The use of propofol as a sedative agent in gastrointestinal endoscopy: a meta-analysis

Safety of propofol sedation administered by interventional radiologists for radiofrequency ablation in patients with hepatocellular carcinoma

PURPOSE

To evaluate the safety of propofol sedation administered by interventional radiologists during radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

Propofol sedation was administered by interventional radiologists in 72 patients (85 procedures, 93 tumors) during RFA for HCC between August 2018 and December 2020. Interventional radiologists equipped with adequate knowledge and skills in sedation and respiratory management were responsible for sedation. Sedation was carefully assessed based on vital signs, including end-tidal carbon dioxide, consciousness status, and bispectral index. The primary endpoint was the incidence of sedation-related complications, which were evaluated separately as respiratory and cardiovascular complications. Secondary endpoints were technical success rate, ablation-related complications, and local tumor control rate. Technical success was defined as completion of ablation in the planned area. Complications were evaluated using the Clavien-Dindo classification. Sedation-related complications, technical success rate, and ablation-related complications were evaluated on a procedure basis, and local tumor control was evaluated on a tumor basis.

RESULTS

Respiratory and cardiovascular complications were observed in eight (8/85, 9.4%) and two (2/85, 2.4%) patients, respectively. Four patients required the jaw thrust maneuver due to glossoptosis, whereas a decrease in oxygen saturation to < 90% was recorded in the other four patients. However, these were temporary, and none required manual ventilation or endotracheal intubation. Bradycardia (< 50 bpm) was detected in two patients; one recovered immediately without treatment, whereas the other rapidly improved after atropine sulfate administration. No severe hypotension (< 80 mmHg) was observed. The technical success rate was 100% (85/85). Grade 3 ablation-related complications were identified in three patients (3/85, 3.5%). The local tumor control rate was 95.7% (89/93).

CONCLUSION

Propofol sedation can be safely administered by interventional radiologists during RFA for HCC. Although it requires special safety considerations, it may be a sedation option during hepatic RFA.

Determining the Target Concentration of Propofol for Sedation in Patients Undergoing Endoscopic Retrograde Cholangiopancreatography: A Target-Controlled Infusion Approach

Introduction Endoscopic retrograde cholangiopancreatography (ERCP) is vital for diagnosing and treating biliary and pancreatic diseases, necessitating deep sedation typically achieved through total intravenous anesthesia. Propofol, with its favorable pharmacokinetic profile, is the preferred sedative, but conventional administration methods of mg/kg boluses or infusion rates pose challenges. Target-controlled infusion (TCI) systems offer a solution that ensures precise dose delivery of propofol. Despite its widespread use, the literature lacks specific guidance on the target plasma concentration (Cp) of propofol for sedation in patients undergoing ERCP. Methods A prospective interventional study was conducted at the Institute of Liver and Biliary Sciences, Delhi, India to determine the target Cp of propofol for sedation during ERCP. The study enrolled 86 American Society of Anesthesiologists (ASA) grade I and II patients aged 18-70 years. The primary objective was to establish the optimal propofol concentration for sedation as guided by a bispectral index (BIS) value of 60-70. Secondary outcomes included induction time, recovery time, total propofol consumption, and the occurrence of adverse events (if any). The Marsh pharmacokinetic model guided the TCI pump, adjusting Cp until the target sedation was achieved. Results The mean Cp of propofol to maintain the BIS value 60-70 was 2.21 ± 0.42 µg/ml. Age-wise analysis revealed variations, emphasizing the need for individualized dosing. Induction time was 4.21 ± 0.68 minutes; recovery times were seven minutes (median, IQR: 5-10 minutes) for BIS >80 and seven minutes (median, IQR: 5-10 minutes) for achieving a Modified Observer's Assessment of Alertness/Sedation score of ≥5. The mean propofol consumption was 6.24 mg/kg/hr. Side effects were minimal, with 1.16% experiencing transient hypoxia and hypotension. Conclusion The study establishes a mean target propofol concentration of 2.21 ± 0.42 µg/ml for sedation in ASA I and II patients undergoing ERCP.

Quality Standards in Upper Gastrointestinal Endoscopy: Can Deep Sedation Influence It?

Introduction

According to the guideline published by ESGE/UEG, a high-quality esophagogastroduodenoscopy (EGD) implies the application of some criteria that enable better healthcare outcomes. Although intra-procedural performance measures are dependent on patient factors, there is no reference to sedation practices in the guideline mentioned above.

Objective

This study aimed to evaluate whether deep sedation influences EGD performance measures established by ESGE/UEG.

Methods

This was a cross-sectional study, with a prospective enrollment, that considered for inclusion consecutive patients referred for EGD. Two questionnaires were used to assess performance measures and patient satisfaction after EGD.

Results

Sedation had a statistically significant impact on most quality indicators, including complete examination (77.2% without sedation vs. 97.8% with sedation), inspection time (6.17 ± 3.45 vs. 8.39 ± 2.67 min), photodocumentation (78% vs. 97.8%), biopsies (39.3% vs. 60.7%), and patient satisfaction (5.42 ± 2.93 vs. 9.1 ± 1.19). The main reason for an incomplete procedure was patient intolerance (82.6%).

Discussion

Deep sedation of patients submitted to EGD proved to be a determinant in the applicability of the ESGE/UEG quality indicators. Patient intolerance was eliminated in the group with sedation, enhancing procedure completeness, adequate pathology identification, management, and consequently, the effectiveness of the exam.

Conclusion

Sedation administration should be considered in patients undergoing EGD since it ensures a high-quality procedure.

Effect of intravenous lidocaine on the ED50 of propofol induction dose in elderly patients undergoing painless gastroscopy: a prospective, randomized, double-blinded, controlled study

BACKGROUND

Intravenous lidocaine could be a potential alternative adjuvant to propofol-based sedation for gastroscopy in elderly patients. This study aimed to evaluate the effect of intravenous lidocaine on the median effective dose (ED50) of propofol induction dose in elderly patients undergoing painless gastroscopy.

METHODS

The study included 70 patients aged ≥ 60 years undergoing painless gastroscopy with 64 randomly assigned to either group L (2% lidocaine 1.5 mg/kg, n = 31) or group N (equal volume normal saline, n = 33). All patients received propofol induction following 0.1 μg/kg intravenous sufentanil. The Dixon "up-and-down" sequential method was used, with a 1.5 mg/kg initial induction dose of propofol followed by a 0.1 mg/kg sequential variable dose. The primary endpoint was the ED50 of the propofol induction dose. The total propofol dose, recovery time, adverse events, and local anesthetic intoxication reactions were also recorded.

RESULTS

The ED50 of propofol induction dose was 0.670 (95% confidence interval [CI] 0.216-0.827) mg/kg in group L and 1.118 (95% CI 0.803-1.232) mg/kg in group N. There was a statistically significant difference between the two groups (p < 0.001). The incidence of hypotension and propofol injection pain were lower in group L than in group N (p < 0.05). Furthermore, the orientation recovery time in group L was shorter compared to group N (p < 0.05). None of the participants in group L observed local anesthetic intoxication reactions after receiving lidocaine.

CONCLUSIONS

The administration of intravenous lidocaine to elderly patients undergoing painless gastroscopy resulted in a significant 40% reduction in the ED50 of propofol induction dose, which may be related to the decreased incidence of hypotension and injection pain, as well as the improved post-gastroscopy orientation recovery.

TRIAL REGISTRATION

ChiCTR, ChiCTR2200065530. Registered on 08 November 2022.

Effect of moderate versus deep sedation on recovery following outpatient gastroscopy in older patients: a randomized controlled trial

BACKGROUND

Although gastrointestinal endoscopy with sedation is increasingly performed in older patients, the optimal level of sedation remains open to debate. In this study, our objective was to compare the effects of moderate sedation (MS) and deep sedation (DS) on recovery following outpatient gastroscopy in elderly patients.

METHODS

In this randomized, partially blinded, controlled trial, we randomly divided 270 patients older than 60 years who were scheduled for elective outpatient gastroscopy into the MS or DS group based on the Modified Observer's Assessment of Alertness/Sedation (MOAA/S) scale. The primary outcome was the duration of stay in the post-anesthesia care unit (PACU). Secondary outcomes included the duration of the total hospital stay, frequency of retching, bucking, and body movements during the examination, endoscopist and patient satisfaction, and sedation-associated adverse events during the procedure.

RESULTS

A total of 264 patients completed the study, of whom 131 received MS and 133 received DS. MS was associated with a shorter PACU stay [16.15 ± 9.01 min vs. 20.02 ± 11.13 min, P < 0.01] and total hospital stay [27.32 ± 9.86 min vs. 30.82 ± 12.37 min, P < 0.05], lesser hypoxemia [2.3% (3/131) vs. 12.8% (17/133), P < 0.01], use of fewer vasoactive drugs (P < 0.001), and more retching (P < 0.001). There was no difference in the incidence of bucking and body movements or endoscopist and patient satisfaction between the two groups.

CONCLUSION

Compared to deep sedation, moderate sedation may be a preferable choice for American Society of Anesthesiologists (ASA) Grade I-III elderly patients undergoing outpatient gastroscopies, as demonstrated by shorter PACU stays and total hospital stays, lower sedation-associated adverse events, and similar levels of endoscopist and patient satisfaction.

Machine learning-based risk prediction of hypoxemia for outpatients undergoing sedation colonoscopy: a practical clinical tool

OBJECTIVES

Hypoxemia as a common complication in colonoscopy under sedation and may result in serious consequences. Unfortunately, a hypoxemia prediction model for outpatient colonoscopy has not been developed. Consequently, the objective of our study was to develop a practical and accurate model to predict the risk of hypoxemia in outpatient colonoscopy under sedation.

METHODS

In this study, we included patients who received colonoscopy with anesthesia in Nanjing First Hospital from July to September 2021. Risk factors were selected through the least absolute shrinkage and selection operator (LASSO). Prediction models based on logistic regression (LR), random forest classifier (RFC), extreme gradient boosting (XGBoost), support vector machine (SVM), and stacking classifier (SCLF) model were implemented and assessed by standard metrics such as the area under the receiver operating characteristic curve (AUROC), sensitivity and specificity. Then choose the best model to develop an online tool for clinical use.

RESULTS

We ultimately included 839 patients. After LASSO, body mass index (BMI) (coefficient = 0.36), obstructive sleep apnea-hypopnea syndrome (OSAHS) (coefficient = 1.32), basal oxygen saturation (coefficient = -0.14), and remifentanil dosage (coefficient = 0.04) were independent risk factors for hypoxemia. The XGBoost model with an AUROC of 0.913 showed the best performance among the five models.

CONCLUSION

Our study selected the XGBoost as the first model especially for colonoscopy, with over 95% accuracy and excellent specificity. The XGBoost includes four variables that can be quickly obtained. Moreover, an online prediction practical tool has been provided, which helps screen high-risk outpatients with hypoxemia swiftly and conveniently.

Etomidate Versus Propofol for Monitored Anesthesia Care During Endoscopic Retrograde Cholangiopancreatography: A Prospective Randomized Controlled Trial

Background and objectives Propofol-based sedation is one of the most commonly used methods for endoscopic retrograde cholangiopancreatography (ERCP). The commonest complications during ERCP are in the form of adverse cardiopulmonary events as a result of sedation. Etomidate has a more stable cardiovascular and respiratory profile than propofol and has been used for sedation in simple gastrointestinal endoscopy but has not been studied for procedural sedation in ERCP. The objective of the present study was to compare the safety and feasibility of etomidate and propofol for sedation during ERCP procedures. Methods This single-center, randomized trial included 100 American Society of Anesthesiologists (ASA) physical status class I to II patients who were scheduled for ERCP. All patients received midazolam 0.02 mg/kg, lignocaine (2%) 1 mg/kg, and fentanyl 1 µg/kg intravenously, followed by etomidate or propofol according to the group allocation. The primary outcome was to compare the mean arterial pressure (MAP) at various timepoints between the two groups and secondary outcomes were to compare oxygen saturation, induction and recovery times, and adverse events. Transient hypotension was defined as any decrease in MAP below 60 mmHg or 20% below the baseline. Transient hypoxia was defined as desaturation (saturation of peripheral oxygen (SpO2) <92%) lasting for more than 10 seconds requiring airway intervention. Results Fifty patients were enrolled in each group (Group E: etomidate and Group P: propofol). Transient hypotension occurred in eight (16%) patients in Group P, and two (4%) patients in Group E (P= 0.045). Baseline MAP was comparable between the two groups but was significantly lower in Group P at three timepoints during the study. Nine (18 %) patients in Group P had a transient hypoxic episode, compared to none in Group E (p= 0.006). The induction and recovery times were similar in the two groups. Conclusions Etomidate offers better hemodynamic and respiratory stability than propofol and can be recommended for use during ERCP in ASA I/II patients.

Efficacy and safety of esketamine for sedation among patients undergoing gastrointestinal endoscopy: a systematic review and meta-analysis

BACKGROUND

Patients who undergo gastrointestinal endoscopy often require propofol-based sedation combined with analgesics. At present, the efficacy and safety of esketamine as an adjunct to propofol for sedation during endoscopic procedures in patients remains controversial. Moreover, there is no universal agreement regarding the appropriate dose of esketamine supplementation. This study aimed to assess the efficacy and safety of esketamine as an adjunct to propofol for sedation during endoscopic procedures in patients.

METHODS

Seven electronic databases and three clinical trial registry platforms were searched and the deadline was February 2023. Randomized controlled trials (RCTs) evaluating the efficacy of esketamine for sedation were included by two reviewers. Data from the eligible studies were combined to calculate the pooled risk ratio or standardized mean difference.

RESULTS

Eighteen studies with 1962 esketamine participants were included in the analysis. As an adjunct to propofol, the administration of esketamine reduced the recovery time compared to normal saline (NS). However, there was no significant difference between the opioids group and ketamine group. For propofol dosage, the administration of esketamine required a lower propofol dosage compared to the NS group and opioids group].For complications, the esketamine group had fewer complications compared to the NS group and opioid group in patients, but there were no significant differences between the esketamine group and ketamine group. Notably, the coadministration of esketamine was associated with a higher risk of visual disturbance compared to the NS group. In addition, we used subgroup analysis to investigate whether 0.2-0.5 mg/kg esketamine was effective and tolerable for patients.

CONCLUSION

Esketamine as an adjunct to propofol, is an appropriate effective alternative for sedation in participants undergoing gastrointestinal endoscopy. However, considering the possibility of its psychotomimetic effects, esketamine should be used with caution.

The median effective doses of propofol combined with two different doses of nalbuphine for adult patients during painless gastroscopy

Objective: Propofol is the most widely administered intravenous anesthetic to induce deep sedation for gastroscopy procedures. Coadministration of nalbuphine can provide analgesia and sedation to patients experiencing visceral pain, thereby decreasing the amount of propofol needed and reducing the risk of propofol-induced adverse events. We carried out this study to determine the median effective dose (ED50) of propofol in combination with different dosages of nalbuphine and the optimal dosage of nalbuphine during painless gastroscopy.

Methods: We recruited sixty-five patients aged 18–60 years who underwent elective painless gastroscopy. A total of sixty-one patients were allocated randomly to the N1 group (nalbuphine 0.1 mg/kg) or N2 group (nalbuphine 0.15 mg/kg). Three minutes after administration of nalbuphine, patients received a preset dose of propofol at 2.0 mg/kg with a dose gradient of 0.2 mg/kg according to Dixon’s “up-and-down” method. The primary outcome was the ED50 of propofol in combination with nalbuphine. Hemodynamic parameters, recovery time, pain score, and adverse events were recorded as secondary outcomes.

Results: The ED50 of propofol in the N2 group was significantly lower than that observed in the N1 group (p < 0.01). Using probit analysis, the ED50 and ED95 of propofol were 1.632 mg/kg and 2.759 mg/kg in the N1 group and 1.111 mg/kg and 2.243 mg/kg in the N2 group, respectively. The incidence of hypotension in the N2 group was lower than that in the N1 group (p < 0.05), and the recovery time was shorter than that of the N1 group (p < 0.05).

Conclusion: In adult patients, 0.15 mg/kg nalbuphine led to a significant reduction in the ED50 and ED95 of propofol during gastroscopy. This dose of nalbuphine also reduced the incidence of hypotension and shortened the recovery time. Therefore, nalbuphine (0.15 mg/kg) combined with propofol is a safe option for enhancing recovery after painless gastroscopy in adult patients.

Clinical Trial Registration: [https://www.chictr.org.cn/edit.aspx?pid=126699&htm=4], identifier [ChiCTR2100053204].

Anesthesia for digestive tract endoscopy

PURPOSE OF REVIEW

Nonoperating room anesthesia for digestive tract endoscopy has its own specificities and requires practical training. Monitoring devices, anesthetic drugs, understanding of procedures and management of complications are critical aspects.

RECENT FINDINGS

New data are available regarding risk factors for intra- and postoperative complications (based on anesthesia registries), airway management, new anesthetic drugs, techniques of administration and management of advances in interventional endoscopy procedures.

SUMMARY

Digestive tract endoscopy is a common procedure that takes place outside the operating room most of the time and has become more and more complex due to advanced invasive procedures. Prior evaluation of the patient's comorbidities and a good understanding of the objectives and constraints of the endoscopic procedures are required. Assessing the risk of gastric content aspiration is critical for determining appropriate anesthetic protocols. The availability of adequate monitoring (capnographs adapted to spontaneous ventilation, bispectral index), devices for administration of anesthetic/sedative agents (target-controlled infusion) and oxygenation (high flow nasal oxygenation) guarantees the quality of sedation and patient' safety during endoscopic procedures. Knowledge of the specificities of each interventional endoscopic procedure (endoscopic retrograde cholangiopancreatography, submucosal dissection) allows preventing complications during anesthesia.

Comparative Study of Moderate Sedation with Propofol Versus Propofol Combined with Midazolam for Ambulatory Care Digestive Endoscopic Procedures

Anesthesia is essential during colonoscopy because it provides patients with necessary sedation to perform the investigation safely and nonetheless to obtain the highest quality of the results. We aimed here to evaluate and establish which of the combinations of anesthetic drugs most frequently used for sedation purposes for gastrointestinal endoscopic procedures performed in the ambulatory best covers the needs of the patient and the gastroenterologist. This is a prospective, randomized, double-blind study carried out on a total of 100 patients, aged between 18 and 80 years, who meet the conditions for inclusion in the study. Patients were randomly allocated into either group A (Propofol) or group B (Midazolam plus Propofol). Evaluation of the dose of Propofol used in the 2 groups, awakening time, anesthetic induction, as well as the occurrence of episodes of bradycardia and hypotension represented the parameters followed in the study. In group A, 50 patients received on average 218.6mg of Propofol in bolus of 10-20mg. In group B, 50 patients received 0.1mg/kg Midazolam and an average of up to 129.2mg of Propofol in bolus of 10-20mg. Awakening time was shorter in group A-3.18 minutes, than in group B-15.7 minutes. Bradycardia and hypotension were met in a larger number in group B than in group A. The quality of the endoscopic evaluation was similar in both groups. The conclusion of our study was that the group to which only Propofol was administered had the best results from all aspects (rapid anesthetic induction, stability of vital functions, lower cost, awakening time much faster) compared to the combination of Propofol with Midazolam.

Safety Profile of Endoscopist-directed Balanced Propofol Sedation for Procedural Sedation: An Experience at a Hospital-based Endoscopy Unit

BACKGROUND

Nurse-administered propofol sedation was restricted to anesthesiologists in 2009, a practice that has contributed to spiraling health care costs in the United States.

AIM

The aim of this study was to evaluate the safety of endoscopist-directed balanced propofol sedation (EDBPS).

MATERIALS AND METHODS

We identified patients undergoing endoscopy with EDBPS from January 1, 2017, to June 20, 2017, and abstracted their medical records. Adverse events (AEs) included: hypoxia (oxygen saturation < 90%); hypotension [(a) systolic blood pressure < 90 mm Hg, (b) systolic blood pressure decline of >50 mm Hg, (c) decline in mean arterial pressure of >30%]; bradycardia (heart rate of < 40 beats/min). Logistic regression identified factors independently associated with AEs.

RESULTS

A total of 1897 patients received EDBPS during the study period [mean age: 55 y (SD=11.4 y); 56.4% women]. Patients received median doses of 50 µg fentanyl, 2 mg of midazolam, and a mean propofol dose of 160±99 mg. There were no major complications (upper 95% confidence interval, 0.19%). Overall, 334 patients (17.6%) experienced a clinically insignificant AE: 65 (3.4%) experienced transient hypoxia, 277 patients (14.6%) experienced hypotension, 2 had transient bradycardia. In bivariate analysis, older age was associated with risk for hypotension, propofol dose was associated with transient hypoxemia, and procedure duration was associated with both hypotension and transient hypoxia. In multivariate analysis, only procedure length was associated with AEs (odds ratio scale 10; odds ratio=1.07; 95% confidence interval, 1.05-1.09, P<0.001).

CONCLUSIONS

EDBPS is safe for endoscopic sedation. Given the higher cost of anesthesia-administered propofol, endoscopists should reinstate EDBPS by revising institutional sedation policies.

Deep sedation with propofol in patients undergoing left atrial ablation procedures - is it safe?

Background

Catheter ablation for atrial fibrillation (AF) or left atrial tachycardia is well established. To avoid body movement and pain, sedative and analgesic agents are used.

Objective

The aim was to investigate safety of sedation/anti-pain protocol administered by electrophysiology (EP) staff.

Methods

A total of 3211 consecutive patients (61% male) undergoing left atrial ablation for paroxysmal AF (37.1%), persistent AF (35.3%) or left atrial tachycardia (27.6%) were included. Midazolam, fentanyl, and propofol were administered by EP staff. In case of respiratory depression, endotracheal intubation (eIT) or noninvasive ventilation (NIV) was implemented. Risk factors for eIT or NIV were analyzed.

Results

Mean doses of propofol, midazolam, and fentanyl were 33.7 ± 16.7 mg, 3 ± 11.1 mg, and 0.16 ± 2.2 mg, respectively. Norepinephrine was administered in 396 of 3211 patients (12.3%) because of blood pressure drop (mean arterial pressure <60 mm Hg). NIV was necessary in 47 patients (1.5%) and eIT in 1 patient (0.03%). Procedure duration, high body mass index (BMI), high CHADS₂-VASC₂ score, high age, low glomerular filtration rate, diabetes mellitus, and low baseline oxygen saturation were associated with NIV or eIT. The only independent predictor for NIV/eIT was high BMI (>30.1 ± 9.0 kg/m²). Therefore, patients with a BMI of ≥30 had a 40% higher risk for the need of NIV/eIT during the procedure in our study.

Conclusion

Sedation/anti-pain control including midazolam, propofol, and fentanyl administered by EP staff is safe, with only 1.53% requirement of NIV/eIT. High BMI (>30 kg/m²) emerged as an independent predictor for eIT/NIV.

Impact of propofol sedation on the diagnostic accuracy of hepatic venous pressure gradient measurements in patients with cirrhosis

BACKGROUND

Measurement of the hepatic venous pressure gradient (HVPG) is the gold standard to evaluate the presence and severity of portal hypertension. The procedure is generally safe and well tolerated, but nevertheless, some patients demand for sedation. However, it is unknown whether propofol sedation would impair the accuracy of portal pressure measurements.

METHODS

This is a prospective observational cohort study including cirrhotic patients with suspected portal hypertension undergoing invasive measurement of HVPG. Measurements of HVPG were performed in awake condition as well as under sedation with propofol infusion.

RESULTS

In total, 37 patients were included. Mean HVPG in awake condition was 15.9 mmHg (IQR 13-19) and during sedation 14.1 mmHg (IQR 12-17). While measures of free hepatic vein pressure (FHVP) were not altered after propofol sedation (p = 0.34), wedged hepatic vein pressure values (WHVP) decreased in an average by  2.05 mmHg (95% CI - 2.46 to - 1.16; p < 0.001) which was proportional to the magnitude of HVPG. In 31 out of 37 patients (83.8%), portal hypertension with HVPG ≥ 12 mmHg was found. Under sedation with propofol, two patients (5.4%) with borderline values would have been incorrectly classified as < 12 mmHg. After adjustment for the average difference of - 10%, all patients were correctly classified. Intraclass correlation coefficient between HVPG measurement in awake condition and under propofol sedation was 0.927 (95% CI 0.594-0.975).

CONCLUSIONS

Propofol sedation during HVPG measurements is generally safe, however it may lead to relevant alterations of HVPG readings.

Effects of intravenous lidocaine on alfentanil consumption during procedural sedation for colonoscopy in patients with inflammatory bowel disease: a randomized controlled trial

Background: Procedural sedation and analgesia (PSA) is used during colonoscopy to facilitate the procedure and relieve patient’s discomfort. The foremost risk of PSA is respiratory depression. Lidocaine could be a promising additional analgesic in IBD patients to minimise side effects of PSA. Objective: Our primary objective was to investigate whether i.v. lidocaine reduces the amount of alfentanil used during PSA in IBD patients. Additionally, we investigated whether lidocaine reduces cardiorespiratory incidents and the amount of propofol required during the procedure. Design: A randomized, double-blind, placebo controlled study. Setting: Single-center study from November 2016 to December 2018. Methods: Seventy-six patients with IBD, ASA 1 or 2, between 18 and 65 years, scheduled for colonoscopy with PSA were included. Exclusion criteria were: pregnancy, emergency colonoscopy, allergies for study medication, rhythm disorders, cardiomyopathy, BMI < 18 kg m -2 , BMI > 35 kg m -2 , obstructive sleep apnea syndrome and uncontrolled hypertension. Patients received lidocaine 1.5 mg kg -1 followed by a continuous infusion of 2 mg kg -1 h -1 (intervention group, n=38) or 0.9% saline in equivalent volumes (control group, n=38) during colonoscopy. Main outcome measures: Amount of alfentanil and propofol used during the interventional procedure. Cardiorespiratory events as defined in methods during the colonoscopy. Results: There was a not statistically significant reduction in the use of alfentanil [327 µg (95%CI=-31-505, p=0.082)] and propofol [39 mg (95%CI=-5-83, p=0.083)] in the lidocaine group compared with the control group. Ten patients (26%) in the control group and 8 patients in the lidocaine group (21%) experienced a period of hypoxia (p=0.788). In both groups, no periods of hypotension were noted. Conclusion: Our investigation has shown a trend for reduced alfentanil and propofol consumption in patients receiving lidocaine during colonoscopy under sedation. The differences were not statistically significant. Lidocaine did not reduce the incidence of cardiorespiratory events.

Pain Intensity at Injection Site during Esophagogastroduodenoscopy Using Long- and Medium-Chain versus Long-Chain Triglyceride Propofol: A Randomized Controlled Double-Blind Study

Background/Aims

The intensities of injection pain resulting from the use of long- and medium-chain triglyceride (LCT/MCT) propofol and conventional LCT propofol during esophagogastroduodenoscopy (EGD) have yet to be compared. We aimed to determine the pain intensity caused by different formulations of propofol and to evaluate the formulation that would be preferred by patients as a sedative agent during their next procedure.

Methods

This study was a single-center, randomized, controlled, and double-blind trial. Pain intensity was estimated 30 seconds after propofol injection by an examiner who was blinded to the group assignment using a numeric (0-10) pain rating scale (NPRS). After 1 week, the patients were asked whether they could recall the pain and were willing to receive the same agent for their next EGD.

Results

One hundred twenty-nine patients were randomly assigned to LCT/MCT or LCT group. Although there was no significant difference in pain incidence between the LCT/MCT and LCT groups (52.9% vs 65.6%, p=0.156), the pain intensity was significantly lower in the LCT/MCT group (NPRS median [interquartile range]; 1 (0-2) vs 2 (0-5), p=0.005). After 1 week, fewer patients in the LCT/MCT group recalled the pain (19.1% vs 63.9%, p<0.001) and more patients in the LCT/MCT group were more willing to use the same agent for their next procedure (86.8% vs 72.1%, p=0.048) than in the LCT group.

Conclusions

LCT/MCT propofol significantly reduced injection pain intensity compared to LCT propofol during EGD and preferred by patients as a sedative agent during their next EGD.

Analgesic comparison of dezocine plus propofol versus fentanyl plus propofol for gastrointestinal endoscopy: A meta-analysis

INTRODUCTION

As the adjunctive anesthesia to propofol, both dezocine and fentanyl showed some potential for gastrointestinal endoscopy. This meta-analysis aimed to compare their efficacy and safety.

METHODS

PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases were systematically searched. Randomized controlled trials (RCTs) assessing the effect of dezocine versus fentanyl for the anesthesia of patients undergoing gastrointestinal endoscopy were included.

RESULTS

Five RCTs involving 677 patients were included in the meta-analysis. Overall, compared with fentanyl plus propofol for gastrointestinal endoscopy, dezocine plus propofol resulted in the reduction in propofol dose(mean difference [MD] = -11.72; 95% confidence interval [CI] = -22.83 to -0.61; P = .04), awakening time (std. MD = -1.79; 95% CI = -3.31 to -0.27; P = .02) and hypopnea (risk ratio [RR] = 0.16; 95% CI = 0.06-0.41; P = .0002), but had no remarkable effect on induction time (MD = 1.20; 95% CI = -0.98 to 3.39; P = .28), postoperative pain score (MD = -0.38; 95% CI = -1.00 to 0.24; P = .24), nausea or vomiting (RR = 0.45; 95% CI = 0.10-1.98; P = .29).

CONCLUSION

Dezocine plus propofol may be better for the anesthesia of gastrointestinal endoscopy than fentanyl plus propofol.

Induction and maintenance of procedural sedation in adults: focus on remimazolam injection

Introduction: Procedural sedation (PS) is a humane way to help patients get through painful medical procedures by the administration of sedative drugs combined with analgesics. However, each of the currently used medications has certain shortcomings, urging the search for a new drug. Remimazolam, a novel benzodiazepine, is an ultra-short-acting hypnotic agent invented out of the 'soft drug' development.Areas covered: This presented review provides an overview of the drugs used in clinical practice for the induction and maintenance of procedural sedation in adults, focusing on the newly investigated benzodiazepine remimazolam. Literature search was conducted using the MEDLINE and ClinicalTrial.gov databases from January 2007 to December 2020.Expert opinion: Based on the reported clinical trials so far, remimazolam has demonstrated its effectiveness and safety with promising properties including rapid onset, short duration of action, predictable and consistent recovery profile, metabolism almost unaffected by liver or renal function, with non or minimal cardiorespiratory depression, and availability with a reversal drug. With marketing approval received recently, remimazolam is expected to have a place in the practice for procedural sedation in the near future if its efficacy and safety are further confirmed by more clinical trials and post-market analyses.

Safety of propofol sedation administered by an endoscopy team for outpatient colonoscopy

Sedation during colonoscopy increases comfort and reduces unexpected patient movement. Colorectal cancer (CRC) screening colonoscopies performed under propofol sedation controlled by our endoscopy team (ET) were retrospectively studied for eight months.

Estimation of effective dose of propofol mono-sedation for successful insertion of upper gastrointestinal endoscope in healthy, non-obese Chinese adults

WHAT IS KNOWN AND OBJECTIVE

Propofol is effective in sedation for upper gastrointestinal (UGI) endoscopy. However, the optimum dose is ill-defined. This study aimed to estimate the effective dose of propofol mono-sedation for successful endoscope insertion in healthy, non-obese Chinese adults undergoing single UGI endoscopy.

METHODS

Twenty-six adult patients undergoing elective single UGI endoscopy were enrolled in this study. A modified Dixon's up-and-down method was utilized to assess the effective dose of propofol for successful endoscope insertion. The initial dose of propofol administered, 1.6 mg/kg, was adjusted with 0.1 mg/kg as a step size. The patient's responses to endoscope insertion were classified as either 'movement' or 'no movement'. When patient's responses were changed from 'movement' to 'no movement' or from 'no movement' to 'movement', a crossover was defined. After eight crossovers had been obtained, patient recruitment was stopped. The mean of midpoints of all crossovers obtained by the modified Dixon's up-and-down method in all 26 patients was defined as calculated median effective dose (ED₅₀ ) of propofol for successful endoscope insertion. Furthermore, probit regression analysis was used to determine the dose of propofol where 50% (ED₅₀ ) and 95% (ED₉₅ ) of endoscope insertion attempts were successful.

RESULTS

The calculated ED₅₀ of propofol for successful endoscope insertion was 1.89 ± 0.12 mg/kg. The probit regression analysis showed that ED₅₀ and ED₉₅ of propofol for successful endoscope insertion were 1.90 mg/kg (95% CI, 1.78-2.10 mg/kg) and 2.15 mg/kg (95% CI, 2.01-3.56 mg/kg), respectively. No any patient had hypoxaemia and gag reflex during the UGI endoscopy with propofol mono-sedation.

WHAT IS NEW AND CONCLUSION

In healthy, non-obese Chinese adults, propofol mono-sedation can provide excellent conditions of UGI endoscopy and the estimated ED₅₀ of propofol for successful endoscope insertion is 1.89 ± 0.12 mg/kg.

Endoscopic sedation practices of Greek gastroenterologists: a nationwide survey

Background:

Sedation in gastrointestinal endoscopy is rapidly evolving worldwide. However, this has led to significant disagreements, especially regarding the use of propofol by non-anesthesiologists. The aim of this study was to document the practices of Greek gastroenterologists regarding sedation and compare them to previous surveys.

Methods:

The study was conducted in 2 periods, December 2015 and June 2018. In each period, the same online questionnaire regarding endoscopic sedation practices was sent to all registered Greek gastroenterologists (509 and 547 gastroenterologists, respectively).

Results:

The response rates were 38.3% and 47.1%, respectively. In each period, 25.1% and 16.7% of physicians did not use sedation. Most gastroenterologists (approx. 70% in both instances) answered that they “almost never” collaborate with an anesthesiologist during endoscopy. Midazolam was by far the most popular sedation agent, used by almost 90% of physicians in both periods. Propofol was used by 30.8% and 27% of physicians, respectively. Physicians using propofol were significantly more satisfied with the sedation than other physicians, while propofol was the agent selected by most physicians if they were to undergo endoscopy themselves. Most physicians cited medicolegal reasons and inadequate training as chief reasons for not using propofol.

Conclusions:

Sedation use is widespread among Greek gastroenterologists. Although midazolam is the most commonly used agent, propofol is preferred (theoretically) by most physicians and achieves the best satisfaction. The introduction of a strict training curriculum for endoscopic sedation can effectively eliminate the barriers preventing gastroenterologists from administering propofol, while at the same time ensuring optimal patient safety during endoscopy.

Operative Gynecological Laparoscopy Under Conscious Sedation

BACKGROUND AND OBJECTIVES

Operative laparoscopy is generally performed under general anesthesia. Local anesthesia and conscious sedation may be useful in select short procedures. In the present study, we evaluated safety and efficacy of operative laparoscopy under conscious sedation.

METHODS

Retrospective observational study evaluating patients undergoing gynecologic laparoscopy. Laparoscopy under conscious sedation was performed for each patient with umbilical direct insertion of a 12-mm port, followed by 2 ancillary ports at 1 cm medially to the anterior superior iliac spine. Conversion to conventional laparoscopy or laparotomy was recorded. Conscious sedation was obtained using Remifentanil and Propofol, administered by an infusion system based on pharmacokinetic and pharmacodynamic models. Local anesthesia was administered at port insertion sites and for paracervical block. Pain intensity was evaluated with the Visual Analog Scale (VAS). Adverse events and drug concentrations throughout the procedure were retrieved.

RESULTS

Our study population included 166 patients. They underwent laparoscopic unilateral versus bilateral salpingo-oophorectomy, ovarian cystectomy, bilateral salpingo-oophorectomy and omentectomy for a borderline ovarian tumor, myomectomy; or underwent surgery for unexplained infertility evaluation, pelvic pain, staging of ovarian cancer. Mean duration of pneumoperitoneum was 22.3 ± 7.2 min. Rate of conversion to laparoscopy under general anesthesia was 17/166 (10.2%) and there were only 3 cases of patients with low tolerability to the procedure. No severe adverse events occurred. Hospital discharge occurred in all unconverted cases after 6 to 18 h.

CONCLUSIONS

Operative laparoscopy under conscious sedation and local anesthesia appears to be a feasible technique in gynecologic surgery with no adverse patient outcomes.

Effectiveness and safety of sedation in gastrointestinal endoscopy: An opinion review

Although endoscopy is a less invasive procedure than surgery, patients can experience pain without sedation. Patients expect reduced pain during endoscopies from effective and safe sedatives. Midazolam and propofol are used for endoscopic sedation in many countries and regions. Midazolam is a widely available benzodiazepine, and many clinical trials have shown it to be an effective sedative. However, patients who are sedated with midazolam require rest in the recovery room due to its relatively long half-life, and an antagonist such as flumazenil may need to be administered in cases of deep or prolonged sedation. Propofol is a short-acting sedative with a short half-life and a quick recovery time. Therefore, the use of propofol has been increasing. However, propofol has a narrow margin of safety and often induces adverse effects such as respiratory depression. Also, propofol has no specific antagonist, and should be administered by an anesthesiologist or an endoscopist familiar with anesthesia. Remimazolam, which is a novel ultra-short-acting benzodiazepine, has recently gained attention. Remimazolam has a short half-life and an antagonist. Both effective and safe sedation is desired in accordance with the increasing need for sedative endoscopies. Therefore, in this review each sedative is summarized.

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.

A comparison of ventilation with a non-invasive ventilator versus standard O2 with a nasal cannula for colonoscopy with moderate sedation using propofol

The aim of this study was to test the effects of CPAP on moderately sedated patients undergoing colonoscopy. Our hypothesis was that CPAP can reduce the incidence and duration of obstructive apnea and hemoglobin oxygen desaturation in patients undergoing procedural sedation for colonoscopy. Two groups of consenting adult patients scheduled to undergo routine colonoscopy procedures and sedated with propofol and fentanyl were monitored in this study: control and intervention. Patients in the intervention group were connected via a facemask to a ventilator that delivered supplemental oxygen (100%) through a standard air-cushion mask. The mask had a built-in leak to facilitate CO₂ clearance during CPAP. Patients in the control group received 2-10 L/min of oxygen via nasal cannula or non-rebreather mask. Subjects in the control group were collected in a prior study and used as historical controls. The primary outcome measures were the number of apneic events and the cumulative duration of apneic events. An apneic event was defined as a period longer than 10 s without respiration. The secondary outcome was the area under the curve (AUC) for the arterial oxygen saturation less than 90% versus time during sedative and analgesic administration (time (s) below threshold multiplied by percent below threshold). A desaturation event was defined as a period of time during which arterial oxygen saturation was less than 90%. 29 patients were enrolled in the intervention group and 156 patients were previously enrolled in the control group as part of an earlier study. The median number of apneic events in the control group was 7 compared to 0 in the intervention group. The intervention group experienced apnea less than 1% of the total procedure time compared to 17% in the control group (p < 0.001). There were no desaturation events observed in the 29 patients in the intervention group. In contrast, 27 out of 156 patients in the control group experienced a desaturation event. Average AUC of patients in the control group was 70%-s (time (s) * oxygen saturation below < 90%) (95% CI 32.34-108.60%) whereas the average AUC in intervention group patients was 0%-s (% time (s) * oxygen saturation < 90%) (95% CI 0-0%), p = 0.01. This preliminary study found that CPAP via a tight-fitting mask may be an effective tool to reduce the incidence and duration of obstructive apneic events as well as hemoglobin oxygen desaturation during lower endoscopy procedures that use propofol and fentanyl for sedation.Clinical Trial Registration ClinicalTrials.gov ID: NCT02623270. https://clinicaltrials.gov/ct2/show/NCT02623270 .

High-flow nasal cannula oxygen therapy and hypoxia during gastroscopy with propofol sedation: a randomized multicenter clinical trial

BACKGROUND AND AIMS

Hypoxia is one of the most frequent adverse events with sedated GI endoscopy and can lead to serious consequences. No modalities have been found previously to prevent hypoxia. High-flow nasal cannula (HFNC) supportive oxygen therapy provides heated and humidified oxygen up to 60 L/minute. Because of its ability to improve respiratory function and good tolerance, we aimed to evaluate the validity and safety of HFNC supportive oxygen therapy in preventing the incidence of hypoxia in patients undergoing gastroscopy with propofol sedation.

METHODS

In a multicenter, prospective randomized single-blinded study, 1994 outpatients undergoing routine gastroscopy with propofol sedation provided by an anesthesiologist were randomized into 2 groups: the nasal cannula group (O₂ [2 L/minute] was supplied via an HFNC) and the HFNC group (O₂ [30-60 L/minute] was supplied via an HFNC) at 3 centers from November 2017 to February 2018. The primary outcome was the incidence of hypoxia. Other adverse events were also recorded.

RESULTS

HFNC supportive oxygen therapy decreased the incidence of hypoxia (75% ≤ Spo₂ < 90% for <60 seconds) and severe hypoxia (Spo₂ < 75% for any duration or 75% ≤ Spo₂ < 90% for ≥60 seconds) from 8.4% to 0% (P < .001) and from 0.6% to 0% (P = .03), respectively. The only HFNC-related adverse event was xeromycteria/rhinalgia (1.7%), which was observed 1 minute after the procedure and disappeared after 30 minutes.

CONCLUSIONS

HFNC supportive oxygen therapy can prevent the incidence of hypoxia and severe hypoxia in patients in America Society of Anesthesiologists class I-II undergoing elective gastroscopy under propofol sedation, with minimal related adverse events and good tolerance. (Clinical trial registration number: NCT03332433.).

Occurrence of Cortical Arousal at Recovery from Respiratory Disturbances during Deep Propofol Sedation

Abstract: Recent evidences suggest that non-arousal mechanisms can restore and stabilize breathing in sleeping patients with obstructive sleep apnea. This possibility can be examined under deep sedation which increases the cortical arousal threshold. We examined incidences of cortical arousal at termination of apneas and hypopneas in elderly patients receiving propofol sedation which increases the cortical arousal threshold. Ten elderly patients undergoing advanced endoscopic procedures under propofol-sedation were recruited. Standard polysomnographic measurements were performed to assess nature of breathing, consciousness, and occurrence of arousal at recovery from apneas and hypopneas. A total of 245 periodic apneas and hypopneas were identified during propofol-induced sleep state. Cortical arousal only occurred in 55 apneas and hypopneas (22.5%), and apneas and hypopneas without arousal and desaturation were most commonly observed (65.7%) regardless of the types of disordered breathing. Chi-square test indicated that incidence of no cortical arousal was significantly associated with occurrence of no desaturation. Higher dose of propofol was associated with a higher apnea hypopnea index (r = 0.673, p = 0.033). In conclusion, even under deep propofol sedation, apneas and hypopneas can be terminated without cortical arousal. However, extensive suppression of the arousal threshold can lead to critical hypoxemia suggesting careful respiratory monitoring.

Safety and efficacy of combined use of propofol and etomidate for sedation during gastroscopy: Systematic review and meta-analysis

BACKGROUND

Sedation with etomidate or propofol alone during gastroscopy has many side effects. A systematic review and meta-analysis were conducted to evaluate the safety and efficacy of the combined use of propofol and etomidate for sedation during gastroscopy.

METHODS

PubMed, Embase, Medline (via Ovid SP), Cochrane library databases, CINAHL (via EBSCO), China Biology Medicine disc (CBMdisc), Wanfang, VIP, and China National Knowledge Infrastructure (CNKI) databases were systematically searched. We included randomized controlled trials (RCTs) comparing the combined use of propofol and etomidate vs etomidate or propofol alone for sedation during gastroscopy. Data were pooled using the random-effects models or fixed-effect model based on heterogeneity.

RESULTS

Fifteen studies with 2973 participants were included in the analysis. Compared to propofol alone, the combined use of propofol and etomidate possibly increased recovery time (SMD = 0.14, 95% CI = 0.04-0.24; P = .005), and the risk for myoclonus (OR = 3.07, 95% CI = 1.73-5.44; P < .001), injection pain, and nausea and vomiting. Furthermore, compared to propofol alone, the combination of propofol and etomidate produced an apparent beneficial effect for mean arterial pressure (MAP) after anesthesia (SMD = 1.32, 95% CI = 0.38-2.26; P = .006), SPO2 after anesthesia (SMD = 0.99, 95% CI = 0.43-1.55; P < .001), apnea or hypoxemia (OR = 0.16, 95% CI = 0.08-0.33; P < .001), injection pain, and body movement. Further, compared to etomidate alone, the combination of propofol and etomidate reduced the risk for myoclonus (OR = 0.15, 95% CI = 0.11-0.22; P < .001), body movement, and nausea and vomiting.

CONCLUSION

The combination of propofol and etomidate might increase recovery time vs that associated with propofol, but it had fewer side effects on circulation and respiration in patients undergoing gastroscopy. The combined use of propofol and etomidate can improve and produce an apparent beneficial effect on the adverse effects of propofol or etomidate alone, and it was safer and more effective than propofol or etomidate alone.

Propofol sedation in colonoscopy: from satisfied patients to improved quality indicators

Background

Propofol-mediated sedation is safe and clearly associated with increased patient satisfaction. However, whether it results in a favorable effect on colonoscopy outcomes and performance compared to standard sedation with benzodiazepines/opiates remains unclear.

Objectives

To determine the effect of propofol-mediated sedation on colonoscopy-quality measures compared to traditional sedation.

Methods

A large cohort of 44,794 patients who had undergone sedated colonoscopies were included. Colonoscopy-quality indicators were examined in benzodiazepine/opiate-sedated patients and compared with a propofol-mediated sedation group. Adjustment for potential confounders, such as age, sex, quality of bowel preparation, procedural setting, and indication was performed.

Results

Patients who received propofol-mediated sedation were more likely, and in a dose-dependent manner, to have an enhanced polyp-detection rate (22.8% vs 20.9%, P<0.001), cecal intubation rate (90.4% vs 87.3%, P<0.001), and terminal ileum-intubation rate (6.4% vs 1.6%, P<0.001). On multivariate analysis, these findings were maintained, as propofol-mediated sedation use was significantly associated with improved colonoscopy indicators.

Conclusion

Propofol-mediated sedation during colonoscopy is associated with better examination performance and improved outcomes. Further prospective or randomized trials to support these findings are warranted.

Propofol sedation without endotracheal intubation is safe for endoscopic submucosal dissection in the esophagus and stomach

Background

Endoscopic submucosal dissection (ESD) for early esophageal and stomach cancer is usually performed under general anesthesia. However, propofol sedation without endotracheal intubation has been suggested as a viable alternative.

Objective

The objective of this study was to evaluate the safety of propofol sedation without endotracheal intubation during ESD in the upper gastrointestinal tract.

Methods

We performed a retrospective cohort study of patients who underwent ESD for upper gastrointestinal tumors with propofol-remifentanil analgosedation in a tertiary referral center in the Netherlands between October 2013 and February 2018. Primary endpoints were the rates of intraprocedural endoscopy- and anesthesia-related complications. Secondary endpoints were the postprocedural complication rates within 30 days and endotracheal intubation conversion rates.

Results

Of 88 patients, intraprocedural ESD-related complications occurred in three patients (3.4%). Intraprocedural anesthesia-related complications occurred in two patients (2.3%), one of whom required conversion to endotracheal intubation. Postprocedural ESD-related complications occurred in 14 patients (15.9%), and minor postprocedural complications occurred in two patients (2.3%). Eighty-two (93.2%) patients were discharged within one day after ESD. No patient was readmitted for anesthesia-related complications.

Conclusion

Propofol-based sedation without endotracheal intubation is safe for ESD procedures in the esophagus and stomach with low anesthesia-related complication rates and short hospital stay.

Conscious sedation using propofol versus midazolam in cirrhotic patients during upper GI endoscopy: A comparative study

AIM

We aimed to assess the safety and efficacy of propofol versus midazolam in cirrhotic patients undergoing upper GI endoscopy.

METHODS

Ninety compensated cirrhotic patients (all met class I-III criteria according to the American Society of Anesthesia) were enrolled in this comparative study. They were classified into three groups according to scheduled pre-endoscopy sedation drugs; the midazolam group, which included 30 patients who received IV weight-dependent midazolam (0.05 mg/kg with additional doses of 1 mg every 2 min when necessary, up to a maximum dose of 0.1 mg/kg or 10 mg); the propofol group, which included 30 patients who received a propofol bolus dose according to age and weight (0.25 mg/kg with additional doses of 20-30 mg every 30-60 s when necessary, up to a maximum dose of 400 mg); and the combined group, which included 30 patients who received half a dose of midazolam and of propofol.

RESULTS

Prolonged postendoscopy recovery times were reported in the midazolam group, while shorter recovery times were reported in the propofol and combined groups. All patients in the propofol and combined groups gained consciousness shortly postendoscopy; however, only half of the midazolam group's patients gained consciousness after the standard recovery time (10-30 min). Highly significant differences were found among the three groups regarding consciousness level according to the Glasgow coma scale, as well as regarding the occurrence of hypoxia during endoscopy.

CONCLUSION

Considering safety and efficacy issues, propofol is better than midazolam in gastrointestinal endoscopy, especially in patients with liver cirrhosis.

Recovery of cognitive function after sedation with propofol for outpatient gastrointestinal endoscopy

BACKGROUND/AIM

Most endoscopies performed in the United States utilize sedation. Anesthesia provides patient comfort and improved procedural quality but adds to the complexity of scheduling routine outpatient procedures. We aimed to assess the return of cognitive function after propofol administration in patients undergoing outpatient endoscopies.

PATIENTS AND METHODS

Cognitive recovery for patients undergoing endoscopy under monitored anesthesia care was evaluated using EncephalApp. Patients were tested before and after procedure and healthy controls were tested twice, 30 min apart. Results were tabulated in on state (on time) and off state (off time) and total time (on time + off time). The time difference between pre- and post-tests, "delta," was calculated for on, off, and total times. Wilcoxon rank test was used to check the difference in mean delta of all three test times between cases and controls and to check for statistical significance.

RESULTS

The difference in mean time between cases and controls was significant for off (P < 0.0001) and total (P = 0.0002) times. No statistically significant difference was noted in mean time for on time (P = 0.013) between cases and controls. Cognitive flexibility, a measure of on time, returned to baseline after procedural sedation even though psychomotor speed, a measure of off time and total time, had not.

CONCLUSION

Cognitive flexibility returns to baseline within 30-45 min after propofol sedation despite delayed return of psychomotor speed and reaction time.

Propofol Sedation by Pediatric Gastroenterologists for Endoscopic Procedures: A Retrospective Analysis

Background: There is a substantial literature on the favorable outcome of propofol administration by non-anesthesiologists for endoscopy in adults; however, very few data are currently available on propofol sedation by pediatric gastroenterologists. Aims: to evaluate the safety of propofol sedation by pediatric gastroenterologists. Methods: A retrospective chart review of all children who were sedated by pediatric gastroenterologists in three Northern Israeli hospitals over a 4 years period Demographic and medical characteristics and any data regarding the procedure were extracted from patient's records. The main outcome measurements were procedure completion and reported adverse events. Results: Overall, 1,214 endoscopic procedures for were performed during this period. Complete data was available for 1,190 procedures. All children sedated by pediatric gastroenterologists were classified as ASA I or II. Propofol dosage (in mg/kg) inversely correlated with patient age. The younger the child the higher the dose needed to reach a satisfactory level of sedation (r = -0.397, p < 0.001). The addition of fentanyl significantly decreased propofol dosage needed to provide optimal sedation, p < 0.001. Nine (0.7%) reversible adverse events were reported. All the procedures were successfully completed and all patients were discharged home. Conclusions: We conclude that our approach is safe in children as it is in adults and can be implemented for children with ASA I, II.

Safety of sedation for gastrointestinal endoscopy in a group of university-affiliated hospitals: a prospective cohort study

BACKGROUND

Service models for gastrointestinal endoscopy sedation must be safe, as endoscopy is the most common procedure performed under sedation in many countries. The aim of this prospective cohort study was to determine the patient risk profile, and incidence of and risk factors for significant unplanned events, in adult patients presenting for gastrointestinal endoscopy in a group of university-affiliated hospitals where most sedation is managed by anaesthetists.

METHODS

Patients aged ≥18 yr presenting for elective and emergency gastrointestinal endoscopy under anaesthetist-managed sedation at nine hospitals affiliated with the University of Melbourne, Australia, were included. Outcomes included significant airway obstruction, hypoxia, hypotension and bradycardia; unplanned tracheal intubation; abandoned procedure; advanced life support; prolonged post-procedure stay; unplanned over-night admission and 30-day mortality.

RESULTS

2,132 patients were included. Fifty percent of patients were aged >60 yr, 50% had a BMI >27 kg m ^-2, 42% were ASA physical status III-V and 17% were emergency patients. The incidence of significant unplanned events was 23.0% (including significant hypotension 11.8%). Significant unplanned intraoperative events were associated with increasing age, BMI <18.5 kg m ^-2, ASA physical status III-V, colonoscopy and planned tracheal intubation. Thirty-day mortality was 1.2% (0.2% in electives and 6.0% in emergencies) and was associated with ASA physical status IV-V and emergency status.

CONCLUSIONS

Patients presenting for gastrointestinal endoscopy at a group of public university-affiliated hospitals where most sedation is managed by anaesthetists, had a high risk profile and a substantial incidence of significant unplanned intraoperative events and 30-day mortality.

Endoscopy and sedation: an inseparable binomial for the gastroenterologist

The development of endoscopy and its increasing demand among the population have led to a growing need for propofol-based sedation techniques. Benefit is indisputable for both patients and endoscopists, but some aspects require considering the "who" and "how" of sedation as related to safety and health care costs. Propofol is first-choice in endoscopy for the European Society of Gastrointestinal Endoscopy because of its fast onset of action and short half-life, and many reports exist on its safety when used by gastroenterologists rather than anesthesiologists. In this issue of REED several originals support the efficiency and safety of propofol even for complex, high-risk, or protracted procedures such as endoscopic retrograde cholangiopancreatography (ERCP) and enteroscopy. Propofol may be safely and effectively administered by a team with specific skills acquired through education and using a specific procedure. However, difficulties arise in real-world clinical practice that preclude such training, which in Spain should be included in the MIR (médico interno residente) specialization program curriculum. The Comisión Nacional de Digestivo (Spanish National Commission on Digestive Diseases), sensitive to this training gap, has included in their latest version of the MIR program (under assessment) four additional competences, with number 145 (training in deep sedation) being most relevant here. In addition, the Spanish Society of Gastrointestinal Endoscopy (SEED) has invested significant efforts in sedation training, with over 50 courses on sedation for endoscopists and nurses. Continuing education and training in this field (for instance, refresher courses on advanced cardiopulmonary resuscitation) should be a goal for all endoscopy units. Because of the diversity found among hospitals, with single or multiple endoscopy rooms, efforts should be made to persuade those in charge of gastroenterology and anesthesiology departments to establish the necessary care circuits in order to guarantee patient safety by developing accurate protocols and promoting consensus among the scientific societies involved (Spanish Society for Digestive Diseases [SEPD], SEED and Spanish Society of Anaesthesiology, Resuscitation and Pain Management [SEDAR]) and their respective national commissions.

Propofol for gastrointestinal endoscopy

Most gastrointestinal endoscopic procedures are now performed with sedation. Moderate sedation using benzodiazepines and opioids continues to be widely used, but propofol sedation is becoming more popular because its unique pharmacokinetic properties make endoscopy almost painless, with a very predictable and rapid recovery process. There is controversy as to whether propofol should be administered only by anesthesia professionals. According to published values, endoscopist-directed propofol has a lower mortality rate than endoscopist-delivered benzodiazepines and opioids, and a comparable rate to general anesthesia by anesthesiologists. Rapid recovery has a major impact on patient satisfaction, post-procedure education and the general flow of the endoscopy unit. According to estimates, the absolute economic benefit of endoscopist-directed propofol implementation in a screening setting is probably substantial, with 10-year savings of $3.2 billion in the USA. Guidelines concerning the use of propofol emphasize the need for adequate training and certification in sedation by non-anesthetists.

Monitoring of colonoscopy quality indicators in an academic endoscopy facility reveals adherence to international recommendations

Background

We monitor colonoscopy service quality biannually, by measuring sedation administration, colonoscopy completion, adenoma detection and early complications rates (CR). We herein present our audit results for the years 2013 and 2015.

Methods

In our endoscopy facility, five rotating senior gastroenterologists perform colonoscopies, on a daily basis. We measured the quality indicators in three cohorts: A, intention for total colonoscopy cases; B, cohort A excluding bowel obstruction cases; C, colorectal cancer (CRC) screening cases.

Results

In 2015, overall sedation administration rate (SAR) was 93.0% (91.6-94.4%), achieving our target to give conscious sedation to >90% of patients undergoing colonoscopy in all three cohorts. Colonoscopy completion rate (CCR) increased significantly (P<0.0001) from 94.8% (93.4-96.2%) to 98.1% (97.3-98.9%) in cohort B and numerically from 96.6% (94.4-98.8%) to 98.6% (97.4-99.7%) in cohort C, at the same periods. In cohort C, adenoma detection rates (ADR) were similar-27.1% (21.7-32.5%) and 27% (22.7-31.3%)-in the two periods. There were only two serious early complications: one cardiorespiratory event and one perforation in 2013 and 2015, respectively. While significant variability regarding SAR (ranging from 80% to 100%) was detected among the participating endoscopists, all but one of them constantly achieved [judged by the lower confidence interval (CI) of the quality indicator] CCRs higher than the recommended by international guidelines. On the contrary ADR was variable among endoscopists during the studied periods.

Conclusions

Although there is certain variability in endoscopists' performance, the overall colonoscopy quality indicators meet or exceed the internationally recommended standards, in our endoscopy facility.

Determination of the maximum tolerated dose of intranasal sufentanil and midazolam in Chinese: a pilot study

BACKGROUND

The purpose of this study was to determine the maximum tolerated dose (MTD, the dose of causing 10% respiratory depression) of intranasal sufentanil (SUF) and midazolam (MID) for sedation during gastroscopy by continual reassessment method (CRM).

METHODS

Patients (18-65 years old) scheduled for gastroscopy were recruited in this study. Subjects received intranasal SUF and MID for sedation. The dose of MID (5 mg) was fixed, while the dose of SUF was increased progressively (six incremental doses ranging from 0-0.60 μg/kg, n = 3 for each dose). The first cohort received a conservative, predetermined dose of 5 mg MID and 0 μg/kg SUF, subsequent cohorts received doses of SUF that were determined by the responses of all previous patients using Bayesian-based software. The dose allocated to the next cohort is the one with an updated posterior response probability closest to 10%.

RESULTS

Thirty Chinese patients scheduled for gastroscopy were included. Probability of respiratory depression at each dose was as follows: 5 mg MID + 0 μg/kg SUF, 0.4%; 5 mg MID + 0.1 μg/kg SUF, 0.8%; 5 mg MID + 0.2 μg/kg SUF, 1.8%; 5 mg MID + 0.3 μg/kg SUF, 3.7%; 5 mg MID + 0.4 μg/kg SUF, 9.9%; 5 mg MID + 0.5 μg/kg SUF, 17.8%; 5 mg MID + 0.6 μg/kg SUF, 36.0%.

CONCLUSION

The MTD of intranasal MID and SUF for sedation during gastroscopy causing 10% respiratory depression is 5 mg MID + 0.4 μg/kg SUF, based on CRM.

Paradigm shift: should the elderly undergo propofol sedation for DBE? A prospective cohort study

OBJECTIVE

Evaluate the safety of propofol-assisted double balloon enteroscopy (DBE) in elderly patients against a younger cohort.

DESIGN

Prospective cohort study.

SETTING

All patients undergoing DBE over a 30-month period were recruited at our tertiary centre.

PATIENTS

215 procedures in 161 patients were performed. An age cut-off of 65 years and above was used to define those who were elderly.

INTERVENTIONS

Patients were subcategorised into four groups: elderly or young undergoing DBE with propofol or conventional sedation (with midazolam±fentanyl).

MAIN OUTCOME MEASURES

Patient demographics, comorbidities, procedural data, complications, diagnostic and therapeutic yield were compared.

RESULTS

Cardiovascular disease and a higher American Society of Anaethesiologists (ASA) status were more prevalent in elderly patients undergoing DBE with propofol (p<0.05). Common indications for DBE were occult and overt obscure gastrointestinal bleeding and suspected Crohn's disease (elderly vs young: 50.7% vs 42.3%, 17.8% vs 12% and 19.2% vs 26.1%, respectively). Diagnostic yield was higher in elderly compared with young patients (75.3% vs 58.5%, p=0.016). The most common findings in elderly and young patients were angioectasia (30.1% and. 18.3%, respectively) and ulcers (17.8% and 9.2%, respectively), while therapeutic intervention rates were comparable (42.5% vs 32.4%, p=0.18). ASA status did not affect propofol dose (p=0.55) or procedure duration (p=0.31). Tolerance scores were favourable in those receiving propofol compared with conventional sedation (p<0.05). There was no difference in complications between the four groups (p=0.17).

CONCLUSION

Compared with young patients, propofol-assisted DBE in the elderly is safe and has a high diagnostic yield.

Nonoperating room anesthesia for gastrointestinal endoscopic procedures

PURPOSE OF REVIEW

To assess the trends in nonoperating room anesthesia (NORA) for gastrointestinal endoscopy over the past few years, and to describe alternative methods of delivering propofol sedation in selected low-risk patients.

RECENT FINDINGS

The use of NORA for routine gastrointestinal endoscopic procedures has been rising steadily over the past decade in the United States, considerably increasing healthcare costs. Because of this, there have been attempts to develop nonanesthesiologist-administered propofol sedation methods in low-risk patients. There is controversy as to whether properly trained nonanesthesia personnel can use propofol safely via the modalities of nurse-administered propofol sedation, computer-assisted propofol sedation or nurse-administered continuous propofol sedation SUMMARY: The deployment of nonanesthesia-administered propofol sedation for low-risk procedures allows for optimal allocation of scarce anesthesia resources, which can be more appropriately used for more complex cases. This can address some of the current shortages in anesthesia provider supply, and can potentially reduce overall healthcare costs without sacrificing sedation quality. We also address the realm of anesthesia provider care for advanced endoscopic procedures including setup for administration of anesthesia, decision-making regarding placement of an endotracheal tube, and the potential need to move a challenging case to the operating room.

Efficacy and safety of etomidate-midazolam for screening colonoscopy in the elderly: A prospective double-blinded randomized controlled study

BACKGROUND AND AIMS

Recent studies have shown that etomidate is associated with fewer serious adverse events than propofol and has a noninferior sedative effect. We investigated whether etomidate-midazolam is associated with fewer cardiopulmonary adverse events and has noninferior efficacy compared to propofol-midazolam for screening colonoscopy in the elderly.

METHODS

A prospective, single-center, double-blinded, randomized controlled trial was performed. Patients aged over 65 years who were scheduled to undergo screening colonoscopy were randomized to receive either etomidate or propofol based on midazolam. The primary outcome was all cardiopulmonary adverse events. The secondary outcomes were vital sign fluctuation (VSF), adverse events disturbing the procedure, and sedation-related outcomes.

RESULTS

The incidence of cardiopulmonary adverse events was higher in the propofol group (72.6%) than in the etomidate group (54.8%) (P = .040). VSF was detected in 17 (27.4%) and 31 (50.0%) patients in the etomidate and propofol groups, respectively (P = .010). The incidence rate of adverse events disturbing the procedure was significantly higher in the etomidate group (25.8%) than in the propofol group (8.1%) (P = .008). Moreover, the incidence rate of myoclonus was significantly higher in the etomidate group (16.1%) than in the propofol group (1.6%) (P = .004). There was no statistical significance between the 2 groups with respect to sedation times and sedation-related outcomes including patients' and endoscopist's satisfaction. In the multivariate analysis, the etomidate group had significantly low odds ratio (OR) associated with VSF (OR: 0.407, confidence interval: 0.179-0.926, P = .032).

CONCLUSIONS

We recommend using etomidate-midazolam in patients with high ASA score or vulnerable to risk factors; propofol-midazolam may be used as a guideline in patients with low ASA score.

Efficacy and safety of etomidate-based sedation compared with propofol-based sedation during ERCP in low-risk patients: a double-blind, randomized, noninferiority trial

BACKGROUND AND AIMS

Etomidate is a short-acting intravenous hypnotic with a safety profile that is superior to alternative drugs such as propofol. However, there is a lack of evidence on the safety of etomidate in ERCP. The objective of this study was to compare efficacy and safety profiles of etomidate and propofol for endoscopic sedation.

METHODS

This single-center, randomized, double-blind, noninferiority trial included patients with American Society of Anesthesiologists (ASA) physical status I to II who had been scheduled for ERCP. All patients received .05 mg/kg midazolam intravenously as pretreatment before receiving etomidate or propofol. Either etomidate or propofol was then administered according to group allocation. The primary endpoint was an overall respiratory event. A noninferiority margin of 10% was assumed.

RESULTS

Sixty-three and 64 patients were enrolled in the etomidate and propofol groups, respectively. Respiratory events were identified in 10 patients (15.6%) in the etomidate group and 16 patients (25.4%) on the propofol group, with a rate difference of -9.8% (1-sided 97.5% confidence interval, -∞ to 4.2%). The overall incidence of cardiovascular events tended to be higher in the etomidate group (67.2% vs 50.8%, P = .060). In particular, tachycardia (heart rate > 100 beats/min) was more common in the etomidate group than in the propofol group (64.1% vs 34.9%, P = .001). Transient hypotension tended to be less common in the etomidate group (6.3 vs 15.9%, P = .084).

CONCLUSIONS

Etomidate-based sedation during ERCP was noninferior to propofol-based sedation in terms of the overall incidence of respiratory events in patients with ASA physical status I to II. (International Clinical Trials Registry Platform number: KCT0001926.).

Effects of propofol sedation on pacing thresholds : Results from an observational cohort study

BACKGROUND

Propofol is one of the most commonly used intravenous anaesthetic drugs for surgical procedures. The use of propofol for sedation is also common practice during endoscopic procedures, electrophysiology studies, and ablation procedures, as well as pacemaker and defibrillator implantation. It was found that propofol alters the electrophysiologic properties of the heart and its conduction system. The effects of propofol on pacing thresholds are unknown and could have implications for pacemaker (PM) and defibrillator (ICD) implantation procedures, as well as sedation and anaesthesia in PM and ICD patients in general.

OBJECTIVES

We sought to investigate the effects of propofol sedation on atrial and right ventricular pacing thresholds in PM and ICD patients.

MATERIALS AND METHODS

A total of 50 patients with PM, ICD, or cardiac resynchronization therapy (CRT) undergoing propofol sedation for electrophysiology (EP) investigation, transesophageal echocardiography (TEE), electrocardioversion (ECV), or bronchoscopy were included prospectively. Pacing thresholds, impedance, and sensing were assessed by device interrogation immediately prior to sedation and after the desired sedation depth was achieved by the administration of propofol.

RESULTS

Mean atrial (0.68 V vs 0.77 V, p = 0.136) and mean right ventricular thresholds (0.90 V vs 0.93 V, p = 0.274) remained unchanged. Impedances and sensing remained unaffected in all patients.

CONCLUSIONS

Propofol sedation did not affect pacing thresholds of atrial and right ventricular leads in this cohort of PM and ICD patients.

Italian Society of Digestive Endoscopy (SIED) position paper on the non-anaesthesiologist administration of propofol for gastrointestinal endoscopy

Propofol sedation by non-anesthesiologists in GI endoscopy, despite generally considered a safe procedure, is still a matter of debate. Benefits of propofol sedation include rapid onset of action, greater patient comfort and fast recovery with prompt discharge from the endoscopy unit. The use of propofol for sedation in GI endoscopy, preceded by dedicated training courses, has been approved by several anaesthesiologist and gastroenterologist societies but an Italian position paper taking into account the Italian law is lacking. In the present document, the Italian Society of Digestive Endoscopy (SIED) Sedation Group, on behalf of the SIED, presents a series of updated position statements concerning propofol sedation in GI endoscopy. The paper summarizes the advantages of propofol, how it should be administered and how patients should be monitored. Moreover, details concerning proper training of non-anaesthesiologist personnel involved in its use are provided. Protocols concerning propofol use s must be shared with the hospital's anaesthesiology staff and approved by the hospital's Executive Director.