Cardiopulmonary safety of propofol versus midazolam/meperidine sedation for colonoscopy: a prospective, randomized, double-blinded study

Patient Safety during Propofol Sedation before and after Implementation of Capnography Monitoring

Endoscopic procedures are routinely applied to cancer screening programs and surveillance. The preferred technique is usually deep sedation with propofol being a convenient agent allowing for a quicker patient recovery while maintaining a similar safety profile compared to traditional agents. However, adverse events, including respiratory depression and consequent undesirable cardiovascular side effects, may occur. The goal of this work is to evaluate the patient safety impact of adding capnography during endoscopic procedures under deep propofol sedation. Data were retrospectively collected from patients undergoing deep, procedural sedation for gastrointestinal (GI) endoscopy in October 2019 to January 2021 in a single Turkish university hospital. Included in the analysis were all adult patients classified by the American Society of Anesthesiologists (ASA) as I-IV, who were scheduled for GI endoscopy utilizing propofol alone or in combination. Data on 1840 patients were collected, of whom 1610 (730 pre- and 880 post-capnography implemention) met inclusion criteria. The primary outcome was a change in the composite incidence of mild oxygen desaturation (SpO2 75-90% for <60 s), severe oxygen desaturation (SpO2 < 75% anytime or <90% for >60 s), bradycardia (<60 ppm), and tachycardia (>25% from baseline). Without capnography, on average, 7.5 events of the primary endpoint were observed per 100 procedures and 2.9 with additional capnography monitoring (p < 0.001). A significant reduction was observed for mild oxygen desaturation, with a resulting odds ratio of 0.25 (95% CI 0.14 to 0.46). ASA I patients had the highest difference in combined incidence of any oxygen desaturation of 5.85% in the pre-capnography group and 0.64% in the post-capnography group. Although procedural sedation using propofol is not associated with severe adverse events, the incidence of composite adverse events could be reduced with the addition of capnography monitoring.

Hypotension during propofol sedation for colonoscopy: an exploratory analysis

BACKGROUND

Intraoperative and postoperative hypotension occur commonly and are associated with organ injury and poor outcomes. Changes in arterial blood pressure (BP) during procedural sedation are not well described.

METHODS

Individual patient data from five trials of propofol sedation for colonoscopy and a clinical database were pooled and explored with logistic and linear regression. A literature search and focused meta-analysis compared the incidence of hypotension with propofol and alternative forms of procedural sedation. Hypotensive episodes were characterised by the original authors' definitions (typically systolic BP <90 mm Hg).

RESULTS

In pooled individual patient data (n=939), 36% of procedures were associated with episodes of hypotension. Longer periods of propofol sedation and larger propofol doses were associated with longer-lasting and more-profound hypotension. Amongst 380 patients for whom individual BP measurements were available, 107 (28%) experienced systolic BP <90 mm Hg for >5 min, and in 89 (23%) the episodes exceeded 10 min. Meta-analysis of 18 RCTs identified an increased risk ratio for the development of hypotension in procedures where propofol was used compared with the use of etomidate (two studies; n=260; risk ratio [RR] 2.0 [95% confidence interval: 1.37-2.92]; P=0.0003), remimazolam (one study; n=384; RR 2.15 [1.61-2.87]; P=0.0001), midazolam (14 studies; n=2218; RR 1.46 [1.18-1.79]; P=0.0004), or all benzodiazepines (15 studies; n=2602; 1.67 [1.41-1.98]; P<0.00001). Hypotension was less likely with propofol than with dexmedetomidine (one study; n=60; RR 0.24 [0.09-0.62]; P=0.003).

CONCLUSIONS

Hypotension is common during propofol sedation for colonoscopy and of a magnitude and duration associated with harm in surgical patients.

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.

Intravenous Midazolam as More Effective Than Propofol for Preventing Pruritus After Intrathecal Sufentanil in Surgical Patients: A Randomized Blinded Trial

Background

Pruritus is a troublesome side effect of intrathecal opioids. Midazolam can reinforce GABA-mediated inhibition of the medullary dorsal horn neurons, and thus theoretically has potential to suppress opioid-induced pruritus.

Objectives

This prospective double-blinded randomized trial aimed at comparing the effects of propofol, midazolam, and a combination of the two on the prevention of pruritus induced by intrathecal sufentanil.

Methods

Eighty-four patients undergoing spinal anesthesia with 3 mL hyperbaric bupivacaine 0.5% and 5 μg sufentanil (1 mL) were randomly allocated to one of the three study groups: Group 1, who were administered 20 mg intravenous (IV) propofol bolus, then 50 μg/kg/min IV infusion; Group 2, who were administered 0.03 mg/kg IV midazolam bolus, then 0.02 mg/kg/h IV infusion; and Group 3, who were administered 10 mg IV propofol and 0.015 mg/kg IV midazolam bolus, then 25 μg/kg/min propofol and 0.01 mg/kg/h midazolam IV infusion. The incidence rates and severity of pruritus were assessed intraoperatively and postoperatively for 24 hours.

Results

The Ramsay Sedation Score was highest for the propofol group throughout the duration of the anesthetic process. Overall, 17 patients in the propofol group (60.7%), eight patients in the midazolam group (28.6%), and nine patients in the propofol-midazolam group (32.1%) developed pruritus (P = 0.027). Intraoperative pruritus was observed in seven patients in the propofol group (25%), two patients in the midazolam group (7.1%), and five patients in the midazolam-propofol group (17.9%) (P = 0.196). Postoperative pruritus developed in 12 patients in the propofol group (42.9%), six patients in the midazolam group (21.4%), and four patients in the midazolam-propofol group (14.3%) (P = 0.041). There was no significant difference between the groups with respect to the severity of pruritus (P > 0.05).

Conclusions

This study showed that in comparison with propofol, the administration of 0.03 mg/kg IV midazolam bolus followed by 0.02 mg/kg/h could be more effective in the prevention of intrathecal sufentanil-induced pruritus without increasing sedation and other side effects.