Comparison between Midazolam Used Alone and in Combination with Propofol for Sedation during Endoscopic Retrograde Cholangiopancreatography

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.

Sedation in the Endoscopy Suite

OPINION STATEMENT

Sedation practices in the endoscopy suite have changed dramatically in the decades since the introduction of routine colonoscopy and esophagogastroduodenoscopy (EGD). Patients initially received moderate sedation (or even no sedation), but now frequently receive monitored anesthesia care (MAC). This significant shift has introduced anesthesiologists to the endoscopy suite along with new sedative medications and safety concerns. Appreciating the ramifications of this change requires an understanding of sedation depth, patient selection, drug use, sedation delivery, patient monitoring, recovery from sedation, and patient outcomes. Furthermore, the changing landscape of healthcare quality and reimbursement challenges us to provide the best possible care for our patients in the most economical way possible. The endoscopy suite is a unique sedation environment, and it is the purpose of this article to review those elements that contribute to a uniquely demanding work environment.

Non-radiation endoscopic retrograde cholangiopancreatography in the management of choledocholithiasis during pregnancy

Gallstone diseases are common during pregnancy. In most cases, patients are asymptomatic and do not require any treatment. However, choledocholithiasis, cholangitis, and gallstone pancreatitis may potentially become life-threatening for both mother and fetus and often require urgent intervention. Although endoscopic retrograde cholangiopancreatography (ERCP) has become the standard technique for removing common bile duct stones, it is associated with ionizing radiation that could carry teratogenic risk. Non-radiation ERCP (NR-ERCP) is reported to be effective without incurring this risk. Two techniques have been described to confirm bile duct cannulation: bile aspiration and image guidance. With bile aspiration, biliary cannulation is confirmed by applying suction to the cannula to yield bile, thus confirming an intrabiliary position. Image guidance involves using ultrasound or direct visualization (choledochoscopy) to confirm selective biliary cannulation or duct clearance. Once cannulation is achieved, the stones are removed using standard ERCP techniques and tools. Case series and retrospective studies have reported success rates of up to 90% for NR-ERCP with complication rates similar to standard ERCP. Pregnancy outcomes are not adversely affected by NR-ERCP, but whether the avoidance of radiation carries benefit for the baby is unknown. Prospective comparative trials are lacking. NR-ERCP is technically demanding and should be attempted only by skilled biliary endoscopists in properly equipped and staffed health-care institutions, in a multidisciplinary setting.

Prerequisites of colonoscopy

Colonoscopy is a widely accepted method for the evaluation of the colon and terminal ileum. Its diagnostic accuracy and therapeutic safety are influenced by prerequisites, including modulation of medication and bowel cleansing. Appropriate choices of sedative medication and bowel-cleansing regimen, together with diet modification, should be made based on the patient's underlying disease, age, and medication intake. Moreover, effective methods for patient education regarding bowel preparation should be considered.