Propofol versus Midazolam for Sedation during Esophagogastroduodenoscopy in Children

Up-to-date literature review and issues of sedation during digestive endoscopy

Sedation is common during digestive endoscopy to provide comfort and pain relief for patients. However, the use of sedation in endoscopy also poses potential risks, and recent issues have been raised regarding its safety and administration. This literature review paper will discuss the most recent developments in the field of sedation in digestive endoscopy, including the adverse events that might be associated with sedation and how to manage it, the legal issues associated with administration, the impact of COVID-19 on sedation practices, and sedation in special situations. It will also touch upon the current guidelines and recommendations for sedation, including the importance of patient selection and monitoring and the need for training and certification for endoscopists administering sedation. The review will also analyse studies evaluating the safety and efficacy of various sedation techniques, including propofol, midazolam, and others. It will examine the benefits and drawbacks of these agents.

Procedural Sedation for Pediatric Upper Gastrointestinal Endoscopy in Korea

BACKGROUND

Sedative upper endoscopy is similar in pediatrics and adults, but it is characteristically more likely to lead to respiratory failure. Although recommended guidelines for pediatric procedural sedation are available within South Korea and internationally, Korean pediatric endoscopists use different drugs, either alone or in combination, in practice. Efforts are being made to minimize the risk of sedation while avoiding procedural challenges. The purpose of this study was to collect and analyze data on the sedation methods used by Korean pediatric endoscopists to help physicians perform pediatric sedative upper endoscopy (PSUE).

METHODS

The PSUE procedures performed in 15 Korean pediatric gastrointestinal endoscopic units within a year were analyzed. Drugs used for sedation were grouped according to the method of use, and the depth of sedation was evaluated based on the Ramsay scores. The procedures and their complications were also assessed.

RESULTS

In total, 734 patients who underwent PSUE were included. Sedation and monitoring were performed by an anesthesiologist at one of the institutions. The sedative procedures were performed by a pediatric endoscopist at the other 14 institutions. Regarding the number of assistants present during the procedures, 36.6% of procedures had one assistant, 38.8% had 2 assistants, and 24.5% had 3 assistants. The average age of the patients was 11.6 years old. Of the patients, 19.8% had underlying diseases, 10.0% were taking medications such as epilepsy drugs, and 1.0% had snoring or sleep apnea history. The average duration of the procedures was 5.2 minutes. The subjects were divided into 5 groups as follows: 1) midazolam + propofol + ketamine (M + P + K): n = 18, average dose of 0.03 + 2.4 + 0.5 mg/kg; 2) M + P: n = 206, average dose of 0.06 + 2.1 mg/kg; 3) M + K: n = 267, average dose of 0.09 + 0.69 mg/kg; 4) continuous P infusion for 20 minutes: n = 15, average dose of 6.6 mg/kg; 5) M: n = 228, average dose of 0.11 mg/kg. The average Ramsay score for the five groups was 3.7, with significant differences between the groups (P < 0.001). Regarding the adverse effects, desaturation and increased oxygen supply were most prevalent in the M + K group. Decreases and increases in blood pressure were most prevalent in the M + P + K group, and bag-mask ventilation was most used in the M + K group. There were no reported incidents of intubation or cardiopulmonary resuscitation. A decrease in oxygen saturation was observed in 37 of 734 patients, and it significantly increased in young patients (P = 0.001) and when ketamine was used (P = 0.014). Oxygen saturation was also correlated with dosage (P = 0.037). The use of ketamine (P < 0.001) and propofol (P < 0.001) were identified as factors affecting the Ramsay score in the logistic regression analysis.

CONCLUSION

Although the drug use by Korean pediatric endoscopists followed the recommended guidelines to an extent, it was apparent that they combined the drugs or reduced the doses depending on the patient characteristics to reduce the likelihood of respiratory failure. Inducing deep sedation facilitates comfort during the procedure, but it also leads to a higher risk of complications.

Safety and Recipient Satisfaction of Propofol Sedation in Outpatient Endoscopy: A 24-Hour Prospective Investigation Using a Questionnaire Survey

Background/Aims

The aim of this study was to evaluate the safety of sedation with propofol as an alternative to benzodiazepine drugs in outpatient endoscopy.

Methods

In this prospective study, examinees who underwent outpatient endoscopy under propofol sedation and submitted a nextday questionnaire with providing informed consent were evaluated. Periprocedural acute responses, late adverse events within 24 hours, and examinee satisfaction were evaluated.

Results

Among the 4,122 patients who received propofol in the 17,978 outpatient-based endoscopic examinations performed between November 2016 and March 2018, 2,305 eligible examinees (esophagogastroduodenoscopy for 1,340, endoscopic ultrasonography for 945, and total colonoscopy for 20) were enrolled, and their responses to a questionnaire were analyzed. The mean propofol dose was 69.6±24.4 mg (range, 20–200 mg). Diazepam, midazolam, and/or pentazocine in combination with propofol was administered to 146 examinees. Mild oxygen desaturation was observed in 59 examinees (2.6%); and mild bradycardia, in 2 (0.09%). Other severe reactions or late events did not occur. After eliminating 181 invalid responses, 97.7% (2,065/2,124) of the patients desired propofol sedation in future examinations.

Conclusions

Propofol sedation was found to be safe-without severe adverse events or accidents-for outpatient endoscopy on the basis of the patients’ next-day self-evaluation. Given the high satisfaction level, propofol sedation might be an ideal tool for painless endoscopic screening.

Prevention of anesthesia-induced injection pain of propofol in pediatric anesthesia

Objective:

Propofol is a new anesthetic agent in clinical practice, but randomized double-blinded prospective studies on its role in pediatric anesthesia remain limited. We aimed to compare the preventive effects of pre-injected lidocaine or ketamine and its pre-mixture on the anesthesia-induced injection pain of propofol using a randomized double-blinded prospective method, and to compare the outcomes with those of medium-/long-chain propofol (M/LCT).

Methods:

A total of 360 pediatric patients (aged 5-12 years old) who received elective surgery were randomly divided into six groups (n= 60) as follows. S group: control group; L group: lidocaine group; L + P group: lidocaine + propofol group; K group: ketamine group; K + P group: ketamine + propofol group; M group: M/LCT group. After the drug fluid completely entered the cubital vein, the venous access was closed. During propofol injection, the injection pain was scored using the VRS 4-point scale. Meanwhile, the heart rates before and during injection were recorded, the adverse reactions during and after injection were observed, and the incidence rate and degree of pain were evaluated.

Results:

The VRS 4-point scale showed that the incidence rates of injection pain of S group, L group, L + P group, K group, K + P group and M group were 78.3%, 66.67%, 51.66%, 43.33%, 48.33% and 45% respectively. The incidence rates of injection pain of all experimental groups were significantly lower than that of S group (P<0.01). The incidence rates of injection pain of L + P group, K group, K + P group and M group were significantly lower than that of L group (P<0.05). The differences among the other groups were not statistically significant.

Conclusions:

Intravenous pre-injection of lidocaine, ketamine or those mixed with propofol can all significantly reduce the incidence rate of injection pain of propofol.

[Safety of Non-anesthesiologist Administration of Propofol for Gastrointestinal Endoscopy]

Propofol (2,6-diisopropylphenol) is a hypnotic drug with a very rapid onset and offset of action. It has increasingly been used in gastrointestinal endoscopy. Administration of propofol by nurses or endoscopists is commonly referred to as non-anesthesiologist-administered propofol (NAAP). There have been a lot of studies on the safety of NAAP compared with those by anesthesiologists. Safety results of those studies are summarized in this review.

Complications in pediatric endoscopy

The experience of the "endoscopic community" in pediatric patients is limited, but during recent years increased skills of the endoscopists and technological improvements lead to a standardization of pediatric endoscopy and the development of specialized pediatric endoscopy unit. Adverse events related to diagnostic and therapeutic endoscopy in children are usually rare. Diagnosis, prevention and treatment of complications in pediatric endoscopy is crucial when dealing with benign diseases in children. The complication rate of diagnostic EGD and colonoscopy in children are extremely low. Therapeutic procedures have obviously an increased rate of adverse events. Esophageal dilations are the most common indication for endoscopic therapy in children and can lead to perforations which requires prompt diagnosis and management. Complications of ERCP in pediatric age are similar to those reported in adults. The experience in pediatric emergency endoscopy (mainly foreign body removal) is consolidated and related adverse events extremely rare. Sedation of children during endoscopy maybe needs further evaluation and standardization, to reduce the rate of specific complications.

Propofol-alfentanyl versus midazolam-alfentanyl in inducing procedural amnesia of upper gastrointestinal endoscopy in children--blind randomised trial

In paediatric patients, esophagogastroduodenoscopy (EGD) is commonly performed with the use of sedation. The aim of the study was to compare the effectiveness of propofol and midazolam in providing procedural amnesia and controlling behaviour in children undergoing diagnostic EGD. Children (9-16 years), classified to the first or second class of the American Society of Anaesthesiologists' physical status classification referred for EGD, were randomly assigned to receive propofol with alfentanyl or midazolam with alfentanyl for sedation during the procedure. Within 120 min after the procedure, patients were repeatedly investigated for memory of the procedure and for memory of pain intensity during EGD with the use of the visual analogue scale. Activity and cooperation of the patient during the procedure was assessed with the relative adequacy scale. Of the 51 children, 48 completed the study. Propofol was significantly better than midazolam in inducing amnesia of procedural pain (mean difference 11.53 mm; 95 % confidence interval [CI] 0.96 to 22.10), loss of memory of the procedure (relative risk 0.4; 95 % CI 0.21 to 0.59) and controlling behaviour (relative risk 2.12; 95 % CI 1.33 to 3.36).

CONCLUSION

In children sedated for EGD, propofol is significantly better than midazolam at providing procedural amnesia and controlling behaviour during the procedure.

Barbiturate Induction for the Prevention of Emergence Agitation after Pediatric Sevoflurane Anesthesia

OBJECTIVES

Emergence agitation (EA) is a common and troublesome problem in pediatric patients recovering from general anesthesia. The incidence of EA is reportedly higher after general anesthesia maintained with sevoflurane, a popular inhalational anesthetic agent for pediatric patients. We conducted this prospective, randomized, double-blind study to test the effect of an intravenous ultra-short-acting barbiturate, thiamylal, administered during induction of general anesthesia on the incidence and severity of EA in pediatric patients recovering from Sevoflurane anesthesia.

METHODS

Fifty-four pediatric patients (1 to 6 years of age) undergoing subumbilical surgeries were randomized into 2 groups. Patients received either intravenous thiamylal 5mg/kg (Group T) or inhalational Sevoflurane 5% (Group S) as an anesthetic induction agent. Following induction, general anesthesia was maintained with Sevoflurane and nitrous oxide (N2O) in both groups. To control the intra- and post-operative pain, caudal block or ilioinguinal/iliohypogastric block was performed. The incidence and severity of EA were evaluated by using the Modified Objective Pain Scale (MOPS: 0 to 6) at 15 and 30 min after arrival in the post-anesthesia care unit (PACU).

RESULTS

Fifteen minutes after arrival in the PACU, the incidence of EA in Group T (28%) was significantly lower than in Group S (64%; p = 0.023) and the MOPS in Group T (median 0, range 0 to 6) was significantly lower than in Group S (median 4, range 0 to 6; p = 0.005). The interval from discontinuation of Sevoflurane to emergence from anesthesia was not significantly different between the 2 groups.

CONCLUSIONS

Thiamylal induction reduced the incidence and severity of EA in pediatric patients immediately after Sevoflurane anesthesia.

Prevalence of Chronic Gastritis or Helicobacter pylori Infection in Adolescent Sleeve Gastrectomy Patients Does Not Correlate with Symptoms or Surgical Outcomes

BACKGROUND

In adults undergoing gastric bypass surgery, it is routine practice to perform pre-operative testing for Helicobacter pylori infection. Evidence suggests that infection impairs anastomotic healing and contributes to complications. There currently are no data for adolescents undergoing bariatric procedures. Despite few patients with pre-operative symptoms, we noted occasional patients with H. pylori detected after sleeve gastrectomy. We reviewed our experience with our adolescent sleeve gastrectomy cohort to determine the prevalence of H. pylori infection, its predictive factors, and association with outcomes. We hypothesized that H. pylori infection would be associated with pre-operative symptoms, but not surgical outcomes.

METHODS

All patients undergoing sleeve gastrectomy at our hospital were included. We conducted a chart review to determine pre- or post-operative symptoms of gastroesophageal reflux disease GERD or gastritis, operative complications, and long-term anti-reflux therapy after surgery. Pathology reports were reviewed for evidence of gastritis and H. pylori infection.

RESULTS

78 adolescents had laparoscopic sleeve gastrectomy from January 2010 through July 2014. The prevalence of chronic gastritis was 44.9% (35/78) and 11.4% of those patients had H. pylori (4/35). Only one patient with H. pylori had pre-operative symptoms, and only 25.7% (9/35) of patients with pathology-proven gastritis had symptoms. One staple line leak occurred but this patient did not have H. pylori or gastritis. Mean patient follow-up was 10 (3-26) mos.

CONCLUSIONS

There is a moderate prevalence of gastritis among adolescents undergoing sleeve gastrectomy, but only a small number of these patients had H. pylori infection. Neither the presence of chronic gastritis nor H. pylori infection correlated with symptoms or outcomes. Thus, in the absence of predictive symptomology or adverse outcome in those who are infected, we advocate for continued routine pathologic evaluation without the required need for pre-operative determination unless or until H. pylori infection is associated with adverse surgical outcomes.

Endoscopic sedation: from training to performance

Adequate sedation and analgesia are considered essential requirements to relieve patient discomfort and pain and ultimately to improve the outcomes of modern gastrointestinal endoscopic procedures. The willingness of patients to undergo sedation during endoscopy has increased steadily in recent years and standard sedation practices are needed for both patient safety and successful procedural outcomes. Therefore, regular training and education of healthcare providers is warranted. However, training curricula and guidelines for endoscopic sedation may have conflicts according to varying legal frameworks and/or social security systems of each country, and well-recognized endoscopic sedation training systems are not currently available in all endoscopy units. Although European and American curricula for endoscopic sedation have been extensively developed, general curricula and guidelines for each country and institution are also needed. In this review, an overview of recent curricula and guidelines for training and basic performance of endoscopic sedation is presented based on the current literature.

Endoscopist-directed propofol: pros and cons

Concerns about the safety of endoscopist-directed propofol (EDP) have been voiced that propofol should be given only by healthcare professionals trained in the administration of general anesthesia. Here we discuss the safety and drawbacks of EDP for routine endoscopic procedures. Currently, both diagnostic and therapeutic endoscopy are well tolerated and accepted by both patients and endoscopists due to the application of sedation in most clinics worldwide. Accordingly, propofol use is increasing in many countries. It is crucial for endoscopists to be very familiar with the use of propofol or a combination of drugs. However, the controversy regarding the administration of sedation by an endoscopist or an anesthesiologist continues. Until now, there have been no randomized control trials comparing sedation induced by propofol administered by an endoscopist or by an anesthesiologist. It might be difficult to perform this kind of study. For the convenience and safety of sedative endoscopy, it would be important that EDP be generally applied to endoscopic procedures, and for more safety, an anesthesiologist may automatically take care of particular patients at high risk of suffering from propofol side effects.

Same-day bidirectional endoscopy with nonanesthesiologist administration of propofol: safety and cost-effectiveness compared with separated exams

BACKGROUND AND AIM

The safety and cost-effectiveness of a combination of esophagogastroduodenoscopy (EGD) and colonoscopy [or bidirectional endoscopy (BDE)] versus alternative-day EGD and colonoscopy when using nonanesthesiologist administration of propofol have never been evaluated.

PATIENTS AND METHODS

This was a single-center prospective registry of consecutive American Society of Anaesthesiology class I-III outpatients undergoing EGD, colonoscopy, and BDE. Propofol was the sole sedative used. Adverse events, recovery time, and procedure-related costs were analyzed.

RESULTS

Among the 1500 study participants (51.5% women), EGD, colonoscopy, and BDE were carried out on 449, 702, and 349 patients, respectively. All patients were discharged directly from the endoscopy unit. No sex differences were found with respect to age (mean 54.4, range 18-96 years), BMI, or procedure type. Propofol doses for BDE were 25.9% less than when EGD and colonoscopy were performed separately (P<0.001). Adverse events, including transient O2 saturation less than 90%, systolic blood pressure less than 90 mmHg, and bradycardia (<50 bpm), appeared in 10.7% of single EGD and 8.6% of EGD within BDE; for colonoscopies, the figures were 8.6 and 9.5%, respectively (P=NS). Recovery time to discharge after BDE was 47.9% shorter than when EGD and colonoscopy were performed separately (P<0.001). The cost of same-day BDE was 28.1% lower than that of EGD and colonoscopy performed as separated procedures (P<0.001).

CONCLUSION

Same-day BDE with nonanesthesiologist administration of propofol resulted in reductions in propofol doses, recovery time, and procedure-related costs as compared with carrying out EGD and colonoscopy separately, without an increase in adverse events.