Safety of Propofol versus Nonpropofol-Based Sedation in Children Undergoing Gastrointestinal Endoscopy: A Systematic Review and Meta-Analysis

Propofol Sedation in Pediatric Upper Endoscopy: A Study of Pharmacodynamics and the Effects of Gastroenterologists, Anesthesiologists, and Supervised Participants on the Procedure Time and Sedation Time

Background and aims Propofol combined with fentanyl is a commonly used sedative for pediatric upper endoscopies (UEs). The primary aim was to study the association between propofol dose and procedure and sedation time. The secondary aims were to assess the pharmacodynamics of propofol use with fentanyl and evaluate if gastroenterologists' and anesthesiologists' years of experience or the presence of supervised participants (such as students, residents, and fellows) have any influence on the procedure and sedation time. Methods A retrospective study was performed at the Children's Hospital of Michigan on patients under 18 years who underwent UEs with propofol sedation with fentanyl over a two-year period. Results A correlation was found between the propofol amount used expressed per body mass index (BMI)/body surface area (BSA), procedure time, and sedation time (p < 0.0001). Throat pain was the most common post-procedural adverse event (4.48%). The impact of psychoactive drugs on these events was not statistically significant, but attention-deficit/hyperactivity disorder (ADHD) medication use was related to increased post-procedural pain complaints. The use of prescribed psychoactive medications was associated with larger propofol dose usage (p = 0.007) without a significant increase in sedation time. Individual gastroenterologists, their years of experience, and the presence of supervised participants were associated with different procedure times (p <0.0001, <0.0001, 0.01). Fellow participation was associated with a 1.11-minute procedure time increase (p = 0.04). Individual anesthesiologists, their years of experience, and the presence of supervised participants were associated with different sedation times (p <0.0001, <0.0001, 0.01). Conclusion We found a novel correlation between propofol dosing expressed by the BMI/BSA and sedation time. The UE procedure time and sedation time are associated with individual gastroenterologists and anesthesiologists, their years of experience, and the presence of supervised participants.

Sedative effect and safety of different doses of S-ketamine in combination with propofol during gastro-duodenoscopy in school-aged children: a prospective, randomized study

Background

Propofol combined with opioids can reduce the dosage of propofol and improve the safety of endoscopy. However, there are few studies on propofol combined with S-ketamine in children undergoing gastro-duodenoscopy. We aim to determine the sedative effect and safety of different doses of S-ketamine in combination with propofol in school-aged children undergoing gastro-duodenoscopy.

Methods

This is a prospective, randomized trial. Totally, 120 school-aged children who underwent gastro-duodenoscopy were randomly allocated into Group P, Group S0.3, Group S0.5 and Group S0.7. During induction, children in Group P, Group S0.3, Group S0.5 and Group S0.7 received 0, 0.3 mg.kg−1, 0.5 mg.kg−1 and 0.7 mg.kg−1 S-ketamine, respectively, following 3 mg.kg−1 propofol injection. During gastro-duodenoscopy, 1 mg.kg−1 of propofol was added according to the condition of the children and the BIS (bispectral index) value. The primary outcome was smooth placement rate of the first endoscope insertion. The secondary outcome was the times of additional propofol, the total amount of propofol, adverse events, recovery time, length of PACU (post anesthesia care unit) stay and endoscopist satisfaction.

Results

The smooth placement rate of the first endoscope insertion in Group P, Group S0.3 and Group S0.5 was significantly lower than that in Group S0.7 (16.70%, 34.50%, 50.00% vs. 83.30%, respectively, P < 0.001). The times of additional propofol in Group S0.3 (P = 0.018), Group S0.5 (P = 0.014) and Group S0.7 (P = 0.001) were significantly less than Group P. The total amount of propofol in Group S0.7 was significantly less than Group P (P < 0.001). The incidence of intraoperative hypotension in Group S0.5 and Group S0.7 was low. Group S0.7 had significantly higher incidence of postoperative dizziness (P = 0.003), longer PACU stay (P = 0.018) and higher endoscopist satisfaction (P = 0.001) than Group P. There was no difference in the recovery time among groups.

Conclusion

S-ketamine (0.7 mg.kg−1) in combination with propofol can provide satisfactory sedative effect and reduce the dosage of propofol in school-aged children undergoing gastro-duodenoscopy, but there are higher incidence of postoperative dizziness and longer PACU stay.

Safety, Efficacy and High-Quality Standards of Gastrointestinal Endoscopy Procedures in Personalized Sedoanalgesia Managed by the Gastroenterologist: A Retrospective Study

Performing GI endoscopy under sedoanalgesia improves the quality-indices of the examination, in particular for cecal intubation and adenoma detection rates during colonoscopy. The implementation of procedural sedoanalgesia in GI endoscopy is also strongly recommended by the guidelines of the major international scientific societies. Nevertheless, there are regional barriers that prevent the widespread adoption of this good practice. A retrospective monocentric analytic study was performed on a cohort of 529 patients who underwent EGDS/Colonoscopy in sedoanalgesia, with personalized dosage of Fentanyl and Midazolam. ASA class, age and weight were collected for each patient. The vital parameters were recorded during, pre- and post-procedure. The rates of cecal intubation and of procedure-related complications were entered. The VAS scale was used to evaluate the efficacy of sedoanalgesia, and the Aldrete score was used for patient discharge criteria. No clinically significant differences were found between vital signs pre- and post-procedure. Both anesthesia and endoscopic-related complications occurring were few and successfully managed. At the end of examination, both the mean Aldrete score (89.56), and the VAS score (<4 in 99.1%) were suitable for discharge. For the colonoscopies, the cumulative adenoma detection rate (25%) and the cecal intubation rate in the general group (98%) and in the colorectal cancer screening group (100%) were satisfying. Pain control management is an ethical and medical issue aimed at increasing both patient compliance and the quality of the procedures. The findings of this work underscore that in selected patients personalized sedoanalgesia in GI endoscopy can be safely managed by gastroenterologists.

ED50 and ED95 of propofol combined with different doses of esketamine for children undergoing upper gastrointestinal endoscopy: A prospective dose-finding study using up-and-down sequential allocation method

WHAT IS KNOWN AND OBJECTIVE

Propofol and esketamine are routine anaesthetics used in sedation or general anaesthesia for paediatric procedures. Coadministration could reduce the dose of either propofol or esketamine required and lower the incidence of drug-related adverse events. We designed a four-arm randomized controlled trial in children undergoing diagnostic upper gastrointestinal endoscopy to investigate the dose of propofol with different doses of esketamine inducing appropriate depth of anaesthesia in 50% patients (median effective dose, ED₅₀ ).

METHODS

After getting the approval of the research ethics committee and informed consent, 92 paediatric patients planning for upper gastrointestinal endoscopy were divided into four groups randomly: esketamine 0, 0.25, 0.5 and 1 mg/kg groups (n = 23/group). Propofol doses followed the Dixon and Massey up-and-down method with different starting and interval doses between groups. During the first attempt of endoscope insertion, if patients' reactions prevented the insertion, it would be considered as a failure. The awakening time, total propofol doses, as well as the perioperative and post-procedure adverse events were evaluated and recorded for each patient.

RESULTS AND DISCUSSION

The ED₅₀ (median, 95% confidence interval) of propofol was significantly greater in esketamine 0 and 0.25 mg/kg groups in comparison with the esketamine 0.5 and 1 mg/kg groups (4.1 [3.3-4.9]; 3.1 [2.5-3.8] mg/kg vs. 1.8 [1.1-2.4]; 0.8 [0.2-1.3] mg/kg, respectively, p < .05). The total doses of propofol in esketamine 0.5 and 1 mg/kg groups were statistically lower than these in esketamine 0 and 0.25 mg/kg group (p < .01). The mean blood pressure was lower in the esketamine 0 mg/kg group than that in 1 mg/kg group after administration and during the procedure (p < .01). The esketamine 1 mg/kg group showed a higher incidence of vomiting and visual disturbances than the other three groups (p < .001).

WHAT IS NEW AND CONCLUSION

In children who accomplished diagnostic paediatric upper gastrointestinal endoscopy under deep sedation/anaesthesia, the total dosage of propofol needed was reduced significantly in esketamine 0.5 and 1 mg/kg groups with a corresponding reduce in propofol-related hemodynamic changes. However, a higher incidence of esketamine-related adverse effects was found in esketamine 1 mg/kg group.

Gastrointestinal endoscopy in children and adults: How do they differ?

Gastrointestinal endoscopy has grown dramatically over the past century, and with subsequent improvements in technology and anaesthesia, it has become a safe and useful tool for evaluation of GI pathology in children. There are substantial differences between paediatric and adult endoscopy beyond size, including: age-related patho-physiology and the different spectrum of diseases in children. Literature on endoscopic procedures in children is sparse but significant. The present review aims at describing the current knowledges on paediatric endoscopy practice and highlights the main areas of differences between paediatric and adult practice.

Anti-tumor Activity of Propofol: A Focus on MicroRNAs

BACKGROUND

MicroRNAs are endogenous, short, non-coding RNAs with the length as low as 20 to 25 nucleotides. These RNAs are able to negatively affect the gene expression at the post-transcriptional level. It has been demonstrated that microRNAs play a significant role in cell proliferation, cell migration, cell death, cell differentiation, infection, immune response, and metabolism. Besides, the dysfunction of microRNAs has been observed in a variety of cancers. So, modulation of microRNAs is of interest in the treatment of disorders.

OBJECTIVE

The aim of the current review is to investigate the modulatory effect of propofol on microRNAs in cancer therapy.

METHODS

This review was performed at PubMed, SCOPUS and Web of Science data-bases using keywords "propofol', "microRNA", "cancer therapy", "propofol + microRNA" and "propofol + miR".

RESULTS

It was found that propofol dually down-regulates/upregulates microRNAs to exert its antitumor activity. In terms of oncogenesis microRNAs, propofol exert an inhibitory effect, while propofol significantly enhances the expression of oncosuppressor microRNAs.

CONCLUSION

It seems that propofol is a potential modulator of microRNAs and this capability can be used in the treatment of various cancers.

Deep Sedation for Pediatric Parotid Sialendoscopy in Juvenile Recurrent Parotitis

Sialendoscopy is a minimally invasive diagnostic and therapeutic tool for juvenile recurrent parotitis (JRP); the procedure is under general anesthesia, but local anesthesia has been used for sialendoscopy in children >8 years. Based on the experience in children with sedation for gastrointestinal endoscopy, we investigated the reliability and safety of deep sedation for sialendoscopy in JRP. Six children (3 females, 6-13 years) with episodes of parotid swelling underwent interventional (duct dilation and steroid irrigation) sialendoscopy with intravenous bolus of 1 mg/kg propofol and 1 mcg/kg fentanyl, and continuous infusion of 2 mg/kg/h propofol. Sialendoscopy under deep sedation was successfully performed in all the patients; the procedure was well tolerated, without any adverse effects. One event of full awakening was registered and promptly solved without needing to interrupt the procedure. Effectiveness of sialendoscopy under deep sedation was subjectively attested by high positive scores obtained at post-operative standardized questionnaires administered to the patients and their parents, and objectively by the lack of clinical recurrences during the follow-up. The combination of propofol and fentanyl seems to be a reliable and safe means of sedating children with JRP undergoing sialendoscopy.

A comparison of ketamine-midazolam combination and propofol-fentanyl combination on procedure comfort and recovery process in pediatric colonoscopy procedures

Objective

To compare the efficacy and safety of midazolam-ketamine combination versus fentanyl-propofol combination in pediatric diagnostic colonoscopy.

Methods

This is a retrospective study of 68 children undergoing diagnostic gastroenterology with midazolam-ketamine combination (Group-K) or with fentanyl-propofol combination (Group-P) in the pediatric gastroentology department at a Turkish tertiary hospital between January 2015 and June 2017. An intravenous midazolam was administered one minute before ketamine administration in Group K. Intravenous fentanyl was given to Group P, followed by intravenous propofol.

Results

There were statistically no significant differences between the groups as for age, gender, weight, duration of colonoscopy and complications observed during procedure. Ramsay sedation score was significantly higher in Group K. Recovery time and the rate of complications during the recovery of Group-K (23 patients, 65.7%) was significantly higher than that of Group P (8 patients, 24.2%) (p= 0.001).

Conclusions

Colonoscopy procedures can be quite comfortable in children when using the midazolam-ketamine combination. However, adverse effects related to ketamine were observed during recovery.

Variation in Pediatric Anesthesiologist Sedation Practices for Pediatric Gastrointestinal Endoscopy

Background: Despite a worldwide shift toward anesthesiologist-administered sedation for gastrointestinal endoscopy in children, ideal sedation regimens remain unclear and best practices undefined. Aim: The aim of our study was to document variation in anesthesiologist-administered sedation for pediatric endoscopy. Outcomes of interest included coefficients of variation, procedural efficiency, as well as adverse events. Methods: IRB approval was obtained to review electronic health records of children undergoing routine endoscopy at our medical center during a recent calendar year. Descriptive and multivariate analyses were used to examine predictors of sedation practices. Results: 258 healthy children [2-21 years (median 15, (Q1-Q3 = 10-17)] underwent either upper and/or lower endoscopies with sedation administered by anesthesiologists (n = 21), using different sedation regimens (29) that ranged from a single drug administered to 6 sedatives in combination. Most patients did not undergo endotracheal tube intubation for the procedure (208, 81%), and received propofol (255, 89%) either alone or in combination with other sedatives. A total of 10 (3.8%) adverse events (9 sedation related) were documented to occur. The coefficient of variation (CV) for sedation times was high at 64.2%, with regression analysis suggesting 8% was unexplained by procedure time. Multivariable model suggested that longer procedure time (p < 0.0001), younger age (p < 0.0001), and use of endotracheal tube intubation (p = 0.02) were associated with longer sedation time. Discussion: We found great variation in anesthesiologist administered regimens for pediatric endoscopy at our institution that may be unwarranted, presenting may opportunities for minimizing patient risk, as well as for optimizing procedural efficiency.

Effects of Sedation Performed by an Anesthesiologist on Pediatric Endoscopy: a Single-Center Retrospective Study in Korea

BACKGROUND

Endoscopy is used for diagnosing and treating various digestive diseases in children as well as in adults. However, in pediatric patients, it is recommended that sufficient sedation should be ensured before conducting endoscopy, since insufficient sedation may cause serious complications. However, in Korea, no studies have yet described the types of sedation drugs, effects of sedation, and efficiency of endoscopy with respect to the sedation instructor. Thus, we investigated the effectiveness of sedative procedures performed by anesthesiologists.

METHODS

We retrospectively reviewed the medical records of patients aged < 18 years who underwent endoscopy during March 2014-July 2019. Data of sedation instructors, sedation drugs and their doses, complications, and the recovery after sedation were evaluated.

RESULTS

Of 257 patients, 217 underwent esophagogastroduodenoscopy (EGD) and 40 underwent colonoscopies. Before EGD, 29 patients (13.4%) underwent sedation by the pediatric endoscopist and 188 (86.6%) were sedated by the anesthesiologist. The anesthesiologist performed the sedation for all 40 patients who underwent colonoscopy. Endoscopic examinations performed by the anesthesiologist were relatively more time-consuming (401.0 ± 135.1 seconds vs. 274.9 ± 106.1 seconds, P < 0.001). We observed that in patients who underwent EGD, there was a difference in the dose of midazolam administered (P = 0.000). When comparing EGD and colonoscopy in patients undergoing sedation by the anesthesiologist, there were no significant differences in the doses of midazolam and ketamine, but the dose of propofol increased for colonoscopy (2.50 ± 0.95 mg/kg vs. 4.71 ± 1.66 mg/kg, P = 0.000). The cognitive recovery time according to drug dose was associated with propofol only in EGD with a shorter endoscopy time. The longer cognitive recovery time in colonoscopy and the discharge time of EGD and colonoscopies were not associated with propofol use.

CONCLUSION

When sedation is performed by an anesthesiologist, various drugs are used with sufficient doses and complications are reduced, but the discharge time does not change. For performing pediatric endoscopy in Korea, anesthesiologists should be considered for inducing anesthesia.

Propofol use in newborns and children: is it safe? A systematic review

OBJECTIVES

To determine the main indications and assess the most common adverse events with the administration of hypnotic propofol in most pediatric clinical scenarios.

SOURCES

A systematic review of PubMed, SciELO, Cochrane, and EMBASE was performed, using filters such as a maximum of five years post-publication, and/or references or articles of importance, with emphasis on clinical trials using propofol. All articles of major relevance were blind-reviewed by both authors according to the PRISMA statement, looking for possible bias and limitations or the quality of the articles.

SUMMARY OF THE FINDINGS

Through the search criterion applied, 417 articles were found, and their abstracts evaluated. A total of 69 papers were thoroughly studied. Articles about propofol use in children are increasing, including in neonates, with the majority being cohort studies and clinical trials in two main scenarios: upper digestive endoscopy and magnetic resonance imaging. A huge list of adverse events has been published, but most articles considered them of low risk.

CONCLUSIONS

Propofol is a hypnotic drug with a safe profile of efficacy and adverse events. Indeed, when administered by non-anesthesiologists, quick access to emergency care must be provided, especially in airway events. The use of propofol in other scenarios must be better studied, aiming to reduce the limitations of its administration by general pediatricians.

Propofol vs traditional sedatives for sedation in endoscopy: A systematic review and meta-analysis

BACKGROUND

Propofol is commonly used for sedation during endoscopic procedures. Data suggests its superiority to traditional sedatives used in endoscopy including benzodiazepines and opioids with more rapid onset of action and improved post-procedure recovery times for patients. However, Propofol requires administration by trained healthcare providers, has a narrow therapeutic index, lacks an antidote and increases risks of cardio-pulmonary complications.

AIM

To compare, through a systematic review of the literature and meta-analysis, sedation with propofol to traditional sedatives with or without propofol during endoscopic procedures.

METHODS

A literature search was performed using MEDLINE, Scopus, EMBASE, the Cochrane Library, Scopus, LILACS, BVS, Cochrane Central Register of Controlled Trials, and The Cumulative Index to Nursing and Allied Health Literature databases. The last search in the literature was performed on March, 2019 with no restriction regarding the idiom or the year of publication. Only randomized clinical trials with full texts published were included. We divided sedation therapies to the following groups: (1) Propofol versus benzodiazepines and/or opiate sedatives; (2) Propofol versus Propofol with benzodiazepine and/or opioids; and (3) Propofol with adjunctive benzodiazepine and opioid versus benzodiazepine and opioid. The following outcomes were addressed: Adverse events, patient satisfaction with type of sedation, endoscopists satisfaction with sedation administered, dose of propofol administered and time to recovery post procedure. Meta-analysis was performed using RevMan5 software version 5.39.

RESULTS

A total of 23 clinical trials were included (n = 3854) from the initial search of 6410 articles. For Group I (Propofol vs benzodiazepine and/or opioids): The incidence of bradycardia was not statistically different between both sedation arms (RD: -0.01, 95%CI: −0.03–+0.01, I²: 22%). In 10 studies, the incidence of hypotension was not statistically difference between sedation arms (RD: 0.01, 95%CI: −0.02–+0.04, I²: 0%). Oxygen desaturation was higher in the propofol group but not statistically different between groups (RD: −0.03, 95%CI: −0.06–+0.00, I²: 25%). Patients were more satisfied with their sedation in the benzodiazepine + opioid group compared to those with monotherapy propofol sedation (MD: +0.89, 95%CI: +0.62–+1.17, I²: 39%). The recovery time after the procedure showed high heterogeneity even after outlier withdrawal, there was no statistical difference between both arms (MD: -15.15, 95%CI: −31.85–+1.56, I²: 99%). For Group II (Propofol vs propofol with benzodiazepine and/or opioids): Bradycardia had a tendency to occur in the Propofol group with benzodiazepine and/or opioid-associated (RD: -0.08, 95%CI: −0.13–−0.02, I²: 59%). There was no statistical difference in the incidence of bradycardia (RD: -0.00, 95%CI: −0.08–+0.08, I²: 85%), desaturation (RD: −0.00, 95%CI: −0.03–+0.02, I²: 44%) or recovery time (MD: -2.04, 95%CI: −6.96–+2.88, I²: 97%) between sedation arms. The total dose of propofol was higher in the propofol group with benzodiazepine and/or opiates but with high heterogeneity. (MD: 70.36, 95%CI: +53.11–+87.60, I²: 61%). For Group III (Propofol with benzodiazepine and opioid vs benzodiazepine and opioid): Bradycardia and hypotension was not statistically significant between groups (RD: -0.00, 95%CI: −0.002–+0.02, I²: 3%; RD: 0.04, 95%CI: −0.05–+0.13, I²: 77%). Desaturation was evaluated in two articles and was higher in the propofol + benzodiazepine + opioid group, but with high heterogeneity (RD: 0.15, 95%CI: 0.08–+0.22, I²: 95%).

CONCLUSION

This meta-analysis suggests that the use of propofol alone or in combination with traditional adjunctive sedatives is safe and does not result in an increase in negative outcomes in patients undergoing endoscopic procedures.

Evaluation of the safety of using propofol for paediatric procedural sedation: A systematic review and meta-analysis

Propofol is one of the most widely used drugs for paediatric procedural sedation owing to its known advantages, but some concerns remain regarding respiratory and/or cardiac complications in patients receiving propofol. Although a considerable number of randomised controlled clinical trials (RCTs) have been conducted to compare it with other sedative agents or opioids for children undergoing various procedures, propofol is still being used off-label for this indication in many countries. We performed a systematic review and meta-analysis of those RCTs to provide an overall summation of evidence that can potentially be considered for further regulatory decisions, including reimbursement policies. We searched for RCTs in MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials from their inception to January 31, 2018. Our meta-analysis of 30 RCTs confirmed that propofol sedation had advantages in recovery time when compared with other drugs, without excessive concerns for cardiovascular or respiratory adverse events. Its safety profile regarding coughing, nausea or vomiting, and emergence delirium was also similar to that of other drugs. The overall evidence suggests that propofol sedation for paediatric procedures should be considered more positively in the context of regulatory decisions.

Comparison of Cognitive Impairments After Intensive Care Unit Sedation Using Dexmedetomidine and Propofol Among Older Patients

Despite the high prevalence of cognitive impairment among older adults, little is known about the association of the selection of dexmedetomidine and propofol on cognitive functions of patients after a critical illness. Patients aged ≥70 years who received intensive care unit (ICU) care from Cangzhou Central Hospital between 2013 and 2016 were enrolled and randomized into a dexmedetomidine group and a propofol group with matched demographic and clinical characteristics. At discharge from the ICU and 4 weeks later, the cognitive status of patients was assessed and compared using the Montreal Cognitive Assessment system. There were 164 patients included in the dexmedetomidine group and 159 patients in the propofol group. No significant difference was observed between the 2 groups in terms of age, female sex, body weight, educational level, ICU and hospital stay, comorbidities, and medications. Further, patients from the 2 groups at ICU discharge did not demonstrate significant difference on the Montreal Cognitive Assessment component scores, which showed significant differences between the 2 groups 4 weeks later (P < .05). Moreover, dexmedetomidine and propofol showed different levels of impacts on the cognitive function of patients discharged from the postanesthesia care unit, neurological ICU, and medical ICU. This study demonstrated that patients discharged from the ICU who received propofol for sedation showed less impairment on the cognitive functions when compared with patients who received dexmedetomidine during ICU care 4 weeks after discharge. Despite some limitations, this study provides insights to the decision-making process in the selection of appropriate sedation strategy, especially for the elderly patients.