short-acting opioid such as alfentanil. General anaesthesia: initial bolus injection of propofol between 2 and 3.5 mg.kg-1, combined with 10 mg of lidocaine in the same syringe; maintenance with a syringe pump: 6 to 9 mg.kg-1.h-1 combined with an opioid, with or without coadministration of muscle relaxants. Intubation avoiding respiratory depression: syringe pump with a fast infusion rate (50 to 100 mg.min-1), which allows induction with propofol and intubation without co-administration of muscle relaxants.

The use of third molar surgery in clinical pharmacology

This review discusses the various sequelae that arise after third molar surgery and their use for assessing the efficacy of a variety of therapeutic measures. The surgical procedure provides an opportunity to investigate onset, depth, duration and possible systemic effects of local anaesthetic solutions. Also, the anxiety which often accompanies such surgery lends itself to the appraisal of different anxiolytic agents and sedation techniques. The immediate postoperative sequelae of pain, buccal swelling and trismus provides a useful clinical model for evaluating the efficacy of analgesics and anti-inflammatory drugs. Third molar tooth sockets are susceptible to infection and this propensity enables the assessment of different antibiotic regimens. A further advantage of the third molar model is its application for crossover studies, with the patient acting as their own control. Very few surgical procedures afford this facility, which further adds to the value of this model in clinical pharmacology.

Outcomes after same-day oral surgery: a review of 1,180 cases at a major teaching hospital

Outcome was measured from data collected on 1,180 consecutive ambulatory oral surgery patients, two thirds of whom were treated under general anesthesia and the remainder who were treated under local anesthesia supplemented with intravenous sedation. Three patients (0.25%) required admission on the day of surgery; all had undergone general anesthesia. The surgery-related complication rate in the general anesthesia group (1:132) was similar to that for local anesthesia and sedation (1:128). However, anesthesia-related complications had an incidence of 1:99 in the general anesthesia group, but were absent in those receiving local anesthesia and sedation. Eight patients (0.7%) required hospital readmission after being discharged, mostly because of complications of surgery. The incidence of postoperative nausea and vomiting in the recovery room after local anesthesia and sedation (6%) was less than after general anesthesia (14%) (P < .01) Average recovery times to sitting out of bed and being ready for discharge were less after local anesthesia and sedation (38 +/- 15 minutes and 120 +/- 39 minutes, respectively) than after general anesthesia (61 +/- 50 minutes and 141 +/- 62 minutes). At the time of follow-up during the first few postoperative days, 7% of patients had gone to a family doctor and 4% to hospital accident and emergency departments, usually for minor problems. Paracetamol 500 mg plus codeine phosphate 30 mg was effective in 97% of cases when provided as a take-home analgesic. Ninety-nine percent of patients were satisfied with their management.

Recovery following thiopentone or propofol anaesthesia assessed by computerized coordination measurements

Quantitative measurements of coordination ability and performance speed were carried out on 76 female day-case patients undergoing minor gynaecological operations. The women were assigned at random to the anaesthetic agent used, propofol 2.5 mg/kg or thiopentone 4 mg/kg. Spacing control, timing control and performance speed were recorded using a newly developed computerized coordination ability test system. The patients were tested once before the operation and 0.5, 1 and 2 h after awakening. Postoperatively the initial impairment and the subsequent regression towards preoperative test results were very similar whether the anaesthetic agent was propofol or thiopentone. Although the test apparatus was able to detect even minor differences, no postoperative test showed statistically significant differences between the two groups. We find it reasonable to conclude that there is no difference in recovery of coordination ability following propofol- or thiopentone-induced anaesthesia.

Sedation for bronchofiberoscopy: comparison between propofol infusion and intravenous boluses of fentanyl and diazepam

Two methods of sedation were evaluated in unpremedicated patients undergoing elective bronchofiberoscopy. The patients were randomly allocated to receive either propofol infusion 1 mg kg-1 h-1 preceded by a 1 mg kg-1 bolus (15 patients) (the propofol group) or intravenous fentanyl 1 micrograms kg-1 and diazepam 0.05 mg kg-1 (15 patients) (the fentanyl+diazepam group). Thirteen patients were treated twice during the study period and sedated with both methods (the first treatment according to random order and the second with the method not used on the first occasion). A topical anaesthetic was applied to the selected nostril with two cotton swabs soaked in 4% lidocaine. Epiglottis, vocal cords, trachea and bronchi were anaesthetized by spraying 4% lidocaine through the working channel of the fiberoscope as the instrument was advanced. The patients in the propofol group were more sedated than those in the fentanyl+diazepam groups (P less than 0.01). The working conditions were the same. After sedation, respiratory frequency decreased only in the fentanyl+diazepam group (P less than 0.05). Before sedation, haemoglobin saturation of oxygen was 95 +/- 2% (mean +/- s.d.) in the propofol group and 94 +/- 3% in the fentanyl+diazepam group. Immediately before the start of bronchofiberoscopy, it was 89 +/- 4% and 90 +/- 3%, respectively. The decrease was statistically significant in both groups (P less than 0.001). After sedation, systolic arterial pressures (SAP) decreased in both groups (P less than 0.01). Compared to values immediately before starting bronchofiberoscopy, SAP increased during the procedure in both groups (P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Intra-operative patient-controlled sedation

Patient-controlled sedation using propofol is described in 23 ASA 1 patients undergoing surgical extraction of third molars. Cardiovascular and respiratory stability was maintained and sedation was no deeper than full eyelid closure with prompt response to verbal command. Amnesia for the extractions was common (70%), but there was no significant amnesia for recovery room events. Intra-operative patient cooperation was good, postoperative patient satisfaction high and all patients stated they liked the self-administration and would use the same technique again. Propofol dose was correlated with both procedure length (r = 0.587; p = 0.003) and surgical difficulty (rs = 0.550; p = 0.010).