Dexmedetomidine versus midazolam for conscious sedation in endoscopic retrograde cholangiopancreatography: An open-label randomised controlled trial

Moderate Sedation or Deep Sedation for ERCP: What Are the Preferences in the Literature?

One of the most essential procedures for individuals with biliopancreatic disorders is endoscopic retrograde cholangiopancreatography (ERCP). It is based on the combination of endoscopy and radiology to study the biliopancreatic ducts and apply therapeutic solutions. ERCP is currently used to treat choledocholithiasis with or without cholangitis, as well as pancreatic duct stones, benign bile, and pancreatic leaks. On the other hand, ERCP is an unpleasant procedure that must be conducted under anesthetic (moderate sedation, deep sedation, or general anesthesia). With procedures becoming more challenging, the role of anesthesia in ERCP has become even more relevant, and the use of general anesthesia has become better defined. In the last decades, many drugs have been used and some new drugs, like dexmedetomidine, have been recently introduced for sedation or anesthesia during ERCP. Moreover, the scientific community is still divided on the level of sedation to be applied, as well as on appropriate airway management. We therefore performed a narrative review of the literature to assess currently available anesthetic medications for elective ERCP and evidence supporting their effectiveness.

Safety and efficacy of dexmedetomidine vs. midazolam in complex gastrointestinal endoscopy: A systematic review and meta-analysis

OBJECTIVE

This study aims to perform a meta-analysis to evaluate the safety and efficacy of dexmedetomidine versus midazolam for complex digestive endoscopy procedures, with the goal of offering comprehensive clinical evidence.

METHODS

Following predefined inclusion criteria, five databases were systematically searched, with a focus on identifying randomized controlled trials (RCTs) that compared the administration of dexmedetomidine and midazolam during complex digestive endoscopy procedures. The statistical software Stata 15.1 was employed for meticulous data analysis.

RESULTS

Sixteen RCTs were encompassed, involving a total of 1218 patients. In comparison to the midazolam group, dexmedetomidine administration was associated with a reduced risk of respiratory depression (RR=0.25, 95 %CI: 0.11-0.56) and hypoxemia (RR=0.22, 95 %CI: 0.12-0.39). Additionally, the dexmedetomidine group exhibited lower incidence rates of choking (RR=0.27, 95 %CI: 0.16-0.47), physical movement (RR=0.16, 95 %CI: 0.09-0.27), and postoperative nausea and vomiting (RR=0.56,95 %CI: 0.34-0.92). Patients and endoscopists in the dexmedetomidine group reported higher levels of satisfaction (patient satisfaction: SMD=0.73, 95 %CI: 0.26-1.21; endoscopist satisfaction: SMD=0.84, 95 %CI: 0.24-1.44). The incidence of hypotension and anesthesia recovery time did not significantly differ between the two groups (hypotension: RR=1.73,95 %CI:0.94-3.20; anesthesia recovery time: SMD=0.02, 95 %Cl: 0.44-0.49). It is noteworthy that the administration of dexmedetomidine was associated with a significant increase in the incidence of bradycardia in patients.

CONCLUSION

Compared to midazolam, dexmedetomidine exhibits a favorable safety profile for use in complex gastrointestinal endoscopy by significantly reducing the risk of respiratory depression and hypoxemia. Despite this, dexmedetomidine is associated with a higher incidence of bradycardia. These findings underscore the need for further research through larger, multi-center studies to thoroughly investigate dexmedetomidine's safety and efficacy.

Dexmedetomidine as an Adjunct to Propofol in Patients Undergoing Elective Endoscopic Retrograde Cholangio-Pancreaticography - A Double-blind Randomized Controlled Study

Background

Propofol is the drug of choice for procedural sedation. The addition of α2 agonist dexmedetomidine may improve the safety profile of the procedure by providing stable hemodynamics, better sedation quality, and decreasing the side effects of each drug during elective endoscopic retrograde cholangio-pancreaticography (ERCP).

Materials and Methods

Eighty patients aged between 18 and 60 years were distributed randomly into two groups. The dexmedetomidine + propofol group (group DP) received an injection of dexmedetomidine at the dose of 1 mcg/kg in 100 mLsaline, and the propofol group (group P) received plain 100 mL normal saline over 10 min. Subsequently, both groups received a bolus dose of injection propofol 1 mg/kg as sedation, and a modified observer's assessment of alertness/sedation score (MOASS) score was assessed, followed by infusion at the rate of 50 mcg/kg/min during the procedure. A rescue bolus dose (20 mg) of propofol was administered when the patient showed signs of inadequate sedation or analgesia in both groups. Cardiovascular and respiratory parameters were recorded every 10 min throughout the procedure. Post-procedure modified Aldrete score was evaluated for 30 min, and the endoscopist's score was noted at the end of the procedure.

Results

There was a significant difference (P = 0.001) in the additional number of rescue doses of propofol administered in group DP (3.47 ± 0.77) as compared to group P (8.78 ± 1.11). The total dose of propofol was lower in group DP (316.59 ± 43.29 mg) than in group P (443 ± 41.1 mg) with P value = 0.001. Statistically significant differences in the hemodynamic values were observed in group DP during infusion (P value < 0.05) of dexmedetomidine and throughout the procedure (P < 0.05) when compared with group P. Endoscopists graded the satisfaction score as very high (3.477 ± 0.77) in group DP.

Conclusion

The addition of dexmedetomidine to propofol during ERCP provided better and safer sedation.

Efficacy and safety of sedation with dexmedetomidine in adults undergoing gastrointestinal endoscopic procedures: systematic review and meta-analysis of randomized controlled trials

Background: The sedative role of dexmedetomidine (DEX) in gastrointestinal endoscopic procedures is unclear. We performed this systematic review and meta-analysis to assess the efficacy and safety of sedation with DEX during gastrointestinal endoscopic procedures with a view to providing evidence-based references for clinical decision-making. Methods: The PubMed, Embase, Cochrane Library, Web of Science, and ClinicalTrials.gov databases were searched for randomized controlled trials (RCTs) that compared DEX with different sedatives comparators (such as propofol, midazolam, and ketamine) for sedation in a variety of adult gastrointestinal endoscopic procedures from inception to 1 July 2022. Standardized mean difference (SMD) and weighted mean difference (WMD) with 95% confidence interval (CI) or pooled risk ratios (RR) with 95% CI were used for continuous outcomes or dichotomous outcomes, respectively, and a random-effect model was selected regardless of the significance of the heterogeneity. Results: Forty studies with 2,955 patients were assessed, of which 1,333 patients were in the DEX group and 1,622 patients were in the control (without DEX) group. The results suggested that the primary outcomes of sedation level of DEX are comparable to other sedatives, with similar RSS score and patient satisfaction level, and better in some clinical outcomes, with a reduced risk of body movements or gagging (RR: 0.60; 95% CI: 0.37 to 0.97; p = 0.04; I2 = 68%), and a reduced additional requirement for other sedatives, and increased endoscopist satisfaction level (SMD: 0.41; 95% CI: 0.05 to 0.77; p = 0.03; I2 = 86%). In terms of secondary outcomes of adverse events, DEX may benefit patients in some clinical outcomes, with a reduced risk of hypoxia (RR:0.34; 95% CI: 0.20 to 0.55; p < 0.0001; I2 = 52%) and cough (RR: 0.25; 95% CI: 0.12 to 0.54; p = 0.0004; I2 = 0%), no significant difference in the risk of hypotension, while an increased risk of bradycardia (RR: 3.08; 95% CI: 2.12 to 4.48; p < 0.00001; I2 = 6%). Conclusion: This meta-analysis indicates that DEX is a safe and effective sedative agent for gastrointestinal endoscopy because of its benefits for patients in some clinical outcomes. Remarkably, DEX is comparable to midazolam and propofol in terms of sedation level. In conclusion, DEX provides an additional option in sedation for gastrointestinal endoscopic procedures. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/#searchadvanced.

A Comparison of the Sedative Effect of Dexmedetomidine and Midazolam on Patients Undergoing Gastrointestinal Endosonography Outside the Operating Room

Background

Patients may experience anxiety, discomfort, and pain during endoscopy, which cannot be tolerated without sedative drugs.

Objectives

This study aimed to compare the sedative effects of dexmedetomidine and midazolam on patients undergoing endosonography outside the operating room.

Methods

This randomized, double-blind clinical trial was conducted on 126 patients aged 18 - 65 years old with American Society of Anesthesiologists (ASA) physical status I - II undergoing elective endosonography. Patients were randomly divided into 2 groups. The dexmedetomidine group received dexmedetomidine (1 μg/kg) for 25 minutes with propofol (0.5 mg/kg) and fentanyl (1 μg/kg) at the start of the procedure. The midazolam group received midazolam (0.03 mg/kg) with propofol (0.5 mg/kg) and fentanyl (1 μg/kg). Heart rate, mean arterial pressure (MAP), and oxygen saturation (SpO2) were recorded before and 5, 10, and 15 minutes after starting the procedure. The Ramsay Sedation Scale (RSS) and the need for an additional dose of propofol were recorded during the procedure. The Numeric Pain Rating scale (Ambesh score) scores were recorded at the beginning, immediately after, and 1 hour after the procedure. Nausea and vomiting were assessed using the Visual Analogue Scale in cooperation with the patient.

Results

The dexmedetomidine group had significantly higher SpO2 and RSS scores during sedation than the midazolam group (P = 0.02). Overall, specialist satisfaction was higher in the dexmedetomidine group than in the midazolam group. There was no clinically significant difference in pain score and nausea and vomiting frequencies between the 2 groups.

Conclusions

Dexmedetomidine is more effective than midazolam for sedation during gastrointestinal endosonography.

A Perioperative Intervention to Prevent and Treat Emergence Delirium at a Veterans Affairs Medical Center

Emergence delirium (ED) is a temporary condition associated with a patient awakening from an anesthetic and/or adjunct agent (e.g., sedatives and analgesics). During the condition, patients risk harming themselves or staff by engaging in dangerous behavior, which may include thrashing, kicking, punching, and attempting to exit the bed/table. A multidisciplinary team at Veterans Affairs Pittsburgh Healthcare System (VAPHS) developed and implemented a multicomponent intervention to reduce the severity and occurrence of ED. The intervention consists of a training component and 21 clinical components. The 21 clinical components are implemented on a patient-by-patient basis and include routine screening for risk factors, enhanced communication among staff, adjusting the environment, following a specific medication strategy, and application of manual restraint (hands-on). The authors provide 15 online Supplemental Materials (S1–S15) to promote replication of the intervention. To our knowledge, this is the first manuscript that describes this type of multicomponent intervention in sufficient detail to allow others to replicate it. Following implementation of the intervention at VAPHS, perioperative staff reported that they observed a substantial reduction in the occurrence and severity of ED, ED-related patient and staff injuries, and ED-related loss of intravenous access and airway patency. Despite staff’s reported success of the intervention, rigorous research is needed to evaluate the efficacy of the intervention.

Online Supplement to “A Perioperative Intervention to Prevent and Treat Emergence Delirium at a Veteran Affairs Medical Center”

This supplementary material was provided by the authors to give readers additional information and resources to replicate their work.

Guidelines for sedation in gastroenterological endoscopy (second edition)

Sedation in gastroenterological endoscopy has become an important medical option in routine clinical care. Here, the Japan Gastroenterological Endoscopy Society and the Japanese Society of Anesthesiologists together provide the revised "Guidelines for sedation in gastroenterological endoscopy" as a second edition to address on-site clinical questions and issues raised for safe examination and treatment using sedated endoscopy. Twenty clinical questions were determined and the strength of recommendation and evidence quality (strength) were expressed according to the "MINDS Manual for Guideline Development 2017." We were able to release up-to-date statements related to clinical questions and current issues relevant to sedation in gastroenterological endoscopy (henceforth, "endoscopy"). There are few reports from Japan in this field (e.g., meta-analyses), and many aspects have been based only on a specialist consensus. In the current scenario, benzodiazepine drugs primarily used for sedation during gastroenterological endoscopy are not approved by national health insurance in Japan, and investigations regarding expense-related disadvantages have not been conducted. Furthermore, including the perspective of beneficiaries (i.e., patients and citizens) during the creation of clinical guidelines should be considered. These guidelines are standardized based on up-to-date evidence quality (strength) and supports on-site clinical decision-making by patients and medical staff. Therefore, these guidelines need to be flexible with regard to the wishes, age, complications, and social conditions of the patient, as well as the conditions of the facility and discretion of the physician.

Efficacy of combination therapy with dexmedetomidine for benzodiazepines-induced disinhibition during endoscopic retrograde cholangiopancreatography

BACKGROUND

Benzodiazepines (BZDs) and analgesics are widely used for conscious sedation during endoscopic ultrasound (EUS) or endoscopic retrograde cholangiopancreatography (ERCP). However, endoscopic procedures are sometimes discontinued because of BZD-induced disinhibitory reactions such as excessive movement. We evaluated the usefulness of dexmedetomidine (DEX) for BZD-induced disinhibition in ERCP.

METHODS

Between February 2018 and August 2019, 22 patients who underwent EUS or ERCP were enrolled. All patients showed BZD-induced excessive movement at the first examination (BZD group) and received DEX at the second examination (DEX group). The initial DEX dose was 6 μg/kg/h for a 10-min loading, followed by 0.4 μg/kg/h during the procedure. BZDs and analgesics were administered before scope insertion. An additional sedative was administered to achieve a Ramsay sedation scale (RSS) of 4-5. Sedative effect, procedure completion rate, and changes in circulatory and respiratory dynamics were evaluated.

RESULTS

Mean RSS scores were significantly higher (p < 0.001) in the DEX (5.1 ± 0.5) compared with the BZD (4.0 ± 0.5) group. The movement score (p < 0.001) and number of additional sedatives required (p < 0.01) were lower in the DEX group. The procedure completion rate was significantly higher in the DEX (95.5%) compared with the BZD group (63.6%; p < 0.05). Significant differences in the frequency of hypotension (p = 1.00), bradycardia (p = 0.22), and respiratory depression (p = 0.68) were not noted between groups.

CONCLUSIONS

The addition of DEX to BZD therapy yielded better sedative efficacy, lower excessive movement, a reduction in BZDs used, and a higher procedure complete rate. DEX may be used as an alternative method for BZD-induced inhibition during ERCP.

Psychomotor recovery of dexmedetomidine compared with propofol after sedation during spinal anesthesia: A randomized control trial

Background and Aims:

Early psychomotor recovery is an essential part of day care surgery which depends on brain integration of motor and sensory co-ordination. Even though dexmedetomidine is commonly used for day care procedures, the recovery profile was not studied. Hence, this study was designed to evaluate the psychomotor recovery of sedation with dexmedetomidine during spinal anesthesia.

Material and Methods:

Sixty-six patients were included. Group D received dexmedetomidine 0.5 μg/kg (loading dose) followed by 0.2–1 μg/kg/hour. Group P received propofol infusion of 25–100 μg/kg/minute. Psychomotor recovery was assessed by finger-tapping, manual dexterity, visual spatial memory capacity, and pen and paper tests. Psychomotor tasks were given to the patients postoperatively at every 30 minutes for 2 hours followed by every hour up to 4 hours after surgery. Distribution of patients, age, weight, duration of surgery, and the level of sensory blockade was compared using independent t-test. Student's t-test has been used to find the significance of parameters such as heart rate, mean arterial pressure, oxygen saturation (SpO₂), psychomotor recovery between two groups. P < 0.05 was considered as significant.

Results:

The motor recovery using finger tapping test was faster in Group D than Group P (73.94 ± 42.13 vs 101.21 ± 37.98 minutes, P–value = 0.007). Motor recovery using peg board test was faster in Group P than Group D (82.12 ± 40.37 vs 99.39 ± 43.08 minutes, P–value = 0.098). Visual spatial capacity memory test and pen and paper test were unaffected.

Conclusions:

We conclude that patients who received dexmedetomidine showed earlier recovery with finger tapping test. Hence, we suggest to use dexmedetomidine for complete psychomotor recovery and fast-track discharging of the patient after spinal anesthesia.

A Comparative Study of Midazolam Alone or in Combination with Dexmedetomidine or Clonidine for Awake Fiberoptic Intubation

Background:

Awake fiberoptic intubation (AFOI) is the gold standard technique for managing patients with anticipated difficult airway. Conscious sedation is desirable, not only to make the procedure more tolerable and comfortable for the patient but also to ensure optimal intubating conditions. Ideal sedation regime for AFOI should provide comfort, cooperation, hemodynamic stability, and amnesia along with maintenance of spontaneous respiration. Several sedative agents have been assessed over the past two decades for this purpose but α2 agonists appear to be the favorable choice owing to its sedative, analgesic, amnestic, and sympatholytic properties along with good hemodynamic profile.

Aims:

The present study has been aimed to recognize the characteristics of dexmedetomidine, clonidine, and midazolam and to compare their efficacy in providing optimal intubating conditions as well as hemodynamic stability during AFOI.

Settings and Design:

A prospective double-blind randomized study done in tertiary care hospital.

Materials and Methods:

Sixty patients of American Society of Anesthesiologists physical status Classes I and II aged 18–60 years with anticipated difficult airway were randomly allocated into three groups. All the patients received injection midazolam bolus followed by sedation infusion of midazolam, dexmedetomidine, and clonidine according to the allocated group. Primary outcome includes the time to achieve Ramsay Sedation Score (RSS) ≥2, time taken in intubation, intubation score, comfort score for fiberoptic insertion and intubation, and patient tolerance after intubation. The secondary outcome was hemodynamic, and respiratory variables include changes in heart rate (HR), mean arterial pressure (MAP), oxygen saturation (SpO₂), and respiratory rate during the procedure.

Statistical Analysis:

All data were recorded, summarized, tabulated, and statistically analyzed using SPSS 16.0 version (Chicago, Inc., USA). The data were presented in mean ± standard deviation. P < 0.05 was considered as statistically significant.

Results:

All the three groups were comparable in terms of demographic profile. Time to achieve RSS ≥2 and mean intubation time was significantly less in Groups D and C as compared to Group M (P < 0.001). Among groups, Group D took least time to achieve RSS ≥2 (5.53 ± 0.74) and mean intubation time (4.53 ± 0.91). Similarly, overall intubation score, comfort, and patient tolerance score were significantly more in Group M as compared to Groups D and C (P < 0.001). Among the groups, Group D achieved least intubation score (3.80 ± 0.67) and comfort score (2.53 ± 0.74). Although Groups D and C have a lower mean HR and MAP during the procedure and intubation compared to Group M, the incidence of SpO₂ is most frequent with clonidine.

Conclusions:

Patients who received α2 agonist were calmer and cooperative with less pain and discomfort than the patients who received midazolam. Dexmedetomidine allows better endurance, stable hemodynamics, and patent airway as compared to clonidine.

A Comparison of Stress Response between Insertion of Gastro-laryngeal Tube and Endotracheal Intubation in Patients Undergoing Upper Gastrointestinal Endoscopic Procedures for Endoscopic Retrograde Cholangiopancreatography

BACKGROUND

Complex gastrointestinal (GI) endoscopic procedures like endoscopic retrograde cholangiopancreatography (ERCP) require deep sedation or general anesthesia. Comorbidities with the poor physiological condition warrant endotracheal intubation to prevent hypoxia and aspiration. The gastro-laryngeal tube (GLT), a new supraglottic airway device with a separate channel for endoscope looks promising.

AIMS

The aim of the study is to compare the stress response during insertion of GLT and endotracheal intubation (ETT) in patients undergoing upper GI endoscopic procedures like ERCP.

SUBJECTS AND METHODS

This control versus comparison study comprised two groups with 30 patients each who underwent ETT and GLT insertion. The standard general anesthesia technique was used. In GLT group, the device was inserted without neuromuscular blocker. In ETT group, injection atracurium 0.5 mg/kg intravenous was administered as muscle relaxant for aiding endotracheal intubation. Hemodynamic parameters and time taken for the insertion of GLT/ETT were recorded.

STATISTICAL ANALYSIS

Data were analyzed using SPSS version 20. Student's t-test was used to compare quantitative data between the groups. ANOVA test was applied for intragroup comparisons between GLT and ETT groups. Categorical variables were analyzed using the Chi-square test.

RESULTS

Heart rate and mean arterial pressure increased from baseline in ETT group, following laryngoscopy and endotracheal intubation as well as with GLT insertion. However, the stress response caused by endotracheal intubation was significantly greater than that caused by GLT insertion.

CONCLUSION

GLT as an airway device is a safe alternative with decreased stress response compared to endotracheal intubation for upper GI endoscopy procedures.

Comparative Evaluation of Dexmedetomidine versus Midazolam as Premedication to Propofol Anesthesia in Endoscopic Retrograde Cholangiopancreatography

Background:

Endoscopic retrograde cholangiopancreatography (ERCP) is used to diagnose and treat pancreaticobiliary diseases. It is a potentially uncomfortable procedure that needs to be performed under conscious sedation. Safe and effective sedation protocol is the need of an hour.

Aims:

This study aims to evaluate the requirement of propofol using midazolam and dexmedetomidine as premedication for ERCP. The degree of comfort experienced by endoscopist and the patients was also assessed.

Materials and Methods:

A total of sixty patients were enrolled in a randomized, assessor-blinded study in the age group of 40–80 years, American Society of Anesthesiologists physical class II–III undergoing elective ERCP procedures. They were divided into two groups of 30 each. Group D (n = 30): Dexmedetomidine (100 μg/mL + 18 mL saline) loading dose at 1 μg/kg intravenous (IV) over 10 min followed by 0.5 μg/kg/h infusion, and Group M (n = 30): Midazolam at 0.05 mg/kg IV bolus over 10 min followed by normal saline infusion under hemodynamic monitoring. Satisfaction scores, total propofol requirement, and complications such as gagging, restlessness, agitation, postoperative nausea and vomiting were noted and analyzed statistically.

Statistical Analysis:

Statistical analysis was performed using SSPS 17.0 software (SPSS Inc., 233 South Wacker Drive, Chicago, USA). The Chi-square test was applied for nonparametric data and parametric numerical data, unpaired t-test for intergroup comparison, and repeated measures ANOVA for intragroup comparison. Results were expressed as a mean ± standard deviation. Value of P < 0.05 was considered statistically significant and <0.001 as highly significant.

Results:

Surgeons and patients were more satisfied and comfortable along with less requirement of propofol in the dexmedetomidine group. The incidence of complications was also less in the dexmedetomidine group as compared to that of midazolam group.

Conclusion:

Both dexmedetomidine and midazolam can be safely administered as an anesthetic adjuvant to propofol for short procedures like ERCP's. Dexmedetomidine provided intense and better sedation quality along with lesser requirement of propofol doses. Moreover, it provided stable hemodynamic conditions and good recovery characteristics as compared to midazolam group.

Effect of different doses of dexmedetomidine on hemodynamic and respiratory parameters in elderly patients undergoing endoscopic retrograde cholangiopancreatography

AIM

To investigate the effect of different doses of dexmedetomidine on hemodynamic and respiratory parameters in elderly patients undergoing endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

From August 2015 to July 2017, 104 elderly patients who underwent ERCP at our hospital were randomly divided into a control group (n = 26), a low-dose group (n = 26), a middle-dose group (n = 26), and a high-dose group (n = 26). The control group was given fentanyl, and the low-, middle-, and high-dose groups were intravenously injected with dexmedetomidine at 0.4, 0.7, and 1 μg/kg, respectively. Propofol dosage, operative time, time to recovery, hemodynamic and respiratory parameters [respiratory rate (RR), heart rate (HR), diastolic blood pressure (DBP), and systolic blood pressure (SBP)] at different time points [preoperative (T0), fentanyl or dexmedetomidine infusion completion (T1), duodenal endoscopy into the esophagus (T2)], serum cortisol (Cor) level, and incidence of adverse reactions in the four groups were recorded.

RESULTS

There was a significant difference in the dosage of propofol among the four groups (P < 0.05). There was no significant difference in operative time or time to recovery among the four groups. In the middle-dose group, the dosage of propofol was less than those of the other groups (P < 0.05). There was no significant difference in DBP, SBP, HR, or RR at T0 among the four groups, but there was a significant difference among the four groups in DBP, SBP, HR, and RR at T1 and T2 (P < 0.05); the amplitude of each index in the middle-dose group was significantly lower than that of the other groups (P < 0.05). There was no significant difference in the levels of serum Cor among the four groups at T0, but there was a significant difference in serum Cor levels among the four groups at T1 and T2 (P < 0.05). The increase of serum Cor in the middle-dose group was significantly smaller than that of the other groups (P < 0.05). There was a significant difference in the incidence of adverse reactions among the four groups (P < 0.05), and the incidence of adverse reactions in the control group was higher than that of the other three groups (P < 0.05).

CONCLUSION

Anesthesia with a moderate dose of dexmedetomidine in ERCP can reduce the dosage of propofol, has no impact on operative time and time to recovery, and can avoid the influence on hemodynamics and respiratory conditions in elderly patients, with little stress response, few adverse reactions, and high safety.

Dexmedetomidine provides less body motion and respiratory depression during sedation in double-balloon enteroscopy than midazolam

Objectives:

Patients undergoing double-balloon enteroscopy require sedatives such as midazolam; however, patient’s body motion often hampers the outcome of double-balloon enteroscopy. Recently, dexmedetomidine has been used for endoscopic sedation and was reported to effectively reduce body motion. This study aimed to evaluate the efficacy and safety of sedation with dexmedetomidine in double-balloon enteroscopy (UMIN ID000015785).

Methods:

A prospective, observational study was conducted in 81 patients who underwent 111 double-balloon enteroscopy from July to December 2015 (dexmedetomidine group). The medical records of 112 patients who underwent 166 double-balloon enteroscopy with midazolam and pentazocine sedation from January 1 to October 31, 2014, were used for comparison (midazolam group). After propensity score matching, 182 double-balloon enteroscopy (91 double-balloon enteroscopy for each group) were analyzed.

Results:

There were 13 cases (11.7%) with body movements in the dexmedetomidine group. Comparison of the two groups matched by propensity score showed that the dexmedetomidine group had less body movement (12.1% vs 34.1%, p = 0.001) and less respiratory depression (50.5% vs 68.1%, p = 0.023). Hypotension (8.8% vs 4.4%, p = 0.232) and bradycardia (2.2% vs 0%, p = 0.497) were not significantly different in the two groups.

Conclusion:

Using dexmedetomidine for conscious sedation can reduce body motion and respiratory depression compared to our previous records.

Efficacy of Dexmedetomidine as a Sole Sedative Agent in Small Diagnostic and Therapeutic Procedures: A Systematic Review

Dexmedetomidine is an upcoming agent with sedative, anxiolytic, and analgesic properties. This review summarizes empirical evidence for the efficacy of dexmedetomidine as a sole sedative agent, and its effectiveness for small diagnostic and therapeutic procedure, in comparison with other frequently used sedatives. All randomized controlled trials on the effect of dexmedetomidine were reviewed. Pain level, patient satisfaction, operator satisfaction, procedure duration, recovery time, and hemodynamic and respiratory characteristics were examined. A total of 1993 patients (1,621 adults; 372 children) from 35 studies were included. In the adult studies, dexmedetomidine yielded significantly lower pain levels compared to the other sedatives (in 31.25% of the included studies) and significantly more patient satisfaction (68.2%). In studies on children, more favorable results concerning respiratory safety and the level of adequate sedation were found compared to the control sedatives. Implications for future studies are discussed.

Comparison of pain experience during 23-G vitreoretinal surgery under topical and retrobulbar anesthesia

The objective of this study is to compare pain and discomfort scores of patients during 23-G vitreoretinal surgery under topical and retrobulbar anesthesia without using sedation. A total of 157 patients with various vitreoretinal disorders were included in this study. Patients were randomly divided into two groups: topical (group 1, n = 76) and retrobulbar anesthesia (group 2, n = 81). Patients underwent 23-G vitreoretinal surgery without using sedation. All patients rated the level of experienced pain during the surgical procedure using a visual analogue pain scale. Pain and discomfort scores while performing anesthesia were significantly higher in group 2 than group 1 (p < 0.001). Patients in group 1 experienced more pain than group 2 during trocar insertion, endolaser photocoagulation, and scleral indentation steps of surgery (for all; p < 0.001). There was no significant difference in overall pain and discomfort scores and surgeon comfort scores between groups (p = 0.163, p = 0.097; respectively). None of the patients required additional anesthesia or sedation during or after the procedure. Topical anesthesia without using sedation is a safe and effective, alternative method for 23-G vitreoretinal surgeries in selected patients with various vitreoretinal pathologies.

Sedation during endoscopic retrograde cholangiopancreatography: a randomized controlled study of patient-controlled propofol sedation and that given by a nurse anesthetist

OBJECTIVE

Different regimens are used for sedation during endoscopic retrograde cholangiopancreatography (ERCP). Our objectives were to compare safety, ease of treatment, recovery, and patients' experiences using patient-controlled sedation (PCS) with propofol, nurse anesthetist-controlled sedation (ACS), or the department's standard of care, midazolam given by the procedure team (control group).

MATERIAL AND METHODS

The study included 281 adults in 301 procedures. The PCS group (n = 101) delivered bolus doses of 5 mg of propofol according to their need for sedation. The ACS group (n = 100) had 2-8 mg/kg/h of propofol infused, with the target for sedation being level 3 of the Observer's Assessment of Alertness/Sedation (OAA/S) scale. The control group was given 2-3 mg of midazolam for induction and additional 1 mg if required.

RESULTS

PCS and ACS increased the ease of the procedure and reduced the number of sedation failures compared to midazolam sedation (ACS n = 0; PCS n = 4; midazolam n = 20). The ACS group had more deeply sedated patients (OAA/S level 2), desaturation, and obstructed airways than the PCS and midazolam groups. Time to full recovery (Aldrete score ≥9) was shortest following PCS. PCS resulted in the least fatigue and pain after the procedure. Patients' preference for PCS and ACS was the same.

CONCLUSION

PCS with propofol is superior to midazolam and comparable to ACS. PCS resulted in a rapid recovery, fewer respiratory events, and was almost as effective as ACS in ensuring a successful examination.

Dexmedetomidine in gastrointestinal endoscopic procedures

Gastrointestinal endoscopy is the gold standard in the examination and the treatment of the diseases of gastrointestinal system, but the disadvantage of being painful process. At this point the sedative and analgesic agents may be important. Dexmedetomidine is a new sedoanalgesic agent which is alternative to benzodiazepines and opioids. It has analgesia, amnesia, sedative and anxiolytic properties. The use of dexmedetomidine as the sole anesthetic agent and as the adjuvant analgesic agent has been published but has not been approved because of the inconsistency of efficacy and safety. The author has been collected the published papers in the literature. This article is aimed to describe the use of dexmedetomidine in various gastrointestinal endoscopic procedures.

Comparative evaluation of two different loading doses of dexmedetomidine with midazolam-fentanyl for sedation in vitreoretinal surgery under peribulbar anaesthesia

Background and Aims:

Midazolam-fentanyl (MDZ:FEN) combination has been routinely used for intravenous sedation in ophthalmic surgeries. Dexmedetomidine (DEX), a recent α₂ adrenoreceptor agonist indicated for sedation for ophthalmic use at a loading dose of 0.5 μg/kg over 10 min, can cause deeper plane of sedation and surgeon dissatisfaction. Therefore, we proposed to evaluate the efficacy and safety of two different loading doses of DEX.

Methods:

In a prospective study, 60 patients aged 50-70 years, scheduled for retinal surgery under peribulbar block were divided equally to receive either MDZ:FEN or DEX 0.5 μg/kg (DEX full) or DEX 0.25 μg/kg (DEX half) loading dose over 10 min followed by titrated maintenance dose of DEX 0.25-0.4 μg/kg/h. Vital parameters, level of sedation (Ramsay Sedation Scale 1–6), effect on respiration and surgeon satisfaction were assessed at regular intervals. Surgeon satisfaction score (0–3) was noted.

Results:

‘DEX half’ group patients had predominantly stable haemodynamics, level 3 sedation and surgeon satisfaction score of 2–3 (good to excellent operating conditions). This group had no vomiting and no respiratory depression. ‘DEX full’ group had a higher incidence of bradycardia, hypotension, level 4 sedation (Ramsay Sedation Scale) and lower surgeon satisfaction. Incidence of nausea and vomiting was higher in MDZ:FEN group compared to other two groups.

Conclusion:

DEX 0.25 μg/kg loading dose over 10 min followed by titrated maintenance dose is an effective alternative to MDZ:FEN and provides controlled (level 3) sedation and stable haemodynamics maximising surgeon satisfaction. Avoiding narcotic analgesics with its associated post-operative nausea and vomiting is an additional benefit.

Dexmedetomidine versus midazolam for sedation during endoscopy: A meta-analysis

Patients undergoing endoscopy frequently require sedation, which commonly includes the administration of midazolam or dexmedetomidine. Previous meta-analyses have mainly focused on comparing the effects of these two drugs in intensive care unit patients. In the present study, randomized controlled trials (RCTs) that compared the sedative and clinical effectiveness of these two drugs in patients undergoing endoscopy were searched in a number of databases. The meta-analysis showed that dexmedetomidine demonstrated a significantly lower rate of respiratory depression and adverse events compared with those presented upon midazolam administration. A significant difference was also observed in the sedation potency of the sedatives. The current controlled data suggest that dexmedetomidine may be an alternative to midazolam in the sedation for endoscopy. However, more high-quality and well-designed studies are required to further evaluate this conclusion.

Efficacy of dexmedetomidine on postoperative nausea and vomiting: a meta-analysis of randomized controlled trials

PURPOSE

Postoperative nausea and vomiting (PONV) is a frequent complication in postoperative period. The aim of the current meta-analysis was to assess the efficacy of dexmedetomidine on PONV.

METHODS

Two researchers independently searched PubMed, Embase and Cochrane Central Register of Controlled Trials for randomized controlled trials (RCTs). The meta-analysis was performed with Review Manager.

RESULTS

Eighty-two trials with 6,480 patients were included in this meta-analysis. Dexmedetomidine reduced postoperative nausea (Risk Ratio (RR) = 0.61, 95% confidence interval (CI): 0.50 to 0.73) and vomiting (RR = 0.48, 95% CI: 0.36 to 0.64) compared with placebo, with an effective dose of 0.5 ug/kg (RR = 0.46, 95% CI: 0.34 to 0.62) and 1.0 ug/kg (RR = 0.29, 95% CI: 0.12 to 0.75), respectively. The antiemetic effect can only be achieved intravenously, not epidurally or intrathecally. The efficacy of dexmedetomidine was similar to that of widely used agents, such as propofol, midazolam etc., but better than opioid analgesics. Moreover, application of dexmedetomidine reduced intraoperative requirement of fentanyl (Standard Mean Difference = -1.91, 95% CI: -3.20 to -0.62).

CONCLUSIONS

The present meta-analysis indicates that dexmedetomidine shows superiority to placebo, but not to all other anesthetic agents on PONV. And this efficacy may be related to a reduced consumption of intraoperative opioids.

Efficacy of dexmedetomidine on postoperative nausea and vomiting: a meta-analysis of randomized controlled trials

PURPOSE

Postoperative nausea and vomiting (PONV) is a frequent complication in postoperative period. The aim of the current meta-analysis was to assess the efficacy of dexmedetomidine on PONV.

METHODS

Two researchers independently searched PubMed, Embase and Cochrane Central Register of Controlled Trials for randomized controlled trials (RCTs). The meta-analysis was performed with Review Manager.

RESULTS

Eighty-two trials with 6,480 patients were included in this meta-analysis. Dexmedetomidine reduced postoperative nausea (Risk Ratio (RR) = 0.61, 95% confidence interval (CI): 0.50 to 0.73) and vomiting (RR = 0.48, 95% CI: 0.36 to 0.64) compared with placebo, with an effective dose of 0.5 μg/kg (RR = 0.46, 95% CI: 0.34 to 0.62) and 1.0 μg/kg (RR = 0.29, 95% CI: 0.12 to 0.75), respectively. The antiemetic effect can only be achieved intravenously, not epidurally or intrathecally. The efficacy of dexmedetomidine was similar to that of widely used agents, such as propofol, midazolam etc., but better than opioid analgesics. Moreover, application of dexmedetomidine reduced intraoperative requirement of fentanyl (Standard Mean Difference = -1.91, 95% CI: -3.20 to -0.62).

CONCLUSIONS

The present meta-analysis indicates that dexmedetomidine shows superiority to placebo, but not to all other anesthetic agents on PONV. And this efficacy may be related to a reduced consumption of intraoperative opioids.

A comparison of propofol vs. dexmedetomidine for sedation, haemodynamic control and satisfaction, during esophagogastroduodenoscopy under conscious sedation

WHAT IS KNOWN AND OBJECTIVE

Esophagogastroduodenoscopy (EGD) is a common diagnostic procedure which requires sedation for most patients. We undertook a prospective, randomized, double-blinded study to compare the effect of propofol vs. dexmedetomidine on the sedation of outpatients during EGD.

METHODS

Prior to the procedure, outpatients received either propofol at 0·6 mg/kg, with additional doses of 10-20 mg until the Observer's Assessment of Alertness/Sedation Scale (OAA/S) score reached 2-4, or dexmedetomidine at a loading dose of 1 μg/kg over a 10-min period followed by a 0·5 μg/kg/h infusion until the OAA/S score reached 2-4. Vital signs, sedation level, adverse events, patients' and endoscopist's satisfaction score, and an evaluation of the recovery time were assessed.

RESULTS AND DISCUSSION

Negligible haemoglobin oxygen saturation (SpO2 ) and respiratory rate variations were observed in both groups, although respiratory depression occurred in two cases (5·9%) in the propofol group. Mean arterial pressure (MAP) in the propofol group decreased during the procedure compared with baseline (P < 0·05) and was also lower in comparison with the dexmedetomidine group (P < 0·05). Heart rate (HR) decreased after the loading dose in the dexmedetomidine group (P < 0·05). More patients in the propofol group underwent deeper sedation at the beginning of the procedure (P < 0·05), although the recovery time was comparable between the two groups (P > 0·05). Three cases (9·1%) in the dexmedetomidine group were delayed because of dizziness, bradycardia and nausea. There was a higher satisfaction score among patients in the propofol group (P < 0·05), although the endoscopist's satisfaction score was comparable between the two groups (P > 0·05).

WHAT IS NEW AND CONCLUSION

Propofol and dexmedetomidine provide a relatively satisfactory level of sedation without clinically notable adverse effects during EGD. In addition, patients preferred propofol administration for the deeper sedation and rapid recovery, and dexmedetomidine exhibited minimal adverse effects on respiratory function.

Comparison of dexmedetomidine and propofol used for drug-induced sleep endoscopy in patients with obstructive sleep apnea syndrome

Backround: Surgical operations are alternative treatments in persons with Obstructive Sleep Apnea Syndrome who cannot tolerate continuous positive airway pressure therapy. Drug-Induced Sleep Endoscopy is a method with which somnolence is pharmacologically induced and collapse is evaluated through nasal endoscopy in patients with Obstructive Sleep Apnea Syndrome.

AIMS

We aimed to evaluate efficiency of dexmedetomidine or propofol used for sedation in patients undergoing drug-induced sleep endoscopy.

METHODS

A total of 40 patients aged between 18 and 65 years old in the ASA STATUS I-II group were included in the study. After premedicatıon wıth midazolam 0.05 mg/kg intravenously, patients were randomly divided into two groups and administered intravenous (iv) propofol with the loading dose of 0.7 mg/kg for 10 minutes, followed 0.5 mg/kg/h infusion (Group P); or dexmedetomidine with the loading dose of 1 mcg/kg for 10 minutes, followed by 0.3 mcg/kg/h infusion (Group D). Haemodynamic and respiratuary parameters, Bispectral index score, Ramsey sedation score, time to achieve sufficient sedation, surgeon's and patients' satisfaction, postoperative Aldrete score and side effects were recorded.

RESULTS

Time to achieve sufficient sedation, Bispectral index scores at 5, 10 and 15th. minutes intraoperatively, first Aldrete score in the recovery room, SpO2 values and respiratory rates all over the surgical procedure and in the recovery room were found lower in Group P (P<0.05). Bispectral index scores, mean arterial pressure and heart rate in the recovery room were significantly lower in Group D (P<0.05).

CONCLUSION

Dexmedetomidine may be preferred as a safer agent with respecting to respiratory function compared with propofol in obstructive sleep apnea patients who known to be susceptible to hypoxia and hypercarbia.

Dexmedetomidine versus midazolam for gastrointestinal endoscopy: a meta-analysis

BACKGROUND AND AIM

Patients who undergo gastrointestinal endoscopy often require sedatives such as midazolam and the more recently developed alpha-2 agonist, dexmedetomidine. To assess the efficacy and safety of dexmedetomidine sedation for gastrointestinal endoscopy, we conducted a systematic review and meta-analysis of randomized controlled trials comparing dexmedetomidine with midazolam.

METHODS

We searched PubMed, the Cochrane library, and the Igaku-chuo-zasshi database in order to identify randomized trials eligible for inclusion in our meta-analysis. Data from the eligible studies were combined to calculate pooled odds ratios (OR) or weighted mean differences (WMD).

RESULTS

We identified nine randomized trials from the database search. Compared to that of midazolam, the pooled OR for restlessness of dexmedetomidine was 0.078 (95% confidence interval [CI]: 0.013-0.453, P < 0.0001), and there was no significant heterogeneity among the trial results. Dexmedetomidine significantly increased Ramsay sedation score compared with midazolam (WMD: 0.401, 95% CI: 0.110-0.692, P = 0.0069), without significant heterogeneity. Compared with midazolam, the pooled OR for hypoxia, hypotension, and bradycardia with dexmedetomidine sedation were 0.454 (95% CI: 0.098-2.11), 1.370 (95% CI: 0.516-3.637), and 2.575 (95% CI: 0.978-6.785), respectively, with no significant differences detected between the groups.

CONCLUSION

This meta-analysis shows that dexmedetomidine is a safe and effective sedative agent for gastrointestinal endoscopy, especially endoscopic retrograde cholangiopancreatography and endoscopic submucosal dissection.