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Cuiabano IS, de Miranda Garbin P, Módolo NSP, do Nascimento P. Safety and efficacy of target-controlled infusion versus intermittent bolus administration of propofol for sedation in colonoscopy: a randomized controlled trial. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2023; 73:751-757. [PMID: 35803368 PMCID: PMC10625152 DOI: 10.1016/j.bjane.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 06/13/2022] [Accepted: 06/15/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Our objective was to compare the safety and efficacy of Target-Controlled Infusion (TCI) versus intermittent bolus of propofol for colonoscopy sedation. METHODS We conducted a randomized (1:1), single-blind, parallel-group superiority trial with fifty ASA I or II patients, both sexes, aged 18 to 65 years, Body Mass Index ≤ 30 kg.m-2, undergoing colonoscopy, allocated to receive propofol by TCI (effect-site, 2 μg.mL-1 plus 0.5 μg.mL-1 until unconsciousness and as necessary for agitation) or intermittent bolus (1 mg.kg-1 plus 0.5 mg.kg-1 every 5 minutes or as above). The primary safety outcome was the need for airway maneuvers and the primary efficacy outcome was the need for interventions to adjust the level of sedation. Secondary outcomes included incidence of agitation, propofol dose, and time to recovery. RESULTS The median (IQR) number of airway maneuvers and interventions needed to adjust sedation was 0 (0‒0) vs. 0 (0‒0) (p = 0.239) and 1 (0‒1) vs. 3 (1‒4) (p < 0.001) in the TCI and control groups, respectively. Agitation was more common in the intermittent bolus group ‒ 2 (0‒2) vs. 1 (0‒1), p < 0.001. The mean ± SD time to recovery was 4.9 ± 1.4 minutes in the TCI group vs. 2.3 ± 1.6 minutes in the control group (p < 0.001). The total propofol dose was higher in the TCI group (234 ± 46 µg.kg-1.min-1 vs. 195 ± 44 µg.kg-1.min-1 (p = 0.040)). CONCLUSIONS During colonoscopy, TCI is as safe as intermittent bolus of propofol while reducing the incidence of agitation and the need for dose adjustments. However, intermittent bolus administration was associated with lower total propofol dose and earlier recovery.
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Affiliation(s)
| | - Priscila de Miranda Garbin
- Hospital de Câncer de Mato Grosso (Hcan-MT), Cuiabá, MT, Brazil; Hospital Nossa Senhora do Perpétuo Socorro, Gaspar, SC, Brazil
| | - Norma Sueli Pinheiro Módolo
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu, Departamento de Especialidades Cirúrgicas e Anestesiologia, São Paulo, SP, Brazil
| | - Paulo do Nascimento
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu, Departamento de Especialidades Cirúrgicas e Anestesiologia, São Paulo, SP, Brazil
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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
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Joy PJ, Blanshard HJ. Propofol-remifentanil patient-controlled sedation for endoscopic procedures: a prospective service audit. Can J Anaesth 2023; 70:1735-1743. [PMID: 37814120 DOI: 10.1007/s12630-023-02593-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 04/02/2023] [Accepted: 04/10/2023] [Indexed: 10/11/2023] Open
Abstract
PURPOSE Following demand, we established a patient-controlled propofol-remifentanil sedation service for endoscopy overseen by an anesthesiologist. To assess the effectiveness of the intervention of this service and any complications, we prospectively audited the service. Our primary outcomes of interest were adequacy of sedation and patient satisfaction. Secondary outcomes included any adverse events associated with the sedation. METHODS Patients were referred for failure of procedure under endoscopist-administered sedation, refusal of procedure without general anesthesia (GA), or planned complex procedure. We included all 670 procedures performed between 2017 and 2021. We used a mixture of 8.9 mg·mL-1 propofol and 5.4 µg·mL-1 remifentanil with a 1-mL bolus and 20-sec lockout. We assessed the adequacy of sedation using the Modified Gloucester Scale and categorized adverse events according to the Tracking and Reporting Outcomes of Procedural Sedation. RESULTS All 670 procedures were accomplished with adequate sedation without the need for ventilation or GA, and all patients were satisfied with the sedation. The complication rate was low, with no sentinel airway or respiratory events. Nineteen out of 670 patients (2.8%) had an incidence of airway obstruction (requiring a simple airway maneuver). The body mass index (BMI) was documented in 18/19 of these patients and the average BMI in this group was 35 kg·m-2. Seven of the 670 patients (1%) had self-terminating apnea, 3/670 patients (0.4%) vomited, no patients aspirated, and 17/665 patients (2.6%) required a vasopressor to maintain blood pressure within 20% of preprocedure values. CONCLUSION The results from our prospective service audit indicate that propofol-remifentanil patient-controlled sedation is a safe and reliable technique in patients undergoing endoscopic procedures.
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Affiliation(s)
- Paula J Joy
- School of Anaesthesia, Severn Deanery, Bristol, UK
| | - Hannah J Blanshard
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
- Department of Anaesthesia (A704), Bristol Royal Infirmary, Level 7, Queens Building, Upper Maudlin Street, Bristol, BS2 8HW, UK
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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
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Grossmann B, Nilsson A, Sjöberg F, Bernfort L, Nilsson L. Patient-controlled sedation with propofol for endoscopic procedures-A cost analysis. Acta Anaesthesiol Scand 2020; 64:53-62. [PMID: 31436310 DOI: 10.1111/aas.13463] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 08/07/2019] [Accepted: 08/09/2019] [Indexed: 01/15/2023]
Abstract
BACKGROUND Patient-controlled sedation (PCS) with propofol accompanied by a bedside nurse anaesthetist is an alternative sedation method for endoscopic procedures compared with midazolam administered by a nurse or endoscopist. Increasing costs in health care demands an economic perspective when introducing alternative methods. We applied a hospital perspective on a cost analysis comparing different methods of sedation and the resource use that were expected to affect cost differences related to the sedation. METHODS Based on two randomised previous studies, the direct costs were determined for different sedation methods during two advanced endoscopic procedures: endoscopic retrograde cholangiopancreatography (ERCP) and flexible bronchoscopy including endobronchial ultrasound. ERCP comparisons were made between midazolam sedation by the endoscopic team, PCS with a bedside nurse anaesthetist and propofol sedation administered by a nurse anaesthetist. Bronchoscopy comparisons were made between midazolam sedation by the endoscopic team and PCS with a bedside nurse anaesthetist, categorised by premedication morphine-scopolamine or glycopyrronium. RESULTS Propofol PCS with a bedside nurse anaesthetist resulted in lower costs per patient for sedation for both ERCP (233 USD) and bronchoscopy (premedication morphine-scopolamine 267 USD, premedication glycopyrronium 269 USD) compared with midazolam (ERCP 425 USD, bronchoscopy 337 USD). Aborted procedures that needed to be repeated and prolonged hospital stays significantly increased the cost for the midazolam groups. CONCLUSION Propofol PCS with a bedside nurse anaesthetist reduces the direct sedation costs for ERCP and bronchoscopy procedures compared with midazolam sedation.
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Affiliation(s)
- Benjamin Grossmann
- Department of Clinical and Experimental Medicine Linköping University Linköping Sweden
- Department of Anaesthesia and Intensive Care Linköping University Hospital Linköping Sweden
| | - Andreas Nilsson
- Department of Anaesthesia and Intensive Care Linköping University Hospital Linköping Sweden
- Department of Medical and Health Sciences Linköping University Linköping Sweden
| | - Folke Sjöberg
- Department of Clinical and Experimental Medicine Linköping University Linköping Sweden
- Department of Hand and Plastic Surgery and Intensive Care Linköping University Hospital Linköping Sweden
| | - Lars Bernfort
- Division of Health Care Analysis Linköping University Linköping Sweden
| | - Lena Nilsson
- Department of Anaesthesia and Intensive Care Linköping University Hospital Linköping Sweden
- Department of Medical and Health Sciences Linköping University Linköping Sweden
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Kreienbühl L, Elia N, Pfeil-Beun E, Walder B, Tramèr MR. Patient-Controlled Versus Clinician-Controlled Sedation With Propofol: Systematic Review and Meta-analysis With Trial Sequential Analyses. Anesth Analg 2019; 127:873-880. [PMID: 29750696 DOI: 10.1213/ane.0000000000003361] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Sedation with propofol is frequently used to facilitate diagnostic and therapeutic procedures. Propofol can be administrated by the patient (patient-controlled sedation [PCS]) or by a clinician (clinician-controlled sedation [CCS]). We aimed to compare these 2 techniques. METHODS PubMed, Embase, CENTRAL, and trial registries were searched up to October 2017 for randomized controlled trials comparing PCS with CCS with propofol. The primary end points were the risks of presenting at least 1 episode of oxygen desaturation, arterial hypotension, and bradycardia, and the risk of requiring a rescue intervention (pharmacologic therapies or physical maneuvers) for sedation-related adverse events. Secondary end points were the dose of propofol administrated, operator and patient satisfaction, and the risk of oversedation. A random-effects model and an α level of .02 to adjust for multiple analyses were used throughout. Trial sequential analyses were performed for primary outcomes. Quality of evidence was assessed according to the Grades of Recommendation, Assessment, Development, and Evaluation system. RESULTS Thirteen trials (1103 patients; median age, 47 years; American Society of Anesthesiologists physical status I-III) describing various diagnostic and therapeutic procedures with propofol sedation were included. PCS had no impact on the risk of oxygen desaturation (11 trials, 31/448 patients [6.9%] with PCS versus 46/481 [9.6%] with CCS; risk ratio, 0.74 [98% confidence interval, 0.35-1.56]) but decreased the risk of requiring a rescue intervention for adverse events (11 trials, 29/449 patients [6.5%] with PCS versus 74/482 [15.4%] with CCS; risk ratio, 0.45 [98% confidence interval, 0.25-0.81]). For both outcomes, Trial sequential analyses suggested that further trials were unlikely to change the results, although the quality of evidence was graded very low for all primary outcomes. For the risk of arterial hypotension and bradycardia, the required sample size for a definitive conclusion had not been reached. Analysis of secondary outcomes suggested that PCS decreased the risk of oversedation and had no impact on propofol dose administrated, or on operator or patient satisfaction. CONCLUSIONS PCS with propofol, compared with CCS with propofol, had no impact on the risk of oxygen desaturation, but significantly decreased the risk of rescue interventions for sedation-related adverse events. Further high-quality trials are required to assess the risks and benefits of PCS.
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Affiliation(s)
- Lukas Kreienbühl
- From the Division of Anesthesiology, Geneva University Hospitals, Geneva, Switzerland
| | - Nadia Elia
- From the Division of Anesthesiology, Geneva University Hospitals, Geneva, Switzerland
| | - Elvire Pfeil-Beun
- From the Division of Anesthesiology, Geneva University Hospitals, Geneva, Switzerland
| | - Bernhard Walder
- From the Division of Anesthesiology, Geneva University Hospitals, Geneva, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Martin R Tramèr
- From the Division of Anesthesiology, Geneva University Hospitals, Geneva, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland
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Kayaaltı S, Kayaaltı Ö. Safety of applying midazolam-ketamine-propofol sedation combination under the supervision of endoscopy nurse with patient-controlled analgesia pump in colonoscopy. World J Clin Cases 2018; 6:1146-1154. [PMID: 30613673 PMCID: PMC6306640 DOI: 10.12998/wjcc.v6.i16.1146] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 11/09/2018] [Accepted: 11/23/2018] [Indexed: 02/05/2023] Open
Abstract
AIM To compare the results of midazolam-ketamine-propofol sedation performed by an endoscopy nurse and anaesthetist during colonoscopy in terms of patient satisfaction and safety. METHODS American Statistical Association (ASA) I-II 60 patients who underwent colonoscopy under sedation were randomly divided into two groups: sedation under the supervision of an anaesthetist (SSA) and sedation under the supervision of an endoscopy nurse (SSEN). Both groups were initially administered 1 mg midazolam, 50 mg ketamine and 30-50 mg propofol. Continuation of sedation was performed by the anaesthetist in the SSA group and the nurse with a patient-controlled analgesia (PCA) pump in the SSEN group. The total propofol consumption, procedure duration, recovery times, pain using the visual analogue scale (VAS) and satisfaction score of the patients, and side effects were recorded. In addition, the patients were asked whether they remembered the procedure and whether they would prefer the same method in the case of re-endoscopy. RESULTS Total propofol consumption in the SSEN group was significantly higher (P < 0.05) than that in the SSA group. When the groups were compared in terms of VAS score, recovery time, patient satisfaction, recall of the procedure, re-preference for the same method in case of re-endoscopy, and side effects, there were no significant differences (P > 0.05) between the two groups. No long-term required intervention side effects were observed in either group. CONCLUSION Colonoscopy sedation in ASA I-II patients can be safely performed by an endoscopy nurse using PCA pump with the incidence of side effects and patient satisfaction levels similar to sedation under anaesthetist supervision.
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Affiliation(s)
- Selda Kayaaltı
- Division of Anaesthesiology and Reanimation, Develi Public Hospital, Develi, Kayseri 38400, Turkey
| | - Ömer Kayaaltı
- Computer Technology, Kayseri University, Develi Huseyin Sahin Vocational College, Develi, Kayseri 38400, Turkey
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Zhang W, Zhu Z, Zheng Y. Effect and safety of propofol for sedation during colonoscopy: A meta-analysis. J Clin Anesth 2018; 51:10-18. [DOI: 10.1016/j.jclinane.2018.07.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 07/23/2018] [Accepted: 07/23/2018] [Indexed: 02/08/2023]
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Early DS, Lightdale JR, Vargo JJ, Acosta RD, Chandrasekhara V, Chathadi KV, Evans JA, Fisher DA, Fonkalsrud L, Hwang JH, Khashab MA, Muthusamy VR, Pasha SF, Saltzman JR, Shergill AK, Cash BD, DeWitt JM. Guidelines for sedation and anesthesia in GI endoscopy. Gastrointest Endosc 2018; 87:327-337. [PMID: 29306520 DOI: 10.1016/j.gie.2017.07.018] [Citation(s) in RCA: 290] [Impact Index Per Article: 48.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 07/13/2017] [Indexed: 02/08/2023]
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Tilz RR, Chun KRJ, Deneke T, Kelm M, Piorkowski C, Sommer P, Stellbrink C, Steven D. Positionspapier der Deutschen Gesellschaft für Kardiologie zur Kardioanalgosedierung. KARDIOLOGE 2017. [DOI: 10.1007/s12181-017-0179-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Abstract
Endoscopist-directed propofol (EDP) refers to delivery of propofol for endoscopic sedation under the direction of an endoscopist without any involvement of an anesthesia specialist (anesthesiologist or nurse anesthetist). EDP has been proven to be safe and is also cost-effective compared with the anesthetist delivered sedation for endoscopy. EDP has been endorsed by US gastroenterology societies as an appropriate paradigm for clinical practice. EDP has proliferated in Switzerland and Germany, but its expansion in the United States has been limited by financial disincentives, concerns about medical-legal risk for endoscopists, and regulatory obstacles.
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Affiliation(s)
- Douglas K Rex
- Indiana University Hospital, Room 4100, 550 North University Boulevard, Indianapolis, IN 46202, USA.
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Visvabharathy L, Xayarath B, Weinberg G, Shilling RA, Freitag NE. Propofol Increases Host Susceptibility to Microbial Infection by Reducing Subpopulations of Mature Immune Effector Cells at Sites of Infection. PLoS One 2015; 10:e0138043. [PMID: 26381144 PMCID: PMC4575148 DOI: 10.1371/journal.pone.0138043] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 08/24/2015] [Indexed: 12/24/2022] Open
Abstract
Anesthetics are known to modulate host immune responses, but separating the variables of surgery from anesthesia when analyzing hospital acquired infections is often difficult. Here, the bacterial pathogen Listeria monocytogenes (Lm) was used to assess the impact of the common anesthetic propofol on host susceptibility to infection. Brief sedation of mice with physiologically relevant concentrations of propofol increased bacterial burdens in target organs by more than 10,000-fold relative to infected control animals. The adverse effects of propofol sedation on immune clearance of Lm persisted after recovery from sedation, as animals given the drug remained susceptible to infection for days following anesthesia. In contrast to propofol, sedation with alternative anesthetics such as ketamine/xylazine or pentobarbital did not increase susceptibility to systemic Lm infection. Propofol altered systemic cytokine and chemokine expression during infection, and prevented effective bacterial clearance by inhibiting the recruitment and/or activity of immune effector cells at sites of infection. Propofol exposure induced a marked reduction in marginal zone macrophages in the spleens of Lm infected mice, resulting in bacterial dissemination into deep tissue. Propofol also significantly increased mouse kidney abscess formation following infection with the common nosocomial pathogen Staphylococcus aureus. Taken together, these data indicate that even brief exposure to propofol severely compromises host resistance to microbial infection for days after recovery from sedation.
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Affiliation(s)
- Lavanya Visvabharathy
- Department of Microbiology and Immunology, University of Illinois at Chicago, Chicago, Illinois, United States of America
| | - Bobbi Xayarath
- Department of Microbiology and Immunology, University of Illinois at Chicago, Chicago, Illinois, United States of America
| | - Guy Weinberg
- Department of Anesthesiology, University of Illinois at Chicago, Chicago, Illinois, United States of America
| | - Rebecca A. Shilling
- Department of Microbiology and Immunology, University of Illinois at Chicago, Chicago, Illinois, United States of America
- Department of Pulmonary, Critical Care, Sleep and Allergy, University of Illinois at Chicago, Chicago, Illinois, United States of America
| | - Nancy E. Freitag
- Department of Microbiology and Immunology, University of Illinois at Chicago, Chicago, Illinois, United States of America
- * E-mail:
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Fernandes N, Bryant D, Griffith L, El-Rabbany M, Fernandes NM, Kean C, Marsh J, Mathur S, Moyer R, Reade CJ, Riva JJ, Somerville L, Bhatnagar N. Outcomes for patients with the same disease treated inside and outside of randomized trials: a systematic review and meta-analysis. CMAJ 2014; 186:E596-609. [PMID: 25267774 PMCID: PMC4216275 DOI: 10.1503/cmaj.131693] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND It is unclear whether participation in a randomized controlled trial (RCT), irrespective of assigned treatment, is harmful or beneficial to participants. We compared outcomes for patients with the same diagnoses who did ("insiders") and did not ("outsiders") enter RCTs, without regard to the specific therapies received for their respective diagnoses. METHODS By searching the MEDLINE (1966-2010), Embase (1980-2010), CENTRAL (1960-2010) and PsycINFO (1880-2010) databases, we identified 147 studies that reported the health outcomes of "insiders" and a group of parallel or consecutive "outsiders" within the same time period. We prepared a narrative review and, as appropriate, meta-analyses of patients' outcomes. RESULTS We found no clinically or statistically significant differences in outcomes between "insiders" and "outsiders" in the 23 studies in which the experimental intervention was ineffective (standard mean difference in continuous outcomes -0.03, 95% confidence interval [CI] -0.1 to 0.04) or in the 7 studies in which the experimental intervention was effective and was received by both "insiders" and "outsiders" (mean difference 0.04, 95% CI -0.04 to 0.13). However, in 9 studies in which an effective intervention was received only by "insiders," the "outsiders" experienced significantly worse health outcomes (mean difference -0.36, 95% CI -0.61 to -0.12). INTERPRETATION We found no evidence to support clinically important overall harm or benefit arising from participation in RCTs. This conclusion refutes earlier claims that trial participants are at increased risk of harm.
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Affiliation(s)
- Natasha Fernandes
- Faculty of Medicine (Natasha Fernandes, Mathur), University of Ottawa, Ottawa, Ont.; Faculty of Health Sciences (Bryant, Marsh, Moyer) and Schulich School of Medicine and Dentistry (Bryant), The University of Western Ontario, London, Ont.; Department of Clinical Epidemiology and Biostatistics (Bryant, Griffith), Department of Medicine (Nisha Fernandes), Health Sciences Library (Bhatnagar), Department of Family Medicine (Riva) and Division of Gynecologic Oncology (Reade), McMaster University, Hamilton, Ont.; Faculty of Dentistry (El-Rabbany), University of Toronto, Toronto, Ont.; School of Medical and Applied Sciences (Kean), Central Queensland University, Rockhampton, Australia; Department of Orthopaedic Surgery (Somerville), London Health Sciences Centre, London, Ont.
| | - Dianne Bryant
- Faculty of Medicine (Natasha Fernandes, Mathur), University of Ottawa, Ottawa, Ont.; Faculty of Health Sciences (Bryant, Marsh, Moyer) and Schulich School of Medicine and Dentistry (Bryant), The University of Western Ontario, London, Ont.; Department of Clinical Epidemiology and Biostatistics (Bryant, Griffith), Department of Medicine (Nisha Fernandes), Health Sciences Library (Bhatnagar), Department of Family Medicine (Riva) and Division of Gynecologic Oncology (Reade), McMaster University, Hamilton, Ont.; Faculty of Dentistry (El-Rabbany), University of Toronto, Toronto, Ont.; School of Medical and Applied Sciences (Kean), Central Queensland University, Rockhampton, Australia; Department of Orthopaedic Surgery (Somerville), London Health Sciences Centre, London, Ont
| | - Lauren Griffith
- Faculty of Medicine (Natasha Fernandes, Mathur), University of Ottawa, Ottawa, Ont.; Faculty of Health Sciences (Bryant, Marsh, Moyer) and Schulich School of Medicine and Dentistry (Bryant), The University of Western Ontario, London, Ont.; Department of Clinical Epidemiology and Biostatistics (Bryant, Griffith), Department of Medicine (Nisha Fernandes), Health Sciences Library (Bhatnagar), Department of Family Medicine (Riva) and Division of Gynecologic Oncology (Reade), McMaster University, Hamilton, Ont.; Faculty of Dentistry (El-Rabbany), University of Toronto, Toronto, Ont.; School of Medical and Applied Sciences (Kean), Central Queensland University, Rockhampton, Australia; Department of Orthopaedic Surgery (Somerville), London Health Sciences Centre, London, Ont
| | - Mohamed El-Rabbany
- Faculty of Medicine (Natasha Fernandes, Mathur), University of Ottawa, Ottawa, Ont.; Faculty of Health Sciences (Bryant, Marsh, Moyer) and Schulich School of Medicine and Dentistry (Bryant), The University of Western Ontario, London, Ont.; Department of Clinical Epidemiology and Biostatistics (Bryant, Griffith), Department of Medicine (Nisha Fernandes), Health Sciences Library (Bhatnagar), Department of Family Medicine (Riva) and Division of Gynecologic Oncology (Reade), McMaster University, Hamilton, Ont.; Faculty of Dentistry (El-Rabbany), University of Toronto, Toronto, Ont.; School of Medical and Applied Sciences (Kean), Central Queensland University, Rockhampton, Australia; Department of Orthopaedic Surgery (Somerville), London Health Sciences Centre, London, Ont
| | - Nisha M Fernandes
- Faculty of Medicine (Natasha Fernandes, Mathur), University of Ottawa, Ottawa, Ont.; Faculty of Health Sciences (Bryant, Marsh, Moyer) and Schulich School of Medicine and Dentistry (Bryant), The University of Western Ontario, London, Ont.; Department of Clinical Epidemiology and Biostatistics (Bryant, Griffith), Department of Medicine (Nisha Fernandes), Health Sciences Library (Bhatnagar), Department of Family Medicine (Riva) and Division of Gynecologic Oncology (Reade), McMaster University, Hamilton, Ont.; Faculty of Dentistry (El-Rabbany), University of Toronto, Toronto, Ont.; School of Medical and Applied Sciences (Kean), Central Queensland University, Rockhampton, Australia; Department of Orthopaedic Surgery (Somerville), London Health Sciences Centre, London, Ont
| | - Crystal Kean
- Faculty of Medicine (Natasha Fernandes, Mathur), University of Ottawa, Ottawa, Ont.; Faculty of Health Sciences (Bryant, Marsh, Moyer) and Schulich School of Medicine and Dentistry (Bryant), The University of Western Ontario, London, Ont.; Department of Clinical Epidemiology and Biostatistics (Bryant, Griffith), Department of Medicine (Nisha Fernandes), Health Sciences Library (Bhatnagar), Department of Family Medicine (Riva) and Division of Gynecologic Oncology (Reade), McMaster University, Hamilton, Ont.; Faculty of Dentistry (El-Rabbany), University of Toronto, Toronto, Ont.; School of Medical and Applied Sciences (Kean), Central Queensland University, Rockhampton, Australia; Department of Orthopaedic Surgery (Somerville), London Health Sciences Centre, London, Ont
| | - Jacquelyn Marsh
- Faculty of Medicine (Natasha Fernandes, Mathur), University of Ottawa, Ottawa, Ont.; Faculty of Health Sciences (Bryant, Marsh, Moyer) and Schulich School of Medicine and Dentistry (Bryant), The University of Western Ontario, London, Ont.; Department of Clinical Epidemiology and Biostatistics (Bryant, Griffith), Department of Medicine (Nisha Fernandes), Health Sciences Library (Bhatnagar), Department of Family Medicine (Riva) and Division of Gynecologic Oncology (Reade), McMaster University, Hamilton, Ont.; Faculty of Dentistry (El-Rabbany), University of Toronto, Toronto, Ont.; School of Medical and Applied Sciences (Kean), Central Queensland University, Rockhampton, Australia; Department of Orthopaedic Surgery (Somerville), London Health Sciences Centre, London, Ont
| | - Siddhi Mathur
- Faculty of Medicine (Natasha Fernandes, Mathur), University of Ottawa, Ottawa, Ont.; Faculty of Health Sciences (Bryant, Marsh, Moyer) and Schulich School of Medicine and Dentistry (Bryant), The University of Western Ontario, London, Ont.; Department of Clinical Epidemiology and Biostatistics (Bryant, Griffith), Department of Medicine (Nisha Fernandes), Health Sciences Library (Bhatnagar), Department of Family Medicine (Riva) and Division of Gynecologic Oncology (Reade), McMaster University, Hamilton, Ont.; Faculty of Dentistry (El-Rabbany), University of Toronto, Toronto, Ont.; School of Medical and Applied Sciences (Kean), Central Queensland University, Rockhampton, Australia; Department of Orthopaedic Surgery (Somerville), London Health Sciences Centre, London, Ont
| | - Rebecca Moyer
- Faculty of Medicine (Natasha Fernandes, Mathur), University of Ottawa, Ottawa, Ont.; Faculty of Health Sciences (Bryant, Marsh, Moyer) and Schulich School of Medicine and Dentistry (Bryant), The University of Western Ontario, London, Ont.; Department of Clinical Epidemiology and Biostatistics (Bryant, Griffith), Department of Medicine (Nisha Fernandes), Health Sciences Library (Bhatnagar), Department of Family Medicine (Riva) and Division of Gynecologic Oncology (Reade), McMaster University, Hamilton, Ont.; Faculty of Dentistry (El-Rabbany), University of Toronto, Toronto, Ont.; School of Medical and Applied Sciences (Kean), Central Queensland University, Rockhampton, Australia; Department of Orthopaedic Surgery (Somerville), London Health Sciences Centre, London, Ont
| | - Clare J Reade
- Faculty of Medicine (Natasha Fernandes, Mathur), University of Ottawa, Ottawa, Ont.; Faculty of Health Sciences (Bryant, Marsh, Moyer) and Schulich School of Medicine and Dentistry (Bryant), The University of Western Ontario, London, Ont.; Department of Clinical Epidemiology and Biostatistics (Bryant, Griffith), Department of Medicine (Nisha Fernandes), Health Sciences Library (Bhatnagar), Department of Family Medicine (Riva) and Division of Gynecologic Oncology (Reade), McMaster University, Hamilton, Ont.; Faculty of Dentistry (El-Rabbany), University of Toronto, Toronto, Ont.; School of Medical and Applied Sciences (Kean), Central Queensland University, Rockhampton, Australia; Department of Orthopaedic Surgery (Somerville), London Health Sciences Centre, London, Ont
| | - John J Riva
- Faculty of Medicine (Natasha Fernandes, Mathur), University of Ottawa, Ottawa, Ont.; Faculty of Health Sciences (Bryant, Marsh, Moyer) and Schulich School of Medicine and Dentistry (Bryant), The University of Western Ontario, London, Ont.; Department of Clinical Epidemiology and Biostatistics (Bryant, Griffith), Department of Medicine (Nisha Fernandes), Health Sciences Library (Bhatnagar), Department of Family Medicine (Riva) and Division of Gynecologic Oncology (Reade), McMaster University, Hamilton, Ont.; Faculty of Dentistry (El-Rabbany), University of Toronto, Toronto, Ont.; School of Medical and Applied Sciences (Kean), Central Queensland University, Rockhampton, Australia; Department of Orthopaedic Surgery (Somerville), London Health Sciences Centre, London, Ont
| | - Lyndsay Somerville
- Faculty of Medicine (Natasha Fernandes, Mathur), University of Ottawa, Ottawa, Ont.; Faculty of Health Sciences (Bryant, Marsh, Moyer) and Schulich School of Medicine and Dentistry (Bryant), The University of Western Ontario, London, Ont.; Department of Clinical Epidemiology and Biostatistics (Bryant, Griffith), Department of Medicine (Nisha Fernandes), Health Sciences Library (Bhatnagar), Department of Family Medicine (Riva) and Division of Gynecologic Oncology (Reade), McMaster University, Hamilton, Ont.; Faculty of Dentistry (El-Rabbany), University of Toronto, Toronto, Ont.; School of Medical and Applied Sciences (Kean), Central Queensland University, Rockhampton, Australia; Department of Orthopaedic Surgery (Somerville), London Health Sciences Centre, London, Ont
| | - Neera Bhatnagar
- Faculty of Medicine (Natasha Fernandes, Mathur), University of Ottawa, Ottawa, Ont.; Faculty of Health Sciences (Bryant, Marsh, Moyer) and Schulich School of Medicine and Dentistry (Bryant), The University of Western Ontario, London, Ont.; Department of Clinical Epidemiology and Biostatistics (Bryant, Griffith), Department of Medicine (Nisha Fernandes), Health Sciences Library (Bhatnagar), Department of Family Medicine (Riva) and Division of Gynecologic Oncology (Reade), McMaster University, Hamilton, Ont.; Faculty of Dentistry (El-Rabbany), University of Toronto, Toronto, Ont.; School of Medical and Applied Sciences (Kean), Central Queensland University, Rockhampton, Australia; Department of Orthopaedic Surgery (Somerville), London Health Sciences Centre, London, Ont
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14
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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.
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Affiliation(s)
- Saurabh Sethi
- Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, USA
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15
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Chun SY, Kim KO, Park DS, Kim SY, Park JW, Baek IH, Kim JH, Park CK. Safety and efficacy of deep sedation with propofol alone or combined with midazolam administrated by nonanesthesiologist for gastric endoscopic submucosal dissection. Gut Liver 2012; 6:464-70. [PMID: 23170151 PMCID: PMC3493727 DOI: 10.5009/gnl.2012.6.4.464] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Accepted: 06/22/2012] [Indexed: 12/26/2022] Open
Abstract
Background/Aims Endoscopic submucosal dissection (ESD) is accepted as a treatment for gastric neoplasms and usually requires deep sedation. The aim of this study was to evaluate the safety and efficacy profiles of deep sedation induced by continuous propofol infusion with or without midazolam during ESD. Methods A total of 135 patients scheduled for ESDs between December 2008 and June 2010 were included in this prospective study and were randomly assigned to one of two groups: the propofol group or the combination group (propofol plus midazolam). Results The propofol group reported only one case of severe hypoxemia with no need of mask ventilation or intubation. Additionally, 18 cases of mild hypotension were observed in the propofol group, and 11 cases were observed in the combination group. The combination group had a lower mean total propofol dose (378 mg vs 466 mg, p<0.012), a longer mean recovery time (10.5 minutes vs 7.9 minutes, p=0.027), and a lower frequency of overall adverse events (32.8% vs 17.6%, p=0.042). Conclusions Deep sedation induced by continuous propofol infusion was shown to be safe during ESD. The combination of continuous propofol infusion and intermittent midazolam injection can decrease the total dose and infusion rate of propofol and the overall occurrence of adverse events.
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Affiliation(s)
- Seung Yeon Chun
- Department of Internal Medicine, Hallym University College of Medicine, Anyang, Korea
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16
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Riphaus A, Geist C, Schrader K, Martchenko K, Wehrmann T. Intermittent manually controlled versus continuous infusion of propofol for deep sedation during interventional endoscopy: a prospective randomized trial. Scand J Gastroenterol 2012; 47:1078-85. [PMID: 22631051 DOI: 10.3109/00365521.2012.685758] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Beside the traditional, intermittent bolus application of propofol, continuous propofol infusion via infusion pump is an alternative procedure for deep sedation during long-lasting interventional endoscopy. However, up to now, there are no randomized comparisons for gastrointestinal endoscopy. METHODS One hundred patients (ERCP: n = 60, EUS: n = 40) were randomly assigned to receive intermittent bolus application ("bolus group") or continuous infusion ("perfusor group") of propofol sedation after induction with 3 mg midazolam for deep sedation. Patients in the bolus group received an initial propofol dose according to body weight (bw <70 kg: 40 mg; bw ≥ 70 kg 60 mg). In the perfusor group, bw-adapted, continuous propofol infusion (6 mg/kg) via the Injectomat 2000 MC (Fresenius-Kabi) was administered after an initial bolus of 1 mg/kg. Vital signs, dose of propofol, patient cooperation (VAS 1-10), sedation depth, and the recovery time as well as the quality of recovery were evaluated. RESULTS Total propofol dose in the bolus group 305 ± 155 mg (100-570 mg) and in the perfusor group 343 ± 123 mg (126-590 mg, p = 0.5) were comparable. Oxygen saturation below 90% was seen in four patients of each group, with no need for assisted ventilation. Arterial blood pressure <90 mmHg was documented in two patients in the bolus group and seven patients in the perfusor group (p = 0.16). Patients' cooperation was rated as good in both groups (bolus group, 9.1 ± 0.9; perfusor group, 8.9 ± 1; p = 0.17). Recovery time was significantly shorter in the bolus group compared with the perfusor group (19 ± 5 versus 23 ± 6 min, p < 0.001) whereas the quality of recovery was nearly identical in both groups. CONCLUSION Both sedation regimens allow nearly identical good controllability of propofol sedation. However, recovery time was significantly slower and hypotension was tended to occur more often in the perfusor group.
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17
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The Colorado Behavioral Numerical Pain Scale in assessing medication-free colonoscopy patients' pain. Gastroenterol Nurs 2011; 34:136-43. [PMID: 21455046 DOI: 10.1097/sga.0b013e318211dda3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Pain scales have been tested in clinical settings, but rarely with colonoscopy. The aim of this study was to evaluate the Colorado Behavioral Numerical Pain Scale (CBNPS) when assessing medication-free colonoscopy patients' pain intensity. During the first phase in 2005, the expert panelists (n = 17) described medication-free colonoscopy patients' behavior on a scale ranging from 0 to 5 scale. The descriptions were analyzed by quantitative and qualitative content analysis and compared with those of CBNPS. During the second phase in 2006, data from 138 medication- free colonoscopy patients and 11 nurses were collected using questionnaires (CBNPS, visual analogue scale [VAS], and verbal rating scale [VRS]) and analyzed statistically. The descriptions made by expert nurses were found similar to those of the CBNPS. Nurses' estimations with the CBNPS, VAS, and VRS of patients' pain were correlated with each other. According to our results, the CBNPS is an adequate instrument when assessing patients' pain intensity during medication-free colonoscopy. It provides an opportunity to evaluate the total pain intensity and the pain during the phases of the procedure. It is also a proper tool for improving nursing documentation. Results from this study highlight the need for further research to examine the pain scales.
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Abstract
The issue of propofol administration by nonanesthesiologists for upper endoscopy and colonoscopy remains controversial. A recent study investigated the efficacy and safety of a novel computer-assisted personalized sedation device. Patients sedated using the device experienced fewer serious cardiorespiratory events than patients undergoing standard sedation by bolus administration using a hand-held syringe.
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European Society of Gastrointestinal Endoscopy, European Society of Gastroenterology and Endoscopy Nurses and Associates, and the European Society of Anaesthesiology Guideline: Non-anaesthesiologist administration of propofol for GI endoscopy. Eur J Anaesthesiol 2011; 27:1016-30. [PMID: 21068575 DOI: 10.1097/eja.0b013e32834136bf] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Propofol sedation by non-anaesthesiologists is an upcoming sedation regimen in several countries throughout Europe. Numerous studies have shown the efficacy and safety of this sedation regimen in gastrointestinal endoscopy. Nevertheless, this issue remains highly controversial. The aim of this evidence- and consensus-based set of guideline is to provide non-anaesthesiologists with a comprehensive framework for propofol sedation during digestive endoscopy. This guideline results from a collaborative effort from representatives of the European Society of Gastrointestinal Endoscopy (ESGE), the European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) and the European Society of Anaesthesiology (ESA). These three societies have endorsed the present guideline.The guideline is published simultaneously in the Journals Endoscopy and European Journal of Anaesthesiology.
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20
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Maslekar S, Balaji P, Gardiner A, Culbert B, Monson JRT, Duthie GS. Randomized controlled trial of patient-controlled sedation for colonoscopy: Entonox vs modified patient-maintained target-controlled propofol. Colorectal Dis 2011; 13:48-57. [PMID: 19575742 DOI: 10.1111/j.1463-1318.2009.01988.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM Propofol sedation is often associated with deep sedation and decreased manoeuvrability. Patient-maintained sedation has been used in such patients with minimal side-effects. We aimed to compare novel modified patient-maintained target-controlled infusion (TCI) of propofol with patient-controlled Entonox inhalation for colonoscopy in terms of analgesic efficacy (primary outcome), depth of sedation, manoeuvrability and patient and endoscopist satisfaction (secondary outcomes). METHOD One hundred patients undergoing elective colonoscopy were randomized to receive either TCI propofol or Entonox. Patients in the propofol group were administered propofol initially to achieve a target concentration of 1.2 μg/ml and then allowed to self-administer a bolus of propofol (200 μg/kg/ml) using a patient-controlled analgesia pump with a handset. Entonox group patients inhaled the gas through a mouthpiece until caecum was reached and then as required. Sedation was initially given by an anaesthetist to achieve a score of 4 (Modified Observer's Assessment of Alertness and Sedation Scale), and colonoscopy was then started. Patients completed an anxiety score (Hospital Anxiety and Depression questionnaire), a baseline letter cancellation test and a pain score on a 100-mm visual analogue scale before and after the procedure. All patients completed a satisfaction survey at discharge and 24 h postprocedure. RESULTS The median dose of propofol was 174 mg, and the median number of propofol boluses was four. There was no difference between the two groups in terms of pain recorded (95% confidence interval of the difference -0.809, 5.02) and patient/endoscopist satisfaction. There was no difference between the two groups in either depth of sedation or manoeuvrability. CONCLUSION Both Entonox and the modified TCI propofol provide equally effective sedation and pain relief, simultaneously allowing patients to be easily manoeuvred during the procedures.
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Affiliation(s)
- S Maslekar
- University of Hull, Castle Hill Hospital, Hull, UK
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21
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Bell A, Lipp T, Greenslade J, Chu K, Rothwell S, Duncan A. A Randomized Controlled Trial Comparing Patient-Controlled and Physician-Controlled Sedation in the Emergency Department. Ann Emerg Med 2010; 56:502-8. [DOI: 10.1016/j.annemergmed.2010.04.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2009] [Revised: 04/19/2010] [Accepted: 04/23/2010] [Indexed: 10/19/2022]
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Cohen LB, Ladas SD, Vargo JJ, Paspatis GA, Bjorkman DJ, Van der Linden P, Axon ATR, Axon AE, Bamias G, Despott E, Dinis-Ribeiro M, Fassoulaki A, Hofmann N, Karagiannis JA, Karamanolis D, Maurer W, O'Connor A, Paraskeva K, Schreiber F, Triantafyllou K, Viazis N, Vlachogiannakos J. Sedation in digestive endoscopy: the Athens international position statements. Aliment Pharmacol Ther 2010; 32:425-42. [PMID: 20456310 DOI: 10.1111/j.1365-2036.2010.04352.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Guidelines and practice standards for sedation in endoscopy have been developed by various national professional societies. No attempt has been made to assess consensus among internationally recognized experts in this field. AIM To identify areas of consensus and dissent among international experts on a broad range of issues pertaining to the practice of sedation in digestive endoscopy. METHODS Thirty-two position statements were reviewed during a 1 (1/2)-day meeting. Thirty-two individuals from 12 countries and four continents, representing the fields of gastroenterology, anaesthesiology and medical jurisprudence heard evidence-based presentations on each statement. Level of agreement among the experts for each statement was determined by an open poll. RESULTS The principle recommendations included the following: (i) sedation improves patient tolerance and compliance for endoscopy, (ii) whenever possible, patients undergoing endoscopy should be offered the option of having the procedure either with or without sedation, (iii) monitoring of vital signs as well as the levels of consciousness and pain/discomfort should be performed routinely during endoscopy, and (iv) endoscopists and nurses with appropriate training can safely and effectively administer propofol to low-risk patients undergoing endoscopic procedures. CONCLUSIONS While the standards of practice vary from country to country, there was broad agreement among participants regarding most issues pertaining to sedation during endoscopy.
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Affiliation(s)
- L B Cohen
- Mount Sinai School of Medicine, New York, NY, USA.
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23
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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.
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Affiliation(s)
- Andrea Riphaus
- Department of Internal Medicine I, Gastroenterology and Interventional Endoscopy, Hospital Siloah, Hannover, Germany.
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Thomson A, Andrew G, Jones DB. Optimal sedation for gastrointestinal endoscopy: review and recommendations. J Gastroenterol Hepatol 2010; 25:469-78. [PMID: 20370725 DOI: 10.1111/j.1440-1746.2009.06174.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Sedation practices for endoscopy vary widely. The present review focuses on the commonly used regimens in endoscopic sedation and the associated risks and benefits together with the appropriate safety measures and monitoring practices. In addition, alternatives and additions to intravenous sedation are discussed. Personnel requirements for endoscopic sedation are reviewed; there is evidence presented to indicate that non-anesthetists can administer sedative drugs, including propofol, safely and efficaciously in selected cases. The development of endoscopic sedation as a multi-disciplinary field is highlighted with the formation of the Australian Tripartite Endoscopy Sedation Committee. This comprises representatives of the Australian and New Zealand College of Anaesthetists, the Gastroenterological Society of Australia and the Royal Australasian College of Surgeons. Possible future directions in this area are also briefly summarized.
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Affiliation(s)
- Andrew Thomson
- Gastroenterology and Hepatology Unit, The Canberra Hospital and the Australian National University, Australia.
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25
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Dolwani S, Ragunath K. Quality Criteria for a Good Screening Colonoscopy. CURRENT COLORECTAL CANCER REPORTS 2010. [DOI: 10.1007/s11888-009-0040-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Harris EA, Lubarsky DA, Candiotti KA. Monitored anesthesia care (MAC) sedation: clinical utility of fospropofol. Ther Clin Risk Manag 2009; 5:949-59. [PMID: 20057894 PMCID: PMC2801588 DOI: 10.2147/tcrm.s5583] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2009] [Indexed: 01/28/2023] Open
Abstract
Fospropofol, a phosphorylated prodrug version of the popular induction agent propofol, is hydrolyzed in vivo to release active propofol, formaldehyde, and phosphate. Pharmacodynamic studies show fospropofol provides clinically useful sedation and EEG/bispectral index suppression while causing significantly less respiratory depression than propofol. Pain at the injection site, a common complaint with propofol, was not reported with fospropofol; the major patient complaint was transitory perianal itching during the drug's administration. Although many clinicians believe fospropofol can safely be given by a registered nurse, the FDA mandated that fospropofol, like propofol, must be used only in the presence of a trained anesthesia provider.
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Affiliation(s)
- Eric A Harris
- Department of Anesthesiology, Perioperative Management, and Pain Medicine, University of Miami/Miller School of Medicine
| | - David A Lubarsky
- Department of Anesthesiology, Perioperative Management, and Pain Medicine, University of Miami/Miller School of Medicine
| | - Keith A Candiotti
- Department of Anesthesiology, Perioperative Management, and Pain Medicine, University of Miami/Miller School of Medicine
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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
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28
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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
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Mönkemüller K, Fry LC, Malfertheiner P, Schuckardt W. Gastrointestinal endoscopy in the elderly: current issues. Best Pract Res Clin Gastroenterol 2009; 23:821-7. [PMID: 19942160 DOI: 10.1016/j.bpg.2009.10.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2009] [Revised: 09/22/2009] [Accepted: 10/01/2009] [Indexed: 01/31/2023]
Abstract
Even though endoscopy is performed in patients of all ages, currently there is little literature on this topic in elderly patients. As a result of population demographics the use of endoscopy is expected to rise in this section of the population. Elderly patients represent a special group of patients, as they usually have a higher incidence of co-morbid diseases and may be more susceptible to endoscopic interventions. Due to the decreased physiologic reserve and associated diseases, complications in elderly patients can be more severe than in adult or young subjects. Moreover, ethical considerations play a special role in elderly frail patients with a potential poor prognosis. Thus, the endoscopist needs to pay special attention when considering or performing endoscopy in elderly patients. The aim of this article is to review the role of endoscopy in elderly patients, paying special emphasis on indications, special precautions and specific interventions.
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Affiliation(s)
- Klaus Mönkemüller
- Department of Internal Medicine, Gastroenterology, Hepatology and Infectious Diseases, Marienhospital GmbH, Josef-Albers-Strasse 70, Bottrop, Germany.
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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
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Vargo JJ. Procedural sedation and obesity: waters left uncharted. Gastrointest Endosc 2009; 70:980-4. [PMID: 19879405 DOI: 10.1016/j.gie.2009.07.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2009] [Accepted: 07/03/2009] [Indexed: 02/08/2023]
Abstract
BACKGROUND Moderate sedation during endoscopy may pose increased risks among obese patients. OBJECTIVE To review the literature that considers aspects of sedation within the obese population and to identify gaps in our knowledge. DESIGN Literature-based review. RESULTS There may be increased risks among obese patients undergoing moderate sedation. In particular, the presence of obstructive sleep apnea may identify a subset of patients at higher risk for complications. LIMITATIONS English language literature only. CONCLUSIONS Although obesity may be associated with increased risks of procedural sedation, future studies should better clarify such risks to better inform clinical decision making.
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Affiliation(s)
- John J Vargo
- Section of Therapeutic Endoscopy, Department of Gastroenterology, Digestive Disease Institute, and Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio 44195, USA
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Ylinen ER, Vehviläinen-Julkunen K, Pietilä AM, Hannila ML, Heikkinen M. Medication-free colonoscopy--factors related to pain and its assessment. J Adv Nurs 2009; 65:2597-607. [PMID: 19824909 DOI: 10.1111/j.1365-2648.2009.05119.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
AIM This paper is a report of a study conducted to determine the possibility of performing colonoscopy without medication, elucidate the factors related to a painful colonoscopy experience and compare colonoscopy patients' reported pain assessment to nurses' and endoscopists' observations. BACKGROUND Sedation and pain medication are routinely administered for colonoscopies in many countries. However, medication-free colonoscopies have attracted attention because the use of medication requires a time commitment from patients and increases complications. Earlier studies show that, for instance, gender, age and pelvic operations may increase the risk of painful colonoscopy and those healthcare professionals and patients appear to assess pain differently. METHOD A cross-sectional descriptive study was conducted in a Finnish university hospital using questionnaires developed for this study and analysed statistically. The sample of 138 colonoscopy patients, 11 nurses and 11 endoscopists was recruited in 2006. RESULTS Over three-quarters of patients reported mild pain or no pain at all. Patients' nervousness is a risk factor for experiencing pain during colonoscopy. Both nurses and endoscopists slightly underestimated the intensity of pain experienced by patients. CONCLUSION It is possible to perform colonoscopy without medication with most patients and focus sedation and pain medication on at-risk patients, especially those who are nervous. Before the procedure, nurses must devote time to discovering which patients are nervous and at risk of having a painful colonoscopy to present them for sedation. To improve pain management for patients having colonoscopy, endoscopists and nurses should participate systematically in pain education and use pain scales.
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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.
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Affiliation(s)
- Douglas K Rex
- Division of Gastroenterology/Hepatology, Indiana University Medical Center, Indianapolis, Indiana 46202, USA.
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Abstract
A successful population-based colorectal cancer screening requires efficient colonoscopy practices that incorporate high throughput, safety, and patient satisfaction. There are several different modalities of nonanesthesiologist-administered sedation currently available and in development that may fulfill these requirements. Modern-day gastroenterology endoscopic procedures are complex and demand the full attention of the attending gastroenterologist and the complete cooperation of the patient. Many of these procedures will also require the anesthesiologist's knowledge, skills, abilities, and experience to ensure optimal procedure results and good patient outcomes. The goal of this review is (1) to provide a gastroenterology perspective on the use of propofol in gastroenterology endoscopic practice, and (2) to describe newer GI endoscopy procedures that gastroenterologists perform that might involve anesthesiologists.
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Affiliation(s)
- Willem J S de Villiers
- Division of Digestive Diseases and Nutrition, Department of Internal Medicine, University of Kentucky Medical Center, University of Kentucky College of Medicine, 800 Rose Street, Room MN649, Lexington, KY 40536, USA.
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Abstract
The role of sedation in endoscopic procedures has increased and so has the demand for advances in its administration. The pursuit of new agents or administration techniques and their study specific to endoscopic nonsurgical procedures is necessary to improve patient comfort and safety.The science of moderate and deep sedation specific to endoscopy is fledgling but approaching new horizons.
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Affiliation(s)
- Daniel J Pambianco
- Charlottesville Medical Research, 1340 Stony Point Road, Suite 102, Charlottesville, VA 22911, USA.
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Heuss LT, Peter S. Propofol use by gastroenterologists-the European experience. Gastrointest Endosc Clin N Am 2008; 18:727-38, ix. [PMID: 18922411 DOI: 10.1016/j.giec.2008.06.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The administration of propofol as a sedative in gastrointestinal endoscopies became very popular in many European countries during the last years. Nevertheless there are huge regional differences in the way that the drug is used. Switzerland, the country with highest propagation of gastroenterologist guided propofol sedation, serves as a case study of its safe use in daily practice. The experiences of this spread are summarized in this article.
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Affiliation(s)
- Ludwig T Heuss
- Division of Gastroenterology, University of Basel, St. Peter's Square 1, Basel CH-4003, Switzerland.
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Voynarovska M, Cohen LB. The role of the endoscopy nurse or assistant in endoscopic sedation. Gastrointest Endosc Clin N Am 2008; 18:695-705, viii. [PMID: 18922408 DOI: 10.1016/j.giec.2008.06.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Properly trained nursing personnel and allied staff are essential to the safe and effective practice of endoscopic sedation. Such individuals should possess a thorough understanding of the pharmacology of sedation agents, as well as the ability to monitor patients under sedation, recognize potential complications, and initiate appropriate and timely interventions. The endoscopy nurse or assistant must also understand their institutional policies and procedures pertaining to procedural sedation.
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Affiliation(s)
- Maya Voynarovska
- New York Gastroenterology Associates, 311 East 79th Street, New York, NY 10021, USA
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Rex DK, Deenadayalu V, Eid E. Gastroenterologist-directed propofol: an update. Gastrointest Endosc Clin N Am 2008; 18:717-25, ix. [PMID: 18922410 DOI: 10.1016/j.giec.2008.06.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Gastroenterologist directed propofol has been proven safe in more than 220,000 published cases. Administration of low doses of opioid and/or benzodiazepine ("balanced propofol sedation") is the safest format for gastroenterologist directed propofol. Specific training is needed to undertake gastroenterologist directed propofol administration.
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Affiliation(s)
- Douglas K Rex
- Department of Medicine, Division of Gastroenterology, Indiana University School of Medicine, 550 North University Boulevard, UH 4100, Indianapolis, IN 46202, USA.
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41
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Abstract
Sedation for endoscopy provides comfort for the patient and better examination conditions for the endoscopist. The high costs of providing anaesthesia by specialists and the relative lack of specialist personnel in many countries have led to the wider introduction of sedation delivered by non-anaesthesiologists. Such sedation should be targeted for moderate levels of sedation; however, personnel should be able to avoid - and rescue patients from - deeper sedation levels. Several conditions have to be fulfilled to provide proper and safe non-anaesthesiologist sedation for endoscopy, especially when propofol is to be used. These conditions include formal training, supervision by anaesthesiology staff, and definition of standard operating procedures on the national as well as local levels.
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Affiliation(s)
- Jaroslaw Regula
- Department of Gastroenterology, Medical Centre for Postgraduate Education and the Maria-Sklodowska-Curie Memorial Cancer Center, Institute of Oncology, 02-781 Warsaw, Poland.
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Abstract
Endoscopic sedation is changing, in response to economic pressures, regulatory requirements, and new technology. Each endoscopy unit must tailor its personnel and equipment practices to its particular case mix, sedation preferences, and to its external environment. This article discusses sedation-related considerations regarding procedure room design, equipment for drug administration, equipment for patient monitoring, equipment for managing emergencies, and staff selection, training, and responsibilities.
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Affiliation(s)
- James Aisenberg
- Mount Sinai School of Medicine (New York City), New York Gastroenterology Associates, 311 East 79th Street, New York, NY 10021, USA.
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Vist GE, Bryant D, Somerville L, Birminghem T, Oxman AD. Outcomes of patients who participate in randomized controlled trials compared to similar patients receiving similar interventions who do not participate. Cochrane Database Syst Rev 2008; 2008:MR000009. [PMID: 18677782 PMCID: PMC8276557 DOI: 10.1002/14651858.mr000009.pub4] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Some people believe that patients who take part in randomised controlled trials (RCTs) face risks that they would not face if they opted for non-trial treatment. Others think that trial participation is beneficial and the best way to ensure access to the most up-to-date physicians and treatments. This is an updated version of the original Cochrane review published in Issue 1, 2005. OBJECTIVES To assess the effects of patient participation in RCTs ('trial effects') independent both of the effects of the clinical treatments being compared ('treatment effects') and any differences between patients who participated in RCTs and those who did not. We aimed to compare similar patients receiving similar treatment inside and outside of RCTs. SEARCH STRATEGY In March 2007, we searched The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, The Cochrane Methodology Register, SciSearch and PsycINFO for potentially relevant studies. Our search yielded 7586 new references. In addition, we reviewed the reference lists of relevant articles. SELECTION CRITERIA Randomized studies and cohort studies with data on clinical outcomes of RCT participants and similar patients who received similar treatment outside of RCTs. DATA COLLECTION AND ANALYSIS At least two review authors independently assessed studies for inclusion, assessed study quality and extracted data. MAIN RESULTS We identified 30 new non-randomized cohort studies (45 comparisons): no new RCTs were found. This update now includes five RCTs (yielding 6 comparisons) and 80 non-randomized cohort studies (130 comparisons), with 86,640 patients treated in RCTs and 57,205 patients treated outside RCTs. In the randomised studies, patients were invited to participate in an RCT or not; these comparisons provided limited information because of small sample sizes (a total of 412 patients) and the nature of the questions they addressed. When the results of RCTs and non-randomized cohorts that reported dichotomous outcomes were combined, there were 98 comparisons; there was also heterogeneity (P < 0.00001, I(2) = 42.2%) between studies. No statistical significant differences were found for 85 of the 98 comparisons. Eight comparisons reported statistically significant better outcomes for patients treated within RCTs, and five comparisons reported statistically significant worse outcomes for patients treated within RCTs. There was significant heterogeneity (P < 0.00001, I(2) = 58.2%) among the 38 continuous outcome comparisons. No statistically significant differences were found for 30 of the 38 comparisons. Three comparisons reported statistically significant better outcomes for patients treated within RCTs, and five comparisons reported statistically significant worse outcomes for patients treated within RCTs. AUTHORS' CONCLUSIONS This review indicates that participation in RCTs is associated with similar outcomes to receiving the same treatment outside RCTs. These results challenge the assertion that the results of RCTs are not applicable to usual practice.
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Affiliation(s)
- Gunn Elisabeth Vist
- Department of Evidence-Based Health Services, Norwegian Knowledge Centre for Health Services, PO Box 7004, St Olavs Plass, Oslo, Norway, 0130.
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Acceptance of colonoscopy requires more than test tolerance. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2008; 22:41-7. [PMID: 18209780 DOI: 10.1155/2008/107467] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Colon cancer screening, including colonoscopy, lags behind other forms of cancer screening for participation rates. The intrinsic nature of the endoscopic procedure may be an important barrier that limits patients from finding this test acceptable and affects willingness to undergo screening. With colon cancer screening programs emerging in Canada, test characteristics and their impact on acceptance warrant consideration. OBJECTIVES To measure the acceptability of colonoscopy and define factors that contribute to procedural acceptability, in relation to another invasive gastrointestinal scope procedure, gastroscopy. PATIENTS AND METHODS Consecutive patients undergoing a colonoscopy (n=55) or a gastroscopy (n=33) were recruited. Their procedural experience was evaluated and compared pre-endoscopy, immediately before testing and postendoscopy. Questionnaires were used to capture multiple domains of the endoscopy experience and patient characteristics. RESULTS Patient scope groups did not differ preprocedurally for general or procedure-specific anxiety. However, the colonoscopy group did anticipate more pain. Those who had a gastroscopy demonstrated higher preprocedural acceptance than those who had a colonoscopy. The colonoscopy group had a significant decrease in scope concerns and anxiety postprocedurally. As well, they reported less pain than they anticipated. Regardless, postprocedurally, the colonoscopy group's acceptance did not increase significantly, whereas the gastroscopy group was almost unanimous in their test acceptance. The best predictor of pretest acceptability of colonoscopy was anticipated pain. CONCLUSIONS The findings indicate that concerns that relate specifically to colonoscopy, including anticipated pain, influence acceptability of the procedure. However, the experience of a colonoscopy does not lead to improved test acceptance, despite decreases in procedural anxiety and pain. Patients' preprocedural views of the test are most important and should be addressed directly to potentially improve participation in colonoscopy.
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Wehrmann T, Riphaus A. Sedation with propofol for interventional endoscopic procedures: a risk factor analysis. Scand J Gastroenterol 2008; 43:368-74. [PMID: 18938664 DOI: 10.1080/00365520701679181] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Propofol sedation for mainly diagnostic endoscopic procedures has proved safe in recent trials, with no need for endotracheal intubation. However, there is evidence that cardiorespiratory side effects occur more frequently and that assisted ventilation may be necessary if propofol sedation is performed for interventional endoscopic procedures. MATERIAL AND METHODS Over a 6-year period, all adverse events (defined as premature termination of the procedure due to sedation-related events or either the need for assisted ventilation or admission to ICU) occurring during 9547 endoscopic interventions (UGI, n = 5.374, ERCP, n = 3.937, EUS, n=236) under propofol sedation were assessed. RESULTS A total of 135 adverse events (1.4%) were documented. Assisted ventilation was necessary in 40 patients (0.4%); 9 patients required endotracheal intubation (0.09%); 28 needed further monitoring on the ICU (0.3%); and 4 patients died, 3 potentially due to sedation-related side effects (mortality, 0.03%). Independent risk factors for sedation-related side effects were emergency endoscopic examinations and a total propofol dose >100 mg. CONCLUSIONS Interventional endoscopy under propofol sedation is not risk-free. Increased attention must be focused on close monitoring of vital parameters, particularly when undertaking long-lasting interventions and emergency procedures.
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Affiliation(s)
- Till Wehrmann
- Department of Internal Medicine I, Academic Hospital Siloah, Hannover, Germany.
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Mandel JE, Tanner JW, Lichtenstein GR, Metz DC, Katzka DA, Ginsberg GG, Kochman ML. A randomized, controlled, double-blind trial of patient-controlled sedation with propofol/remifentanil versus midazolam/fentanyl for colonoscopy. Anesth Analg 2008; 106:434-9, table of contents. [PMID: 18227297 DOI: 10.1213/01.ane.0000297300.33441.32] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Patient-controlled sedation (PCS) with propofol has been advocated as a method for dealing with the narrow therapeutic window for moderate sedation, but previous studies have methodologic limitations. We hypothesized that, by using remifentanil in conjunction with propofol and using PCS in both arms of the study, we could demonstrate marked improvements in facility use compared with fentanyl plus midazolam. METHODS Fifty patients undergoing elective colonoscopy were randomized (with concealed allocation) to midazolam/fentanyl (group MF) or propofol/remifentanil (group PR) administered via PCS. Time intervals for sedation and recovery, perceptions by patient, nurse, and gastroenterologist, and need for anesthesiologist intervention were assessed. RESULTS Group PR patients were sedated and recovered significantly more rapidly than did group MF (P < 0.0001). In the group PR, recovery room time was actually shorter than procedure room time. Patient, nurse, and gastroenterologist perceptions were equivalent between the groups. Two patients in group PR required anesthesiologist intervention for arterial desaturation exceeding the primary safety end point. CONCLUSIONS PCS with propofol/remifentanil yields superior facility throughput compared with midazolam/fentanyl when used in an appropriate care setting.
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Affiliation(s)
- Jeff E Mandel
- Department of Anesthesiology and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA.
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Lubarsky DA, Candiotti K, Harris E. Understanding modes of moderate sedation during gastrointestinal procedures: a current review of the literature. J Clin Anesth 2007; 19:397-404. [PMID: 17869995 DOI: 10.1016/j.jclinane.2006.11.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2006] [Revised: 11/08/2006] [Accepted: 11/09/2006] [Indexed: 12/26/2022]
Abstract
Recommendations for routine screening for colorectal cancer with colonoscopy are likely to substantially increase the demand for provision of sedation for these procedures. Because of this burgeoning caseload and associated economic constraints, it is unlikely that anesthesiologists will be available for all such procedures, particularly those involving average-risk patients. Thus, sedative agents that can be safely administered by nonanesthesiologists, appropriately trained in monitoring and managing the patient's airway, are desperately needed. New concepts in sedation for colonoscopy include enhanced mechanisms for drug delivery such as patient-controlled sedation/analgesia and target-controlled infusion, along with the development of new drugs such as a modified cyclodextrin-based formulation of propofol and fospropofol disodium (Aquavan Injection), a water-soluble prodrug of propofol.
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Affiliation(s)
- David A Lubarsky
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL 33136, USA.
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Cohen LB, Delegge MH, Aisenberg J, Brill JV, Inadomi JM, Kochman ML, Piorkowski JD. AGA Institute review of endoscopic sedation. Gastroenterology 2007; 133:675-701. [PMID: 17681185 DOI: 10.1053/j.gastro.2007.06.002] [Citation(s) in RCA: 309] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/07/2007] [Indexed: 12/13/2022]
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Martínez J, Casellas JA, Aparicio JR, Garmendia M, Amorós A. [Safety of propofol administration by the staff of a gastrointestinal endoscopy unit]. GASTROENTEROLOGIA Y HEPATOLOGIA 2007; 30:105-9. [PMID: 17374321 DOI: 10.1157/13100070] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Deep sedation controlled by the staff of gastrointestinal endoscopy units is currently controversial. In the last few years, numerous studies have provided data supporting the safety of propofol use in these techniques. We present a large series of patients who underwent gastroscopy or colonoscopy under endoscopist-controlled deep sedation. A total of 875 procedures (297 gastroscopies and 578 colonoscopies) were included. In all procedures intravenous propofol with or without intravenous midazolam was administered. In gastroscopies, complications attributable to the sedation were found in only 6.7% of the patients, mostly due to desaturation, which was resolved without the need for intubation. In colonoscopies, complications were found in 11.2%, the most frequent being bradycardia and desaturation, none of which were serious. No association was found between the presence of complications and the propofol dose administered. In the group of patients undergoing colonoscopy, simultaneous midazolam administration allowed reduction of the propofol dose required to achieve deep sedation. In conclusion, propofol shows a good safety profile and excellent tolerance in patients undergoing gastroscopy and colonoscopy and can be administrated by the endoscopy team. At least in the case of colonoscopy, the associated use of midazolam allows the propofol dose to be decreased, thus, theoretically, reducing the drug's adverse effects.
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Affiliation(s)
- Juan Martínez
- Unidad de Endoscopia Digestiva, Hospital General Universitario de Alicante, España.
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50
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Harrington L. Nurse-administered propofol sedation: a review of current evidence. Gastroenterol Nurs 2006; 29:371-83; quiz 384-5. [PMID: 17038838 DOI: 10.1097/00001610-200609000-00004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
This article highlights a highly controversial practice issue referred to as nurse-administered propofol sedation, which affects registered nurses as well as advanced practice nurses in many different practice settings across the United States. Amid varied advice from professional organizations and state licensing boards, a thorough and systematic review of the current evidence provides insight into the question of safety associated with the practice. The evidence examined includes position statements from professional organizations and state boards, information from the United States Food and Drug Administration and the Joint Commission on Accreditation of Healthcare Organizations, and published research since 1999. The body of evidence demonstrates diverse positions; however, the empirical evidence in the author's opinion unanimously supports nurse-administered propofol sedation as a safe practice in nonintubated adult patients. Under research conditions, participants had a low incidence of untoward events and were adequately rescued with no intubations required and no deaths reported.
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Affiliation(s)
- Linda Harrington
- Texas Christian University, Presbyterian Hospital of Plano, Texas 75287-5144, USA.
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