Propofol may be safely administered by trained nonanesthesiologists. Pro: Propofol demystified: it is time to change the sedation paradigm

Adverse events during monitored anesthesia care for GI endoscopy: an 8-year experience

BACKGROUND

The importance of sedation during endoscopy is well established. There is no consensus about the best techniques for sedation, which specialist should perform it, and in which location.

OBJECTIVE

To provide data on the epidemiology of adverse events during sedation for endoscopy.

DESIGN

Retrospective analysis of a prospective database.

SETTING

Endoscopy unit of a university hospital.

PROCEDURES

A total of 17,999 procedures performed over 8 years.

INTERVENTIONS

Sedation for GI endoscopy.

MAIN OUTCOME MEASUREMENTS

We recorded the following information: sex, age, body mass index, smoking habits, American Society of Anesthesiologists and Mallampati scores, duration of the procedure, type of sedative drug administered, whether the procedure was performed emergently, and endoscopic interventions during the maneuver. Adverse events were defined as occurrences that warranted intervention and were classified as hypotension, desaturation, bradycardia, hypertension, arrhythmia, aspiration, respiratory depression, vomiting, cardiac arrest, respiratory arrest, angina, hypoglycemia, and/or allergic reaction.

RESULTS

Deep sedation with intravenous propofol target controlled infusion pump was the most frequently used means of administering sedation. Adverse events were rare in both the adult (4.5%) and pediatric (2.6%) populations. Six complications occurred in more than 0.1% of adult cases: arterial hypotension, desaturation, bradycardia, arterial hypertension, arrhythmia, and aspiration. Only bradycardia (2.1%) and hypotension (0.44%) occurred in children. Three adult patients (0.017%) died, and no pediatric patients died. Some predictive models for the occurrence of complications are proposed.

LIMITATIONS

Retrospective analysis, single-center data collection.

CONCLUSIONS

Deep sedation during endoscopic procedures is safe in both adults and children. Our data may be useful for the future planning of new clinical strategies in this setting.

A randomized controlled trial of endoscopist vs. anaesthetist-administered sedation for colonoscopy

BACKGROUND

Endoscopist-administered propofol sedation for colonoscopy has not been compared to anaesthetist-administered deep sedation in clinical trials. Our aim was to compare patients' satisfaction and safety during these two sedation modalities.

METHODS

90 adult patients undergoing colonoscopy were randomized into Group A, Endoscopist-administered propofol sedation and Group B, anaesthetist-administered deep sedation. Group A patients received an initial dose of 30-50 mg of intravenous propofol; additional doses were injected by the endoscopist using a pre-programmed pump. Global satisfaction was measured on a 0-100 mm visual analogue scale.

RESULTS

The average satisfaction scores after examination completion amongst group were not statistically different (90.8 mm for Group A vs. 89 mm for Group B). Group A patients expressed more frequently a good level of satisfaction (95% vs. 75%; p=0.03) and willingness to undergo further colonoscopies under the same conditions (95% vs. 79%; p=0.02). Total duration time and procedural difficulty did not differ between the groups. Group A received a lower total propofol dose than Group B (94 mg vs. 260 mg) and experienced fewer side-effects (16 vs. 3, respectively; p < 0.008).

CONCLUSION

Endoscopist-administered propofol sedation for colonoscopy offered a better level of satisfaction and fewer side-effects than anaesthetist-administered deep sedation.

Continuous non-invasive arterial pressure technique improves patient monitoring during interventional endoscopy

INTRODUCTION

Close monitoring of arterial blood pressure (BP) is a central part of cardiovascular surveillance of patients at risk for hypotension. Therefore, patients undergoing diagnostic and therapeutic procedures with the use of sedating agents are monitored by discontinuous non-invasive BP measurement (NIBP). Continuous non-invasive BP monitoring based on vascular unloading technique (CNAP, CN Systems, Graz) may improve patient safety in those settings. We investigated if this new technique improved monitoring of patients undergoing interventional endoscopy.

METHODS

40 patients undergoing interventional endoscopy between April and December 2007 were prospectively studied with CNAP(R) in addition to standard monitoring (NIBP, ECG and oxygen saturation). All monitoring values were extracted from the surveillance network at one-second intervals, and clinical parameters were documented. The variance of CNAP values were calculated for every interval between two NIBP measurements.

RESULTS

2660 minutes of monitoring were recorded (mean 60.1+/-34.4 min/patient). All patients were analgosedated with midazolam and pethidine, and 24/40 had propofol infusion (mean 90.9+/-70.3 mg). The mean arterial pressure for CNAP was 102.4+/-21.2 mmHg and 106.8+/-24.8 mmHg for NIBP. Based on the first NIBP value in an interval between two NIBP measurements, BP values determined by CNAP showed a maximum increase of 30.8+/-21.7% and a maximum decrease of 22.4+/-28.3% (mean of all intervals).

DISCUSSION

Conventional intermittent blood pressure monitoring of patients receiving sedating agents failed to detect fast changes in BP. The new technique CNAP improved the detection of rapid BP changes, and may contribute to a better patient safety for those undergoing interventional procedures.

Nurse-administered propofol sedation: a review of current evidence

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.

Synergistic sedation with oral midazolam as a premedication and intravenous propofol versus intravenous propofol alone in upper gastrointestinal endoscopies in children: a prospective, randomized study

OBJECTIVES

The primary objective of the present study was to compare the required dose of intravenous (IV) propofol between group A (synergistic sedation with an oral dose of midazolam combined with IV propofol) and group B (IV propofol alone), in diagnostic upper gastrointestinal endoscopy (UGIE) in pediatric patients. The secondary objective was to compare the safety, the efficacy, the ease of IV line placement and the ease of separation from parents between the 2 groups.

METHODS

Fifty-four consecutive children (aged 3 y or older) who underwent UGIE were randomly assigned to 1 of the 2 medication regimens. Patients in group A (n = 26, mean age: 8.1 y) received midazolam (0.5 mg/kg) orally. Thirty minutes after the midazolam dose was given, repeated IV doses of propofol 0.5 mg/kg were administered titrated to achieve the level of deep sedation. Patients in group B (n = 28, mean age: 9 y) received IV propofol alone with the same methodology and sedation end point.

RESULTS

The mean dose (1.8 +/- 0.7 mg/kg) of propofol administered in group A patients was remarkably lower compared with that (2.9 +/- 0.9 mg/kg) of group B. Multivariate stepwise logistic regression analysis revealed that among sex, age, ASA grade and the type of sedation, the synergistic sedation was the only factor associated with the ease of IV line placement (chi(2) = 16.3, P < 0.001) and the ease of separation from parents (chi(2) = 41.6, P < 0.001). Additional multivariate stepwise logistic regression analysis revealed that among sex, age, ASA grade and the type of sedation, synergistic sedation was the only factor associated with a higher level of patient comfort (chi(2) = 35.5, P < 0.001). The recovery time was significantly shorter in group B patients (7.7 +/- 3.6 min) compared with that of group A (25.9 +/- 4.1 minutes) (P < 0.01). The 2 regimens were equally safe.

CONCLUSIONS

Our data suggest that synergistic sedation with an oral dose of midazolam combined with propofol may benefit the children who undergo UGIE with regard to lower mean dose of propofol used, easier IV line placement, easier separation from the parents, less pain induced by the IV line placement and greater patient comfort.

Pharmacokinetic and Pharmacodynamic Characteristics of??Medications Used for Moderate Sedation

The ability to deliver safe and effective moderate sedation is crucial to the ability to perform invasive procedures. Sedative drugs should have a quick onset of action, provide rapid and clear-headed recovery, and be easy to administer and monitor. A number of drugs have been demonstrated to provide effective sedation for outpatient procedures but since each agent has its own limitations, a thorough knowledge of the available drugs is required to choose the appropriate drug, dose and/or combination regimen for individual patients. Midazolam, propofol, ketamine and sevoflurane are the most frequently used agents, and all have a quick onset of action and rapid recovery. The primary drawback of midazolam is the potential for accumulation of the drug, which can result in prolonged sedation and a hangover effect. The anaesthetics propofol and sevoflurane have recently been used for sedation in procedures of short duration. Although effective, these agents require monitored anaesthesia care. Ketamine is an effective agent, particularly in children, but there is concern regarding emergence reactions. AQUAVAN injection (fospropofol disodium), a phosphorylated prodrug of propofol, is an investigational agent possessing a unique and distinct pharmacokinetic and pharmacodynamic profile. Compared with propofol emulsion, AQUAVAN is associated with a slightly longer time to peak effect and a more prolonged pharmacodynamic effect. Advances in the delivery of sedation, including the development of new sedative agents, have the potential to further improve the provision of moderate sedation for a variety of invasive procedures.