1
|
Wehrmann T, Riphaus A, Eckardt AJ, Klare P, Kopp I, von Delius S, Rosien U, Tonner PH. Updated S3 Guideline "Sedation for Gastrointestinal Endoscopy" of the German Society of Gastroenterology, Digestive and Metabolic Diseases (DGVS) - June 2023 - AWMF-Register-No. 021/014. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:e654-e705. [PMID: 37813354 DOI: 10.1055/a-2165-6388] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Affiliation(s)
- Till Wehrmann
- Clinic for Gastroenterology, DKD Helios Clinic Wiesbaden, Wiesbaden, Germany
| | - Andrea Riphaus
- Internal Medicine, St. Elisabethen Hospital Frankfurt Artemed SE, Frankfurt, Germany
| | - Alexander J Eckardt
- Clinic for Gastroenterology, DKD Helios Clinic Wiesbaden, Wiesbaden, Germany
| | - Peter Klare
- Department Internal Medicine - Gastroenterology, Diabetology, and Hematology/Oncology, Hospital Agatharied, Hausham, Germany
| | - Ina Kopp
- Association of the Scientific Medical Societies in Germany e.V. (AWMF), Berlin, Germany
| | - Stefan von Delius
- Medical Clinic II - Internal Medicine - Gastroenterology, Hepatology, Endocrinology, Hematology, and Oncology, RoMed Clinic Rosenheim, Rosenheim, Germany
| | - Ulrich Rosien
- Medical Clinic, Israelite Hospital, Hamburg, Germany
| | - Peter H Tonner
- Anesthesia and Intensive Care, Clinic Leer, Leer, Germany
| |
Collapse
|
2
|
Wehrmann T, Riphaus A, Eckardt AJ, Klare P, Kopp I, von Delius S, Rosien U, Tonner PH. Aktualisierte S3-Leitlinie „Sedierung in der gastrointestinalen Endoskopie“ der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS). ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:1246-1301. [PMID: 37678315 DOI: 10.1055/a-2124-5333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Affiliation(s)
- Till Wehrmann
- Klinik für Gastroenterologie, DKD Helios Klinik Wiesbaden, Wiesbaden, Deutschland
| | - Andrea Riphaus
- Innere Medizin, St. Elisabethen Krankenhaus Frankfurt Artemed SE, Frankfurt, Deutschland
| | - Alexander J Eckardt
- Klinik für Gastroenterologie, DKD Helios Klinik Wiesbaden, Wiesbaden, Deutschland
| | - Peter Klare
- Abteilung Innere Medizin - Gastroenterologie, Diabetologie und Hämato-/Onkologie, Krankenhaus Agatharied, Hausham, Deutschland
| | - Ina Kopp
- Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V. (AWMF), Berlin, Deutschland
| | - Stefan von Delius
- Medizinische Klinik II - Innere Medizin - Gastroenterologie, Hepatologie, Endokrinologie, Hämatologie und Onkologie, RoMed Klinikum Rosenheim, Rosenheim, Deutschland
| | - Ulrich Rosien
- Medizinische Klinik, Israelitisches Krankenhaus, Hamburg, Deutschland
| | - Peter H Tonner
- Anästhesie- und Intensivmedizin, Klinikum Leer, Leer, Deutschland
| |
Collapse
|
3
|
Fatima H, Imperiale T. Safety Profile of Endoscopist-directed Balanced Propofol Sedation for Procedural Sedation: An Experience at a Hospital-based Endoscopy Unit. J Clin Gastroenterol 2022; 56:e209-e215. [PMID: 34739402 DOI: 10.1097/mcg.0000000000001630] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 09/27/2021] [Indexed: 12/10/2022]
Abstract
BACKGROUND Nurse-administered propofol sedation was restricted to anesthesiologists in 2009, a practice that has contributed to spiraling health care costs in the United States. AIM The aim of this study was to evaluate the safety of endoscopist-directed balanced propofol sedation (EDBPS). MATERIALS AND METHODS We identified patients undergoing endoscopy with EDBPS from January 1, 2017, to June 20, 2017, and abstracted their medical records. Adverse events (AEs) included: hypoxia (oxygen saturation < 90%); hypotension [(a) systolic blood pressure < 90 mm Hg, (b) systolic blood pressure decline of >50 mm Hg, (c) decline in mean arterial pressure of >30%]; bradycardia (heart rate of < 40 beats/min). Logistic regression identified factors independently associated with AEs. RESULTS A total of 1897 patients received EDBPS during the study period [mean age: 55 y (SD=11.4 y); 56.4% women]. Patients received median doses of 50 µg fentanyl, 2 mg of midazolam, and a mean propofol dose of 160±99 mg. There were no major complications (upper 95% confidence interval, 0.19%). Overall, 334 patients (17.6%) experienced a clinically insignificant AE: 65 (3.4%) experienced transient hypoxia, 277 patients (14.6%) experienced hypotension, 2 had transient bradycardia. In bivariate analysis, older age was associated with risk for hypotension, propofol dose was associated with transient hypoxemia, and procedure duration was associated with both hypotension and transient hypoxia. In multivariate analysis, only procedure length was associated with AEs (odds ratio scale 10; odds ratio=1.07; 95% confidence interval, 1.05-1.09, P<0.001). CONCLUSIONS EDBPS is safe for endoscopic sedation. Given the higher cost of anesthesia-administered propofol, endoscopists should reinstate EDBPS by revising institutional sedation policies.
Collapse
Affiliation(s)
- Hala Fatima
- Division of Gastroenterology/Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN
| | | |
Collapse
|
4
|
Grassi G, Lenci I, Signorello A, Milana M, Baiocchi L. Gastrointestinal endoscopy in cirrhotic patient: Issues on the table. World J Gastrointest Endosc 2021; 13:210-220. [PMID: 34326942 PMCID: PMC8311468 DOI: 10.4253/wjge.v13.i7.210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 06/22/2021] [Accepted: 06/28/2021] [Indexed: 02/06/2023] Open
Abstract
Patients with liver cirrhosis are fragile and present specific clinical hallmarks. When undergoing to gastrointestinal (GI) endoscopy, these subjects require an individual pre evaluation, taking into account: Level of haemostasis impairment, the individual risk of infection, the impact of sedation on hepatic encephalopathy and other factors. The overall assessment of liver function, employing common scoring systems, should be also assessed in the preprocedural phase. Beside some common general problems, regarding GI endoscopy in cirrhotic subjects, also specific issues are present for some frequent indications or procedures. For instance, despite an increased incidence of adenomas in cirrhosis, colon cancer screening remains suboptimal in subjects with this disease. Several studies in fact demonstrated liver cirrhosis as a negative factor for an adequate colon cleansing before colonoscopy. On the other hand, also the routine assessment of gastroesophageal varices during upper GI endoscopy presents some concern, since important inter-observer variability or incomplete description of endoscopic findings has been reported in some studies. In this review we discussed in details the most relevant issues that may be considered while performing general GI endoscopic practice, in patient with cirrhosis. For most of these issues there are no guidelines or clear indications. Moreover until now, few studies focused on these aspects. We believe that targeting these issues with corrective measures may be helpful to develop a tailored endoscopic approach for cirrhosis, in the future.
Collapse
Affiliation(s)
- Giuseppe Grassi
- Hepatology Unit, University of Tor Vergata, Rome 00100, Italy
| | - Ilaria Lenci
- Hepatology Unit, University of Tor Vergata, Rome 00100, Italy
| | | | - Martina Milana
- Hepatology Unit, University of Tor Vergata, Rome 00100, Italy
| | | |
Collapse
|
5
|
McKenzie P, Fang J, Davis J, Qiu Y, Zhang Y, Adler DG, Gawron AJ. Safety of endoscopist-directed nurse-administered balanced propofol sedation in patients with severe systemic disease (ASA class III). Gastrointest Endosc 2021; 94:124-130. [PMID: 33309879 DOI: 10.1016/j.gie.2020.11.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 11/28/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS The safety of endoscopist-directed nurse-administered propofol sedation (EDNAPS) has been demonstrated in low-risk patients (American Society of Anesthesiologists [ASA] class I and II). There are limited data regarding the safety of EDNAPS for endoscopic procedures in ASA class III patients. The purpose of this study was to determine the safety of EDNAPS for routine outpatient endoscopy in this population. METHODS We retrospectively reviewed all outpatient EGDs and colonoscopies performed with EDNAPS at the University of Utah from January 2015 to November 2018. Exclusion criteria were inpatient procedures, combined procedures, ASA IV or higher, use of continuous or bilevel positive airway pressure at the start of the procedure, or procedures performed by a nongastroenterologist. Major adverse events were defined as intubation or death. Minor adverse events were defined as hypoxia, hypotension, bradycardia, or need for airway interventions. Patients were stratified by procedure type and ASA I/II status and were compared with patients with ASA III status and matched according to age, gender, and the involvement of a fellow in a 3 to 1 fashion. RESULTS The final sample size was 18,910 colonoscopy procedures (17,205 patients) and 9178 EGD procedures (6827 patients). In both colonoscopy and EGD procedures, there were no major adverse events such as intubation, need for resuscitation, or death. The rates of any airway intervention, jaw thrust, oral nasal airway, or use of positive pressure ventilation were low in both procedure types and not different between ASA I/II and ASA III patients. CONCLUSION EDNAPS is safe in both ASA I/II and ASA class III patients undergoing routine outpatient endoscopy.
Collapse
Affiliation(s)
| | - John Fang
- University of Utah, Salt Lake City, Utah, USA
| | | | - Yuqing Qiu
- University of Utah, Salt Lake City, Utah, USA
| | - Yue Zhang
- University of Utah, Salt Lake City, Utah, USA
| | | | | |
Collapse
|
6
|
Guacho JAL, de Moura DTH, Ribeiro IB, da Ponte Neto AM, Singh S, Tucci MGB, Bernardo WM, de Moura EGH. Propofol vs midazolam sedation for elective endoscopy in patients with cirrhosis: A systematic review and meta-analysis of randomized controlled trials. World J Gastrointest Endosc 2020; 12:241-255. [PMID: 32879659 PMCID: PMC7443824 DOI: 10.4253/wjge.v12.i8.241] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 06/12/2020] [Accepted: 07/19/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Patients with cirrhosis frequently require sedation for elective endoscopic procedures. Several sedation protocols are available, but choosing an appropriate sedative in patients with cirrhosis is challenging.
AIM To conduct a systematic review and meta-analysis to compare propofol and midazolam for sedation in patients with cirrhosis during elective endoscopic procedures in an attempt to understand the best approach.
METHODS This systematic review and meta-analysis was conducted using the PRISMA guidelines. Electronic searches were performed using MEDLINE, EMBASE, Central Cochrane, LILACS databases. Only randomized control trials (RCTs) were included. The outcomes studied were procedure time, recovery time, discharge time, and adverse events (bradycardia, hypotension, and hypoxemia). The risk of bias assessment was performed using the Revised Cochrane Risk-of-Bias tool for randomized trials (RoB-2). Quality of evidence was evaluated by GRADEpro. The meta-analysis was performed using Review Manager.
RESULTS The search yielded 3,576 records. Out of these, 8 RCTs with a total of 596 patients (302 in the propofol group and 294 in the midazolam group) were included for the final analysis. Procedure time was similar between midazolam and propofol groups (MD: 0.25, 95%CI: -0.64 to 1.13, P = 0.59). Recovery time (MD: -8.19, 95%CI: -10.59 to -5.79, P < 0.00001). and discharge time were significantly less in the propofol group (MD: -12.98, 95%CI: -18.46 to -7.50, P < 0.00001). Adverse events were similar in both groups (RD: 0.02, 95%CI: 0-0.04, P = 0.58). Moreover, no significant difference was found for bradycardia (RD: 0.03, 95%CI: -0.01 to 0.07, P = 0.16), hypotension (RD: 0.03, 95%CI: -0.01 to 0.07, P = 0.17), and hypoxemia (RD: 0.00, 95%CI: -0.04 to 0.04, P = 0.93). Five studies had low risk of bias, two demonstrated some concerns, and one presented high risk. The quality of the evidence was very low for procedure time, recovery time, and adverse events; while low for discharge time.
CONCLUSION This systematic review and meta-analysis based on RCTs show that propofol has shorter recovery and patient discharge time as compared to midazolam with a similar rate of adverse events. These results suggest that propofol should be the preferred agent for sedation in patients with cirrhosis.
Collapse
Affiliation(s)
- John Alexander Lata Guacho
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403-010, Brazil
| | - Diogo Turiani Hourneaux de Moura
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403-010, Brazil
| | - Igor Braga Ribeiro
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403-010, Brazil
| | - Alberto Machado da Ponte Neto
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403-010, Brazil
| | - Shailendra Singh
- Division of Gastroenterology, Department of Internal Medicine, West Virginia University, Charleston, WV 25304, United States
| | - Marina Gammaro Baldavira Tucci
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403-010, Brazil
| | - Wanderley Marques Bernardo
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403-010, Brazil
| | | |
Collapse
|
7
|
Jung JH, Hyun B, Lee J, Koh DH, Kim JH, Park SW. Neurologic Safety of Etomidate-Based Sedation during Upper Endoscopy in Patients with Liver Cirrhosis Compared with Propofol: A Double-Blind, Randomized Controlled Trial. J Clin Med 2020; 9:jcm9082424. [PMID: 32751161 PMCID: PMC7466000 DOI: 10.3390/jcm9082424] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 07/17/2020] [Accepted: 07/24/2020] [Indexed: 12/12/2022] Open
Abstract
(1) Background: Although etomidate-based sedation is an effective and safe protocol in endoscopic procedures, there is a lack of evidence regarding the safety of etomidate in patients with liver cirrhosis (LC). This study aimed to compare the neurologic safety and efficacy of etomidate and propofol for endoscopic sedation in patients with LC. (2) Methods: From December 2017 to December 2019, consecutive cirrhotic patients who underwent sedative endoscopy using either etomidate or propofol were randomly recruited. The primary endpoint was the number connection test (NCT), and the secondary endpoints included factors for the safety of sedatives during endoscopy. (3) Results: 63 patients were enrolled in each of the etomidate and propofol groups. The NCT times were significantly lower in the etomidate group than in the propofol group. Furthermore, severe or very severe degree of encephalopathy was higher in the propofol group but was not significantly different. Pharmacological properties and the overall incidence of respiratory and cardiovascular events did not differ significantly between the groups. (4) Conclusion: Etomidate-based sedation exacerbates neither subclinical nor overt hepatic encephalopathy. It guarantees efficacies similar to those of propofol regarding rapid sedation, fast recovery, and early discharge, with no increased risk of adverse respiratory or cardiovascular events in patients with LC.
Collapse
|
8
|
Edelson J, Suarez AL, Zhang J, Rockey DC. Sedation During Endoscopy in Patients with Cirrhosis: Safety and Predictors of Adverse Events. Dig Dis Sci 2020; 65:1258-1265. [PMID: 31605279 DOI: 10.1007/s10620-019-05845-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Accepted: 09/13/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Sedation during endoscopy in cirrhotic patients is typically via moderate sedation, most commonly using a combination of a benzodiazepine (i.e., midazolam) and narcotic (i.e., fentanyl) or with propofol using monitored anesthesia care (MAC). Here, we examined the safety of moderate sedation and MAC in patients with cirrhosis. METHODS This retrospective cohort study of cirrhotic patients undergoing endoscopy from a large academic medical center between 2010 and 2014 examined extensive clinical data including the following: past history, physical findings, laboratory results, and procedural adverse events. Adverse events were defined a priori and included hypoxia, hypotension, bleeding, and death. RESULTS We identified 2618 patients with cirrhosis who underwent endoscopic procedures; the mean age was 56 years, 36% were female, the mean Child-Pugh score was 9.3 (IQR: 8, 11), and Charlson Comorbidity Index score was 3.2 (IQR: 1, 4); 1157 had MAC; and 1461 had moderate sedation. There was no difference in the frequency of adverse events in MAC and moderate sedation groups, with a total of 15 adverse events (7/1157 MAC and 8/1461 moderate sedation). The most common procedure performed was esophagogastroduodenoscopy (EGD, n = 1667) and was associated with 10 adverse events. Overall, adverse events included bradycardia (1), hypoxia (7), bleeding (5), laryngospasm (1), and perforation (1). The frequency was similar for EGD, ERCP, and colonoscopy-each at a rate of 0.6%. CONCLUSIONS Adverse events in cirrhotic patients undergoing endoscopy appeared to be similar with moderate sedation or MAC, and the frequency was the same for different types of procedures.
Collapse
Affiliation(s)
- Jerome Edelson
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical University of South Carolina, 96 Jonathan Lucas Street, Suite 803, Charleston, SC, 29425, USA
| | - Alejandro L Suarez
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical University of South Carolina, 96 Jonathan Lucas Street, Suite 803, Charleston, SC, 29425, USA
| | - Jingwen Zhang
- Division of General Internal Medicine, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Don C Rockey
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical University of South Carolina, 96 Jonathan Lucas Street, Suite 803, Charleston, SC, 29425, USA.
| |
Collapse
|
9
|
Ichijima R, Esaki M, Suzuki S, Kusano C, Ikehara H, Gotoda T. Effectiveness and safety of sedation in gastrointestinal endoscopy: An opinion review. World J Meta-Anal 2020; 8:48-53. [DOI: 10.13105/wjma.v8.i2.48] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Revised: 03/04/2020] [Accepted: 03/19/2020] [Indexed: 02/06/2023] Open
Abstract
Although endoscopy is a less invasive procedure than surgery, patients can experience pain without sedation. Patients expect reduced pain during endoscopies from effective and safe sedatives. Midazolam and propofol are used for endoscopic sedation in many countries and regions. Midazolam is a widely available benzodiazepine, and many clinical trials have shown it to be an effective sedative. However, patients who are sedated with midazolam require rest in the recovery room due to its relatively long half-life, and an antagonist such as flumazenil may need to be administered in cases of deep or prolonged sedation. Propofol is a short-acting sedative with a short half-life and a quick recovery time. Therefore, the use of propofol has been increasing. However, propofol has a narrow margin of safety and often induces adverse effects such as respiratory depression. Also, propofol has no specific antagonist, and should be administered by an anesthesiologist or an endoscopist familiar with anesthesia. Remimazolam, which is a novel ultra-short-acting benzodiazepine, has recently gained attention. Remimazolam has a short half-life and an antagonist. Both effective and safe sedation is desired in accordance with the increasing need for sedative endoscopies. Therefore, in this review each sedative is summarized.
Collapse
Affiliation(s)
- Ryoji Ichijima
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Chiyoda-ku, Tokyo 101-8309, Japan
| | - Mitsuru Esaki
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Chiyoda-ku, Tokyo 101-8309, Japan
| | - Sho Suzuki
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Chiyoda-ku, Tokyo 101-8309, Japan
| | - Chika Kusano
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Chiyoda-ku, Tokyo 101-8309, Japan
| | - Hisatomo Ikehara
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Chiyoda-ku, Tokyo 101-8309, Japan
| | - Takuji Gotoda
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Chiyoda-ku, Tokyo 101-8309, Japan
| |
Collapse
|
10
|
Safety profile of sedative endoscopy including cognitive performance in liver cirrhosis: A double-blind randomized controlled trial. Sci Rep 2019; 9:16798. [PMID: 31727915 PMCID: PMC6856546 DOI: 10.1038/s41598-019-52897-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 10/24/2019] [Indexed: 12/13/2022] Open
Abstract
The indiscriminate use of sedative drugs during endoscopy can pose multiple risks including cognitive impairment in advanced liver cirrhosis. However, the data are scarce regarding which sedative drugs are safest in these populations. The aim of this study was to evaluate the safety profiles including cognitive performance among midazolam, propofol, and combination therapy in advanced cirrhotic patients. This double-blind randomized controlled study included 60 consecutive advanced cirrhotic patients who underwent upper gastrointestinal endoscopy. The Stroop application was used to screen for cognitive impairment. Patients were randomly assigned to one of 3 groups, midazolam, propofol, or the combination group, and underwent Stroop test before and two hours after the completion of endoscopy. Hemodynamic safety and the subjective satisfaction score were also evaluated. Patients did not show significant changes in on-time or off-time on the Stroop test before and two hours after sedatives, and there was no significant difference among the 3 treatment groups. Also, there were no significant vital sign changes after sedatives. Time-to-recovery was longest in midazolam group, and patient awakening and patient memory were highest in propofol group. However, all 3 groups showed no difference in patient satisfaction, but the combination group was more preferred in terms of subjective satisfaction by physicians. Factors affecting worsened Stroop speed after sedatives were older age, low education level and high MELD score. All sedative methods using midazolam, propofol, or combination therapy showed similar safety profile in advanced cirrhosis, and were not associated with increased risk of cognitive impairment.
Collapse
|
11
|
Edelson JC, Rockey DC. Endoscopic Sedation of the Patient With Cirrhosis. Clin Liver Dis (Hoboken) 2018; 12:165-169. [PMID: 30988936 PMCID: PMC6446456 DOI: 10.1002/cld.762] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 09/10/2018] [Accepted: 09/11/2018] [Indexed: 02/04/2023] Open
Affiliation(s)
- Jerome C. Edelson
- Department of MedicineBrooke Army Medical CenterFort Sam HoustonSan AntonioTX
| | - Don C. Rockey
- Department of MedicineMedical University of South CarolinaCharlestonSC
| |
Collapse
|
12
|
Kikuchi H, Hikichi T, Watanabe K, Nakamura J, Takagi T, Suzuki R, Sugimoto M, Waragai Y, Konno N, Asama H, Takasumi M, Sato Y, Obara K, Ohira H. Efficacy and safety of sedation during endoscopic submucosal dissection of gastric cancers using a comparative trial of propofol versus midazolam. Endosc Int Open 2018; 6:E51-E57. [PMID: 29340298 PMCID: PMC5766337 DOI: 10.1055/s-0043-122225] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Accepted: 09/11/2017] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Proper sedation is necessary for the safe and satisfactory completion of endoscopic submucosal dissection (ESD) for early gastric cancer. This study was conducted as a comparative trial of efficacy and safety, comparing propofol-based sedation and midazolam-based sedation during ESD of early gastric cancer patients. PATIENTS AND METHODS This study examined 64 lesions in 58 patients treated using ESD with midazolam plus pentazocine between July 2013 and January 2014 (group M) and 237 lesions in 216 patients treated by ESD using propofol plus pentazocine between February 2014 and December 2015 (group P). The two groups were compared in terms of the frequency of body movement during ESD as the primary outcome and in terms of the procedure time, en bloc resection rate, intraoperative change in cardiorespiratory dynamics, and postoperative awareness as the secondary outcomes. Body movement was defined as movement by a patient that required interruption of the procedure or restraint of the patient's body trunk, and addition of a sedative agent. RESULTS The median frequency of body movement during ESD was significantly lower in group P (0 times) than in group M (3 times) ( P < 0.001). No significant difference was found for the mean procedure time (117 min in group P; 127 min in group M). Although no significant difference was found in the incidence of hypoxemia, bradycardia, or bradypnea, the incidence of hypotension was significantly higher in group P (31.5 %) than in group M (6.9 %) ( P = 0.004). Patients in group P had significantly higher postoperative awareness immediately after ESD and at 1 hour after ESD ( P = 0.002 and 0.022, respectively). CONCLUSION These results demonstrate the efficacy and safety of propofol-based sedation for gastric ESD.
Collapse
Affiliation(s)
- Hitomi Kikuchi
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan,Department of Gastroenterology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Takuto Hikichi
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan,Corresponding author Takuto Hikichi, MD, PhD Director and Associate ProfessorDepartment of EndoscopyFukushima Medical University Hospital1 HikarigaokaFukushima, Japan, 960-1295+81-24-547-1586
| | - Ko Watanabe
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan,Department of Gastroenterology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Jun Nakamura
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan,Department of Gastroenterology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Tadayuki Takagi
- Department of Gastroenterology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Rei Suzuki
- Department of Gastroenterology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Mitsuru Sugimoto
- Department of Gastroenterology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Yuichi Waragai
- Department of Gastroenterology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Naoki Konno
- Department of Gastroenterology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Hiroyuki Asama
- Department of Gastroenterology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Mika Takasumi
- Department of Gastroenterology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Yuki Sato
- Department of Gastroenterology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Katsutoshi Obara
- Department of Advanced Gastrointestinal Endoscopy, Fukushima Medical University, Fukushima, Japan
| | - Hiromasa Ohira
- Department of Gastroenterology, Fukushima Medical University School of Medicine, Fukushima, Japan
| |
Collapse
|
13
|
Lee JK, Jang DK, Kim WH, Kim JW, Jang BI. [Safety of Non-anesthesiologist Administration of Propofol for Gastrointestinal Endoscopy]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2017; 69:55-58. [PMID: 28135791 DOI: 10.4166/kjg.2017.69.1.55] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Propofol (2,6-diisopropylphenol) is a hypnotic drug with a very rapid onset and offset of action. It has increasingly been used in gastrointestinal endoscopy. Administration of propofol by nurses or endoscopists is commonly referred to as non-anesthesiologist-administered propofol (NAAP). There have been a lot of studies on the safety of NAAP compared with those by anesthesiologists. Safety results of those studies are summarized in this review.
Collapse
Affiliation(s)
- Jun Kyu Lee
- Department of Internal Medicine, Dongguk University College of Medicine, Goyang, Korea
| | - Dong Kee Jang
- Department of Internal Medicine, Dongguk University College of Medicine, Goyang, Korea
| | - Won Hee Kim
- Department of Internal Medicine, CHA University, Seongnam, Korea
| | - Jung Wook Kim
- Department of Internal Medicine, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Byung Ik Jang
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| |
Collapse
|
14
|
Wadhwa V, Issa D, Garg S, Lopez R, Sanaka MR, Vargo JJ. Similar Risk of Cardiopulmonary Adverse Events Between Propofol and Traditional Anesthesia for Gastrointestinal Endoscopy: A Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2017; 15:194-206. [PMID: 27451091 DOI: 10.1016/j.cgh.2016.07.013] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Revised: 07/02/2016] [Accepted: 07/06/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Even though propofol use for gastrointestinal endoscopic procedures has increased over the past decade, there is a perception that it causes a higher rate of cardiopulmonary adverse events. The aim of this study was to compare the sedation-related adverse events associated with use of propofol vs nonpropofol agents for endoscopic procedures. We also wanted to determine the influence of duration or complexity of the procedures and endoscopist-directed (gastroenterologist) vs non-gastroenterologist-directed sedation on the outcomes. METHODS A search was conducted using Medline, EMBASE, and the Cochrane controlled trials registry. The following cardiopulmonary adverse events were assessed: hypoxia, hypotension, and arrhythmias. The procedures were divided into 2 groups based on the procedure length: a nonadvanced endoscopic procedure group consisting of esophagogastroduodenoscopy, colonoscopy, and sigmoidoscopy, and an advanced endoscopic procedures group including endoscopic retrograde cholangiopancreatography, endoscopic ultrasonography, balloon enteroscopy, and endoscopic submucosal dissection. Pooled odds ratios for complications were calculated for all the procedures combined and then separately for the 2 groups. Random-effects models were used for 2-proportion comparisons. RESULTS Of the 2117 citations identified, 27 original studies qualified for this meta-analysis and included 2518 patients. Of these, 1324 received propofol, and 1194 received midazolam, meperidine, pethidine, remifentanil, and/or fentanyl. Most of the included studies were randomized trials of moderate quality and nonsignificant heterogeneity (Cochran Q, 26.07; P = .13). Compared with traditional sedative agents, the pooled odds ratio with the use of propofol for developing hypoxia for all the procedures combined was 0.82 (95% confidence interval [CI], 0.63-1.07), and for developing hypotension was 0.92 (95% CI, 0.64-1.32). In the nonadvanced endoscopic procedure group, those who received propofol were 39% less likely to develop complications than those receiving traditional sedative agents (odds ratio, 0.61; 95% CI, 0.38-0.99). There was no difference in the complication rate for the advanced endoscopic procedure group (odds ratio, 0.86; 95% CI, 0.56-1.34). A subgroup analysis did not show any difference in adverse events when propofol was administered by gastroenterologists or nongastroenterologists. CONCLUSIONS Propofol sedation has a similar risk of cardiopulmonary adverse events compared with traditional agents for gastrointestinal endoscopic procedures. Propofol use in simple endoscopic procedures was associated with a decreased number of complications. When used for gastrointestinal endoscopic procedures of a complex nature and longer duration, propofol was not associated with increased rates of hypoxemia, hypotension, or arrhythmias. Administration of propofol by gastroenterologists does not appear to increase the complication rates.
Collapse
Affiliation(s)
- Vaibhav Wadhwa
- Department of Internal Medicine, Fairview Hospital, Cleveland Clinic, Cleveland, Ohio
| | - Danny Issa
- Department of Gastroenterology and Hepatology, Virginia Commonwealth University, Richmond, Virginia
| | - Sushil Garg
- Department of Internal Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Rocio Lopez
- Department of Biostatistics, Cleveland Clinic, Cleveland, Ohio
| | - Madhusudhan R Sanaka
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio
| | - John J Vargo
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio.
| |
Collapse
|
15
|
Shin S, Park CH, Kim HJ, Park SH, Lee SK, Yoo YC. Patient satisfaction after endoscopic submucosal dissection under propofol-based sedation: a small premedication makes all the difference. Surg Endosc 2016; 31:2636-2644. [DOI: 10.1007/s00464-016-5276-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 10/04/2016] [Indexed: 12/30/2022]
|
16
|
Pena MA, Horga JF, Zapater P. Variations of pharmacokinetics of drugs in patients with cirrhosis. Expert Rev Clin Pharmacol 2016; 9:441-58. [DOI: 10.1586/17512433.2016.1135733] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
|
17
|
Abstract
As advances in liver disease continue, including the increasing use of liver transplantation, the endoscopist needs to be familiar with the standards of care and potential complications in the management of the cirrhotic population. This includes both elective endoscopic procedures, such as screening colonoscopies and variceal banding, as well as the acutely bleeding cirrhotic patient. Peri-procedural management and standards of care for acute gastrointestinal hemorrhaging of cirrhotic patients will be emphasized. This article will focus on the plethora of data available to highlight the benefits of endoscopic intervention in the care of patients with liver disease and outline the areas of future emphasis.
Collapse
|
18
|
Campbell SG, Magee KD, Kovacs GJ, Petrie DA, Tallon JM, McKinley R, Urquhart DG, Hutchins L. Procedural sedation and analgesia in a Canadian adult tertiary care emergency department: a case series. CAN J EMERG MED 2015; 8:85-93. [PMID: 17175868 DOI: 10.1017/s148180350001352x] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
ABSTRACTObjectives:To examine the safety of emergency department (ED) procedural sedation and analgesia (PSA) and the patterns of use of pharmacologic agents at a Canadian adult teaching hospital.Methods:Retrospective analysis of the PSA records of 979 patients, treated between Aug. 1, 2004, and July 31, 2005, with descriptive statistical analysis. This represents an inclusive consecutive case series of all PSAs performed during the study period.Results:Hypotension (systolic blood pressure ≤ 85 mm Hg) was documented during PSA in 13 of 979 patients (1.3%; 95% confidence interval [CI] 0.3%–2.3%), and desaturation (Sao2≤ 90) in 14 of 979 (1.4%; CI 0.1%–2.7%). No cases of aspiration, endotracheal intubation or death were recorded. The most common medication used was fentanyl (94.0% of cases), followed by propofol (61.2%), midazolam (42.5%) and then ketamine (2.7%). The most frequently used 2-medication combinations were propofol and fentanyl (P/F) followed by midazolam and fentanyl (M/F), used with similar frequencies 58.1% (569/979) and 41.0% (401/979) respectively. There was no significant difference in the incidence of hypotension or desaturation between the P/F and M/F treated groups. In these patients, 9.1% (90/979) of patients received more than 2 different drugs.Conclusions:Adverse events during ED PSA are rare and of doubtful clinical significance. Propofol/fentanyl and midazolam/fentanyl are used safely, and at similar frequencies for ED PSA in this tertiary hospital case series. The use of ketamine for adult PSA is unusual in our facility.
Collapse
Affiliation(s)
- Sam G Campbell
- Department of Emergency Medicine, Dalhousie University, Halifax, NS.
| | | | | | | | | | | | | | | |
Collapse
|
19
|
Tsai HC, Lin YC, Ko CL, Lou HY, Chen TL, Tam KW, Chen CY. Propofol versus midazolam for upper gastrointestinal endoscopy in cirrhotic patients: a meta-analysis of randomized controlled trials. PLoS One 2015; 10:e0117585. [PMID: 25646815 PMCID: PMC4315567 DOI: 10.1371/journal.pone.0117585] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 12/28/2014] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Sedation during gastrointestinal endoscopy is often achieved using propofol or midazolam in general population. However, impaired protein synthesis, altered drug metabolism, and compromised hepatic blood flow in patients with liver cirrhosis might affect the pharmacokinetics of sedatives, placing cirrhotic patients undergoing endoscopy at a greater risk of adverse events. The objective of this study was to assess comparative efficacies and safety of propofol and midazolam in cirrhotic patients undergoing endoscopy. METHODS Randomized, controlled trials comparing propofol with midazolam in cirrhotic patients undergoing gastrointestinal endoscopy were selected. We performed the meta-analysis, using a random-effect model, the Review Manager, Version 5.2, statistical software package (Cochrane Collaboration, Oxford, UK) according to the PRISMA guidelines. RESULTS Five studies between 2003 and 2012, including 433 patients, were included. Propofol provided a shorter time to sedation (weight mean difference: -2.76 min, 95% confidence interval: -3.00 to -2.51) and a shorter recovery time (weight mean difference -6.17 min, 95% confidence interval: -6.81 to -5.54) than midazolam did. No intergroup difference in the incidence of hypotension, bradycardia, or hypoxemia was observed. Midazolam was associated with the deterioration of psychometric scores for a longer period than propofol. CONCLUSION This meta-analysis suggests that Propofol sedation for endoscopy provides more rapid sedation and recovery than midazolam does. The risk of sedation-related side effects for propofol does not differ significantly from that of midazolam. The efficacy of propofol in cirrhotic patients undergoing endoscopy is superior to those of midazolam.
Collapse
Affiliation(s)
- Hsiao-Chien Tsai
- Department of Anesthesiology, Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan
| | - Yu-Cih Lin
- Department of Anesthesiology, Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan
- Graduate Institute of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
| | - Ching-Lung Ko
- Department of Anesthesiology, Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan
| | - Horng-Yuan Lou
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taipei Medical University, Taipei, Taiwan
| | - Ta-Liang Chen
- Department of Anesthesiology, Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Ka-Wai Tam
- Division of General Surgery, Department of Surgery, Taipei Medical University—Shuang Ho Hospital, New Taipei City, Taiwan
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Center for Evidence-based Medicine, Taipei Medical University, Taipei, Taiwan
- Center for Evidence-based Health Care, Taipei Medical University-Shuang Ho Hospital, New Taipei City, Taiwan
| | - Chien-Yu Chen
- Department of Anesthesiology, Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan
- Graduate Institute of Humanities in Medicine, Taipei Medical University, Taipei, Taiwan
| |
Collapse
|
20
|
Imagawa A, Hata H, Nakatsu M, Matsumi A, Ueta E, Suto K, Terasawa H, Sakae H, Takeuchi K, Fujihara M, Endo H, Yasuhara H, Ishihara S, Kanzaki H, Jinno H, Kamada H, Kaji E, Moriya A, Ando M. A target-controlled infusion system with bispectral index monitoring of propofol sedation during endoscopic submucosal dissection. Endosc Int Open 2015; 3:E2-6. [PMID: 26134767 PMCID: PMC4423246 DOI: 10.1055/s-0034-1377519] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Accepted: 06/11/2014] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Propofol administration via a target-controlled infusion system with bispectral index monitoring (BIS/TCI system) is expected to prevent complications from sedation during complex and long endoscopic procedures. We evaluated the feasibility of setting the BIS/TCI system for non-anesthesiologist administration of propofol (NAAP) during endoscopic submucosal dissection (ESD). PATIENTS AND METHODS From May 2009 to February 2013, 250 patients with esophagogastric neoplasms were treated with ESD using the BIS/TCI system with NAAP. In the TCI system, the initial target blood concentration of propofol was set at 1.2 μg/mL. The titration speed of propofol was adjusted according to the BIS score and the movement of the patient. The BIS target level ranged from moderate to deep sedation, at which a stable BIS score between 60 and 80 was obtained. RESULTS In 80.4 % of patients, it was possible to maintain stable sedation with a blood concentration of propofol of less than 1.6 µg/mL using TCI throughout the ESD procedure. The default setting for ideal blood concentration of propofol was 1.2 μg/mL, because the medians of the lower and upper bounds of blood concentration were 1.2 μg/mL (range 0.6 - 1.8 μg/mL) and 1.4 μg/mL (range 1.0 - 3.8 μg/mL), respectively. Although hypotension occurred in 27 patients (10.8 %), oxygen desaturation occurred in only nine patients (3.6 %), and severe desaturation in only two patients (0.8 %). CONCLUSIONS Using our settings, it is possible for a non-anesthesiologist to maintain stable sedation during a lengthy endoscopic procedure through propofol sedation with a BIS/TCI system.
Collapse
Affiliation(s)
- Atsushi Imagawa
- Department of Gastroenterology, Mitoyo General Hospital, Kagawa, Japan,Corresponding author Atsushi Imagawa, MD PhD Department of GastroenterologyMitoyo General Hospital708 HimehamaToyohamaKan-onjiKagawaJapan 769-1695+81-875-524936
| | - Hidenori Hata
- Department of Gastroenterology, Mitoyo General Hospital, Kagawa, Japan
| | - Morihito Nakatsu
- Department of Gastroenterology, Mitoyo General Hospital, Kagawa, Japan
| | - Akihiro Matsumi
- Department of Gastroenterology, Mitoyo General Hospital, Kagawa, Japan
| | - Eijiro Ueta
- Department of Gastroenterology, Mitoyo General Hospital, Kagawa, Japan
| | - Kozue Suto
- Department of Gastroenterology, Mitoyo General Hospital, Kagawa, Japan
| | - Hiroyuki Terasawa
- Department of Gastroenterology, Mitoyo General Hospital, Kagawa, Japan
| | - Hiroyuki Sakae
- Department of Gastroenterology, Mitoyo General Hospital, Kagawa, Japan
| | - Keiko Takeuchi
- Department of Gastroenterology, Mitoyo General Hospital, Kagawa, Japan
| | - Manabu Fujihara
- Department of Gastroenterology, Mitoyo General Hospital, Kagawa, Japan
| | - Hitomi Endo
- Department of Gastroenterology, Mitoyo General Hospital, Kagawa, Japan
| | - Hisae Yasuhara
- Department of Gastroenterology, Mitoyo General Hospital, Kagawa, Japan
| | - Shinichi Ishihara
- Department of Gastroenterology, Mitoyo General Hospital, Kagawa, Japan
| | - Hiromitsu Kanzaki
- Department of Gastroenterology, Mitoyo General Hospital, Kagawa, Japan
| | - Hideki Jinno
- Department of Gastroenterology, Mitoyo General Hospital, Kagawa, Japan
| | - Hidenori Kamada
- Department of Gastroenterology, Mitoyo General Hospital, Kagawa, Japan
| | - Eisuke Kaji
- Department of Gastroenterology, Mitoyo General Hospital, Kagawa, Japan
| | - Akio Moriya
- Department of Gastroenterology, Mitoyo General Hospital, Kagawa, Japan
| | - Masaharu Ando
- Department of Gastroenterology, Mitoyo General Hospital, Kagawa, Japan
| |
Collapse
|
21
|
Sethi S, Wadhwa V, Thaker A, Chuttani R, Pleskow DK, Barnett SR, Leffler DA, Berzin TM, Sethi N, Sawhney MS. Propofol versus traditional sedative agents for advanced endoscopic procedures: a meta-analysis. Dig Endosc 2014; 26:515-24. [PMID: 24354404 DOI: 10.1111/den.12219] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Accepted: 11/11/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM The optimum method for sedation for advanced endoscopic procedures is not known. Propofol deep sedation has a faster recovery time than traditional sedative agents, but may be associated with increased complication rates. The aim of the present study was to pool data from all available studies to systematically compare the efficacy and safety of propofol with traditional sedative agents for advanced endoscopic procedures. METHODS Databases including PubMed, Embase, Web of Science and the Cochrane Central Register of Controlled Trials updated as of January 2013 were searched. Main outcome measures were procedure duration, recovery time, incidence of complications (hypotension, hypoxia), sedation level, patient cooperation and amnesia during advanced endoscopic procedures such as endoscopic retrograde cholangiopancreatography, endoscopic ultrasonography, and deep small bowel enteroscopy. RESULTS Nine prospective randomized trials with a total of 969 patients (485 propofol, 484 conscious sedation) were included in the meta-analysis. Pooled mean difference in procedure duration between propofol and traditional sedative agents was -2.3 min [95% CI: -6.36 to 1.76, P = 0.27], showing no significant difference in procedure duration between the two groups. Pooled mean difference in recovery time was -30.26 min [95% CI: -46.72 to -13.80, P < 0.01], showing significantly decreased recovery time with propofol. There was also no significant difference between the two groups with regard to hypoxia and hypotension. CONCLUSIONS Propofol for advanced endoscopic procedures is associated with shorter recovery time, better sedation and amnesia level without an increased risk of cardiopulmonary complications. Overall patient cooperation was also improved with propofol sedation.
Collapse
Affiliation(s)
- Saurabh Sethi
- Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
22
|
Mao W, Wei XQ, Tao J, Zhen FP, Wen ZF, Wu B. The safety of combined sedation with propofol plus fentanyl for endoscopy screening and endoscopic variceal ligation in cirrhotic patients. J Dig Dis 2014; 15:124-30. [PMID: 24224839 DOI: 10.1111/1751-2980.12115] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE We aimed to investigate the safety of combined sedation with propofol plus fentanyl in patients with liver cirrhosis during screening esophagogastroduodenoscopy (SEGD) and a secondary prophylaxis for esophageal varices, endoscopic gastrointestinal ligation (EVL). METHODS A total of 309 patients with liver cirrhosis were enrolled and divided into the sedated SEGD group (n = 83), the sedated EVL group (n = 137) and the conscious EVL group (n = 89), respectively, and 100 participants with no liver diseases who underwent endoscopy for gastritis were regarded as the sedated control group. Patients in the sedated groups were administrated with propofol plus fentanyl during the endoscopic procedures and their minimal hepatic encephalopathy and sedation-related complications, including aspiration, hypoxia, hypotension and bradycardia, were evaluated and compared. The assessments of patient satisfaction and patient cooperation in the sedated and the conscious EVL groups were conducted. RESULTS The incidences of complications during the endoscopic procedures were not significantly different among the sedated groups (20.5% in the sedated SEGD group, 22.6% in the sedated EVL group and 19.0% in the sedated control group). No minimal hepatic encephalopathy was induced in the sedated groups. More patients in the sedated EVL group were satisfactory with the procedure compared with the conscious EVL group, as evaluated by both endoscopists and the cirrhotic patients. CONCLUSIONS A combined sedation with propofol plus fentanyl is safe for EVL as well as for SEGD in cirrhotic patients. Sedation might make it easier for endoscopists to perform procedures and might be more acceptable for cirrhotic patients.
Collapse
Affiliation(s)
- Wei Mao
- Department of Gastroenterology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | | | | | | | | | | |
Collapse
|
23
|
Sieg A, Beck S, Scholl SG, Heil FJ, Gotthardt DN, Stremmel W, Rex DK, Friedrich K. Safety analysis of endoscopist-directed propofol sedation: a prospective, national multicenter study of 24 441 patients in German outpatient practices. J Gastroenterol Hepatol 2014; 29:517-23. [PMID: 24716213 DOI: 10.1111/jgh.12458] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND AIM Since 2008, there exists a German S3-guideline allowing non-anesthesiological administration of propofol for gastrointestinal endoscopy. In this prospective, national, multicenter study, we evaluated the safety of endoscopist-administered propofol sedation (EDP) in German outpatient practices of Gastroenterology. METHODS In this multicenter survey of 53 ambulatory practices of Gastroenterology, we prospectively evaluated 24 441 patients that had received EDP. We recorded adverse events during the endoscopic procedure and additionally retrieved questionnaires investigating subjective parameters 24 h after the endoscopic procedure. RESULTS In 24 441 patients 13 793 colonoscopies, 6467 esophagogastroduodenoscopies, and 4181 double examinations were performed. In this study, 52.1% of the patients received propofol mono-sedation, and 47.9% received a combination of midazolam and propofol. Major adverse events occurred in four patients (0.016%) enrolled to this study (three mask ventilations and one laryngospasm). Minor adverse events were observed in 112 patients (0.46%) with hypoxemia being the most common minor event. All patients with adverse events recovered without persistent impairment. Minor adverse events occurred more frequently in patients sedated with propofol mono compared to propofol and midazolam (P < 0.0001) and correlated with increasing propofol dosages (P < 0.001; Pearson correlation coefficient r = 0.044). Twenty-four hours after the endoscopy, patients sedated with propofol plus midazolam stated a significantly reduced sensation of pain (P < 0.01) and improved symptoms of dizziness, nausea and vomiting (P < 0.001) compared to patients having received propofol mono-sedation. CONCLUSION Four years after the implementation of a German S3-Guideline for endoscopic sedation, we demonstrated that EDP is a safe procedure.
Collapse
|
24
|
Suh SJ, Yim HJ, Yoon EL, Lee BJ, Hyun JJ, Jung SW, Koo JS, Kim JH, Kim KJ, Choung RS, Seo YS, Yeon JE, Um SH, Byun KS, Lee SW, Choi JH, Ryu HS. Is propofol safe when administered to cirrhotic patients during sedative endoscopy? Korean J Intern Med 2014; 29:57-65. [PMID: 24574834 PMCID: PMC3932396 DOI: 10.3904/kjim.2014.29.1.57] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2013] [Revised: 06/18/2013] [Accepted: 07/18/2013] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND/AIMS In patients with liver cirrhosis, drugs acting on the central nervous system can lead to hepatic encephalopathy and the effects may be prolonged. Recently, misuse of propofol has been reported and the associated risk of death have become an issue. Propofol is commonly used during sedative endoscopy; therefore, its safety in high-risk groups must be further investigated. We performed a pilot study of the safety and efficacy of propofol during endoscopy in Korean patients with cirrhosis. METHODS Upper gastrointestinal endoscopy was performed under sedation with propofol along with careful monitoring in 20 patients with liver cirrhosis and 20 control subjects. The presence or development of hepatic encephalopathy was assessed using the number connection test and neurologic examination. RESULTS Neither respiratory depression nor clinically significant hypotension were observed. Immediate postanesthetic recovery at 5 and 10 minutes after the procedure was delayed in the cirrhotic patients compared with the control group; however, at 30 minutes, the postanesthetic recovery was similar in both groups. Baseline psychomotor performance was more impaired in cirrhotic patients, but propofol was not associated with deteriorated psychomotor function even in cirrhotic patients with a minimal hepatic encephalopathy. CONCLUSIONS Sedation with propofol was well tolerated in cirrhotic patients. No newly developed hepatic encephalopathy was observed.
Collapse
Affiliation(s)
- Sang Jun Suh
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Hyung Joon Yim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Eileen L. Yoon
- Division of Hepatology, Department of Internal Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Beom Jae Lee
- Division of Hepatology, Department of Internal Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Jong Jin Hyun
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Sung Woo Jung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Ja Seol Koo
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Ji Hoon Kim
- Division of Hepatology, Department of Internal Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Kyung Jin Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Rok Son Choung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Yeon Seok Seo
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Anam Hospital, Seoul, Korea
| | - Jong Eun Yeon
- Division of Hepatology, Department of Internal Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Soon Ho Um
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Anam Hospital, Seoul, Korea
| | - Kwan Soo Byun
- Division of Hepatology, Department of Internal Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Sang Woo Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Jai Hyun Choi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Ho Sang Ryu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Anam Hospital, Seoul, Korea
| |
Collapse
|
25
|
Reverter E, Blasi A, Abraldes JG, Martínez-Palli G, Seijo S, Turon F, Berzigotti A, Balust J, Bosch J, García-Pagán JC. Impact of deep sedation on the accuracy of hepatic and portal venous pressure measurements in patients with cirrhosis. Liver Int 2014; 34:16-25. [PMID: 23763484 DOI: 10.1111/liv.12229] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Accepted: 05/19/2013] [Indexed: 12/16/2022]
Abstract
BACKGROUND & AIMS Measurement of the hepatic venous pressure gradient (HVPG) offers valuable prognostic information in patients with cirrhosis. In specific circumstances, (children, agitated patients, TIPS placement) deep sedation is required. This study aims to assess the impact of deep sedation on the accuracy of hepatic/portal pressure measurements. METHODS Forty-four patients were included. Measurements of baseline HVPG (n = 30), HVPG response to i.v. propranolol (n = 11), portal pressure gradient (PPG) after TIPS (n = 27) and of cardio-pulmonary pressures (n = 25) were obtained in awake conditions and under deep sedation with propofol and remifentanil. RESULTS During deep sedation, a marked oscillation within respiratory cycle was observed in abdominal pressures. End-expiratory sedated HVPG showed a better agreement with awake HVPG (intra-class correlation coefficient - ICC 0.864) than end-inspiratory HVPG (ICC 0.796). However, in almost half of the patients both values differed by more than 10%. Accuracy was not improved by using mean HVPG along the respiratory cycle. Similarly, changes in HVPG caused by propranolol while under sedation had a poor agreement to those obtained in awake conditions. Indeed, about a half of patients were misclassified according to the 10% HVPG reduction target. After TIPS, PPG values obtained under sedation were significantly different to awake PPG, usually underestimating the awake value. The systemic hemodynamic changes induced by sedation were not associated to a greater variability of PPG/HVPG measurements. CONCLUSION Deep sedation with propofol and remifentanil adds substantial variability and uncertainty to HVPG/PPG measurements. This must be considered when using these values to estimate prognosis, or targeting HVPG/PPG reductions.
Collapse
Affiliation(s)
- Enric Reverter
- Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, IDIBAPS (Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona), Barcelona, Spain; CIBERehd (Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas), Barcelona, Spain
| | | | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Clinical practice guidelines for evidence-based management of sedoanalgesia in critically ill adult patients. ACTA ACUST UNITED AC 2013. [DOI: 10.1016/j.medine.2013.04.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
|
27
|
Celis-Rodríguez E, Birchenall C, de la Cal M, Castorena Arellano G, Hernández A, Ceraso D, Díaz Cortés J, Dueñas Castell C, Jimenez E, Meza J, Muñoz Martínez T, Sosa García J, Pacheco Tovar C, Pálizas F, Pardo Oviedo J, Pinilla DI, Raffán-Sanabria F, Raimondi N, Righy Shinotsuka C, Suárez M, Ugarte S, Rubiano S. Guía de práctica clínica basada en la evidencia para el manejo de la sedoanalgesia en el paciente adulto críticamente enfermo. Med Intensiva 2013; 37:519-74. [DOI: 10.1016/j.medin.2013.04.001] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Accepted: 04/16/2013] [Indexed: 01/18/2023]
|
28
|
Lewis JH, Stine JG. Review article: prescribing medications in patients with cirrhosis - a practical guide. Aliment Pharmacol Ther 2013; 37:1132-56. [PMID: 23638982 DOI: 10.1111/apt.12324] [Citation(s) in RCA: 116] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Revised: 11/30/2012] [Accepted: 04/08/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND Most drugs have not been well studied in cirrhosis; recommendations on safe use are based largely on experience and/or expert opinion, with dosing recommendations often based on pharmacokinetic (PK) changes. AIM To provide a practical approach to prescribing medications for cirrhotic patients. METHODS An indexed MEDLINE search was conducted using keywords cirrhosis, drug-induced liver injury, pharmacodynamics (PDs), PKs, drug disposition and adverse drug reactions. Unpublished information from the Food and Drug Administration and industry was also reviewed. RESULTS Most medications have not been adequately studied in cirrhosis, and specific prescribing information is often lacking. Lower doses are generally recommended based on PK changes, but data are limited in terms of correlating PD effects with the degree of liver impairment. Very few drugs have been documented to have their hepatotoxicity potential enhanced by cirrhosis; most of these involve antituberculosis or antiretroviral agents used for HIV or viral hepatitis. Paracetamol can be used safely when prescribed in relatively small doses (2-3 g or less/day) for short durations, and is recommended as first-line treatment of pain. In contrast, NSAIDs should be used cautiously (or not at all) in advanced cirrhosis. Proton pump inhibitors have been linked to an increased risk of spontaneous bacterial peritonitis (SBP) in cirrhosis and should be used with care. CONCLUSIONS Most drugs can be used safely in cirrhosis, including those that are potentially hepatotoxic, but lower doses or reduced dosing frequency is often recommended, due to altered PKs. Drugs that can precipitate renal failure, gastrointestinal bleeding, SBP and encephalopathy should be identified and avoided.
Collapse
Affiliation(s)
- J H Lewis
- Division of Gastroenterology and Hepatology, Department of Medicine, Georgetown University Medical Center, Washington, DC 20007, USA.
| | | |
Collapse
|
29
|
Wang D, Chen C, Chen J, Xu Y, Wang L, Zhu Z, Deng D, Chen J, Long A, Tang D, Liu J. The use of propofol as a sedative agent in gastrointestinal endoscopy: a meta-analysis. PLoS One 2013; 8:e53311. [PMID: 23308191 PMCID: PMC3540096 DOI: 10.1371/journal.pone.0053311] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Accepted: 11/27/2012] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES To assess the efficacy and safety of propofol sedation for gastrointestinal endoscopy, we conducted a meta-analysis of randomized controlled trials (RCTs) comparing propofol with traditional sedative agents. METHODS RCTs comparing the effects of propofol and traditional sedative agents during gastrointestinal endoscopy were found on MEDLINE, the Cochrane Central Register of Controlled Trials, and EMBASE. Cardiopulmonary complications (i.e., hypoxia, hypotension, arrhythmia, and apnea) and sedation profiles were assessed. RESULTS Twenty-two original RCTs investigating a total of 1,798 patients, of whom 912 received propofol only and 886 received traditional sedative agents only, met the inclusion criteria. Propofol use was associated with shorter recovery (13 studies, 1,165 patients; WMD -19.75; 95% CI -27.65, 11.86) and discharge times (seven studies, 471 patients; WMD -29.48; 95% CI -44.13, -14.83), higher post-anesthesia recovery scores (four studies, 503 patients; WMD 2.03; 95% CI 1.59, 2.46), better sedation (nine studies, 592 patients; OR 4.78; 95% CI 2.56, 8.93), and greater patient cooperation (six studies, 709 patients; WMD 1.27; 95% CI 0.53, 2.02), as well as more local pain on injection (six studies, 547 patients; OR 10.19; 95% CI 3.93, 26.39). Effects of propofol on cardiopulmonary complications, procedure duration, amnesia, pain during endoscopy, and patient satisfaction were not found to be significantly different from those of traditional sedative agents. CONCLUSIONS Propofol is safe and effective for gastrointestinal endoscopy procedures and is associated with shorter recovery and discharge periods, higher post-anesthesia recovery scores, better sedation, and greater patient cooperation than traditional sedation, without an increase in cardiopulmonary complications. Care should be taken when extrapolating our results to specific practice settings and high-risk patient subgroups.
Collapse
Affiliation(s)
- Daorong Wang
- Department of Gastrointestinal Surgery, Subei People’s Hospital of Jiangsu Province (Clinical Medical College of Yangzhou University), Yangzhou, Jiangsu Province, People’s Republic of China
| | - Chaowu Chen
- Department of Gastroenterology, Subei People’s Hospital of Jiangsu Province (Clinical Medical College of Yangzhou University), Yangzhou, Jiangsu Province, People’s Republic of China
| | - Jie Chen
- Department of Gastrointestinal Surgery, Subei People’s Hospital of Jiangsu Province (Clinical Medical College of Yangzhou University), Yangzhou, Jiangsu Province, People’s Republic of China
| | - Yaxiang Xu
- Department of Gastrointestinal Surgery, Subei People’s Hospital of Jiangsu Province (Clinical Medical College of Yangzhou University), Yangzhou, Jiangsu Province, People’s Republic of China
| | - Lu Wang
- Department of Gastroenterology, Subei People’s Hospital of Jiangsu Province (Clinical Medical College of Yangzhou University), Yangzhou, Jiangsu Province, People’s Republic of China
| | - Zhen Zhu
- Department of Gastroenterology, Subei People’s Hospital of Jiangsu Province (Clinical Medical College of Yangzhou University), Yangzhou, Jiangsu Province, People’s Republic of China
| | - Denghao Deng
- Department of Gastroenterology, Subei People’s Hospital of Jiangsu Province (Clinical Medical College of Yangzhou University), Yangzhou, Jiangsu Province, People’s Republic of China
| | - Juan Chen
- Department of Gastroenterology, Subei People’s Hospital of Jiangsu Province (Clinical Medical College of Yangzhou University), Yangzhou, Jiangsu Province, People’s Republic of China
| | - Aihua Long
- Department of Gastroenterology, Subei People’s Hospital of Jiangsu Province (Clinical Medical College of Yangzhou University), Yangzhou, Jiangsu Province, People’s Republic of China
| | - Dong Tang
- Department of Gastrointestinal Surgery, Subei People’s Hospital of Jiangsu Province (Clinical Medical College of Yangzhou University), Yangzhou, Jiangsu Province, People’s Republic of China
- * E-mail: (DT); (JL)
| | - Jun Liu
- Department of Gastroenterology, Subei People’s Hospital of Jiangsu Province (Clinical Medical College of Yangzhou University), Yangzhou, Jiangsu Province, People’s Republic of China
- * E-mail: (DT); (JL)
| |
Collapse
|
30
|
Agrawal A, Sharma BC, Sharma P, Uppal R, Sarin SK. Randomized controlled trial for endoscopy with propofol versus midazolam on psychometric tests and critical flicker frequency in people with cirrhosis. J Gastroenterol Hepatol 2012; 27:1726-32. [PMID: 22861074 DOI: 10.1111/j.1440-1746.2012.07231.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIM People with cirrhosis are at increased risk of development of complications related to sedation. The aim of the present study was to compare the effects of sedation for upper gastrointestinal endoscopy (UGIE) with propofol and midazolam on psychometric tests and critical flicker frequency (CFF) in people with cirrhosis. METHODS A total of 127 people with cirrhosis were randomized into three groups: propofol group (n = 40), midazolam group (n = 42) and no sedation (n = 45). All patients underwent CFF test and combination of psychometry (number connection test-A and B [NCT-A,B]; digit symbol test [DST], line tracing test [LTT] and serial dotting test [SDT]) at baseline and at 2 h post-endoscopy. CFF was done at 30 min and repeated every 30 min for 2 h. RESULTS In the propofol group there was no deterioration in psychometry (NCT-A [55.6 ± 18.7 vs 56.4 ± 19.0 s], NCT-B [98.2 ± 35.1 vs 97.8 ± 34.6 s], DST [26.7 ± 5.7 vs 26.3 ± 5.3], LTT [112.9 ± 35.7 vs 113.7 ± 36.6 s], SDT [94.6 ± 34.1 vs 95.2 ± 34.5 s]). Significant deterioration from baseline (39.8 ± 2.9 Hz) was seen in CFF at 30 min (38.8 ± 2.3 Hz) and 1 h (39.2 ± 2.4 Hz), P = 0.01 but no difference thereafter. In the midazolam group, significant deterioration was observed on psychometry (NCT-A [56.0 ± 18.5 vs 60.4 ± 19.8 s], NCT-B [99.9 ± 29.1 vs 105.9.6 ± 30.3 s], DST [26.1 ± 4.7 vs 25.2 ± 4.3], LTT [129.1 ± 34.5 vs 132.9 ± 35.4 s], SDT [95.6 ± 34.2]). No deterioration was observed in psychometry and CFF in people with cirrhosis without sedation. CONCLUSIONS Propofol sedation for UGIE was associated with earlier recovery compared with midazolam, which causes deterioration of psychometric tests and CFF for a longer time in comparison with propofol.
Collapse
Affiliation(s)
- Amit Agrawal
- Department of Gastroenterology, GB Pant Hospital, New Delhi, India
| | | | | | | | | |
Collapse
|
31
|
Midazolam for sedation during diagnostic or therapeutic upper gastrointestinal endoscopy in cirrhotic patients. Eur J Gastroenterol Hepatol 2012; 24:1214-8. [PMID: 22786572 DOI: 10.1097/meg.0b013e328356ae49] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
AIM The objective of this study was to determine the frequency of clinically overt hepatic encephalopathy (HE) in cirrhotic patients undergoing diagnostic or therapeutic upper gastrointestinal endoscopy (UGE) who received midazolam for sedation. METHODS This was an interventional study carried out at Liaquat National Hospital, Karachi. Consecutive patients presenting to the service of a single consultant gastroenterologist for diagnostic or therapeutic UGE between January 2009 and January 2011, who fulfilled the inclusion and exclusion criteria, were prospectively recruited for the study. The administration of intravenous midazolam was carried out in an incremental manner, whereas pulse and oxygen saturation was monitored during every procedure. During the recovery period, the degree of alertness was measured at 2, 4, and 6 h by the resident using the observer's assessment of alertness and sedation score and time to full recovery was determined. RESULTS A total of 191 consecutive patients who underwent diagnostic or therapeutic UGE fulfilling the inclusion and exclusion criteria were recruited. The mean age was 51.30 ± 10.7 years, with an age range of 12-75 years. The majority of the patients were men (n=108, 56.5%), with 83 women (43.5%). A total of eight patients (4.2%) remained drowsy and developed clinically overt HE after the procedure on assessment at 2 and 4 h. However, all of these patients regained full consciousness at 6 h spontaneously. Among those eight patients who developed clinically overt HE, seven (87.5%) were Child-Pugh class C and one patient (12.5%) was Child-Pugh class B. Overt HE was significantly related to Child-Pugh class (P=0.005) and the dose of midazolam (P=0.02). CONCLUSION We concluded that intravenous midazolam can be used safely in cirrhotic patients of Child-Pugh class A and B undergoing UGE for conscious sedation, but caution should be exercised for patients with advanced liver disease.
Collapse
|
32
|
El Chafic AH, Eckert G, Rex DK. Prospective description of coughing, hemodynamic changes, and oxygen desaturation during endoscopic sedation. Dig Dis Sci 2012; 57:1899-907. [PMID: 22271416 DOI: 10.1007/s10620-012-2057-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2011] [Accepted: 01/05/2012] [Indexed: 12/28/2022]
Abstract
BACKGROUND Deep sedation is increasingly used for endoscopy. The impact of sedation level on hemodynamic status, oxygenation, and aspiration risk is incompletely described. AIMS To describe the incidence of intraprocedural cough, hemodynamic changes, oxygen desaturation, and their relationship to clinical factors and sedation level. METHODS Detailed prospective recordings of hemodynamic changes, oxygen desaturation, and cough during 757 nonemergent endoscopic procedures done under sedation using propofol, midazolam, and/or fentanyl. RESULTS Thirteen percent of patients had at least one cough and 3% had prolonged cough. Cough was more common in nonsmokers (P = 0.05), upper endoscopy (P < 0.0001), with propofol (P = 0.0008), longer procedures (P = 0.0001), and hiccups (P = 0.01). The association between supine positioning during colonoscopy and cough approached significance (P = 0.06). Oxygen desaturation was rare (4%) and associated only with deep sedation (P = 0.02). Mean systolic and diastolic blood pressure (BP) dropped by 7.3 and 5.6% respectively. Decreases in systolic BP were more common in whites (P = 0.03), males (P = 0.004), nonsmokers (P = 0.04), during colonoscopy (P < 0.0001), and in patients receiving midazolam and fentanyl (P = 0.01). Heart rate (HR) dropped >20% from baseline in 15% of patients and was more common during colonoscopy (P = 0.002). HR increased >20% in 20% of patients and was more common with coughing (P < 0.0001) and in younger patients (P = 0.0002). No patient required pharmacologic treatment of BP or HR. CONCLUSIONS We have described procedural predictors of cough that may help clinicians reduce the risk of aspiration during endoscopy. Hemodynamic changes during endoscopy are common but largely clinically insignificant.
Collapse
Affiliation(s)
- Abdul Hamid El Chafic
- Division of Gastroenterology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | | | | |
Collapse
|
33
|
Vargo JJ, DeLegge MH, Feld AD, Gerstenberger PD, Kwo PY, Lightdale JR, Nuccio S, Rex DK, Schiller LR. Multisociety Sedation Curriculum for Gastrointestinal Endoscopy. Am J Gastroenterol 2012:ajg2012112. [PMID: 22613907 DOI: 10.1038/ajg.2012.112] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- John J Vargo
- Department of Gastroenterology and Hepatology, Cleveland Clinic Lerner College of Medicine, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mark H DeLegge
- Digestive Disease Center, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Andrew D Feld
- Group Health Cooperative, Division of Gastroenterology, University of Washington, Seattle, Washington, USA
| | | | - Paul Y Kwo
- Liver Transplantation, Gastroenterology/Hepatology Division, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jenifer R Lightdale
- Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts, USA
| | - Susan Nuccio
- Aurora St Luke's Medical Center, Milwaukee, Wisconsin, USA
| | - Douglas K Rex
- Indiana School of Medicine, Indiana University Hospital, Indianapolis, Indiana, USA
| | - Lawrence R Schiller
- Digestive Health Associates of Texas, Baylor University Medical Center, Dallas, Texas, USA
| |
Collapse
|
34
|
Horiuchi A, Nakayama Y, Kajiyama M, Tanaka N. Effectiveness of outpatient percutaneous endoscopic gastrostomy replacement using esophagogastroduodenoscopy and propofol sedation. World J Gastrointest Endosc 2012; 4:45-9. [PMID: 22347532 PMCID: PMC3280355 DOI: 10.4253/wjge.v4.i2.45] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2011] [Revised: 11/23/2011] [Accepted: 02/06/2012] [Indexed: 02/05/2023] Open
Abstract
AIM: To evaluate the effectiveness of outpatient percutaneous endoscopic gastrostomy (PEG) replacement using esophagogastroduodenoscopy (EGD) and propofol sedation.
METHODS: We retrospectively assessed the outcome and complications of consecutive patients referred for PEG replacement which was performed using EGD under propofol sedation in the outpatient setting. The success rate, the mean dose of propofol, procedure time, EGD findings, discharge time from endoscopy unit, respiratory depression, and complications within 72 h of the procedure were evaluated. In a subset of these patients, the blood concentrations of propofol were measured.
RESULTS: All 221 patients underwent successful PEG replacement. The mean dose of propofol was 34 mg (range, 20-60 mg) with a mean procedure time of 5.9 min (range, 3-8 min). Reflux esophagitis (12 patients), gastric ulcer (5), gastric neoplasm (2), and duodenal ulcer (1) were newly diagnosed at replacement. Discharge from endoscopy unit was possible in 100% of patients 45 min after the procedure. Only 3.6% (8) required transient supplemental oxygen. No complications occurred within 72 h of the procedure. During EGD the level of sedation and propofol blood concentrations after administration of propofol (30 mg) in these PEG patients corresponded to those of propofol (60 mg) in middle aged subjects (control).
CONCLUSION: PEG replacement using EGD and propofol sedationin the outpatient setting was safe and practical.
Collapse
Affiliation(s)
- Akira Horiuchi
- Akira Horiuchi, Yoshiko Nakayama, Masashi Kajiyama, Naoki Tanaka, Digestive Disease Center, Showa Inan General Hospital, Komagane, 399-4117 Matsumoto, Japan
| | | | | | | |
Collapse
|
35
|
Safety of propofol in cirrhotic patients undergoing colonoscopy and endoscopic retrograde cholangiography: results of a prospective controlled study. Eur J Gastroenterol Hepatol 2012; 24:70-6. [PMID: 21941187 DOI: 10.1097/meg.0b013e32834c16ab] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Safety of propofol sedation in patients with liver cirrhosis undergoing colonoscopy or endoscopic retrograde cholangiopancreatography (ERCP) remains to be studied. The aim of this study was to investigate whether the use of propofol is safe for endoscopic procedures more complex than gastroscopy in patients with liver cirrhosis in a prospective controlled study. METHODS Two hundred and fourteen consecutive patients, with or without cirrhosis, who underwent colonoscopy or ERCP with propofol sedation were recruited between January and June 2009. Administration of sedation was performed by anesthesiologists and outcome measures were recorded. Main outcomes were complication rates and recovery times. RESULTS Sixty-one (28.5%) cirrhotic patients and 153 (71.5%) noncirrhotic patients were included. The incidence of sedation-related complications did not significantly differ between the two populations (11.5 vs. 17.0%, respectively, P=0.31). The mean (±SD) dose of propofol administered (213±86 vs. 239±100 mg, P=0.07), the mean time to achieve adequate sedation (3.3±1.1 vs. 3.0±1.2 min, P=0.21), the mean total duration of the endoscopic procedure (24.5±10.6 vs. 27.4±11.8 min, P=0.08), the mean time to reach Observer's Assessment of Alertness and Sedation Scale 5 (17.2±4.4 vs. 18.4±5.6 min, P=0.15), the mean time from completion of the procedure to release (9.0±2.5 vs. 9.1±3.2 min, P=0.86), and the mean time to full recovery (42.2±7.3 vs. 42.3±7.8 min, P=0.88) were very similar between the two groups. The limitation of this study was lack of randomization, and a control group of cirrhotic patients using standard sedation with benzodiazepines and opioids. CONCLUSION Propofol deep sedation administered by an anesthesiologist with appropriate monitorings seems to be a safe procedure during colonoscopy or ERCP in cirrhotic patients.
Collapse
|
36
|
Khamaysi I, William N, Olga A, Alex I, Vladimir M, Kamal D, Nimer A. Sub-clinical hepatic encephalopathy in cirrhotic patients is not aggravated by sedation with propofol compared to midazolam: a randomized controlled study. J Hepatol 2011; 54:72-7. [PMID: 20934771 DOI: 10.1016/j.jhep.2010.06.023] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2010] [Revised: 06/14/2010] [Accepted: 06/14/2010] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS The risk of exacerbating sub-clinical hepatic encephalopathy (HE) by propofol has not been established. The aim of this study is to determine whether the use of propofol, for upper endoscopy in patients with cirrhosis, precipitates sub-clinical HE. METHODS Sixty-one patients with compensated HCV and HBV cirrhosis (CP score 5-6) were randomly selected and divided into two groups (intent-to-treat population) matched for age, gender, and BMI. The first group received a single propofol sedation (N = 31, age 57 ± 12, dose range 70-100 mg/procedure) and the second group (N = 30, age 56 ± 12, dose 3-6 mg/procedure) received a single midazolam sedation, all done by an anesthesiologist. All patients completed number connection test (NCT), cognitive function score, time to recovery, time to discharge sheets, and hemodynamic parameters before sedation, and at discharge from the endoscopy unit, 1h post-procedure. Thirty control subjects without cirrhosis were matched to the cirrhotic patients who received sedation with regard to age, gender, BMI, and education level. RESULTS A total of 58/61 cirrhotic patients (95%) had sub-clinical encephalopathy before the endoscopy (mean NCT 84.7 ± 77 s, normal < 30 s). No patient developed overt HE after sedation. There were no differences between groups in the incidence of adverse effects, cognitive function, MELD score, CP score, oxygen saturation, or respiratory and heart rates before and after sedation. Propofol did not exacerbate minimal HE when compared to midazolam (NCT changed from 87.5 ± 62 s prior to sedation to 74.2 ± 58 s after sedation in the propofol group versus 72.8 ± 62 s before to 85.6 ± 72 s after sedation in the midazolam group; p < 0.01). Time to recovery (4.1 ± 1.9 min vs. 11.5 ± 5.0 min, p < 0.001), and time to discharge (38.0 ± 9 min vs. 110 ± 42 min, p < 0.001) were significantly shorter with propofol than midazolam. Pre- and post-procedure NCT (from 25 ± 20 s to 24 ± 20 s), cognitive function score (from 25 to 26), time to recovery (3.5 ± 1.0 min), and time to discharge (35 ± 10 min) did not change in the healthy controls. CONCLUSIONS Sedation with propofol has a shorter time recovery and a shorter time to discharge than midazolam and does not exacerbate sub-clinical hepatic encephalopathy in patients with compensated liver cirrhosis.
Collapse
Affiliation(s)
- Iyad Khamaysi
- Department of Gastroenterology, Rambam Medical Center, Haifa, Israel
| | | | | | | | | | | | | |
Collapse
|
37
|
Correia LM, Bonilha DQ, Gomes GF, Brito JR, Nakao FS, Lenz L, Rohr MRS, Ferrari AP, Libera ED. Sedation during upper GI endoscopy in cirrhotic outpatients: a randomized, controlled trial comparing propofol and fentanyl with midazolam and fentanyl. Gastrointest Endosc 2011; 73:45-51, 51.e1. [PMID: 21184869 DOI: 10.1016/j.gie.2010.09.025] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2010] [Accepted: 09/14/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND Patients with liver cirrhosis frequently undergo diagnostic or therapeutic upper GI endoscopy (UGIE), and the liver disease might impair the metabolism of drugs usually administered for sedation. OBJECTIVE AND SETTING To compare sedation with a combination of propofol plus fentanyl and midazolam plus fentanyl in cirrhotic outpatients undergoing UGIE. DESIGN A prospective, randomized, controlled trial was conducted between February 2008 and February 2009. MAIN OUTCOMES MEASUREMENTS Efficacy (proportion of complete procedures using the initial proposed sedation scheme), safety (occurrence of sedation-related complications), and recovery time were measured. RESULTS Two hundred ten cirrhotic patients referred for UGIE were randomized to 2 groups: midazolam group (0.05 mg/kg plus fentanyl 50 μg intravenously) or propofol group (0.25 mg/kg plus fentanyl 50 μg intravenously). There were no differences between groups regarding age, sex, weight, etiology of cirrhosis, and Child-Pugh or American Society of Anesthesiologists classification. Sedation with propofol was more efficacious (100% vs 88.2%; P < .001) and had a shorter recovery time than sedation with midazolam (16.23 ± 6.84 minutes and 27.40 ± 17.19 minutes, respectively; P < .001). Complication rates were similar in both groups (14% vs 7.3%; P = .172). LIMITATIONS Single-blind study; sample size. CONCLUSION Both sedation schemes were safe in this setting. Sedation with propofol plus fentanyl was more efficacious with a shorter recovery time compared with midazolam plus fentanyl. Therefore, the former scheme is an alternative when sedating cirrhotic patients undergoing UGIE.
Collapse
Affiliation(s)
- Lucianna Motta Correia
- Disciplina de Gastroenterologia Clínica, Universidade Federal de São Paulo, São Paulo, Brasil
| | | | | | | | | | | | | | | | | |
Collapse
|
38
|
Bittencourt PL, Farias AQ, Strauss E, Mattos AAD. Variceal bleeding: consensus meeting report from the Brazilian Society of Hepatology. ARQUIVOS DE GASTROENTEROLOGIA 2010; 47:202-16. [PMID: 20721469 DOI: 10.1590/s0004-28032010000200017] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2009] [Accepted: 08/17/2009] [Indexed: 02/06/2023]
Abstract
In the last decades, several improvements in the management of variceal bleeding have resulted in a significant decrease in morbidity and mortality of patients with cirrhosis and bleeding varices. Progress in the multidisciplinary approach to these patients has led to a better management of this disease by critical care physicians, hepatologists, gastroenterologists, endoscopists, radiologists and surgeons. In this respect, the Brazilian Society of Hepatology has, recently, sponsored a consensus meeting in order to draw evidence-based recommendations on the management of these difficult-to-treat subjects. An organizing committee comprised of four people was elected by the Governing Board and was responsible to invite 27 researchers from distinct regions of the country to make a systematic review of the subject and to present topics related to variceal bleeding, including prevention, diagnosis, management and treatment, according to evidence-based medicine. After the meeting, all participants met together for discussion of the topics and the elaboration of the aforementioned recommendations. The organizing committee was responsible for writing the final document. The meeting was held at Salvador, May 6th, 2009 and the present manuscript is the summary of the systematic review that was presented during the meeting, organized in topics, followed by the recommendations of the Brazilian Society of Hepatology.
Collapse
|
39
|
Nayar DS, Guthrie WG, Goodman A, Lee Y, Feuerman M, Scheinberg L, Gress FG. Comparison of propofol deep sedation versus moderate sedation during endosonography. Dig Dis Sci 2010; 55:2537-44. [PMID: 20635148 DOI: 10.1007/s10620-010-1308-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2010] [Accepted: 06/14/2010] [Indexed: 12/13/2022]
Abstract
BACKGROUND The purposes of this study are: (1) to prospectively evaluate clinically relevant outcomes including sedation-related complications for endoscopic ultrasound (EUS) procedures performed with the use of propofol deep sedation administered by monitored anesthesia care (MAC), and (2) to compare these results with a historical case-control cohort of EUS procedures performed using moderate sedation provided by the gastrointestinal (GI) endoscopist. MATERIALS AND METHODS Patients referred for EUS between January 1, 2001 and December 31, 2002 were enrolled. Complication rates for EUS using MAC sedation were observed and also compared with a historical case-control cohort of EUS patients who received meperidine/midazolam for moderate sedation, administered by the GI endoscopist. Logistic regression analysis was used to isolate possible predictors of complications. RESULTS A total of 1,000 patients underwent EUS with propofol sedation during the period from January 1, 2001 through December 31, 2002 (mean age 64 years, 53% female). The distribution of EUS indications based on the primary area of interest was: 170 gastroduodenal, 92 anorectal, 508 pancreaticohepatobiliary, 183 esophageal, and 47 mediastinal. The primary endpoint of the study was development of sedation-related complications occurring during a performed procedure. A total of six patients experienced complications: duodenal perforation (one), hypotension (one), aspiration pneumonia (one), and apnea requiring endotracheal intubation (three). The complication rate with propofol was 0.60%, compared with 1% for the historical case-control (meperidine/midazolam moderate sedation) group. CONCLUSIONS There does not appear to be a significant difference between complication rates for propofol deep sedation with MAC and meperidine/midazolam administered for moderate sedation.
Collapse
Affiliation(s)
- D S Nayar
- Gastroenterology Associates of Central Jersey, Edison, NJ, USA
| | | | | | | | | | | | | |
Collapse
|
40
|
Abstract
Endoscopic procedures are often necessary in patients with chronic liver disease. The preprocedure evaluation of such patients should include an assessment of hepatic synthetic function and identification of neuropsychiatric findings suggestive of hepatic encephalopathy. It may be possible, in some cases, to perform diagnostic esophagogastroduodenoscopy without administration of sedation; this is desirable to eliminate the risks of sedation, especially encephalopathy. Nonetheless, most patients undergoing upper and lower endoscopy require sedation. Currently, the use of propofol is preferred to benzodiazepines and opioids for endoscopic sedation of patients with advanced liver disease due to its short biologic half-life and low risk of provoking hepatic encephalopathy. In appropriately selected patients, gastroenterologist-directed propofol administration seems safe.
Collapse
|
41
|
Riphaus A, Lechowicz I, Frenz MB, Wehrmann T. Propofol sedation for upper gastrointestinal endoscopy in patients with liver cirrhosis as an alternative to midazolam to avoid acute deterioration of minimal encephalopathy: a randomized, controlled study. Scand J Gastroenterol 2010; 44:1244-51. [PMID: 19811337 DOI: 10.1080/00365520903194591] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Midazolam sedation for upper gastrointestinal (GI) endoscopy exacerbates minimal hepatic encephalopathy (HE) in patients with liver cirrhosis, therefore an alternative drug regimen for these patients is warranted. The aim of this randomized, controlled study was to assess whether the use of the short-acting propofol as a sedative for GI endoscopy could prevent the exacerbation of minimal HE in patients with liver cirrhosis. MATERIAL AND METHODS The study comprised patients with liver cirrhosis without clinical HE who had undergone upper GI endoscopy for therapeutic purposes (intended variceal band ligation). Sixty patients were randomly assigned into two groups to receive propofol (n=40) or midazolam (n=20) for upper GI endoscopy. The study groups were matched for age, gender and Child-Pugh score. All patients completed number connecting tests (NCTs), as well as a porto-systemic encephalopathy (PSE) syndrome test before and at 2 h after completion of the endoscopic procedure. Time needed to fulfill the tests was documented. Baseline results of the psychomotor test batteries were compared with the post-interventional evaluations. Data were also compared with the results of a healthy control group (n=20) that did not undergo endoscopic sedation. Recovery time and quality (score system) were evaluated. RESULTS The differences in the NCT times before and after sedation (median delta NCT, midazolam group, 11 s (95% CI, -1.2 to 16.1 s) versus the propofol group, -9.5 s (95% CI, -15.7 to -4.6 s), p=0.002) and in the PSE scores (median delta PSE, midazolam group, -1 (95% CI, -1.5 to 0.2) versus the propofol group, 1 (95% CI, 0.5 to 1.5), p=0.0009) differed significantly between the two groups. In addition, the recovery time and quality in patients receiving propofol were significantly improved compared with in the midazolam group (7.8+/-2.9 min versus 18.4+/-6.7 min, 6.1+/-1.1 versus 8.2+/-1.3, both p<0.001). CONCLUSIONS The study demonstrates that propofol sedation for upper GI endoscopy does not cause acute deterioration of minimal hepatic encephalopathy and is associated with improved recovery in patients with liver cirrhosis. Propofol should be recommended for these patients as an alternative to midazolam.
Collapse
Affiliation(s)
- Andrea Riphaus
- Department of Internal Medicine I, Gastroenterology and Interventional Endoscopy, Hospital Siloah, Hannover, Germany.
| | | | | | | |
Collapse
|
42
|
Mason KP. Sedation trends in the 21st century: the transition to dexmedetomidine for radiological imaging studies. Paediatr Anaesth 2010; 20:265-72. [PMID: 20015137 DOI: 10.1111/j.1460-9592.2009.03224.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Sedation for radiological imaging studies encompasses the majority of all sedation-related procedures outside of the intensive care unit. This review will follow the evolution of pediatric sedation for radiological imaging studies in North America as well as the transition of sedation services from the oversight of radiologists to those of other providers. The evolving options for sedation agents will be reviewed, with attention given to examining the advantages, limitations, and risks of replacing the standard sedatives with dexmedetomidine.
Collapse
Affiliation(s)
- Keira P Mason
- Children's Hospital Boston, Department of Anesthesia, Boston, MA 02115, USA.
| |
Collapse
|
43
|
Ivano FH, Romeiro PCM, Matias JEF, Baretta GAP, Kay AK, Sasaki CA, Nakamoto R, Tambara EM. Estudo comparativo de eficácia e segurança entre propofol e midazolam durante sedação para colonoscopia. Rev Col Bras Cir 2010; 37:10-6. [DOI: 10.1590/s0100-69912010000100004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2008] [Accepted: 02/23/2009] [Indexed: 12/22/2022] Open
Abstract
OBJETIVO: Comparar a segurança e a eficácia do propofol com a do midazolam na sedação profunda durante colonoscopias. MÉTODOS: Sessenta e seis pacientes foram submetidos à colonoscopias e estudados prospectivamente. Um total de 50 pacientes recebeu 3,25 mg.kg-1 de peso de propofol. No grupo controle de 16 pacientes foi administrado 2,05 mg.kg-1 de peso de midazolam. A dose de manutenção foi titulada de acordo com a necessidade. Os parâmetros cardiovasculares e respiratórios observados foram a saturação de oxigênio, pressão arterial sistólica e diastólica e frequência cardíaca. Após o procedimento foi realizado um questionário sobre intercorrências como dor, desconforto e satisfação após a colonoscopia, utilizando uma escala visual de zero a dez. Foi aplicado o teste t de Student para a análise estatística. RESULTADOS: A amostra foi similar com relação às variáveis idade, peso, sexo e condição física. Houve diferença estatística significativa para os parâmetros saturação de oxigênio do sangue e pressão arterial sistólica entre os dois grupos. Não houve diferença estatística significativa para os parâmetros pressão arterial diastólica e pulso. Apesar das diferenças nos parâmetros cardiovasculares e respiratórios, não houve repercussões hemodinâmicas significativas. Não houve diferença estatística no parâmetro dor e satisfação. Os pacientes que apresentaram agitação (25%) no grupo midazolam, relataram mais desconforto (p=0,038). CONCLUSÃO: As variações nos parâmetros cardiovasculares e respiratórios, mesmo com diferenças significativas entre os grupos, não causaram repercussões clínicas significativas nos dois grupos, caracterizando a segurança na sedação profunda. A sedação com midazolam ou propofol não está associada a níveis de dor e satisfação diferentes entre os dois grupos. O grupo midazolan referiu significativamente mais desconforto que o grupo propofol.
Collapse
|
44
|
Vargo JJ, Cohen LB, Rex DK, Kwo PY. Position statement: Nonanesthesiologist administration of propofol for GI endoscopy. Hepatology 2009; 50:1683-9. [PMID: 19937691 DOI: 10.1002/hep.23326] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- John J Vargo
- Department of Gastroenterology and Hepatology, Cleveland Clinic Lerner College of Medicine of Case Western University, Cleveland, Ohio, USA
| | | | | | | |
Collapse
|
45
|
Vargo JJ, Cohen LB, Rex DK, Kwo PY. Position statement: Nonanesthesiologist administration of propofol for GI endoscopy. Gastroenterology 2009; 137:2161-7. [PMID: 19961989 DOI: 10.1053/j.gastro.2009.09.050] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2009] [Accepted: 07/10/2009] [Indexed: 12/14/2022]
Affiliation(s)
- John J Vargo
- Department of Gastroenterology and Hepatology, Cleveland Clinic Lerner College of Medicine of Case Western University, Cleveland, Ohio, USA
| | | | | | | | | | | | | | | |
Collapse
|
46
|
Vargo JJ, Cohen LB, Rex DK, Kwo PY. Position statement: nonanesthesiologist administration of propofol for GI endoscopy. Gastrointest Endosc 2009; 70:1053-9. [PMID: 19962497 DOI: 10.1016/j.gie.2009.07.020] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2009] [Accepted: 07/10/2009] [Indexed: 02/08/2023]
Affiliation(s)
- John J Vargo
- Department of Gastroenterology and Hepatology, Cleveland Clinic Lerner College of Medicine of Case Western University, Cleveland, Ohio, USA
| | | | | | | |
Collapse
|
47
|
|
48
|
Rex DK, Deenadayalu VP, Eid E, Imperiale TF, Walker JA, Sandhu K, Clarke AC, Hillman LC, Horiuchi A, Cohen LB, Heuss LT, Peter S, Beglinger C, Sinnott JA, Welton T, Rofail M, Subei I, Sleven R, Jordan P, Goff J, Gerstenberger PD, Munnings H, Tagle M, Sipe BW, Wehrmann T, Di Palma JA, Occhipinti KE, Barbi E, Riphaus A, Amann ST, Tohda G, McClellan T, Thueson C, Morse J, Meah N. Endoscopist-directed administration of propofol: a worldwide safety experience. Gastroenterology 2009; 137:1229-37; quiz 1518-9. [PMID: 19549528 DOI: 10.1053/j.gastro.2009.06.042] [Citation(s) in RCA: 274] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2008] [Revised: 04/29/2009] [Accepted: 06/11/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Endoscopist-directed propofol sedation (EDP) remains controversial. We sought to update the safety experience of EDP and estimate the cost of using anesthesia specialists for endoscopic sedation. METHODS We reviewed all published work using EDP. We contacted all endoscopists performing EDP for endoscopy that we were aware of to obtain their safety experience. These complications were available in all patients: endotracheal intubations, permanent neurologic injuries, and death. RESULTS A total of 646,080 (223,656 published and 422,424 unpublished) EDP cases were identified. Endotracheal intubations, permanent neurologic injuries, and deaths were 11, 0, and 4, respectively. Deaths occurred in 2 patients with pancreatic cancer, a severely handicapped patient with mental retardation, and a patient with severe cardiomyopathy. The overall number of cases requiring mask ventilation was 489 (0.1%) of 569,220 cases with data available. For sites specifying mask ventilation risk by procedure type, 185 (0.1%) of 185,245 patients and 20 (0.01%) of 142,863 patients required mask ventilation during their esophagogastroduodenoscopy or colonoscopy, respectively (P < .001). The estimated cost per life-year saved to substitute anesthesia specialists in these cases, assuming they would have prevented all deaths, was $5.3 million. CONCLUSIONS EDP thus far has a lower mortality rate than that in published data on endoscopist-delivered benzodiazepines and opioids and a comparable rate to that in published data on general anesthesia by anesthesiologists. In the cases described here, use of anesthesia specialists to deliver propofol would have had high costs relative to any potential benefit.
Collapse
Affiliation(s)
- Douglas K Rex
- Division of Gastroenterology/Hepatology, Indiana University Medical Center, Indianapolis, Indiana 46202, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
49
|
Abstract
AIM: To elucidate the efficacy and safety of a split dose of midazolam in combination with meperidine for colonoscopy.
METHODS: Eighty subjects undergoing outpatient colonoscopy were randomly assigned to group A or B. Group A (n = 40) received a split dose of midazolam in combination with meperidine. Group B (n = 40) received a single dose of midazolam in combination with meperidine. Outcome measurements were level of sedation, duration of sedation and recovery, degree of pain and satisfaction, procedure-related memory, controllability, and adverse events.
RESULTS: Group A had a lower frequency of significant hypoxemia (P = 0.043) and a higher sedation score on withdrawal of the endoscope from the descending colon than group B (P = 0.043). Group B recovered from sedation slightly sooner than group A (P < 0.002). Scores for pain and memory, except insertion-related memory, were lower in group A one week after colonoscopic examination (P = 0.018 and P < 0.030, respectively). Poor patient controllability was noted by the endoscopist and nurse in group B (P = 0.038 and P = 0.032, respectively).
CONCLUSION: Split dose midazolam in combination with meperidine resulted in a safer, more equable sedation status during colonoscopic examination and a reduction in procedure-related pain and memory, but resulted in longer recovery time.
Collapse
|
50
|
Thuluvath PJ. Toward safer sedation in patients with cirrhosis: have we done enough? Gastrointest Endosc 2009; 70:269-71. [PMID: 19631803 DOI: 10.1016/j.gie.2009.01.029] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2009] [Accepted: 01/18/2009] [Indexed: 02/08/2023]
|