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Zhang Y, Zhang N, Hu J, Liu C, Li G. Safety and efficacy of a low-dose combination of midazolam, alfentanil, and propofol for deep sedation of elderly patients undergoing ERCP. BMC Gastroenterol 2024; 24:124. [PMID: 38566038 PMCID: PMC10985874 DOI: 10.1186/s12876-024-03197-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 03/06/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Proper sedation of patients, particularly elderly individuals, who are more susceptible to sedation-related complications, is of significant importance in endoscopic retrograde cholangiopancreatography (ERCP). This study aims to assess the safety and efficacy of a low-dose combination of midazolam, alfentanil, and propofol for deep sedation in elderly patients undergoing ERCP, compared to a group of middle-aged patients. METHODS The medical records of 610 patients with common bile duct stones who underwent elective ERCP under deep sedation with a three-drug regimen, including midazolam, alfentanil, and propofol at Shandong Provincial Third Hospital from January 2023 to September 2023 were retrospectively reviewed in this study. Patients were categorized into three groups: middle-aged (50-64 years, n = 202), elderly (65-79 years, n = 216), and very elderly (≥ 80 years, n = 192). Intraoperative vital signs and complications were compared among these groups. RESULTS The three groups showed no significant difference in terms of intraoperative variation of systolic blood pressure (P = 0.291), diastolic blood pressure (P = 0.737), heart rate (P = 0.107), peripheral oxygen saturation (P = 0.188), bispectral index (P = 0.158), and the occurrence of sedation-related adverse events including hypotension (P = 0.170) and hypoxemia (P = 0.423). CONCLUSION The results suggest that a low-dose three-drug regimen consisting of midazolam, alfentanil, and propofol seems safe and effective for deep sedation of elderly and very elderly patients undergoing ERCP procedures. However, further studies are required to verify these findings and clarify the benefits and risks of this method.
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Affiliation(s)
- Yanping Zhang
- Department of Anesthesiology, Cheeloo College of Medicine, Shandong Provincial Third Hospital, Shandong University, No.12 Wuyingshan Middle Road, Jinan, Shandong, 250000, China
| | - Ning Zhang
- Department of Cardiopulmonary rehabilitation, Cheeloo College of Medicine, Shandong Provincial Third Hospital, Shandong University, No.12 Wuyingshan Middle Road, Jinan, Shandong, 250000, China
| | - Jing Hu
- Department of Anesthesiology, Cheeloo College of Medicine, Shandong Provincial Third Hospital, Shandong University, No.12 Wuyingshan Middle Road, Jinan, Shandong, 250000, China
| | - Changlin Liu
- Department of Anesthesiology, Cheeloo College of Medicine, Shandong Provincial Third Hospital, Shandong University, No.12 Wuyingshan Middle Road, Jinan, Shandong, 250000, China
| | - Guanjun Li
- Department of Anesthesiology, Cheeloo College of Medicine, Shandong Provincial Third Hospital, Shandong University, No.12 Wuyingshan Middle Road, Jinan, Shandong, 250000, China.
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Amornyotin S. Anesthetic Consideration for Geriatric Patients. UPDATE IN GERIATRICS 2021. [DOI: 10.5772/intechopen.97003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/03/2023]
Abstract
The geriatric population experiences significant alterations of numerous organ systems as a result of the aging process. They also have several co-morbidities including hypertension, cardiac disease, diabetes, cerebrovascular disease and renal dysfunction. Geriatric patients are considerably vulnerable and especially sensitive to the stress of trauma, surgery and anesthesia. A high incidence of postoperative complications in this population is observed. Appropriate perioperative care was required for geriatric patients. To date, development in anesthesia and surgical techniques has substantially reduced morbidity and mortality in the geriatric patients. Several anesthetic techniques have been utilized for these patients. However, anesthesia-related mortality in geriatric patients is quiet high. All geriatric patients undergoing surgical procedures require a preprocedural evaluation and preparation, monitoring patients during intraprocedural and postprocedural periods as well as postprocedural management. This chapter highlights the physiological changes, preprocedure assessment and preparation, anesthetic techniques, intraprocedural and postprocedural management in geriatric population.
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Bloch F, Karoui I, Boutalha S, Defouilloy C, Dubaele JM. Tolerability of Midazolam to treat acute agitation in elderly demented patients: A systematic review. J Clin Pharm Ther 2019; 44:143-147. [PMID: 30666683 DOI: 10.1111/jcpt.12785] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 10/29/2018] [Accepted: 11/18/2018] [Indexed: 12/28/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Behavioural disorders are difficult to manage in elderly demented patients because of the lack of appropriate drugs or difficulties surrounding the route of administration. The tolerability of Midazolam is well described in the emergency management of agitation for young patients, when administered intramuscularly or intravenously. However, very little data are available on the use of oral Midazolam for this indication and in the elderly population. METHODS A literature review was conducted, and studies were included if involving adults, receiving Midazolam, alone or in combination, whatever the route, dosage or indication and if they reported adverse events related to the use of Midazolam. RESULTS AND DISCUSSION Forty-one articles were included. Eleven different adverse events were identified from the studies. Hypotension and desaturation were the two most frequent adverse events reported. Adverse reactions appear to be more common in older patients but also when Midazolam was used in combination with other drugs. The frequency of these adverse effects was lower than those reported for neuroleptic drugs. WHAT IS NEW AND CONCLUSION The oral route appears to be appropriate to provide a rapid and well-tolerated response. Further studies will be needed to confirm the good tolerance of oral Midazolam in the management of acute agitation in elderly demented patients.
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Affiliation(s)
- Frédéric Bloch
- Department of Geriatric medicine, University Hospital of Amiens-Picardie, Amiens, France
| | - Ilhem Karoui
- Department of Geriatric medicine, University Hospital of Amiens-Picardie, Amiens, France
| | - Samir Boutalha
- Department of Geriatric medicine, University Hospital of Amiens-Picardie, Amiens, France
| | - Christian Defouilloy
- Department of Geriatric medicine, University Hospital of Amiens-Picardie, Amiens, France
| | - Jean-Marc Dubaele
- Department of Pharmacy, University Hospital of Amiens-Picardie, Amiens, France
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Makwana D, Prem K, Patel J, Talukdar J, Thakkar JM. Comparison of combination of ketamine hydrochloride and propofol with fentanyl citrate and propofol for patients undergoing endoscopic retrograde cholangiopancreatography. BALI JOURNAL OF ANESTHESIOLOGY 2019. [DOI: 10.4103/bjoa.bjoa_6_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Amornyotin S. Registered nurse-administered sedation for gastrointestinal endoscopic procedure. World J Gastrointest Endosc 2015; 7:769-76. [PMID: 26191341 PMCID: PMC4501967 DOI: 10.4253/wjge.v7.i8.769] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Revised: 12/24/2014] [Accepted: 05/05/2015] [Indexed: 02/05/2023] Open
Abstract
The rising use of nonanesthesiologist-administered sedation for gastrointestinal endoscopy has clinical significances. Most endoscopic patients require some forms of sedation and/or anesthesia. The goals of this sedation are to guard the patient's safety, minimize physical discomfort, to control behavior and to diminish psychological responses. Generally, moderate sedation for these procedures has been offered by the non-anesthesiologist by using benzodiazepines and/or opioids. Anesthesiologists and non-anesthesiologist personnel will need to work together for these challenges and for safety of the patients. The sedation training courses including clinical skills and knowledge are necessary for the registered nurses to facilitate the patient safety and the successful procedure. However, appropriate patient selection and preparation, adequate monitoring and regular training will ensure that the use of nurse-administered sedation is a feasible and safe technique for gastrointestinal endoscopic procedures.
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Anesthesia for ERCP: Impact of Anesthesiologist's Experience on Outcome and Cost. Anesthesiol Res Pract 2013; 2013:570518. [PMID: 23781243 PMCID: PMC3679699 DOI: 10.1155/2013/570518] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Revised: 05/01/2013] [Accepted: 05/13/2013] [Indexed: 12/17/2022] Open
Abstract
The present study evaluates the effect of anesthesiologist's experience in providing deep sedation for endoscopic retrograde cholangiopancreatography (ERCP) on cost and safety. Methodology. Perioperative records of 1167 patients who underwent ERCP were divided on the basis of anesthesiologist assisting these procedures either on regular basis (Group R) or on ad hoc basis (Group N). Comparisons were made for anesthesia times, complication rates, and airway interventions. Results. Across all American Society of Anesthesiologists (ASA) Classes, regular anesthesiologists were more efficient (overall mean anesthesia time in Group R was 24.82 ± 12.96 versus 48.63 ± 21.53 minutes in Group N). Within Group R, anesthesia times across all ASA classes were comparable. In Group N, anesthesia times for higher ASA status patients were significantly longer (ASA IV, 64.62 ± 35.78 versus ASA I, 45.88 ± 11.19 minutes). Intubation rates (0.76% versus 12.8%) and median minimal oxygen saturation (100% versus 97.01%) were significantly higher in Group R. Had Group R anesthesiologists performed all procedures, the hospital could have saved US $ 758536 (based upon operating room time costs). Conclusion. Experience in providing deep sedation improved patient safety and decreased the operating room turnaround time, thereby lowering operating room costs associated with these procedures.
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Amornyotin S. Sedation and monitoring for gastrointestinal endoscopy. World J Gastrointest Endosc 2013; 5:47-55. [PMID: 23424050 PMCID: PMC3574612 DOI: 10.4253/wjge.v5.i2.47] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Revised: 07/11/2012] [Accepted: 12/01/2012] [Indexed: 02/05/2023] Open
Abstract
The safe sedation of patients for diagnostic or therapeutic procedures requires a combination of properly trained physicians and suitable facilities. Additionally, appropriate selection and preparation of patients, suitable sedative technique, application of drugs, adequate monitoring, and proper recovery of patients is essential. The goal of procedural sedation is the safe and effective control of pain and anxiety as well as to provide an appropriate degree of memory loss or decreased awareness. Sedation practices for gastrointestinal endoscopy (GIE) vary widely. The majority of GIE patients are ambulatory cases. Most of this procedure requires a short time. So, short acting, rapid onset drugs with little adverse effects and improved safety profiles are commonly used. The present review focuses on commonly used regimens and monitoring practices in GIE sedation. This article is to discuss the decision making process used to determine appropriate pre-sedation assessment, monitoring, drug selection, dose of sedative agents, sedation endpoint and post-sedation care. It also reviews the current status of sedation and monitoring for GIE procedures in Thailand.
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Affiliation(s)
- Somchai Amornyotin
- Somchai Amornyotin, Department of Anesthesiology and Siriraj Gastrointestinal Endoscopy Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
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Amornyotin S, Kachintorn U, Kongphlay S. Anesthetic management for small bowel enteroscopy in a World Gastroenterology Organization Endoscopy Training Center. World J Gastrointest Endosc 2012; 4:189-93. [PMID: 22624071 PMCID: PMC3355242 DOI: 10.4253/wjge.v4.i5.189] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2011] [Revised: 12/07/2011] [Accepted: 04/27/2012] [Indexed: 02/05/2023] Open
Abstract
AIM To study the anesthetic management of patients undergoing small bowel enteroscopy in the World Gastroenterology Organization (WGO) Endoscopy Training Center in Thailand. METHODS Patients who underwent small bowel enteroscopy during the period of March 2005 to March 2011 in Siriraj Gastrointestinal Endoscopy Center were retrospectively analyzed. The patients' characteristics, pre-anesthetic problems, anesthetic techniques, anesthetic agents, anesthetic time, type and route of procedure and anesthesia-related complications were assessed. RESULTS One hundred and forty-four patients underwent this procedure during the study period. The mean age of the patients was 57.6 ± 17.2 years, and most were American Society of Anesthesiologists (ASA) class II (53.2%). Indications for this procedure were gastrointestinal bleeding (59.7%), chronic diarrhea (14.3%), protein losing enteropathy (2.6%) and others (23.4%). Hematologic disease, hypertension, heart disease and electrolyte imbalance were the most common pre-anesthetic problems. General anesthesia with endotracheal tube was the anesthetic technique mainly employed (50.6%). The main anesthetic agents administered were fentanyl, propofol and midazolam. The mean anesthetic time was 94.0 ± 50.5 min. Single balloon and oral (antegrade) intubation was the most common type and route of enteroscopy. The anesthesia-related complication rate was relatively high. The overall and cardiovascular-related complication rates including hypotension in the older patient group (aged ≥ 60 years old) were significantly higher than those in the younger group. CONCLUSION During anesthetic management for small bowel enteroscopy, special techniques and drugs are not routinely required. However, for safety reasons anesthetic personnel need to optimize the patient's condition.
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Affiliation(s)
- Somchai Amornyotin
- Somchai Amornyotin, Siriporn Kongphlay, Department of Anesthesiology and Siriraj, Gastrointestinal Endoscopy Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
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Amornyotin S, Leelakusolvong S, Chalayonnawin W, Kongphlay S. Age-dependent safety analysis of propofol-based deep sedation for ERCP and EUS procedures at an endoscopy training center in a developing country. Clin Exp Gastroenterol 2012; 5:123-8. [PMID: 22826640 PMCID: PMC3401056 DOI: 10.2147/ceg.s31275] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasonography (EUS) procedures in elderly patients are on the rise, and they play an important role in the diagnosis and management of various gastrointestinal diseases. The use of deep sedation in these patients has been established as a safe and effective technique in Western countries; however, it is uncertain if the situation holds true among Asians. The present study aimed to evaluate the age-dependent safety analysis and clinical efficacy of propofol-based deep sedation (PBDS) for ERCP and EUS procedures in adult patients at a World Gastroenterology Organization (WGO) Endoscopy Training Center in Thailand. METHODS We undertook a retrospective review of anesthesia or sedation service records of patients who underwent ERCP and EUS procedures. All procedures were performed by staff endoscopists, and all sedations were administered by anesthesia personnel in the endoscopy room. RESULTS PBDS was provided for 491 ERCP and EUS procedures. Of these, 252 patients (mean age, 45.1 + 11.1 years, range 17-65 years) were in the <65 age group, 209 patients (mean age, 71.7 + 4.3 years, range 65-80 years) were in the 65-80 year-old group, and 30 patients (mean age, 84.6 + 4.2 years, range 81-97 years) were in the >80 age group. Common indications for the procedures were pancreatic tumor, cholelithiasis, and gastric tumor. Fentanyl, propofol, and midazolam were the most common sedative drugs used in all three groups. The mean doses of propofol and midazolam in the very old patients were relatively lower than in the other groups. The combination of propofol, midazolam, and fentanyl, as well as propofol and fentanyl, were frequently used in all patients. Sedation-related adverse events and procedure-related complications were not statistically significantly different among the three groups. Hypotension was the most common complication. CONCLUSION In the setting of the WGO Endoscopy Training Center in a developing country, PBDS for ERCP and EUS procedures in elderly patients by trained anesthesia personnel with appropriate monitoring is relatively safe and effective. Although adverse cardiovascular events, including hypotension, in this aged group is common, all adverse events were usually transient, mild, and easily treated, with no sequelae.
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Affiliation(s)
- Somchai Amornyotin
- Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Siriraj GI Endoscopy Center, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Somchai Leelakusolvong
- Siriraj GI Endoscopy Center, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Correspondence: Somchai Amornyotin, Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand, Tel +66 2419 7990, Fax +66 2411 3256, Email
| | - Wiyada Chalayonnawin
- Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Siriraj GI Endoscopy Center, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Siriporn Kongphlay
- Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Siriraj GI Endoscopy Center, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
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