Etomidate Versus Propofol for Monitored Anesthesia Care During Endoscopic Retrograde Cholangiopancreatography: A Prospective Randomized Controlled Trial

Background and objectives Propofol-based sedation is one of the most commonly used methods for endoscopic retrograde cholangiopancreatography (ERCP). The commonest complications during ERCP are in the form of adverse cardiopulmonary events as a result of sedation. Etomidate has a more stable cardiovascular and respiratory profile than propofol and has been used for sedation in simple gastrointestinal endoscopy but has not been studied for procedural sedation in ERCP. The objective of the present study was to compare the safety and feasibility of etomidate and propofol for sedation during ERCP procedures. Methods This single-center, randomized trial included 100 American Society of Anesthesiologists (ASA) physical status class I to II patients who were scheduled for ERCP. All patients received midazolam 0.02 mg/kg, lignocaine (2%) 1 mg/kg, and fentanyl 1 µg/kg intravenously, followed by etomidate or propofol according to the group allocation. The primary outcome was to compare the mean arterial pressure (MAP) at various timepoints between the two groups and secondary outcomes were to compare oxygen saturation, induction and recovery times, and adverse events. Transient hypotension was defined as any decrease in MAP below 60 mmHg or 20% below the baseline. Transient hypoxia was defined as desaturation (saturation of peripheral oxygen (SpO2) <92%) lasting for more than 10 seconds requiring airway intervention. Results Fifty patients were enrolled in each group (Group E: etomidate and Group P: propofol). Transient hypotension occurred in eight (16%) patients in Group P, and two (4%) patients in Group E (P= 0.045). Baseline MAP was comparable between the two groups but was significantly lower in Group P at three timepoints during the study. Nine (18 %) patients in Group P had a transient hypoxic episode, compared to none in Group E (p= 0.006). The induction and recovery times were similar in the two groups. Conclusions Etomidate offers better hemodynamic and respiratory stability than propofol and can be recommended for use during ERCP in ASA I/II patients.

Propofol in ICU Settings: Understanding and Managing Anti-Arrhythmic, Pro-Arrhythmic Effects, and Propofol Infusion Syndrome

Propofol has revolutionized anesthesia and intensive care medicine owing to its favorable pharmacokinetic characteristics, fast onset, and short duration of action. This drug has been shown to be remarkably effective in numerous clinical scenarios. In addition, propofol has maintained an overwhelmingly favorable safety profile; however, it has been associated with both antiarrhythmic and proarrhythmic effects. This review concisely summarizes the dual arrhythmic cardiovascular effects of propofol and a rare but serious complication, propofol infusion syndrome (PRIS). We also discuss the need for careful patient evaluation, compliance with recommended infusion rates, and vigilant monitoring.

Evaluation of Propofol-Sparing Effect of Intravenous Lignocaine in Patients Undergoing Daycare Upper Gastrointestinal Endoscopic Procedures

Background Propofol is the most common sedative for endoscopies. Propofol alone may require larger doses for adequate level of sedation. Lignocaine is known for its anesthetic-sparing effect. We tested whether the addition of intravenous lignocaine to propofol-based sedation reduces its dose. Methods This prospective, randomized study was performed on 90 patients of 18 to 60 years of age, of either sex of the American Society of Anesthesiologists (ASA) Grade-I & II, and was divided into two groups. Group L + P received IV bolus of 1.5 mg/kg 2% lignocaine over 10 minutes followed by 1.5 mg/ kg/ h infusion and group NS + P- received the equivalent volumes of normal saline in bolus and infusion. Patients were induced with fentanyl (2 µg/kg) and propofol (1 mg/kg). To maintain an adequate sedation level, a supplemental bolus of 0.5 mg /kg propofol was administered. The outcomes recorded were the total and supplemental amount of propofol administered, as well as recovery time. Results The mean supplemental propofol for group L + P and group NS + P- 37.00 ± 29.93 and 58.67 ± 19.49 mg, respectively and mean total propofol consumption was 98.22 ± 34.00 mg and 131.11 ± 23.18 mg, respectively, (p < 0.001). Mean recovery time in group L + P was also shorter (5.22 ± 2.14 versus 9.96 ± 2.14). The incidence of adverse events like gag reflux, upper airway obstruction, pain on injection, and hypotension was significantly lower in group L + P (p < 0.05). Conclusion The addition of lignocaine to propofol-based sedation reduced the overall propofol requirement at the same time maintaining hemodynamic stability, spontaneous respiration, and early recovery.

Propofol Infusion Syndrome: A Rare Complication From a Common Medication

Propofol infusion syndrome (PRIS) is a multifactorial condition that, upon propofol administration, can interrupt critical cellular processes. This can lead to cellular damage that translates as multi-organ system failure that has the potential to be life-threatening. Due to the rarity of this condition, we report a case of PRIS in a 46-year-old male to help bring awareness to this severe condition caused by a relatively common medication. This patient was brought in due to unresponsiveness secondary to multi-substance abuse and respiratory disease and initially had elevated creatinine kinase levels that eventually subsided with appropriate management. However, after prolonged infusion of propofol, his creatinine kinase levels began to drastically rise, alluding to the development of propofol infusion syndrome. Once the offending agent was discontinued, the patient's creatinine kinase levels once again began to normalize.