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Sneyd JR. Why sedative hypnotics often fail in development. Curr Opin Anaesthesiol 2024; 37:391-397. [PMID: 38841982 DOI: 10.1097/aco.0000000000001381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
PURPOSE OF REVIEW Drug development to support anaesthesia and sedation has been slow with few candidates emerging from preclinical discovery and limited innovation beyond attempted reformulation of existing compounds. RECENT FINDINGS The market is well supported by low-cost generic products and development compounds have not been shown to improve patient outcomes or possess other distinctive characteristics to justify the cost of development. SUMMARY To make progress in a large-volume, low margin and highly competitive environment requires meaningful advances in relevant basic science. Opportunities exist, but probably require bolder initiatives than further attempts at reformulation or fiddling with the structure of propofol. Extending development ambitions to include nonanaesthesiologist providers challenges professional boundaries but may facilitate cost-effective changes in patterns of care.
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Affiliation(s)
- J Robert Sneyd
- Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth, Plymouth, UK
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2
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Wu F, Zhan L, Xu W, Bian J. Effect of intravenous lidocaine on outcomes in patients receiving propofol for gastrointestinal endoscopic procedures: an updated systematic review and meta-analysis. Eur J Clin Pharmacol 2024; 80:39-52. [PMID: 37962581 DOI: 10.1007/s00228-023-03589-y] [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: 07/07/2023] [Accepted: 10/25/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Gastrointestinal endoscopic procedures (GEPs) are frequently employed for the diagnosis and treatment of various gastrointestinal ailments. While propofol sedation is widely used during these procedures, there is a concern regarding its potential negative effects. Intravenous (IV) lidocaine has been suggested as an add-on to propofol sedation for GEPs, but current evidence on its efficiency and safety is limited. This systematic review and meta-analysis aimed to assess the impact of IV lidocaine on outcomes in patients receiving propofol during GEPs. METHODS Electronic databases were screened for randomized controlled trials (RCTs), published up to 31 March 2023, investigating the effectiveness of intravenous lidocaine addition to propofol sedation during GEPs. RESULTS A total of 12 RCTs involving 712 patients that received IV lidocaine and propofol for GEF and 719 patients that received propofol were analyzed. Adding IV lidocaine to propofol sedation led to significant reduction in pain after the procedure (standardized mean difference (SMD) = - 0.91, 95% confidence interval [CI]; - 1.51 to - 0.32), decreased propofol usage (SMD = - 0.89; 95% CI, - 1.31 to - 0.48), lower recovery time (SMD = - 0.95 min; 95% CI, - 1.48 to - 0.43), and decreased pain score (SMD = - 0.91; 95% CI, - 1.51 to - 0.32). The overall rate of adverse events was markedly less in the lidocaine group than in the control group (RR = 0.74; 95% CI, 0.56 to 0.99). CONCLUSION Our results show that IV lidocaine improves patient outcomes by reducing post-procedural pain, decreasing propofol usage, shortening recovery time, and lowering pain scores. This study provides compelling evidence supporting the use of intravenous lidocaine as an adjunct to propofol sedation for gastrointestinal endoscopic procedures. However, further research is necessary to optimize the use of lidocaine and fully understand its long-term effects.
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Affiliation(s)
- Fangpu Wu
- Department of Anesthesiology, The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People's Hospital, Quzhou, China
| | - Linsen Zhan
- Department of Anesthesiology, The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People's Hospital, Quzhou, China
| | - Wei Xu
- Department of Gastroenterology, The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People's Hospital, No.100, Minjiang Avenue, Kecheng District, Quzhou, China
| | - Jun Bian
- Department of Gastroenterology, The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People's Hospital, No.100, Minjiang Avenue, Kecheng District, Quzhou, China.
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Anderson KJ, Absalom AR. Propofol/remifentanil patient-controlled sedation: caveat emptor! Can J Anaesth 2023; 70:1719-1725. [PMID: 37853278 DOI: 10.1007/s12630-023-02592-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 06/27/2023] [Accepted: 06/28/2023] [Indexed: 10/20/2023] Open
Affiliation(s)
- Keith J Anderson
- Department of Anesthesiology, Perioperative and Pain Medicine, Foothills Medical Centre, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
| | - Anthony R Absalom
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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De Vico P, Biasucci DG, Aversano L, Polidoro R, Zingaro A, Millarelli FR, Del Vecchio Blanco G, Paoluzi OA, Troncone E, Monteleone G, Dauri M. Feasibility and safety of deep sedation with propofol and remifentanil in spontaneous breathing during endoscopic retrograde cholangiopancreatography: an observational prospective study. BMC Anesthesiol 2023; 23:260. [PMID: 37542218 PMCID: PMC10401822 DOI: 10.1186/s12871-023-02218-6] [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: 05/24/2023] [Accepted: 07/23/2023] [Indexed: 08/06/2023] Open
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is an interventional procedure that requires deep sedation or general anaesthesia. The purpose of this prospective observational study was to assess the feasibility and safety of deep sedation in ERCP to maintain spontaneous breathing. METHODS This is a single-centre observational prospective cohort study conducted in a tertiary referral university hospital. All consecutive patients who needed sedation or general anaesthesia for ERCP were included from January 2021 to June 2021. Deep sedation was achieved and maintained by continuous infusion of an association of propofol and remifentanil. The primary endpoint was to assess the prevalence of major anaesthesia-related complications, such as arrhythmias, hypotension, gas exchange dysfunction, and vomiting (safety endpoint). Secondary endpoints were: (a) to assess the prevalence of signs of an insufficient level of sedation, such as movement, cough, and hiccups (feasibility endpoint): (b) time needed to achieve the target level of sedation and for recovery from anaesthesia. In order to do so we collect the following parameters: peripheral oxygen saturation, fraction of inspired oxygen, noninvasive systemic blood pressure, heart rate, number of breaths per minute, neurological functions with the use of the bispectral index to determine depth of anaesthesia, and partially exhaustive CO2 end pressure to continuously assess the ventilatory status. The collected data were analysed by several tests: Shapiro-Wilk, Student's t, Tuckey post-hoc, Wilcoxon rank-sum and Kruskall-Wallis ran. Statistical analysis was performed using Stata/BE 17.0 (StataCorp LLC). RESULTS 114 patients were enroled. Eight patients were excluded because they did not meet the inclusion criteria. We found that all patients were hemodynamically stable: intraoperative mean systolic blood pressure was 139,23 mmHg, mean arterial pressure was on average 106,66 mmHg, mean heart rate was 74,471 bpm. The mean time to achieve the target level of sedation was 63 s, while the mean time for the awakening after having stopped drug infusion was 92 s. CONCLUSIONS During ERCP, deep sedation and analgesia using the association of propofol and remifentanil and maintaining spontaneous breathing are safe and feasible, allowing for a safe and quick recovery from anaesthesia.
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Affiliation(s)
- Pasquale De Vico
- Department of Clinical Science and Translational Medicine, 'Tor Vergata' University of Rome, Rome, Italy
- Emergency Department, 'Tor Vergata' University Hospital of Rome, Rome, Italy
| | - Daniele G Biasucci
- Department of Clinical Science and Translational Medicine, 'Tor Vergata' University of Rome, Rome, Italy
| | - Lucia Aversano
- Emergency Department, 'Tor Vergata' University Hospital of Rome, Rome, Italy.
| | - Roberto Polidoro
- Emergency Department, 'Tor Vergata' University Hospital of Rome, Rome, Italy
| | - Alessia Zingaro
- Emergency Department, 'Tor Vergata' University Hospital of Rome, Rome, Italy
| | | | | | | | - Edoardo Troncone
- Department of Systems Medicine, 'Tor Vergata' University of Rome, Rome, Italy
| | - Giovanni Monteleone
- Department of Systems Medicine, 'Tor Vergata' University of Rome, Rome, Italy
| | - Mario Dauri
- Department of Clinical Science and Translational Medicine, 'Tor Vergata' University of Rome, Rome, Italy
- Emergency Department, 'Tor Vergata' University Hospital of Rome, Rome, Italy
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Xiong Y, Yan H, Qu L, Wang S, Meng X, Zhu X, Zhang P, Yuan S, Shi J. Global Trends of Gastrointestinal Endoscopy Anesthesia/Sedation: A Bibliometric Study (from 2001 to 2022). J Pain Res 2023; 16:2393-2406. [PMID: 37483407 PMCID: PMC10356960 DOI: 10.2147/jpr.s408811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 07/06/2023] [Indexed: 07/25/2023] Open
Abstract
Background Gastrointestinal (GI) endoscopy becomes more and more common now in order to diagnose and treat GI diseases, and anesthesia/sedation plays an important role. We aim to discuss the developmental trends and evaluate the research hotspots using bibliometric methods for GI endoscopy anesthesia/sedation in the past two decades. Methods The original and review articles published from 2001 to December 2022 related to GI endoscopy anesthesia/sedation were extracted from the Web of Science database. Four different softwares (CiteSpace, VOSviewer, and Bibliometrix, Online Analysis Platform of Literature Metrology (Bibliometric)) were used for this comprehensive analysis. Results According to our retrieval strategy, we found a total of 3154 related literatures. Original research articles were 2855, and reviews were 299. There has been a substantial increase in the research on GI endoscopy anesthesia/sedation in recent 22 years. These publications have been cited 66,418 times, with a mean of 21.04 citations per publication. The US maintained a leading position in global research, with the largest number of publications (29.94%), and China ranked second (19.92%). Keyword burst and concurrence showed that conscious sedation, colonoscopy and midazolam were the most frequently occurring keywords. Conclusion Our research found that GI endoscopy anesthesia/sedation was in a period of rapid development and demonstrated the improvement of medical instruments and surgical options that had significantly contributed to the field of GI endoscopy anesthesia/sedation. The US dominates this field, and the selection and dosage of sedative regimens have always been the foci of disease research to improve comfort and safety, while adverse events and risks arouse attention gradually. In the past 20 years, hotspots mainly focus on upper gastrointestinal endoscopy, gastroscopy, and esophagogastroduodenoscopy. These data would provide future directions for clinicians and researchers regarding GI endoscopy anesthesia/sedation.
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Affiliation(s)
- Yujun Xiong
- Department of Gastroenterology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
| | - Haoqi Yan
- Department of Anesthesiology, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences; Peking Union Medical College, Beijing, 100037, People’s Republic of China
| | - Lang Qu
- Department of Anesthesiology, Shanghai General Hospital, Shanghai, People’s Republic of China
| | - Shuqi Wang
- Department of Otolaryngology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, People’s Republic of China
| | - Xiangda Meng
- Department of Neurosurgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Xingyun Zhu
- Department of Endocrinology, Beijing Jishuitan Hospital, Beijing, People’s Republic of China
| | - Pan Zhang
- Department of Gastroenterology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
| | - Su Yuan
- Department of Anesthesiology, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences; Peking Union Medical College, Beijing, 100037, People’s Republic of China
| | - Jihua Shi
- Department of Gastroenterology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
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Chen J, Qian K, Liu CH, Li XL, Chen Y, Wang JQ. Effects of intravenous administration of magnesium sulfate in propofol-based sedation for ERCP in elderly patients: a randomized, double-blind, placebo-controlled study. BMC Geriatr 2023; 23:413. [PMID: 37420201 PMCID: PMC10326926 DOI: 10.1186/s12877-023-04107-6] [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: 12/05/2022] [Accepted: 06/14/2023] [Indexed: 07/09/2023] Open
Abstract
BACKGROUND Propofol-based sedations are widely used in elderly patients for endoscopic retrograde cholangiopancreatography (ERCP) procedure, but respiratory depression and cardiovascular adverse events commonly occur. Magnesium administered intravenously can alleviate pain and decrease propofol requirements during surgery. We hypothesized that intravenous magnesium was used as adjuvant to propofol might be beneficial in elderly patients undergoing ERCP procedures. METHODS Eighty patients aged from 65 to 79 years who were scheduled for ERCP were enrolled. All patients were intravenously administered 0.1 µg/kg sufentanil as premedication. The patients were randomized to receive either intravenous magnesium sulfate 40 mg/kg (group M, n = 40) or the same volume of normal saline (group N, n = 40) over 15 min before the start of sedation. Intraoperative sedation was provided by propofol. Total propofol requirement during ERCP was the primary outcome. RESULTS The total propofol consumption were reduced by 21.4% in the group M compared with the group N (151.2 ± 53.3 mg vs. 192.3 ± 72.1 mg, P = 0.001). The incidences of respiratory depression episodes and involuntary movement were less in the group M than those in the group N (0/40 vs. 6/40, P = 0.011; 4/40 vs. 11/40, P = 0.045; respectively). In the group M, the patients experienced less pain than those in the group N at 30 min after the procedure (1 [0-1] vs. 2 [1-2], P < 0.001). Correspondingly, the patients' satisfaction was clearly higher in the group M (P = 0.005). There was a tendency towards lower intraoperative heart rate and mean arterial pressure in group M. CONCLUSIONS A single bolus of 40 mg/kg of intravenous magnesium can significantly reduce propofol consumption during ERCP, with higher sedation success and lower adverse events. TRIAL REGISTRATION ID UMIN000044737. Registered 02/07/2021.
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Affiliation(s)
- Jie Chen
- Department of Anaesthesiology, People's Hospital of Chongqing Banan District, Chongqing, China
| | - Ke Qian
- Department of Anaesthesiology, People's Hospital of Chongqing Banan District, Chongqing, China
| | - Chun-Hong Liu
- Department of Anaesthesiology, People's Hospital of Chongqing Banan District, Chongqing, China
| | - Xiao-Li Li
- Department of Anaesthesiology, People's Hospital of Chongqing Banan District, Chongqing, China
| | - Yan Chen
- Department of Anaesthesiology, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Jin-Quan Wang
- Department of Anaesthesiology, The Ninth People's Hospital of Chongqing, No. 69, Hejia Road, Jialing village, Beibei District, Chongqing, 400700, P. R. China.
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7
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Driesens M, Absalom A, Scheeren T, Meyer P, Vos JJ, Barends C. Procedural sedation duration and the relation with formation of atelectasis and respiratory complaints. Can J Anaesth 2023; 70:1275-1276. [PMID: 37253860 DOI: 10.1007/s12630-023-02488-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 01/05/2023] [Accepted: 01/08/2023] [Indexed: 06/01/2023] Open
Affiliation(s)
- Mendy Driesens
- Department of Anaesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Anthony Absalom
- Department of Anaesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Thomas Scheeren
- Department of Anaesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Peter Meyer
- Department of Anaesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jaap Jan Vos
- Department of Anaesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Clemens Barends
- Department of Anaesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
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8
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Chen SC, Chen CY, Shen SJ, Tsai YF, Ko YC, Chuang LC, Lin JR, Tsai HI. Application of Bispectral Index System (BIS) Monitor to Ambulatory Pediatric Dental Patients under Intravenous Deep Sedation. Diagnostics (Basel) 2023; 13:diagnostics13101789. [PMID: 37238272 DOI: 10.3390/diagnostics13101789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 05/15/2023] [Accepted: 05/16/2023] [Indexed: 05/28/2023] Open
Abstract
Purpose Intravenous sedation has been well accepted to allow dental restoration in uncooperative children while avoiding aspiration and laryngospasm; however, intravenous anesthetics such as propofol may lead to undesired effects such as respiratory depression and delayed recovery. The use of the bispectral index system (BIS), a monitoring system reflective of the hypnotic state, is con-troversial in the reduction in the risk of respiratory adverse events (RAEs), recovery time, the in-travenous drug dosage, and post-procedural events. The aim of the study is to evaluate whether BIS is advantageous in pediatric dental procedures. Methods A total of 206 cases, aged 2-8 years, receiving dental procedures under deep sedation with propofol using target-controlled infusion (TCI) technique were enrolled in the study. BIS level was not monitored in 93 children whereas it was for 113 children, among which BIS values were maintained between 50-65. Physiological variables and adverse events were recorded. Statistical analysis was conducted using Chi-square, Mann Whitney U, Independent Samples t and Wilcoxon signed tests, with a p value of <0.05 considered to be statistically significant. Results Although no statistical significance in the post-discharge events and total amount of propofol used was observed, a clear significance was identified in periprocedural adverse events (hypoxia, apnea, and recurrent cough, all p value < 0.05) and discharge time (63.4 ± 23.2 vs. 74.5 ± 24.0 min, p value < 0.001) between these two groups. Conclusions The application of BIS in combination with TCI may be beneficial for young children undergoing deep sedation for dental procedures.
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Affiliation(s)
- Shih-Chia Chen
- Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan
| | - Chun-Yu Chen
- Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan 333, Taiwan
| | - Shih-Jyun Shen
- Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Yung-Fong Tsai
- Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan 333, Taiwan
| | - Yu-Chen Ko
- Department of Anesthesiology, Chang Gung Memorial Hospital, Chiayi Branch, Chiayi 613, Taiwan
| | - Li-Chuan Chuang
- Department of Pediatric Dentistry, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan
- Department of Dentistry, School of Dentistry, National Yang-Ming University, Taipei 112, Taiwan
- Graduate Institute of Craniofacial and Dental Science, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Jr-Rung Lin
- Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan
- Clinical Informatics and Medical Statistics Research Center (CIMS) and Graduate Institute of Clinical Medical Sciences, Department of Biomedical Sciences, Gung Gung University, Taoyuan 333, Taiwan
| | - Hsin-I Tsai
- Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan 333, Taiwan
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Lobb D, MiriMoghaddam M, Macalister D, Chrisp D, Shaw G, Lai H. Safety and efficacy of target controlled infusion administration of propofol and remifentanil for moderate sedation in non-hospital dental practice. J Dent Anesth Pain Med 2023; 23:19-28. [PMID: 36819604 PMCID: PMC9911961 DOI: 10.17245/jdapm.2023.23.1.19] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 12/14/2022] [Accepted: 12/27/2022] [Indexed: 02/05/2023] Open
Abstract
Background Fearful and anxious patients who find dental treatment intolerable without sedative and analgesic support may benefit from moderate sedation. Target controlled infusion (TCI) pumps are superior to bolus injection in maintaining low plasma and effect-site concentration variability, resulting in stable, steady-state drug concentrations. We evaluated the safety and efficacy of moderate sedation with remifentanil and propofol using TCI pumps in non-hospital dental settings. Methods A prospective chart review was conducted on 101 patients sedated with propofol and remifentanil using TCI pumps. The charts were completed at two oral surgeons and one general dentist's office over 6 months. Hypoxia, hypotension, bradycardia, and over-sedation were considered adverse events and were collected using Tracking and Reporting Outcomes of Procedural Sedation (TROOPS). Furthermore, patient recovery time, sedation length, drug dose, and patient satisfaction questionnaires were used to measure sedation effectiveness. Results Of the 101 reviewed sedation charts, 54 were of men, and 47 were of women. The mean age of the patients was 40.5 ±18.7 years, and their mean BMI was 25.6 ± 4.4. The patients did not experience hypoxia, bradycardia, and hypotension during the 4694 min of sedation. The average minimum Mean Arterial Pressure (MAP) and heartbeats were 75.1 mmHg and 60.4 bpm, respectively. 98% of patients agreed that the sedation technique met their needs in reducing their anxiety, and 99% agreed that they were satisfied with the sedation 24 hours later. The average sedation time was 46.9 ± 55.6 min, and the average recovery time was 12.4 ± 4.4 min. Remifentanil and propofol had mean initial effect-site concentration doses of 0.96 µ/ml and 1.0 ng/ml respectively. The overall total amount of drug administered was significantly higher in longer sedation procedures compared to shorter ones, while the infusion rate decreased as the procedural stimulus decreased. Conclusion According to the results of this study, no patients experienced adverse events during sedation, and all patients were kept at a moderate sedation level for a wide range of sedation times and differing procedures. The results showed that TCI pumps are safe and effective for administering propofol and remifentanil for moderate sedation in dentistry.
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Affiliation(s)
- Douglas Lobb
- School of Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | | | | | | | | | - Hollis Lai
- School of Dentistry, University of Alberta, Edmonton, Alberta, Canada
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10
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Pujol J, Martínez-Vilavella G, Gallart L, Blanco-Hinojo L, Pacreu S, Bonhomme V, Deus J, Pérez-Sola V, Gambús PL, Fernández-Candil J. Effects of remifentanil on brain responses to noxious stimuli during deep propofol sedation. Br J Anaesth 2023; 130:e330-e338. [PMID: 35973838 DOI: 10.1016/j.bja.2022.06.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 05/24/2022] [Accepted: 06/19/2022] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND The safety of anaesthesia has improved as a result of better control of anaesthetic depth. However, conventional monitoring does not inform on the nature of nociceptive processes during unconsciousness. A means of inferring the quality of potentially painful experiences could derive from analysis of brain activity using neuroimaging. We have evaluated the dose effects of remifentanil on brain response to noxious stimuli during deep sedation and spontaneous breathing. METHODS Optimal data were obtained in 26 healthy subjects. Pressure stimulation that proved to be moderately painful before the experiment was applied to the thumbnail. Functional MRI was acquired in 4-min periods at low (0.5 ng ml-1), medium (1 ng ml-1), and high (1.5 ng ml-1) target plasma concentrations of remifentanil at a stable background infusion of propofol adjusted to induce a state of light unconsciousness. RESULTS At low remifentanil doses, we observed partial activation in brain areas processing sensory-discriminative and emotional-affective aspects of pain. At medium doses, relevant changes were identified in structures highly sensitive to general brain arousal, including the brainstem, cerebellum, thalamus, auditory and visual cortices, and the frontal lobe. At high doses, no significant activation was observed. CONCLUSIONS The response to moderately intense focal pressure in pain-related brain networks is effectively eliminated with safe remifentanil doses. However, the safety margin in deep sedation-analgesia would be narrowed in minimising not only nociceptive responses, but also arousal-related biological stress.
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Affiliation(s)
- Jesus Pujol
- MRI Research Unit, Department of Radiology, Hospital Del Mar, Barcelona, Spain; Centro Investigación Biomédica en Red de Salud Mental, CIBERSAM G21, Barcelona, Spain.
| | | | - Lluís Gallart
- Department of Anesthesiology, Hospital Del Mar-IMIM, Barcelona, Spain; Department of Surgery, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Laura Blanco-Hinojo
- MRI Research Unit, Department of Radiology, Hospital Del Mar, Barcelona, Spain; Centro Investigación Biomédica en Red de Salud Mental, CIBERSAM G21, Barcelona, Spain
| | - Susana Pacreu
- Department of Anesthesiology, Hospital Del Mar-IMIM, Barcelona, Spain
| | - Vincent Bonhomme
- Department of Anesthesia and Intensive Care Medicine, Liege University Hospital, Liege, Belgium; Anesthesia and Intensive Care Laboratory, GIGA-Consciousness Thematic Unit, GIGA-Research, Liege University, Liege, Belgium
| | - Joan Deus
- MRI Research Unit, Department of Radiology, Hospital Del Mar, Barcelona, Spain; Department of Psychobiology and Methodology in Health Sciences, Autonomous University of Barcelona, Barcelona, Spain
| | - Víctor Pérez-Sola
- Centro Investigación Biomédica en Red de Salud Mental, CIBERSAM G21, Barcelona, Spain; Institute of Neuropsychiatry and Addictions, Hospital Del Mar- IMIM, Pompeu I Fabra University, Barcelona, Spain
| | - Pedro L Gambús
- Systems Pharmacology Effect Control & Modeling Research Group, Anesthesiology Department, Hospital Clinic de Barcelona, Barcelona, Spain
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Lin R, Lin H, Elder E, Cerullo A, Carrington A, Stuart G. Nurse-led dexmedetomidine sedation for magnetic resonance imaging in children: a 6-year quality improvement project. Anaesthesia 2023; 78:598-606. [PMID: 36708590 DOI: 10.1111/anae.15973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2022] [Indexed: 01/29/2023]
Abstract
We aimed to safely introduce dexmedetomidine into a nurse-led sedation service for magnetic resonance imaging in children. Secondary aims were to increase the number of children eligible for sedation and to increase the actual number of children having sedation performed by our nurse sedation team. We analysed 1768 consecutive intravenous and 219 intranasal dexmedetomidine sedation episodes in infants, children and adolescents having magnetic resonance imaging scans between March 2016 and March 2022. The overall sedation success rate was 98.4%, with a 98.9% success rate for intravenous dexmedetomidine and a 95.0% success rate for intranasal dexmedetomidine. The incidence of scan interruption during intravenous and intranasal dexmedetomidine sedation was 8.8% and 21.9%, respectively. We conclude that paediatric sedation with dexmedetomidine for magnetic resonance scanning is safe and successful.
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Affiliation(s)
- R Lin
- Department of Anaesthesia, Great Ormond Street Hospital for Children, London, UK
| | - H Lin
- University of Cambridge, UK
| | - E Elder
- University College London, UK
| | - A Cerullo
- Department of Radiology, Great Ormond Street Hospital for Children, London, UK
| | - A Carrington
- Department of Radiology, Great Ormond Street Hospital for Children, London, UK
| | - G Stuart
- Department of Anaesthesia, Great Ormond Street Hospital for Children, London, UK
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12
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Jang MJ, Kim JH, Jeong HJ. Uncontrolled high blood pressure under total intravenous anesthesia with propofol and remifentanil: A case report. World J Clin Cases 2022; 10:9411-9416. [PMID: 36159423 PMCID: PMC9477663 DOI: 10.12998/wjcc.v10.i26.9411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 06/06/2022] [Accepted: 08/12/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Although propofol generally reduces blood pressure, rarely, it causes hypertension. However, the mechanism by which propofol increases blood pressure has not been established, and so far, there are only a few reported cases.
CASE SUMMARY A 46-year-old woman, diagnosed with thyroid cancer, was administered general anesthesia with propofol and remifentanil for a thyroid lobectomy. An increase in the concentrations of intravenous anesthetics further increased her blood pressure. The blood pressure remained stable when anesthesia was maintained with sevoflurane and remifentanil after the interruption of propofol administration.
CONCLUSION We concluded that propofol administration was the cause of increased blood pressure.
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Affiliation(s)
- Min Jung Jang
- Anesthesiology and Pain Medicine, National Cancer Center, Goyang 10408, South Korea
| | - Jee Hee Kim
- Anesthesiology and Pain Medicine, National Cancer Center, Goyang 10408, South Korea
| | - Hae Jeong Jeong
- Anesthesiology and Pain Medicine, National Cancer Center, Goyang 10408, South Korea
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13
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Motamed C, Servin F, Billard V. Adding Low-Dose Propofol to Limit Anxiety during Target-Controlled Infusion of Remifentanil for Gastrointestinal Endoscopy: Respiratory Issues and Safety Recommendations. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58091285. [PMID: 36143961 PMCID: PMC9502783 DOI: 10.3390/medicina58091285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 09/08/2022] [Accepted: 09/14/2022] [Indexed: 11/16/2022]
Abstract
Backgroundand Objectives: Remifentanil-based sedation is one of many protocols proposed for endoscopy procedures in spontaneous ventilation, alone or in combination with propofol. However, the effect of these small doses of propofol on the efficacy and safety of remifentanil target-controlled infusion (TCI) deserves to be examined in this context. The objective of this study was to assess the adverse respiratory and cardiovascular effects of small boluses of propofol combined with remifentanil, in comparison with remifentanil alone, and balanced with the quality of sedation and recovery. Materials andMethods: This was an observational bicenter study, representing a subgroup of a larger study describing remifentanil-based procedural sedation. In center 1, patients scheduled for gastrointestinal (GI) endoscopy had remifentanil TCI alone. In center 2, patients had a 10 mg propofol bolus before TCI and other boluses were allowed during the procedure. Remifentanil TCI was started at a target of 2 ng/mL then adapted by 0.5 ng/mL steps according to patient response to endoscopy stimulations. Results: Center 1 included 29 patients, while center 2 included 60 patients. No difference was found in the patients’ characteristics, incidence of success, average remifentanil consumption, or cardiovascular variables. Light sedation was achieved when propofol was added. The incidence of respiratory events, such as bradypnea, desaturation < 90%, and apnea requiring rescue maneuvers, were significantly higher with propofol. Conclusions: Adding propofol boluses to a remifentanil TCI for GI endoscopy ensures light sedation that may be necessary for anxiolysis but increases respiratory events, even after administration of small-dose boluses. Its safety is acceptable if the procedure is performed in an equipped environment with sedation providers trained to manage respiratory events and drugs titrated to minimal doses.
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Affiliation(s)
- Cyrus Motamed
- Department of Anesthesia, Institut Gustave Roussy, 94805 Villejuif, France
- Correspondence:
| | | | - Valerie Billard
- Department of Anesthesia, Institut Gustave Roussy, 94805 Villejuif, France
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14
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The duration of procedural sedation and the incidence of hypoxaemic events: A retrospective cohort study. Eur J Anaesthesiol 2022; 39:785-787. [PMID: 35013043 DOI: 10.1097/eja.0000000000001655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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15
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Lin YJ, Wang YC, Huang HH, Huang CH, Lin PL. Efficacy and safety of remifentanil for endoscopic ultrasound-guided tissue acquisition: a single center retrospective study. Surg Endosc 2022; 36:6516-6521. [PMID: 35041053 PMCID: PMC9402747 DOI: 10.1007/s00464-021-09006-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 12/31/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Remifentanil is a rapid onset and rapid recovery opioid. The combination of remifentanil and propofol for deep sedation decreases the incidents of movement, cough, and hiccup. We evaluated the efficacy and safety of remifentanil during endoscopic ultrasound-guided tissue acquisition. METHODS We retrospectively reviewed patients in whom endoscopic ultrasound-guided tissue acquisition was performed for solid mass lesions of the upper gastrointestinal tract and adjacent organs. All patients were premedicated with midazolam (2 mg), and target-controlled infusion of propofol, opioid, and Bispectral Index (BIS) monitoring were administered as necessary to maintain moderate-to-deep sedation. The opioids used were a bolus of alfentanil or remifentanil infusion. The discharge time, consumption of propofol and opioid, adverse events, diagnostic accuracy, and sensitivity and specificity for malignancy, were compared. RESULTS Tissue acquisition was achieved in 123 patients (alfentanil group, n = 64; remifentanil group, n = 59). The discharge time of the remifentanil group (16.5 ± 3.2 min) was significantly shorter than that of the alfentanil group (19.0 ± 4.9 min, P = 0.001). The consumption of propofol, adverse events, diagnostic accuracy, sensitivity, and specificity for malignancy in the alfentanil group were not significantly different from those in the remifentanil group. CONCLUSIONS Use of alfentanil or remifentanil for target-controlled infusion of propofol-BIS monitoring can provide good sedative and diagnostic quality for endoscopic ultrasound-guided tissue acquisition. However, remifentanil resulted in faster recovery than alfentanil.
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Affiliation(s)
- Yueh-Juh Lin
- Department of Cardiology, En Chu Kong Hospital, New Taipei City, Taiwan
| | - Yi-Chia Wang
- Department of Anesthesiology, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, 100225, Taiwan
| | - Hui-Hsun Huang
- Department of Anesthesiology, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, 100225, Taiwan
| | - Chi-Hsiang Huang
- Department of Anesthesiology, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, 100225, Taiwan
| | - Pei-Lin Lin
- Department of Anesthesiology, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, 100225, Taiwan.
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16
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Urdaneta F, Wardhan R, Wells G, White JD. Prevention of pulmonary complications in sedated patients undergoing interventional procedures in the nonoperating room anesthesia setting. Curr Opin Anaesthesiol 2022; 35:493-501. [PMID: 35787534 DOI: 10.1097/aco.0000000000001158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW Nonoperating room anesthesia (NORA) procedures have expanded in number, variety, and complexity. NORA involves all age groups, including frail older adults and patients often considered too sick to tolerate traditional surgical interventions. Postoperative pulmonary complications are a significant source of adverse events in the perioperative setting. We present a review focused on preventing pulmonary complications in the interventional NORA setting. RECENT FINDINGS NORA locations should function as independent, autonomous ambulatory units. We discuss a strategic plan involving a thorough preoperative evaluation of patients, including recognizing high-risk patients and their anesthetic management. Finally, we offer guidance on the challenges of conducting sedation and anesthesia in patients with coronavirus disease 2019 (COVID-19) or a history of COVID-19. SUMMARY The demands on the interventional NORA anesthesia team are increasing. Strategic planning, checklists, consistent staffing assignments, and scheduled safety drills are valuable tools to improve patient safety. In addition, through quality improvement initiatives and reporting, NORA anesthetists can achieve reductions in periprocedural pulmonary complications.
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Affiliation(s)
- Felipe Urdaneta
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida, USA
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17
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Sneyd JR, Absalom AR, Barends CRM, Jones JB. The appropriate way to measure blood pressure for sedated colonoscopy. Response to Br J Anaesth 2022. Br J Anaesth 2022; 129:e25-e27. [PMID: 35618536 DOI: 10.1016/j.bja.2022.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 04/21/2022] [Accepted: 04/21/2022] [Indexed: 11/30/2022] Open
Affiliation(s)
- J Robert Sneyd
- Faculty of Medicine and Dentistry, University of Plymouth, John Bull Building, Plymouth Science Park, Plymouth, UK.
| | - Anthony R Absalom
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Clemens R M Barends
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jordan B Jones
- College of Osteopathic Medicine, Rocky Vista University, Ivins, UT, USA
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18
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Fang Y, Xu Y, Cao S, Sun X, Zhang H, Jing Q, Tian L, Li C. Incidence and Risk Factors for Hypoxia in Deep Sedation of Propofol for Artificial Abortion Patients. Front Med (Lausanne) 2022; 9:763275. [PMID: 35572953 PMCID: PMC9092022 DOI: 10.3389/fmed.2022.763275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 04/04/2022] [Indexed: 11/15/2022] Open
Abstract
Background Respiratory depression is a life-threatening adverse effect of deep sedation. This study aimed to investigate the factors related to hypoxia caused by propofol during intravenous anesthesia. Methods Three hundred and eight patients who underwent painless artificial abortion in the outpatient department of Shanghai Tenth People’s Hospital between November 1, 2019 and June 30, 2020 were divided into two groups according to whether the patients experienced hypoxia (SpO2 < 95%). Preoperative anxiety assessments, anesthesia process, and operation-related information of the two groups were analyzed. The univariate analysis results were further incorporated into logistic regression analysis for multivariate analysis to determine the independent risk factors affecting hypoxia. Results Univariate analysis revealed that body mass index (BMI) (21.80 ± 2.94 vs. 21.01 ± 2.39; P = 0.038, 95% confidence interval (CI) = [−1.54, −0.04]), propofol dose (15.83 ± 3.21 vs. 14.39 ± 3.01; P = 0.002, CI = [−2.34, −0.53]), menopausal days (49.64 ± 6.03 vs. 52.14 ± 5.73; P = 0.004, CI = [0.79, 4.21]), State Anxiety Inventory score (51.19 ± 7.55 vs. 44.49 ± 8.96; P < 0.001, CI = [−9.26, −4.15]), and Self-rating Anxiety Scale score (45.86 ± 9.48 vs. 42.45 ± 9.88; P = 0.021, CI = [−6.30, −0.53]) were statistically significant risk factors for hypoxia during the operation. Logistic regression analysis showed that propofol dosage, menopausal days, and State Anxiety Inventory score were independent risk factors for hypoxia. Conclusion Patient anxiety affects the incidence of hypoxia when undergoing deep intravenous anesthesia with propofol. We can further speculate that alleviating patient anxiety can reduce the incidence of hypoxia. Clinical Trial Registration [http://www.chictr.org.cn], identifier [ChiCTR2000032167].
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Affiliation(s)
- Yiling Fang
- Department of Anesthesiology and Perioperative Medicine, School of Medicine, Shanghai Fourth People's Hospital, Tongji University, Shanghai, China.,School of Medicine, Shanghai Fourth People's Hospital, Translational Research Institute of Brain and Brain-Like Intelligence, Tongji University, Shanghai, China.,Clinical Research Center for Anesthesiology and Perioperative Medicine, Tongji University, Shanghai, China.,Department of Anesthesiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China.,Department of General Practice, Zhangjiagang First People's Hospital, Affiliated to Soochow University School of Medicine, Zhangjiagang, China
| | - Yaru Xu
- Department of Anesthesiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Silu Cao
- Department of Anesthesiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xiaoru Sun
- Department of Anesthesiology and Perioperative Medicine, School of Medicine, Shanghai Fourth People's Hospital, Tongji University, Shanghai, China.,School of Medicine, Shanghai Fourth People's Hospital, Translational Research Institute of Brain and Brain-Like Intelligence, Tongji University, Shanghai, China.,Clinical Research Center for Anesthesiology and Perioperative Medicine, Tongji University, Shanghai, China
| | - Hui Zhang
- Department of Anesthesiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Qi Jing
- Department of Anesthesiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Li Tian
- Department of Anesthesiology and Perioperative Medicine, School of Medicine, Shanghai Fourth People's Hospital, Tongji University, Shanghai, China.,School of Medicine, Shanghai Fourth People's Hospital, Translational Research Institute of Brain and Brain-Like Intelligence, Tongji University, Shanghai, China.,Clinical Research Center for Anesthesiology and Perioperative Medicine, Tongji University, Shanghai, China
| | - Cheng Li
- Department of Anesthesiology and Perioperative Medicine, School of Medicine, Shanghai Fourth People's Hospital, Tongji University, Shanghai, China.,School of Medicine, Shanghai Fourth People's Hospital, Translational Research Institute of Brain and Brain-Like Intelligence, Tongji University, Shanghai, China.,Clinical Research Center for Anesthesiology and Perioperative Medicine, Tongji University, Shanghai, China
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19
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Sneyd J. Developments in procedural sedation for adults. BJA Educ 2022; 22:258-264. [DOI: 10.1016/j.bjae.2022.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2022] [Indexed: 12/01/2022] Open
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20
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Abstract
Ensuring and maintaining adequate tissue oxygenation at the microcirculatory level might be considered the holy grail of optimal hemodynamic patient management. However, in clinical practice we usually focus on macro-hemodynamic variables such as blood pressure, heart rate, and sometimes cardiac output. Other macro-hemodynamic variables like pulse pressure or stroke volume variation are additionally used as markers of fluid responsiveness. In recent years, an increasing number of technological devices assessing tissue oxygenation or microcirculatory blood flow have been developed and validated, and some of them have already been incorporated into clinical practice. In this review, we will summarize recent research findings on this topic as published in the last 2 years in the Journal of Clinical Monitoring and Computing (JCMC). While some techniques are already currently used as routine monitoring (e.g. cerebral oxygenation using near-infrared spectroscopy (NIRS)), others still have to find their way into clinical practice. Therefore, further research is needed, particularly regarding outcome measures and cost-effectiveness, since introducing new technology is always expensive and should be balanced by downstream savings. The JCMC is glad to provide a platform for such research.
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21
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Lobb D, Ameli N, Ortiz S, Lai H. Comparison of the effects of target-controlled infusion-remifentanil/midazolam and manual fentanyl/midazolam administration on patient parameters in dental procedures. J Dent Anesth Pain Med 2022; 22:117-128. [PMID: 35449782 PMCID: PMC8995675 DOI: 10.17245/jdapm.2022.22.2.117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 01/20/2022] [Accepted: 03/16/2022] [Indexed: 11/25/2022] Open
Abstract
Background Moderate sedation is an integral part of dental care delivery. Target-controlled infusion (TCI) has the potential to improve patient safety and outcome. We compared the effects of using TCI to administer remifentanil/manual bolus midazolam with manual bolus fentanyl/midazolam administration on patient safety parameters, drug administration times, and patient recovery times. Methods In this retrospective chart review, records of patients who underwent moderate intravenous sedation over 12 months in a private dental clinic were assessed. Patient indicators (pre-, intra-, and post-procedure noninvasive systolic and diastolic blood pressure, respiration, and heart rate) were compared using independent t-test analysis. Patient recovery time, procedure length, and midazolam dosage required were also compared between the two groups. Results Eighty-five patient charts were included in the final analysis: 47 received TCI-remifentanil/midazolam sedation, and 38 received manual fentanyl/midazolam sedation. Among the physiological parameters, diastolic blood pressure showed slightly higher changes in the fentanyl group (P = 0.049), respiratory rate changes showed higher changes in the fentanyl group (P = 0.032), and the average EtCO2 was slightly higher in the remifentanil group (P = 0.041). There was no significant difference in the minimum SpO2 levels and average procedure length between the fentanyl and remifentanil TCI pump groups (P > 0.05). However, a significant difference was observed in the time required for discharge from the chair (P = 0.048), indicating that patients who received remifentanil required less time for discharge from the chair than those who received fentanyl. The dosage of midazolam used in the fentanyl group was 0.487 mg more than that in the remifentanil group; however, the difference was not significant (P > 0.05). Conclusion The combination of TCI administered remifentanil combined with manual administered midazolam has the potential to shorten the recovery time and reduce respiration rate changes when compared to manual administration of fentanyl/midazolam. This is possibly due to either the lower midazolam dosage required with TCI remifentanil administration or achieving a stable, steady-state low dose remifentanil concentration for the duration of the procedure.
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Affiliation(s)
- Doug Lobb
- School of Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Nazila Ameli
- School of Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Silvia Ortiz
- School of Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Hollis Lai
- School of Dentistry, University of Alberta, Edmonton, Alberta, Canada
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22
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Sneyd JR, Absalom AR, Barends CRM, Jones JB. Hypotension during propofol sedation for colonoscopy: an exploratory analysis. Br J Anaesth 2021; 128:610-622. [PMID: 34916051 PMCID: PMC9008870 DOI: 10.1016/j.bja.2021.10.044] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 10/11/2021] [Accepted: 10/17/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Intraoperative and postoperative hypotension occur commonly and are associated with organ injury and poor outcomes. Changes in arterial blood pressure (BP) during procedural sedation are not well described. METHODS Individual patient data from five trials of propofol sedation for colonoscopy and a clinical database were pooled and explored with logistic and linear regression. A literature search and focused meta-analysis compared the incidence of hypotension with propofol and alternative forms of procedural sedation. Hypotensive episodes were characterised by the original authors' definitions (typically systolic BP <90 mm Hg). RESULTS In pooled individual patient data (n=939), 36% of procedures were associated with episodes of hypotension. Longer periods of propofol sedation and larger propofol doses were associated with longer-lasting and more-profound hypotension. Amongst 380 patients for whom individual BP measurements were available, 107 (28%) experienced systolic BP <90 mm Hg for >5 min, and in 89 (23%) the episodes exceeded 10 min. Meta-analysis of 18 RCTs identified an increased risk ratio for the development of hypotension in procedures where propofol was used compared with the use of etomidate (two studies; n=260; risk ratio [RR] 2.0 [95% confidence interval: 1.37-2.92]; P=0.0003), remimazolam (one study; n=384; RR 2.15 [1.61-2.87]; P=0.0001), midazolam (14 studies; n=2218; RR 1.46 [1.18-1.79]; P=0.0004), or all benzodiazepines (15 studies; n=2602; 1.67 [1.41-1.98]; P<0.00001). Hypotension was less likely with propofol than with dexmedetomidine (one study; n=60; RR 0.24 [0.09-0.62]; P=0.003). CONCLUSIONS Hypotension is common during propofol sedation for colonoscopy and of a magnitude and duration associated with harm in surgical patients.
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Affiliation(s)
- J Robert Sneyd
- Faculty of Medicine and Dentistry, University of Plymouth, Plymouth, UK.
| | - Anthony R Absalom
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Clemens R M Barends
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Jordan B Jones
- College of Osteopathic Medicine, Rocky Vista University, Ivins, UT, USA
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23
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Hung KC, Yew M, Lin YT, Chen JY, Wang LK, Chang YJ, Chang YP, Lan KM, Ho CN, Sun CK. Impact of intravenous and topical lidocaine on clinical outcomes in patients receiving propofol for gastrointestinal endoscopic procedures: a meta-analysis of randomised controlled trials. Br J Anaesth 2021; 128:644-654. [PMID: 34749993 DOI: 10.1016/j.bja.2021.08.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 08/02/2021] [Accepted: 08/24/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The efficacy of i.v. or topical lidocaine as an anaesthesia adjunct in improving clinical outcomes in patients receiving gastrointestinal endoscopic procedures under propofol sedation remains unclear. METHODS Electronic databases (MEDLINE, EMBASE, and Cochrane Library) were searched for RCTs comparing the clinical outcomes with or without lidocaine application (i.v. or topical) in patients receiving propofol for gastrointestinal endoscopic procedures from inception to 29 March 2021. The primary outcome was propofol dosage, while secondary outcomes included procedure time, recovery time, adverse events (e.g. oxygen desaturation), post-procedural pain, and levels of endoscopist and patient satisfaction. RESULTS Twelve trials (1707 patients) published between 2011 and 2020 demonstrated that addition of i.v. (n=7) or topical (n=5) lidocaine to propofol sedation decreased the level of post-procedural pain (standardised mean difference [SMD]=-0.47, 95% confidence interval [CI]: -0.8 to -0.14), risks of gag events (risk ratio [RR]=0.51, 95% CI: 0.35-0.75), and involuntary movement (RR=0.4, 95% CI: 0.16-0.96). Subgroup analysis demonstrated that only i.v. lidocaine reduced propofol dosage required for gastrointestinal endoscopic procedures (SMD=-0.83, 95% CI: -1.19 to -0.47), increased endoscopist satisfaction (SMD=0.75, 95% CI: 0.21-1.29), and shortened the recovery time (SMD=-0.83, 95% CI: -1.45 to -0.21). Intravenous or topical lidocaine did not affect the incidence of oxygen desaturation (RR=0.72, 95% CI: 0.41-1.24) or arterial hypotension (RR=0.6, 95% CI: 0.22-1.65) and procedure time (SMD=0.21, 95% CI: -0.09 to 0.51). CONCLUSION This meta-analysis demonstrated that i.v. or topical lidocaine appears safe to use and may be of benefit for improving propofol sedation in patients undergoing gastrointestinal endoscopic procedures. Further large-scale trials are warranted to support our findings.
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Affiliation(s)
- Kuo-Chuan Hung
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan; Department of Hospital and Health Care Administration, College of Recreation and Health Management, Chia Nan University of Pharmacy and Science, Tainan City, Taiwan
| | - Ming Yew
- Department of Anesthesiology, Chi Mei Hospital, Tainan City, Taiwan
| | - Yao-Tsung Lin
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan; Department of Hospital and Health Care Administration, College of Recreation and Health Management, Chia Nan University of Pharmacy and Science, Tainan City, Taiwan
| | - Jen-Yin Chen
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Li-Kai Wang
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan; Department of Hospital and Health Care Administration, College of Recreation and Health Management, Chia Nan University of Pharmacy and Science, Tainan City, Taiwan
| | - Ying-Jen Chang
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan; Department of Recreation and Health-Care Management, College of Recreation and Health Management, Chia Nan University of Pharmacy and Science, Tainan City, Taiwan
| | - Yang-Pei Chang
- Department of Neurology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Kuo-Mao Lan
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Chun-Ning Ho
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Cheuk-Kwan Sun
- Department of Emergency Medicine, E-Da Hospital, Kaohsiung City, Taiwan; College of Medicine, I-Shou University, Kaohsiung City, Taiwan.
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24
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Sneyd JR. What we do, what we call ourselves, and how we spell it. Br J Anaesth 2021; 127:505-508. [PMID: 34548151 DOI: 10.1016/j.bja.2021.04.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 04/26/2021] [Accepted: 04/26/2021] [Indexed: 11/16/2022] Open
Affiliation(s)
- J Robert Sneyd
- Faculty of Medicine and Dentistry, University of Plymouth, Plymouth, UK.
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25
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Nielsen JR. Sedation Safety and Satisfaction. Anesth Analg 2021; 132:e76. [PMID: 33857993 DOI: 10.1213/ane.0000000000005437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- James R Nielsen
- Department of Anaesthesia, Concord Repatriation Hospital, Concord, Australia, Faculty of Health & Medical Sciences, Macquarie University, Sydney, Australia,
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Current status of perioperative hypnotics, role of benzodiazepines, and the case for remimazolam: a narrative review. Br J Anaesth 2021; 127:41-55. [PMID: 33965206 DOI: 10.1016/j.bja.2021.03.028] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 02/22/2021] [Accepted: 03/10/2021] [Indexed: 12/19/2022] Open
Abstract
Anaesthesiologists and non-anaesthesiologist sedationists have a limited set of available i.v. hypnotics, further reduced by the withdrawal of thiopental in the USA and its near disappearance in Europe. Meanwhile, demand for sedation increases and new clinical groups are using what traditionally are anaesthesiologists' drugs. Improved understanding of the determinants of perioperative morbidity and mortality has spotlighted hypotension as a potent cause of patient harm, and practice must be adjusted to respect this. High-dose propofol sedation may be harmful, and a critical reappraisal of drug choices and doses is needed. The development of remimazolam, initially for procedural sedation, allows reconsideration of benzodiazepines as the hypnotic component of a general anaesthetic even if their characterisation as i.v. anaesthetics is questionable. Early data suggest that a combination of remimazolam and remifentanil can induce and maintain anaesthesia. Further work is needed to define use cases for this technique and to determine the impact on patient outcomes.
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Azad SS, Cobey FC, Price LL, Schumann R, Shapeton AD. Supraglottic Airway Use for Transfemoral-Transcatheter Aortic Valve Replacement. J Cardiothorac Vasc Anesth 2020; 34:3243-3249. [PMID: 32507460 DOI: 10.1053/j.jvca.2020.04.059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 04/26/2020] [Accepted: 04/29/2020] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Examine outcome differences in patients managed either with a supraglottic airway or an endotracheal tube for general anesthesia during transcatheter aortic valve replacement. The authors hypothesized that patients managed with a supraglottic airway would have shorter post-anesthesia care unit and hospital stays and receive fewer opioids, norepinephrine equivalents, and neuromuscular blocking agents, without an increase in 30-day major adverse cardiovascular events. DESIGN Retrospective chart review with 1:2 supraglottic airway-to-endotracheal tube patient propensity score matching. SETTING Single, urban, tertiary care, academic medical center. PARTICIPANTS Patients undergoing transfemoral- transcatheter aortic valve replacement between 2017 and 2019. INTERVENTIONS Supraglottic or endotracheal tube airway management during general anesthesia. MEASUREMENTS AND MAIN RESULTS Thirty-one supraglottic airway patients were propensity score matched with 62 endotracheal tube patients. There was no significant difference for postanesthesia care unit (p = 0.58) or hospital (p = 0.16) lengths of stay. Supraglottic airway patients received significantly fewer neuromuscular blockers (p < 0.0001) and trended toward fewer opioids (p = 0.05), but received a similar number of norepinephrine equivalents (p = 0.76). The major adverse cardiovascular event odds ratio between groups was 1.39 (p = 0.51). The time under general anesthesia (p = 0.02) and total time in the operating room (p = 0.04) were significantly shorter for supraglottic airway patients. CONCLUSIONS Supraglottic airway management in transcatheter aortic valve replacement was feasible without an increase in major adverse cardiovascular outcomes compared with endotracheal tube management during general anesthesia. Supraglottic airway patients trended toward receiving fewer opioids and received significantly fewer neuromuscular blockers while also having significantly shorter time under general anesthesia and total time in the operating room.
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Affiliation(s)
- Shara S Azad
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA
| | - Frederick C Cobey
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA
| | - Lori Lyn Price
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA; Institute of Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA
| | - Roman Schumann
- Tufts University School of Medicine, Boston, MA; Department of Anesthesia, Critical Care and Pain Medicine, Boston Veterans Affairs Health Care System, West Roxbury, MA
| | - Alexander D Shapeton
- Tufts University School of Medicine, Boston, MA; Department of Anesthesia, Critical Care and Pain Medicine, Boston Veterans Affairs Health Care System, West Roxbury, MA.
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