Propofol sedation during endoscopic treatment for early gastric cancer compared to midazolam

Efficacy and safety of esketamine for pediatric gastrointestinal endoscopy: a meta-analysis and trial sequential analysis

Objective

The role of esketamine in pediatric gastrointestinal endoscopy is still unclear. This study aims to evaluate the efficacy and safety of esketamine for pediatric gastrointestinal endoscopy.

Methods

Clinical trials of esketamine for pediatric gastrointestinal endoscopy were searched in eight common databases, up to October 2023. These clinical trials were included in the meta-analysis and trial sequential analysis (TSA). The risk ratio (RR) and weighted mean difference (WMD) were used as the effect sizes for dichotomous variables and continuity variables, respectively. When the heterogeneity test showed I2 < 50%, the fixed effects model was used for the meta-analysis and TSA; Otherwise, the random effects model was used for them.

Results

In terms of efficacy endpoints, the meta-analysis showed that compared with placebo or blank, esketamine significantly decreased recovery time by 2.34 min (WMD -2.34; 95% Confidence interval [CI] -3.65, -1.02; p = 0.0005) and propofol consumption by 0.70 mg/kg (WMD -0.70; 95% CI -0.98, -0.43; p < 0.00001), and increased mean heart rate by 4.77 beats/min (WMD 4.77; 95% CI 2.67, 6.87; p < 0.00001) and mean arterial pressure by 3.10 mmHg (WMD 3.10; 95% CI 1.52, 4.67; p = 0.0001), while induction time and mean blood oxygen remained comparable. TSA indicated conclusive evidence for these benefits. In terms of safety endpoints, the meta-analysis revealed that esketamine significantly reduced involuntary movements by 59% (RR 0.41; 95% CI 0.22, 0.76; p = 0.005) and choking by 51% (RR 0.49; 95% CI 0.26, 0.92; p = 0.03), while significantly increasing dizziness by 98% (RR 1.98; 95% CI 1.11, 3.56; p = 0.02) and there were no significant differences in total adverse events, respiratory depression, and vomiting. TSA demonstrated conclusive evidence for involuntary movements and dizziness. Low-dose analysis showed that esketamine at ≤0.3 mg/kg significantly reduced recovery time, propofol consumption and involuntary movements, and significantly increasing mean heart rate, with no increase in dizziness. The Begg's test (p = 0.327) and the Egger's test (p = 0.413) indicated no significant publication bias, yet the funnel plot suggested potential publication bias.

Conclusion

Esketamine is an effective adjuvant anesthesia for children undergoing gastrointestinal endoscopy. However, the general dose of esketamine may increase the risk of dizziness, which can be avoided by administering a low dose (≤0.3 mg/kg).

Comparison of the effects of esketamine, sufentanil, or lidocaine combined with propofol on tussis reflection during upper gastrointestinal endoscopy: study protocol for a randomised, two centre, three-blind, controlled trial

BACKGROUND

Tussis, which increases the incidence of airway spasm, aspiration, nausea, and vomiting, is a common complication faced during upper gastrointestinal (GI) endoscopy. However, sedatives and analgesics exhibit inhibitory actions against airway reflexes to different degrees. Our assumption is a combination of propofol and small doses of sufentanil, esketamine, or lidocaine, especially the combination of propofol and esketamine, might reduce tussis incidence.

METHOD

The study will be performed as a randomised controlled three-blind, two-centre trial. Patients undergoing upper GI endoscopy, ≥ 18 years old, with American Society of Anesthesiologists (ASA) classification I-III will be randomised to four groups: P group (single administration of propofol), P + S group (administration of propofol and sufentanil in combination), P + K group (administration of propofol and esketamine in combination), and P + L group (administration of propofol and lidocaine in combination) (N = 100 per group). The primary endpoints include the frequency of tussis, nausea and vomiting, and/or body movements observed at the insertion of the endoscope into the pharyngeal cavity or within 5 min of endoscope insertion. Secondary outcomes are recovery assessment, patients' and endoscopists' satisfaction with the procedure, MMSE scores, MET scores, sleep condition, and the number of sedation-related events. Data on sedation-related events are collected by recording of vital signs. Satisfaction parameters and mental states are collected by means of questionnaires and evaluation scales before and after the procedure and on different following days.

DISCUSSION

Esketamine can reduce tussis occurrence with good tolerability and relax the bronchus and also provides high clearance rates and low possibility of adverse reactions. We aim to demonstrate that the combination of esketamine with propofol for sedation in patients subjected to upper GI procedure is nevertheless superior to only administration of propofol or a combination of propofol with other anaesthetics, such as opioids or lidocaine.

TRIAL REGISTRATION

ClinicalTrials.gov. NCT05497492 , Registered 09 August 2022.

Comparison of remimazolam-remifentanil and propofol-remifentanil during laparoscopic cholecystectomy

BACKGROUND

Remimazolam is a novel benzodiazepine with fast onset and short half-life. We compared the effects of remimazolam and propofol on recovery profiles for general anesthesia in patients undergoing laparoscopic cholecystectomy.

METHODS

We randomly assigned 108 patients to either a remimazolam (n=54) or propofol (n=54) group. Remimazolam and propofol were used for induction and maintanance of anesthesia. Following anesthesia, we recorded the time until an Aldrete score of 9 was achieved as the primary surrogate marker of complete recovery. The time to reach a Modified Observer's Assessment of Alertness/Sedation (MOAA/S) score of 2 and the time from the end of anesthesia to eye opening time, recovery time of orientation, time to spontaneous breathing, extubation time, and the time required for analgesics were measured. Heart rate, blood pressure, and bispectral index were assessed before, during, and after pneumoperitoneum.

RESULTS

We included 101 patients in the analysis. In the remimazolam group, it took longer to reach an Aldrete score of 9 after the drug infusion ended (P = 0.031). There was no difference in the time to reach MOAA/S 2 between the two groups. The time to eye opening, recovery time of orientation, and time required for analgesics were longer and heart rate was higher in the remimazolam group. Neither blood pressure, nor extubation time differed between groups.

CONCLUSIONS

Remimazolam and propofol provided safe induction and maintenance of anesthesia in patients undergoing laparoscopic cholecystectomy. The recovery time from anesthesia was longer than that with propofol. Fewer hemodynamic changes were observed with remimazolam, but further studies are needed.

Efficacy and safety of remimazolam-based sedation for intensive care unit patients undergoing upper gastrointestinal endoscopy: a cohort study

BACKGROUND

Remimazolam is a novel ultra-short-acting sedative, but its safety and adverse events (AEs) in high-risk patients in the intensive care unit (ICU) setting remain unknown.

METHODS

This was a single-center, retrospective study that compared remimazolam to propofol and midazolam in patients undergoing upper gastrointestinal endoscopy. The primary outcome was the incidence of treatment-related AEs. The secondary outcomes were the time to extubation, the length of ICU stay, and the average cost of sedative per case.

RESULTS

Of the 88 patients analyzed, 47 were treated with remimazolam (mean dose, 7.90±4.84 mg), and 41 were treated with propofol (21.19±17.98 mg) or midazolam (3.08±2.17 mg). There was no statistically significant difference in the average duration of the endoscopic procedure (35.89±13.37 min vs. 44.51±21.68 min, P=0.133) or the time to extubation (15.00±9.75 h vs. 20.59±18.71 h, P=0.211) in the remimazolam group (group I) compared to the propofol or midazolam group (group II). ICU stays (5.40±2.93 d vs. 4.63±3.31 d, P=0.072) and treatment-related AEs (48.61% vs. 51.38%, P=0.056) were similar between groups. The average cost of sedative per case was significantly lower in the group I than in the group II (RMB 16.07±10.58 yuan vs. RMB 24.37±15.46 yuan, P=0.016).

CONCLUSION

Remimazolam-based sedation was noninferior to the classic sedatives and had lower average cost per case, indicating that it may be used as a promising sedative for high-risk patients during endoscopic procedures in the ICU setting.

The median effective concentration of propofol in combination with different doses of esketamine during gastrointestinal endoscopy in adults

We designed a four-arm randomized controlled trial to investigate the median effective concentration (EC50) of propofol in combination with different doses of esketamine inducing appropriate depth of anaesthesia during gastrointestinal endoscopy in adults. One hundred patients aged 18-65 years planning for gastrointestinal endoscopy were divided into four groups randomly: esketamine 0, 0.15, 0.25 and 0.5 mg/kg groups (n = 25). Propofol doses followed the Dixon and Massey up-and-down method with different starting between groups. The primary endpoint was the EC50 of propofol. Secondary outcomes included the cumulative dose of propofol, the duration of the procedure, recovery time, and adverse effects. The EC50 (median, 95% confidence interval) of propofol was significantly less in the esketamine 0.5 mg/kg group compared with the esketamine 0, 0.15, and 0.25 mg/kg groups [1.34 (1.15, 1.54) vs. 3.48 (3.25, 3.71), 2.82 (2.58, 3.07), and 2.36 (2.11, 2.61), respectively; p < 0.001]. The total dose of propofol (mean ± SD) required for the whole procedure was significantly less in the esketamine 0.5 mg/kg group compared with the esketamine 0, 0.15, and 0.25 mg/kg groups [95.5 ± 43.1 vs. 277.4 ± 49.0, 207.8 ± 31.6, and 135.1 ± 27.7, respectively; p < 0.001]. The recovery time was significantly longer in esketamine 0 and 0.5 mg/kg group compared with other two groups (p < 0.001). More patients in the esketamine 0.5 mg/kg group experienced visual disturbance compared with the other groups (p = 0.016). Additionally, the incidence of hypotensionin the esketamine 0 mg/kg group after inducation was higher compared with other groups (p < 0.001). In summary, the administration of esketamine significantly and dose-dependently reduced the dose of propofol required to accomplish procedures.

Validity Analysis of Neck Circumference as a Screening Test for Hypoxia Occurrence in Patients Undergoing Sedative Endoscopy

This study was performed to check the validity of and propose a cutoff point for measuring the neck circumference for screening hypoxia occurrence in patients undergoing sedative endoscopy. Data were collected from 168 patients who visited the Endoscopy Center of G University Hospital between 27 April 2020 and 12 June 2020 to undergo sedative endoscopy. Hypoxia occurrences were measured using sleep questionnaires (STOP-BANG and Berlin questionnaires), and the neck circumference measurements of the patients were compared. Neck circumference as a predictor of hypoxia and its sensitivity and specificity according to the cutoff values were high; thus, it is a valid screening test for hypoxia in patients undergoing sedative endoscopy. The most appropriate cutoff values for sitting neck circumference and lying neck circumference in men were 40.5 and 40.3, respectively, and those for women were 35.3 and 35.8, respectively. Hypoxia can be predicted in patients undergoing sedative endoscopy by measuring their neck circumference.

Anesthesia for Advanced Endoscopic Procedures

The gastrointestinal endoscopy paradigm is rapidly changing, and technological advancements are largely responsible. In tandem, anesthesia providers are adapting to the changing needs and demands. The challenges are unique. Complications arising from the procedures are both routine, such as aspiration and hypoxia, and procedure specific, such as bleeding, pneumothorax, pneumopericardium, and pneumoperitoneum. It is crucial for the anesthesia provider to have a good understanding of the techniques employed by the endoscopist. A higher index of suspicion is also essential to diagnose and appropriately manage many of the complications. In this review, an effort is made to discuss both procedural aspects and anesthesia challenges. We hope that both endoscopists and anesthesia providers will benefit from this review.

Propofol Alone versus Propofol in Combination with Midazolam for Sedative Endoscopy in Patients with Paradoxical Reactions to Midazolam

Background/Aims

The efficacy of propofol in gastrointestinal endoscopy for patients with midazolam-induced paradoxical reactions remains unclarified. This study aimed to compare the efficacy and safety of propofol-based sedation in patients who previously experienced paradoxical reactions.

Methods

This was a prospective, single-blinded, randomized controlled pilot study. Participants with a history of paradoxical reactions to midazolam during a previous esophagogastroduodenoscopy were recruited and randomly assigned to group I (propofol monosedation) or group II (combination of propofol and midazolam). The primary endpoint was the occurrence of a paradoxical reaction.

Results

A total of 30 participants (mean age, 54.7±12.6 years; male, 19/30) were randomly assigned to group I (n=16) or group II (n=14). There were no paradoxical reactions in group I, but there were two in group II, without a significant difference (p=0.209). The mean dose of propofol was higher in group I than in group II (p=0.002). Meanwhile, the procedure and recovery times did not differ between groups.

Conclusions

Propofol-based sedation was safe and effective for patients who experienced paradoxical reactions to midazolam. However, caution is needed because few cases of paradoxical reaction again can happen in group II in which midazolam was readministered.

Factors influencing development of non-cardiac chest pain after endoscopic submucosal dissection for esophageal neoplasms: a retrospective case-control study of 309 patients from a single center

Endoscopic submucosal dissection (ESD) is widely used for early stage esophageal cancer and precancerous lesions. Non-cardiac chest pain (NCCP) is a frequent complication of ESD. However, little is known about its incidence and associated factors. This study investigated the pain incidence and predictive factors for pain development after ESD for esophageal neoplasms. We enrolled a total of 309 patients with esophageal neoplasms, who underwent ESD in our center from January 2018 to June 2019. Sociodemographic and clinicopathological information for all patients was collected, and patients were divided into either a pain-free group (n = 156) or a pain group (n = 153) according to whether there was onset of NCCP 24-48 hours after surgery. We made comparisons between groups using Student's t test or the χ2 test. Logistic-regression analysis was used to screen for risk factors. There were statistically significant differences in histories of previous surgery (P = 0.039), lesion size (P = 0.026), operation time (P = 0.009), and postoperative fever (P = 0.001). History of previous surgery (P = 0.043) and postoperative fever (P = 0.007) were independent risk factors for chest pain after esophageal ESD treatment. Chest pain and fever prolonged postoperative hospitalization time (P = 0.005, P = 0.001) and increased hospitalization cost (P = 0.034, P < 0.001). A history of previous surgery and postoperative fever was associated with the occurrence of NCCP after ESD in patients with esophageal neoplasms. NCCP and fever after esophageal ESD increased both hospitalization time and cost.

Factors Associated with Occurrence of Atelectasis during Sedation for Imaging in Pediatric Patients: A Retrospective Single Center Cohort Study

Sedation can induce atelectasis which may cause suboptimal image quality. This study aimed to identify factors associated with the occurrence of atelectasis during sedation for imaging in pediatric patients. Patients < 18 years who had undergone whole-body magnetic resonance imaging (MRI) under sedation with propofol or dexmedetomidine were included in this study. The development of atelectasis was visually and quantitatively assessed by coronal short tau inversion recovery images of the thoracic level. Multivariable logistic regression was performed to identify the independent factors associated with the development of atelectasis. Ninety-one patients were included in the analysis. In the multivariable analysis, administration of supplemental oxygen was the only factor significantly associated with the occurrence of atelectasis (adjusted odds ratio, 4.84; 95% confidence interval, 1.48-15.83; p = 0.009). Univariable analysis showed that the use of dexmedetomidine was associated with a lower incidence of atelectasis; however, this could not be verified in the multivariable analysis. Among the pediatric patients who had undergone imaging under sedation, additional oxygen supplementation was the only independent factor associated with atelectasis occurrence. A prospective clinical trial is required to identify the cause-effect relationship between oxygen administration and occurrence of atelectasis during sedation.

Effect of intravenous administration of lidocaine on the ED50 of propofol induction dose during gastroscopy in adult patients: A randomized, controlled study

WHAT IS KNOWN AND OBJECTIVE

Propofol provides a prominent sedation effect in gastroscopy. However, sedation with propofol alone during gastroscopy might result in circulatory and respiratory depression. This study aimed to test the hypothesis that the addition of intravenous lidocaine to propofol-based sedation could decrease the ED50 of propofol induction dose during gastroscopy in adult patients while the respiratory and haemodynamic stability were not compromised.

METHODS

Patients undergoing gastroscopy were randomly enrolled into lidocaine + propofol (L + P) group or normal saline + propofol (NS + P) group. Subjects were initially administered intravenous bolus of 1.5 mg/kg lidocaine in L + P group or equivalent volume of 0.9% saline in NS + P group. Anaesthesia was then induced with a single bolus of 1.0 μg sufentanil followed by injection of propofol in all patients. The induction dose of propofol for each individual patient was determined by the protocol of Dixon "up-and-down" method for both groups. The primary end point was the ED50 of propofol induction dose.

RESULTS

Totally, 48 patients were enrolled and completed this study. Compared with the NS + P group, the ED50 of propofol induction dose was significantly reduced in the L + P group (2.01 mg/kg vs. 1.69 mg/kg) (U = 61.5, p < 0.001).

WHAT IS NEW AND CONCLUSION

The addition of intravenous lidocaine significantly reduced the ED50 of propofol induction dose during gastroscopy in adult patients.

TRIAL REGISTRATION

The present clinical trial was registered at http://www.chictr.org.cn/ (registration No. ChiCTR1900024025, 23 June 2019).

Combination of propofol and dezocine to improve safety and efficacy of anesthesia for gastroscopy and colonoscopy in adults: A randomized, double-blind, controlled trial

BACKGROUND

Gastroscopy and colonoscopy are important and common endoscopic methods for the diagnosis and treatment of gastrointestinal and colorectal diseases. However, endoscopy is usually associated with adverse reactions such as nervousness, nausea, vomiting, choking cough, and pain. Severe discomfort, such as vomiting, coughing, or body movement, may lead to aggravation of a pre-existing condition or even interruption of examination or treatment, especially in some critically ill patients with physiological dysfunction (e.g., cardiovascular or respiratory disease). The optimal methods for inducing analgesia and sedation in endoscopy are areas of ongoing debate; nevertheless, determining an appropriate regimen of sedation and analgesia is important.

AIM

To evaluate the effects of propofol combined with dezocine, sufentanil, or fentanyl in painless gastroscopy and colonoscopy.

METHODS

Four hundred patients were randomly assigned to one of four groups for anesthesia: intravenous dezocine, sufentanil, fentanyl, or saline. Propofol was administered intravenously for induction and maintenance of anesthesia.

RESULTS

The dosage of propofol in the dezocine group was significantly lower than those in other groups (P < 0.01). Bispectral index and Steward score (0-6 points, an unresponsive, immobile patient whose airway requires maintenance to a fully recovered patient) after eye opening in the dezocine group were significantly higher than those in other groups (P < 0.01). Awakening time and postoperative pain score (0-10 points, no pain to unbearable pain) in the dezocine group were significantly lower than those in other groups (P < 0.01). Mean arterial pressure and pulse oxygen saturation in the dezocine group were significantly more stable at various time points (before dosing, disappearance of eyelash reflex, and wakeup) than those in other groups (P < 0.01). The rates of hypopnea, jaw thrust, body movements, and usage of vasoactive drugs in the dezocine group were significantly lower than those in other groups (P < 0.01). Additionally, the rates of reflex coughing, nausea, and vomiting were not statistically different between the four groups (P > 0.05).

CONCLUSION

The combination of propofol and dezocine can decrease propofol dosage, reduce the risk for the development of inhibitory effects on the respiratory and cardiovascular systems, increase analgesic effect, decrease body movement, shorten awakening time, and improve awakening quality.

Efficacy and safety of sedation during endoscopic submucosal dissection of gastric cancers using a comparative trial of propofol versus midazolam

BACKGROUND AND STUDY AIMS

Proper sedation is necessary for the safe and satisfactory completion of endoscopic submucosal dissection (ESD) for early gastric cancer. This study was conducted as a comparative trial of efficacy and safety, comparing propofol-based sedation and midazolam-based sedation during ESD of early gastric cancer patients.

PATIENTS AND METHODS

This study examined 64 lesions in 58 patients treated using ESD with midazolam plus pentazocine between July 2013 and January 2014 (group M) and 237 lesions in 216 patients treated by ESD using propofol plus pentazocine between February 2014 and December 2015 (group P). The two groups were compared in terms of the frequency of body movement during ESD as the primary outcome and in terms of the procedure time, en bloc resection rate, intraoperative change in cardiorespiratory dynamics, and postoperative awareness as the secondary outcomes. Body movement was defined as movement by a patient that required interruption of the procedure or restraint of the patient's body trunk, and addition of a sedative agent.

RESULTS

The median frequency of body movement during ESD was significantly lower in group P (0 times) than in group M (3 times) ( P  < 0.001). No significant difference was found for the mean procedure time (117 min in group P; 127 min in group M). Although no significant difference was found in the incidence of hypoxemia, bradycardia, or bradypnea, the incidence of hypotension was significantly higher in group P (31.5 %) than in group M (6.9 %) ( P  = 0.004). Patients in group P had significantly higher postoperative awareness immediately after ESD and at 1 hour after ESD ( P  = 0.002 and 0.022, respectively).

CONCLUSION

These results demonstrate the efficacy and safety of propofol-based sedation for gastric ESD.