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Xie G, Estevez M, Heybati K, Vogt M, Smith M, Moshe C, Chan J, Kumbhari V, Chadha R. Single-agent versus combination regimens containing propofol: a retrospective cohort study of recovery metrics and complication rates in a hospital-based endoscopy suite. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2025; 75:844602. [PMID: 40023496 PMCID: PMC11951190 DOI: 10.1016/j.bjane.2025.844602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2024] [Revised: 01/29/2025] [Accepted: 01/31/2025] [Indexed: 03/04/2025]
Abstract
BACKGROUND Anesthesiologists are often tasked with overseeing sedation in non-surgical settings. We aim to determine whether adding adjuvant sedatives to propofol affects the recovery times and complication rates after endoscopy. METHODS We conducted a retrospective cohort study of adults (≥18) who received propofol while undergoing esophagogastroduodenoscopy (EGD) and/or colonoscopy (COL) at a large academic institution over a four-year period. Patients receiving propofol alone were compared against patients receiving propofol in combination with midazolam, fentanyl, ketamine, or dexmedetomidine. The primary outcome was PACU length of stay, adjusted for age, sex, and ASA Score. Secondary outcomes included incidence of PACU postoperative nausea and vomiting, hypoxemia (SpO2 < 90%), bradycardia (HR < 60 bpm), and escalation of care (hospital admission), reported in adjusted odds ratios and their 95% confidence intervals. RESULTS Across the study period, 28,532 cases were included. Colonoscopies performed under propofol+fentanyl sedation were associated with significantly longer PACU LOS compared to propofol alone. Adjusted mean PACU LOS was significantly longer in patients receiving adjuvant fentanyl, compared to propofol alone (p < 0.01) and propofol + dexmedetomidine (p < 0.01). Patients receiving propofol alone exhibited a 9.4% incidence of bradycardia, 16.0% hypoxia, 0.89% PONV, and 0.40% hospitalization. Adjuvant fentanyl use was associated with higher odds of hypoxia across all procedure types (p < 0.05). Adjuvant dexmedetomidine was associated with higher rates of bradycardia, but lower rates of hypoxia, PONV, and hospitalization (p < 0.05). CONCLUSIONS With the exception of fentanyl, combining propofol with other sedatives was not associated with longer recovery times. The incidence of complications differed significantly with the use of adjuvant fentanyl or dexmedetomidine.
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Affiliation(s)
- Guozhen Xie
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, USA
| | - Maria Estevez
- Clinical Studies Unit, Mayo Clinic Jacksonville, FL, USA
| | - Kiyan Heybati
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, USA
| | - Matthew Vogt
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Michael Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Jacksonville, FL, USA
| | - Christine Moshe
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Jacksonville, FL, USA
| | - Johanna Chan
- Department of Gastroenterology and Hepatology, Mayo Clinic Jacksonville, FL, USA
| | - Vivek Kumbhari
- Department of Gastroenterology and Hepatology, Mayo Clinic Jacksonville, FL, USA
| | - Ryan Chadha
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Jacksonville, FL, USA.
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Xie G, Estevez M, Heybati K, Vogt M, Smith M, Moshe C, Chan J, Kumbhari V, Chadha R. Outcomes of anesthesia-supported versus endoscopist-driven sedation modalities: a retrospective cohort study. Gastrointest Endosc 2025:S0016-5107(25)00048-3. [PMID: 39880215 DOI: 10.1016/j.gie.2025.01.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2024] [Revised: 12/09/2024] [Accepted: 01/19/2025] [Indexed: 01/31/2025]
Abstract
BACKGROUND AND AIMS The use of anesthesia has become commonplace in many procedural settings. The goal of this study is to compare sedation modalities used by endoscopists and anesthesiologists in the endoscopy suite, particularly with respect to recovery time and adverse events. METHODS We conducted a retrospective cohort study including adults (≥18 years of age) undergoing outpatient EGD and/or colonoscopy at Mayo Clinic in Jacksonville, Florida between October 1st, 2018 and December 31st, 2022. Cases were classified as using propofol only, propofol ± adjuvants (PA; including dexmedetomidine, ketamine, fentanyl, and midazolam), general anesthesia (GA) with endotracheal tube, or fentanyl/midazolam (FM) only. The primary outcome was length of stay (LOS) in the postanesthesia care unit (PACU), and secondary outcomes included the incidence of postoperative nausea and vomiting (PONV), hypoxemia (Spo2 risk 90%), bradycardia (heart rate <60 bpm), and escalation of care (hospital admission). RESULTS The analysis included 56,361 cases. Among patients who received FM sedation, the mean PACU LOS was 52.01, 49.68, and 53.24 minutes for EGD, colonoscopy, and combined procedures, respectively. This was significantly higher than the mean PACU LOS for GA (44.65, 41.41, and 41.92 minutes, respectively), for PA (32.35, 35.75, and 33.42 minutes, respectively), and for propofol (31.63, 32.61, and 33.29 minutes, respectively; P < .0001). Of patients receiving FM, 8.39% experienced bradycardia, 6.12% experienced hypoxia, 0.24% experienced PONV, and 0.05% were hospitalized. These were substantially lower than the rates for other sedation groups, and odds ratios were significantly lower than 1.00 (P < .05) in 30 of 36 comparisons across procedural, sedative, and outcome categories. CONCLUSIONS Sedation achieved with FM correlated with a lower rate of adverse events but a significantly longer PACU LOS compared with propofol, PA, or GA.
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Affiliation(s)
- Guozhen Xie
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Maria Estevez
- Clinical Studies Unit, Mayo Clinic, Jacksonville, Florida, USA
| | - Kiyan Heybati
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthew Vogt
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Christine Moshe
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Johanna Chan
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Vivek Kumbhari
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Ryan Chadha
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida, USA.
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Liu Y, Xiao J, Chen T, Shi D, Qiao Y, Liao X. Comparative Efficacy and Safety of Anesthetic and Sedative Regimens for Endoscopic Retrograde Cholangiopancreatography: A Network Meta-Analysis. Dig Dis 2024; 43:84-95. [PMID: 39536718 PMCID: PMC11817864 DOI: 10.1159/000542380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2024] [Accepted: 10/29/2024] [Indexed: 11/16/2024]
Abstract
INTRODUCTION This study evaluates the efficacy and safety of various anesthetic and sedative regimens for endoscopic retrograde cholangiopancreatography (ERCP) procedures. METHODS A systematic search was conducted across PubMed, Web of Science, Scopus, and Embase to identify randomized controlled trials (RCTs) published until March 2024. Primary outcomes included procedure time, patient satisfaction, oxygen saturation (SpO2), incidence of SpO2 below 90%, and adverse events. The analysis was performed using R software, analyzing continuous outcomes with mean differences and dichotomous outcomes with risk ratios. RESULTS 42 RCTs were included. Combination therapies such as remifentanil plus tramadol and propofol plus midazolam plus pethidine demonstrated significantly shorter procedure times. Propofol plus oxycodone yielded higher patient satisfaction. Oxygenation results indicated that propofol plus fentanyl, oxycodone, and ketamine improved SpO2. Propofol plus oxycodone (RR <0.01), dexmedetomidine plus fentanyl (RR <0.01), propofol plus nalbuphine (RR = 0.01), Mg sulfate plus propofol (RR = 0.01), and propofol plus fentanyl (RR = 0.02) showed a significant lower rate of patients with SpO2 below 90% compared to propofol. Midazolam plus pethidine plus dexmedetomidine (RR = 0.01), propofol plus oxycodone (RR = 0.09), and dexmedetomidine plus fentanyl (RR = 0.2) exhibited lower rates of adverse events compared to propofol. CONCLUSION This study provides comprehensive evidence to guide clinical decision-making and optimize anesthetic management for ERCP procedures. INTRODUCTION This study evaluates the efficacy and safety of various anesthetic and sedative regimens for endoscopic retrograde cholangiopancreatography (ERCP) procedures. METHODS A systematic search was conducted across PubMed, Web of Science, Scopus, and Embase to identify randomized controlled trials (RCTs) published until March 2024. Primary outcomes included procedure time, patient satisfaction, oxygen saturation (SpO2), incidence of SpO2 below 90%, and adverse events. The analysis was performed using R software, analyzing continuous outcomes with mean differences and dichotomous outcomes with risk ratios. RESULTS 42 RCTs were included. Combination therapies such as remifentanil plus tramadol and propofol plus midazolam plus pethidine demonstrated significantly shorter procedure times. Propofol plus oxycodone yielded higher patient satisfaction. Oxygenation results indicated that propofol plus fentanyl, oxycodone, and ketamine improved SpO2. Propofol plus oxycodone (RR <0.01), dexmedetomidine plus fentanyl (RR <0.01), propofol plus nalbuphine (RR = 0.01), Mg sulfate plus propofol (RR = 0.01), and propofol plus fentanyl (RR = 0.02) showed a significant lower rate of patients with SpO2 below 90% compared to propofol. Midazolam plus pethidine plus dexmedetomidine (RR = 0.01), propofol plus oxycodone (RR = 0.09), and dexmedetomidine plus fentanyl (RR = 0.2) exhibited lower rates of adverse events compared to propofol. CONCLUSION This study provides comprehensive evidence to guide clinical decision-making and optimize anesthetic management for ERCP procedures.
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Affiliation(s)
- Yufang Liu
- Department of Anesthesiology, 904th Hospital of The Joint Logistics Support Force of the PLA, Wuxi, China
| | - Jifeng Xiao
- Department of Anesthesiology, 904th Hospital of The Joint Logistics Support Force of the PLA, Wuxi, China
| | - Tian Chen
- Department of Anesthesiology, 904th Hospital of The Joint Logistics Support Force of the PLA, Wuxi, China
| | - Dongdong Shi
- Department of Anesthesiology, 904th Hospital of The Joint Logistics Support Force of the PLA, Wuxi, China
| | - Yan Qiao
- Department of Anesthesiology, 904th Hospital of The Joint Logistics Support Force of the PLA, Wuxi, China
| | - Xingzhi Liao
- Department of Anesthesiology, 904th Hospital of The Joint Logistics Support Force of the PLA, Wuxi, China
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Salloum E, Lotte Seibold E, Azimaraghi O, Rudolph MI, Beier J, Schaefer MS, Sauer WJ, Tam C, Fassbender P, Kiyatkin M, Eikermann M, Wongtangman K. Association of ketamine use during procedural sedation with oxygen desaturation and healthcare utilisation: a multicentre retrospective hospital registry study. Br J Anaesth 2024; 132:779-788. [PMID: 38087741 DOI: 10.1016/j.bja.2023.11.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 11/13/2023] [Accepted: 11/13/2023] [Indexed: 03/05/2024] Open
Abstract
BACKGROUND We investigated the effects of ketamine on desaturation and the risk of nursing home discharge in patients undergoing procedural sedation by anaesthetists. METHODS We included adult patients who underwent procedures under monitored anaesthetic care between 2005 and 2021 at two academic healthcare networks in the USA. The primary outcome was intraprocedural oxygen desaturation, defined as oxygen saturation <90% for ≥2 consecutive minutes. The co-primary outcome was a nursing home discharge. RESULTS Among 234,170 included patients undergoing procedural sedation, intraprocedural desaturation occurred in 5.6% of patients who received ketamine vs 5.2% of patients who did not receive ketamine (adjusted odds ratio [ORadj] 1.22, 95% confidence interval [CI] 1.15-1.29, P<0.001; adjusted absolute risk difference [ARDadj] 1%, 95% CI 0.7-1.3%, P<0.001). The effect was magnified by age >65 yr, smoking, or preprocedural ICU admission (P-for-interaction <0.001, ORadj 1.35, 95% CI 1.25-1.45, P<0.001; ARDadj 2%, 95% CI 1.56-2.49%, P<0.001), procedural risk factors (upper endoscopy of longer than 2 h; P-for-interaction <0.001, ORadj 2.91, 95% CI 1.85-4.58, P<0.001; ARDadj 16.2%, 95% CI 9.8-22.5%, P<0.001), and high ketamine dose (P-for-trend <0.001, ORadj 1.61, 95% CI, 1.43-1.81 for ketamine >0.5 mg kg-1). Concomitant opioid administration mitigated the risk (P-for-interaction <0.001). Ketamine was associated with higher odds of nursing home discharge (ORadj 1.11, 95% CI 1.02-1.21, P=0.012; ARDadj 0.25%, 95% CI 0.05-0.46%, P=0.014). CONCLUSIONS Ketamine use for procedural sedation was associated with an increased risk of oxygen desaturation and discharge to a nursing home. The effect was dose-dependent and magnified in subgroups of vulnerable patients.
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Affiliation(s)
- Elie Salloum
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Eva Lotte Seibold
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Omid Azimaraghi
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Maíra I Rudolph
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA; Department for Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Juliane Beier
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Maximilian S Schaefer
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
| | - William J Sauer
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Christopher Tam
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Philipp Fassbender
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA; Klinik für Anästhesiologie, Operative Intensivmedizin, Schmerz- und Palliativmedizin, Marien Hospital Herne, Universitätsklinikum der Ruhr-Universität Bochum, Herne, Germany
| | - Michael Kiyatkin
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Matthias Eikermann
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA; Klinik für Anä¨sthesiologie and Intensivmedizin, Universität Duisburg-Essen, Essen, Germany.
| | - Karuna Wongtangman
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA; Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Zhang N, Li G. Comparing sedation protocols for endoscopic retrograde cholangiopancreatography (ERCP): A retrospective study. Heliyon 2024; 10:e27447. [PMID: 38463814 PMCID: PMC10923846 DOI: 10.1016/j.heliyon.2024.e27447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 01/27/2024] [Accepted: 02/28/2024] [Indexed: 03/12/2024] Open
Abstract
Background Endoscopic retrograde cholangiopancreatography (ERCP) is a widely used diagnostic and therapeutic procedure. Effective sedation is crucial to enhance patient comfort and optimize endoscopist performance. Various sedation protocols, including Propofol and Dexmedetomidine (Pro-Dex), Ketamine and Propofol (Keto-Fol), Propofol and Midazolam (Pro-Mid), and Propofol alone, have been utilized during ERCP. This retrospective study aims to compare the safety and efficacy of these four sedation protocols. Methods A retrospective analysis was conducted on data from 600 patients who underwent ERCP between 2018 and 2021, with each patient receiving one of the four sedation protocols. Protocol assignment was based on the endoscopist's preference. Data on hemodynamic parameters, sedation level, recovery time, and procedure-related complications were collected. Results Baseline data showed no significant differences among the groups pre-procedure. The Pro-Dex group exhibited significantly lower mean total propofol dose, shorter recovery time, and faster achievement of Ramsay Sedation Scale (RSS) score 3-4 compared to the other groups. The Pro-group demonstrated significantly longer hospital stay than the other three groups (median, 4.19 ± 1.1 vs. 3.48 ± 1.2 days in the KP groups, p = 0.042). There were no significant variations in the incidence of respiratory depression, hypotension, or bradycardia among the four groups. Additionally, notable trends were found for hemodynamic measures, total propofol dosage, time to reach the desired level of sedation (as measured by the Ramsay Sedation Scale), and hospital stay based on BMI categories, indicating that higher BMI is linked to more serious outcomes. Conclusion Our retrospective study demonstrates that the Pro-Dex protocol offers superior sedation quality, faster recovery, and fewer complications compared to the other protocols during ERCP. However, the incidence of ERCP-related adverse events did not significantly differ among the four sedation protocols. These findings can aid clinicians in selecting the most appropriate sedation protocol for ERCP, considering patient and endoscopist preferences.
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Affiliation(s)
- Ning Zhang
- Department of Cardiopulmonary Rehabilitation, Shandong Provincial Third Hospital, No.12, Wuyingshan Middle Road, Jinan, Shandong, 250000, China
| | - Guanjun Li
- Department of Anesthesiology, Shandong Provincial Third Hospital, No.12, Wuyingshan Middle Road, Jinan, Shandong, 250000, China
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Wehrmann T, Riphaus A, Eckardt AJ, Klare P, Kopp I, von Delius S, Rosien U, Tonner PH. Updated S3 Guideline "Sedation for Gastrointestinal Endoscopy" of the German Society of Gastroenterology, Digestive and Metabolic Diseases (DGVS) - June 2023 - AWMF-Register-No. 021/014. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:e654-e705. [PMID: 37813354 DOI: 10.1055/a-2165-6388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Affiliation(s)
- Till Wehrmann
- Clinic for Gastroenterology, DKD Helios Clinic Wiesbaden, Wiesbaden, Germany
| | - Andrea Riphaus
- Internal Medicine, St. Elisabethen Hospital Frankfurt Artemed SE, Frankfurt, Germany
| | - Alexander J Eckardt
- Clinic for Gastroenterology, DKD Helios Clinic Wiesbaden, Wiesbaden, Germany
| | - Peter Klare
- Department Internal Medicine - Gastroenterology, Diabetology, and Hematology/Oncology, Hospital Agatharied, Hausham, Germany
| | - Ina Kopp
- Association of the Scientific Medical Societies in Germany e.V. (AWMF), Berlin, Germany
| | - Stefan von Delius
- Medical Clinic II - Internal Medicine - Gastroenterology, Hepatology, Endocrinology, Hematology, and Oncology, RoMed Clinic Rosenheim, Rosenheim, Germany
| | - Ulrich Rosien
- Medical Clinic, Israelite Hospital, Hamburg, Germany
| | - Peter H Tonner
- Anesthesia and Intensive Care, Clinic Leer, Leer, Germany
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Wehrmann T, Riphaus A, Eckardt AJ, Klare P, Kopp I, von Delius S, Rosien U, Tonner PH. Aktualisierte S3-Leitlinie „Sedierung in der gastrointestinalen Endoskopie“ der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS). ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:1246-1301. [PMID: 37678315 DOI: 10.1055/a-2124-5333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Affiliation(s)
- Till Wehrmann
- Klinik für Gastroenterologie, DKD Helios Klinik Wiesbaden, Wiesbaden, Deutschland
| | - Andrea Riphaus
- Innere Medizin, St. Elisabethen Krankenhaus Frankfurt Artemed SE, Frankfurt, Deutschland
| | - Alexander J Eckardt
- Klinik für Gastroenterologie, DKD Helios Klinik Wiesbaden, Wiesbaden, Deutschland
| | - Peter Klare
- Abteilung Innere Medizin - Gastroenterologie, Diabetologie und Hämato-/Onkologie, Krankenhaus Agatharied, Hausham, Deutschland
| | - Ina Kopp
- Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V. (AWMF), Berlin, Deutschland
| | - Stefan von Delius
- Medizinische Klinik II - Innere Medizin - Gastroenterologie, Hepatologie, Endokrinologie, Hämatologie und Onkologie, RoMed Klinikum Rosenheim, Rosenheim, Deutschland
| | - Ulrich Rosien
- Medizinische Klinik, Israelitisches Krankenhaus, Hamburg, Deutschland
| | - Peter H Tonner
- Anästhesie- und Intensivmedizin, Klinikum Leer, Leer, Deutschland
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Tokmak S, Cetin MF, Torun S. Efficacy and safety of endoscopic retrograde cholangiopancreatography in the very elderly by using a combination of intravenous midazolam, ketamine and pethidine. Geriatr Gerontol Int 2021; 21:887-892. [PMID: 34427037 DOI: 10.1111/ggi.14252] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 06/14/2021] [Accepted: 07/07/2021] [Indexed: 11/30/2022]
Abstract
AIM The number of therapeutic endoscopic procedures in elderly individuals keeps increasing and this population has a high risk of adverse events related to sedation and general anesthesia. However, there is a paucity on data about the efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) in this population. METHODS In total, 417 consecutive ERCP procedures were performed in 362 patients between September 2018 and January 2020. Of these, 59 patients (74 sessions) were aged ≥80 years (Group A) and 173 patients (193 procedures) were aged ≤65 years (Group B). We analyzed the prospectively collected data of patient- and procedure-related variables. RESULTS The procedure time was significantly longer in Group A (P < 0.05). The prevalence of comorbidities, use of anticoagulants and American Society of Anesthesiologists (ASA) physical status classification levels were significantly higher in Group A (P < 0.05). The incidence of periampullary diverticula, malignancy, rate of difficult cannulation, mean number of stones, use of biliary stents and stent dysfunction was also significantly higher in Group A (P < 0.05). The medication doses used were significantly higher and emergence symptoms were significantly more frequent in Group B (P < 0.05). The rates of bleeding, pancreatitis, perforation, cholangitis, hypoxia, hypotension and the length of hospital stay did not significantly differ between the two groups. The overall success rate of the procedure was comparable in the two groups (P = 0.874). CONCLUSIONS ERCP can be safely performed in elderly patients using a combination of midazolam and ketamine without propofol. The incidence of complications is comparable with that observed in younger patients. Geriatr Gerontol Int 2021; 21: 887-892.
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Affiliation(s)
- Salih Tokmak
- Department of Gastroenterology, Internal Medicine, Duzce University, Duzce, Turkey
| | | | - Serkan Torun
- Department of Gastroenterology, Internal Medicine, Duzce University, Duzce, Turkey
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Ramchandani M, Rughwani H, Inavolu P, Singh AP, Tevethia HV, Jagtap N, Sekaran A, Kanakagiri H, Darishetty S, Reddy DN. Diagnostic yield and therapeutic impact of novel motorized spiral enteroscopy in small-bowel disorders: a single-center, real-world experience from a tertiary care hospital (with video). Gastrointest Endosc 2021; 93:616-626. [PMID: 32663489 DOI: 10.1016/j.gie.2020.07.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 07/02/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Novel motorized spiral enteroscopy (NMSE) is a recent advancement in the field of enteroscopy and offers multiple features, including self-propulsion, better irrigation, and shorter enteroscope length with a larger channel. The aim of this study was to evaluate the efficacy in terms of diagnostic yield and therapeutic success of NMSE in patients undergoing enteroscopy by antegrade and/or retrograde approaches for suspected small-bowel disease. METHODS We retrospectively evaluated consecutive patients with symptomatic small-bowel disease who underwent enteroscopy over a 6-month period. Diagnostic yield, therapeutic success, total enteroscopy rate (TER), technical success, total procedural time, depth of maximal insertion, and adverse events related to the NMSE procedure were noted. RESULTS Of 61 patients (mean age, 45.67 ± 15.37 years; 43 men) included for NMSE, 57 patients underwent successful enteroscopy with a technical success of 93.4%. The overall diagnostic yield was 65.5% (95% confidence interval, 52.31-77.27) and 70.1% (95% confidence interval, 56.60-81.57) in patients who underwent successful NMSE; TER was 60.6%: 31.1% by the antegrade approach and 29.5% by a combined antegrade and retrograde approach. Depth of maximal insertion and procedural time was of 465 cm (range, 100-650) and 40 minutes (range, 25-60), respectively, by the antegrade approach and 140 cm (range, 50-200) and 35 minutes (range, 30-60) by the retrograde route. Lesions were classified as inflammatory (n = 25), vascular (n = 10), and mass (n = 4). Biopsy specimens were obtained in 50.8% subjects, and 23% patients underwent therapeutic procedures. No major adverse events were seen. CONCLUSIONS NMSE is a promising technology, showing high efficacy as a diagnostic and therapeutic tool in the management of otherwise difficult-to-treat small-bowel disease.
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Affiliation(s)
- Mohan Ramchandani
- Department of Gastroenterology, Asian Institute of Gastroenterology Hospitals, Hyderabad, India
| | - Hardik Rughwani
- Department of Gastroenterology, Asian Institute of Gastroenterology Hospitals, Hyderabad, India
| | - Pradev Inavolu
- Department of Gastroenterology, Asian Institute of Gastroenterology Hospitals, Hyderabad, India
| | - Aniruddha Pratap Singh
- Department of Gastroenterology, Asian Institute of Gastroenterology Hospitals, Hyderabad, India
| | - Harsh Vardhan Tevethia
- Department of Gastroenterology, Asian Institute of Gastroenterology Hospitals, Hyderabad, India
| | - Nitin Jagtap
- Department of Gastroenterology, Asian Institute of Gastroenterology Hospitals, Hyderabad, India
| | - Anuradha Sekaran
- Department of Pathology, Asian Institute of Gastroenterology Hospitals, Hyderabad, India
| | - Haranath Kanakagiri
- Department of Anesthesiology, Asian Institute of Gastroenterology Hospitals, Hyderabad, India
| | - Santosh Darishetty
- Department of Anesthesiology, Asian Institute of Gastroenterology Hospitals, Hyderabad, India
| | - D Nageshwar Reddy
- Department of Gastroenterology, Asian Institute of Gastroenterology Hospitals, Hyderabad, India
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Liu FK, Wan L, Shao LJZ, Zou Y, Liu SH, Xue FS. Estimation of effective dose of propofol mono-sedation for successful insertion of upper gastrointestinal endoscope in healthy, non-obese Chinese adults. J Clin Pharm Ther 2020; 46:484-491. [PMID: 33217028 DOI: 10.1111/jcpt.13312] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 10/28/2020] [Accepted: 10/28/2020] [Indexed: 12/27/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Propofol is effective in sedation for upper gastrointestinal (UGI) endoscopy. However, the optimum dose is ill-defined. This study aimed to estimate the effective dose of propofol mono-sedation for successful endoscope insertion in healthy, non-obese Chinese adults undergoing single UGI endoscopy. METHODS Twenty-six adult patients undergoing elective single UGI endoscopy were enrolled in this study. A modified Dixon's up-and-down method was utilized to assess the effective dose of propofol for successful endoscope insertion. The initial dose of propofol administered, 1.6 mg/kg, was adjusted with 0.1 mg/kg as a step size. The patient's responses to endoscope insertion were classified as either 'movement' or 'no movement'. When patient's responses were changed from 'movement' to 'no movement' or from 'no movement' to 'movement', a crossover was defined. After eight crossovers had been obtained, patient recruitment was stopped. The mean of midpoints of all crossovers obtained by the modified Dixon's up-and-down method in all 26 patients was defined as calculated median effective dose (ED50 ) of propofol for successful endoscope insertion. Furthermore, probit regression analysis was used to determine the dose of propofol where 50% (ED50 ) and 95% (ED95 ) of endoscope insertion attempts were successful. RESULTS The calculated ED50 of propofol for successful endoscope insertion was 1.89 ± 0.12 mg/kg. The probit regression analysis showed that ED50 and ED95 of propofol for successful endoscope insertion were 1.90 mg/kg (95% CI, 1.78-2.10 mg/kg) and 2.15 mg/kg (95% CI, 2.01-3.56 mg/kg), respectively. No any patient had hypoxaemia and gag reflex during the UGI endoscopy with propofol mono-sedation. WHAT IS NEW AND CONCLUSION In healthy, non-obese Chinese adults, propofol mono-sedation can provide excellent conditions of UGI endoscopy and the estimated ED50 of propofol for successful endoscope insertion is 1.89 ± 0.12 mg/kg.
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Affiliation(s)
- Fu K Liu
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Lei Wan
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Liu J Z Shao
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yi Zou
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Shao H Liu
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Fu S Xue
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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Delgado AADA, de Moura DTH, Ribeiro IB, Bazarbashi AN, dos Santos MEL, Bernardo WM, de Moura EGH. Propofol vs traditional sedatives for sedation in endoscopy: A systematic review and meta-analysis. World J Gastrointest Endosc 2019; 11:573-588. [PMID: 31839876 PMCID: PMC6885729 DOI: 10.4253/wjge.v11.i12.573] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 08/17/2019] [Accepted: 09/11/2019] [Indexed: 02/06/2023] Open
Abstract
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, I 2: 22%). In 10 studies, the incidence of hypotension was not statistically difference between sedation arms (RD: 0.01, 95%CI: -0.02-+0.04, I 2: 0%). Oxygen desaturation was higher in the propofol group but not statistically different between groups (RD: -0.03, 95%CI: -0.06-+0.00, I 2: 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, I 2: 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, I 2: 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, I 2: 59%). There was no statistical difference in the incidence of bradycardia (RD: -0.00, 95%CI: -0.08-+0.08, I 2: 85%), desaturation (RD: -0.00, 95%CI: -0.03-+0.02, I 2: 44%) or recovery time (MD: -2.04, 95%CI: -6.96-+2.88, I 2: 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, I 2: 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, I 2: 3%; RD: 0.04, 95%CI: -0.05-+0.13, I 2: 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, I 2: 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.
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Affiliation(s)
- Aureo Augusto de Almeida Delgado
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403000, Brazil
| | - Diogo Turiani Hourneaux de Moura
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403000, Brazil
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Igor Braga Ribeiro
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403000, Brazil
| | - Ahmad Najdat Bazarbashi
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Marcos Eduardo Lera dos Santos
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403000, Brazil
| | - Wanderley Marques Bernardo
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403000, Brazil
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12
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Pushkarna G, Sarangal P, Pushkarna V, Gupta R. Comparative Evaluation of Dexmedetomidine versus Midazolam as Premedication to Propofol Anesthesia in Endoscopic Retrograde Cholangiopancreatography. Anesth Essays Res 2019; 13:297-302. [PMID: 31198249 PMCID: PMC6545960 DOI: 10.4103/aer.aer_62_19] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
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.
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Affiliation(s)
| | - Pankaj Sarangal
- Department of Anaesthesia, SGRDIMSAR, Amritsar, Punjab, India
| | - Varun Pushkarna
- Department of Critical Care, Fortis Escort Hospital, Amritsar, Punjab, India
| | - Ruchi Gupta
- Department of Anaesthesia, SGRDIMSAR, Amritsar, Punjab, India
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13
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Yoon SW, Choi GJ, Lee OH, Yoon IJ, Kang H, Baek CW, Jung YH, Woo YC. Comparison of propofol monotherapy and propofol combination therapy for sedation during gastrointestinal endoscopy: A systematic review and meta-analysis. Dig Endosc 2018; 30:580-591. [PMID: 29526045 DOI: 10.1111/den.13050] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 03/05/2018] [Indexed: 01/22/2023]
Abstract
BACKGROUND AND AIM Previous randomized controlled trials have reported conflicting findings comparing propofol combination therapy (PCT) with propofol monotherapy (PMT) for sedation of patients undergoing gastrointestinal endoscopy. Therefore, a systematic review was carried out to compare the efficacy and safety of PCT and PMT in such patients. METHODS We searched MEDLINE, EMBASE and CENTRAL databases to identify all randomized controlled trials that compared the efficacy and safety of PCT and PMT for sedation of patients undergoing gastrointestinal endoscopy. Primary endpoints were incidence of respiratory complications, hypotension and arrhythmia, dose of propofol used, and recovery time. Procedure duration and the satisfaction of patients and doctors were also evaluated. RESULTS A total of 2250 patients from 22 studies were included in the final analysis. The combined analysis did not show any difference between PCT and PMT in the incidence of respiratory complications (risk ratio [RR], 0.80; 95% CI, 0.52 to 1.23; I2 = 58.34%), hypotension (RR, 1.06; 95% CI, 0.63 to 1.78; I2 = 72.13%), arrhythmia (RR,1.40; 95% CI, 0.74 to 2.64; I2 = 43.71%), recovery time (standardized mean difference [SMD], 0.16; 95% CI, -0.49 to 0.81; I2 = 95.9%), procedure duration (SMD, 0.04; 95% CI, -0.05 to 0.14; I2 = 0.0%), patient satisfaction (SMD, 0.13; 95% CI, -0.26 to 0.52; I2 = 89.63%) or doctor satisfaction (SMD, 0.01; 95% CI, -0.15 to 0.17; I2 = 0.00%). However, the dose of propofol used was significantly lower in PCT than in PMT (SMD, -1.38; 95% CI, -1.99 to -0.77; I2 = 97.70%). CONCLUSION PCT showed comparable efficacy and safety to PMT with respect to respiratory complications, hypotension and arrhythmia, recovery time, procedure duration, patient satisfaction, and doctor satisfaction. However, the average dose of propofol used was higher in PMT.
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Affiliation(s)
- Sang Won Yoon
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Geun Joo Choi
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Oh Haeng Lee
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Il Jae Yoon
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Hyun Kang
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Chong Wha Baek
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Yong Hun Jung
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Young Cheol Woo
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Korea
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14
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Kumari A, Singh AP, Vidhan J, Gupta R, Dhawan J, Kaur J. The Sedative and Propofol-Sparing Effect of Dexmedetomidine and Midazolam as Premedicants in Minor Gynecological Day Care Surgeries: A Randomized Placebo-Controlled Study. Anesth Essays Res 2018; 12:423-427. [PMID: 29962610 PMCID: PMC6020601 DOI: 10.4103/aer.aer_8_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND AND AIMS Ambulatory surgery is continually evolving specialty in the majority of surgical procedures. Dexmedetomidine and midazolam are newer adjuvants for sedation and reducing the dose of anesthetic agents. The aim of this study was to compare the sedative and propofol-sparing effect of dexmedetomidine and midazolam in minor gynecological day care surgeries. Observer's Assessment of Activity and Sedation, dose of additional propofol, Aldrete and street fitness score were studied as primary outcomes. Hemodynamic parameters and side effects were evaluated as secondary outcomes. MATERIALS AND METHODS A prospective randomized placebo-controlled study was conducted on 150 American Society of Anesthesiologists ASA physical status Classes I and II gynecological patients between 18 and 50 years and were allocated into three groups of fifty each. Group A received intravenous (i.v.) dexmedetomidine 0.1 μg/kg, Group B received i.v. midazolam 0.04 mg/kg, and Group C received normal saline 10 min before induction. RESULTS Sedation score was statistically highly significant between Group A and B (P < 0.001). Between Group A and C, it was statistically significant (P < 0.05); however, score was nonsignificant between Groups B and C (P > 0.05). During recovery at 120 min after surgery, score 5 was achieved equally by all three groups which was found to be statistically insignificant (P > 0.05). Mean dose of additional propofol used was less in Group A (14 ± 9.25) than B (25 ± 5.40) and C (53 ± 10.96). On intergroup comparison between all three groups, it was found to be statistically highly significant (P < 0.001). Comparison of bispectral index (BIS) values between Groups A and C and Groups B and C were highly significant (P < 0.001). However, it was statistically significant between Groups A and B (P < 0.05). Aldrete scoring and street fitness scores were highly significant between Groups A and B, B and C, and also between Groups A and C (P < 0.001). No significant hemodynamic derangements and side effects were noted in any of three groups. CONCLUSION Dexmedetomidine had good sedation and better recovery characteristics than midazolam. BIS monitoring was helpful in maintaining the depth of anesthesia.
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Affiliation(s)
- Anita Kumari
- Department of Anaesthesia, SGRD Medical College, Amritsar, Punjab, India
| | - Arvinder Pal Singh
- Department of Anaesthesia, SGRD Medical College, Amritsar, Punjab, India
| | - Jyoti Vidhan
- Department of Anaesthesia, SGRD Medical College, Amritsar, Punjab, India
| | - Ruchi Gupta
- Department of Anaesthesia, SGRD Medical College, Amritsar, Punjab, India
| | - Jonny Dhawan
- Department of Anaesthesia, SGRD Medical College, Amritsar, Punjab, India
| | - Jasleen Kaur
- Department of Anaesthesia, SGRD Medical College, Amritsar, Punjab, India
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15
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Lee JK, Jang DK, Kim WH, Kim JW, Jang BI. [Safety of Non-anesthesiologist Administration of Propofol for Gastrointestinal Endoscopy]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2017; 69:55-58. [PMID: 28135791 DOI: 10.4166/kjg.2017.69.1.55] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Jun Kyu Lee
- Department of Internal Medicine, Dongguk University College of Medicine, Goyang, Korea
| | - Dong Kee Jang
- Department of Internal Medicine, Dongguk University College of Medicine, Goyang, Korea
| | - Won Hee Kim
- Department of Internal Medicine, CHA University, Seongnam, Korea
| | - Jung Wook Kim
- Department of Internal Medicine, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Byung Ik Jang
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
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16
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Sathananthan D, Young E, Nind G, George B, Ashby A, Drummond S, Redel K, Green N, Singh R. Assessing the safety of physician-directed nurse-administered propofol sedation in low-risk patients undergoing endoscopy and colonoscopy. Endosc Int Open 2017; 5:E110-E115. [PMID: 28210707 PMCID: PMC5305421 DOI: 10.1055/s-0042-121667] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background and study aims Physician-directed nurse-administered balanced propofol sedation (PhD NAPS) in patients undergoing endoscopy and/or colonoscopy is being increasingly utilized worldwide. However, this method of sedation is not universally employed in Australian hospitals due to concerns surrounding its safety. The aim of this study was to assess the safety of PhD NAPS in low-risk patients undergoing endoscopy and/or colonoscopy. Patients and methods This study was conducted at a single tertiary teaching hospital in Adelaide, Australia. It was a prospective study involving 1000 patients with an ASA score of 1 - 3 presenting with any indication for endoscopy, colonoscopy or both. A total of 981 patients (451 male) with a mean age of 53 years (range: 16 - 87) were recruited from January 2010 to October 2012. 440 endoscopies, 420 colonoscopies, and 121 combined procedures were performed. The intra-procedural adverse events (AEs) were recorded. Results There were no major intra-procedural adverse events. Minor AEs occurred in 6.42 % of patients, and resolved spontaneously or with intravenous fluid boluses in all cases. Conclusion PhD NAPS is safe when the proceduralist and nursing staff are adequately trained and strict patient selection criteria are used.
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Affiliation(s)
| | - Edward Young
- University of Adelaide Medical School, Adelaide, South Australia
| | - Garry Nind
- Lyell McEwin Hospital – Gastroenterology, Adelaide, South Australia
| | - Biju George
- Lyell McEwin Hospital – Gastroenterology, Adelaide, South Australia
| | - Angelie Ashby
- University of Adelaide/Lyell McEwin Hospital, Endoscopy Unit, Elizabeth Vale, South Australia
| | - Sharon Drummond
- University of Adelaide/Lyell McEwin Hospital, Endoscopy Unit, Elizabeth Vale, South Australia
| | - Kasia Redel
- University of Adelaide/Lyell McEwin Hospital, Endoscopy Unit, Elizabeth Vale, South Australia
| | - Neville Green
- Lyell McEwin Hospital – Anaesthetics, Elizabeth Vale, South Australia
| | - Rajvinder Singh
- Lyell McEwin Hospital – Gastroenterology, Adelaide, South Australia
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17
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Darisetty S, Arjunan S, Tandan M, Gupta R, Ramchandani M, Reddy DN. Carbon dioxide insufflation is superior to air insufflation during endoscopic retrograde cholangiopancreatography: A randomized trial. JOURNAL OF DIGESTIVE ENDOSCOPY 2016. [DOI: 10.4103/0976-5042.180085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Abstract
Background: Carbon dioxide (CO2) insufflation has been shown to be superior to air insufflation in colonoscopy, and double balloon enteroscopy. However, the value of CO2 insufflation in endoscopic retrograde cholangiopancreatography (ERCP) is not established. This study aims to assess the efficacy and safety of CO2 insufflation during ERCP. Materials and Methods: Consecutive patients referred for ERCP at a single center were randomized to either air or CO2 insufflation during ERCP. The primary objectives were a post-ERCP abdominal pain (measured by 10 cm visual analog scale [VAS] 30 and 90 min, and 3 h and 24 h after ERCP). Secondary objectives included end-tidal CO2 (ETCO2) values and procedural complications. Results: We randomized 298 patients; 149 into air group and 149 into CO2 group. The VAS score for pain was higher in the air group compared to the CO2 group at 30 min, with a median of 1 (interquartile range 1–0) versus median of 1 (interquartile range 1–0); P = 0.031 and 90 min after the procedure with a median of 0 (interquartile range 1–0) versus median of 0 (interquartile range 0–0); P = 0.006. There were no serious adverse events, and the ETCO2 was within normal limits in both groups. Conclusions: CO2 insufflation is superior to air insufflation during ERCP with regard to patient pain and discomfort and warrants wide adoption. Clinical Trials.gov registration number NCT 01321203.
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Affiliation(s)
- Santosh Darisetty
- Departments of Anesthesiology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Saravanan Arjunan
- Department of Anesthesiology, Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Manu Tandan
- Department of Anesthesiology, Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Rajesh Gupta
- Department of Anesthesiology, Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Mohan Ramchandani
- Department of Anesthesiology, Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Duvvur Nageshwar Reddy
- Department of Anesthesiology, Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
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18
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Khoi CS, Wong JJ, Wang HC, Lu CW, Lin TY. Age correlates with hypotension during propofol-based anesthesia for endoscopic retrograde cholangiopancreatography. ACTA ACUST UNITED AC 2015; 53:131-4. [PMID: 26627000 DOI: 10.1016/j.aat.2015.10.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2015] [Revised: 10/07/2015] [Accepted: 10/19/2015] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure used for diagnostic and therapeutic purposes. Most of the patients may feel pain, anxiety, and discomfort during this procedure, so conscious sedation is usually used during ERCP. General anesthesia would be considered if conscious sedation fails to achieve the requirement of the endoscopists. Several studies showed that propofol-based sedation could provide a better recovery profile. However, propofol has a narrow therapeutic window and complications may occur beyond this window. The present study aimed to find out the complications and the associated risk factors during ERCP procedure under propofol-based deep sedation. METHODS We retrospectively reviewed data from anesthetic and procedure records of the patients who underwent ERCP under propofol-based deep sedation from January 2006 to July 2010 at Far Eastern Memorial Hospital, Taipei, Taiwan. All propofol-based deep sedations were conducted by anesthesiologists. The incidence of complications was determined and the independent risk factors identified by the multivariable logistic regression model. RESULT Propofol-based deep sedation was provided for 552 patients who received ERCP procedure. The majority of the patients were male, the mean age was 60 ± 16 years and American Society of Anesthesiologists physical status II-III. Almost 30% of patients experienced hypotension during the procedure, although no mortality or morbidity was associated with this complication. Sex, age, anesthetic time, American Society of Anesthesiologists status, hypertension, and arrhythmia were significantly different (p < 0.05) between patients with hypotension and without hypotension during the procedure. Multivariable logistic regression identified sex and age to be the independent predictors of hypotension. CONCLUSION Hypotension was the most frequent anesthetic complication during procedure under propofol-based deep sedation, but this method was safe and effective under appropriate monitoring. Age is the strongest predictor of hypotension and therefore propofol-based deep sedation should be conducted with caution in the elderly.
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Affiliation(s)
- Chong-Sun Khoi
- Department of Anesthesiology, Far Eastern Memorial Hospital, Ban-Chiao, Taipei County, Taiwan
| | - Jen-Jeng Wong
- Department of Anesthesiology, Far Eastern Memorial Hospital, Ban-Chiao, Taipei County, Taiwan
| | - Hao-Chin Wang
- Department of Anesthesiology, Far Eastern Memorial Hospital, Ban-Chiao, Taipei County, Taiwan
| | - Cheng-Wei Lu
- Department of Anesthesiology, Far Eastern Memorial Hospital, Ban-Chiao, Taipei County, Taiwan; Department of Mechanical Engineering, Yuan Ze University, Chung-Li, Taiwan.
| | - Tzu-Yu Lin
- Department of Anesthesiology, Far Eastern Memorial Hospital, Ban-Chiao, Taipei County, Taiwan; Department of Mechanical Engineering, Yuan Ze University, Chung-Li, Taiwan
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Mukhopadhyay S, Niyogi M, Sarkar J, Mukhopadhyay BS, Halder SK. The dexmedetomidine "augmented" sedato analgesic cocktail: An effective approach for sedation in prolonged endoscopic retrograde cholangio-pancreatography. J Anaesthesiol Clin Pharmacol 2015; 31:201-6. [PMID: 25948901 PMCID: PMC4411834 DOI: 10.4103/0970-9185.155149] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND AND AIMS In absence of any published standard guideline for sedation or anesthesia practice for prolonged therapeutic "endoscopic retrograde cholangio-pancreatography (ERCP)", safe and cost-effective sedation protocol is the need of the hour. Our study aims to evaluate the efficacy of a dexmedetomidine as an add-on for prolonged deep sedation for ERCP and to compare three deep sedation regimens regarding safety and efficacy. MATERIAL AND METHODS Forty-five consecutively enrolled patients planned for therapeutic ERCP and assumed to have prolonged procedural duration (>50 min) were divided into three groups in a randomized assessor blinded fashion. Group 1 received propofol and midazolam, Group 2 received the sedato-analgesic cocktail containing ketamine-propofol-midazolam-pentazocine, and the Group 3 received sedate-analgesic cocktail plus dexmedetomidine infusion under monitoring of vital parameters and according to the judgment of the concerned anesthesiologist. Total propofol requirement, episodes of gagging, oxygen desaturation, changes in mean blood pressure (MBP), recovery and satisfaction score of endoscopist, anesthetist and patient were noted and analyzed statistically using one way ANOVA with Bonferroni correction and Chi-square test. RESULTS Mean propofol requirement, incidences of gagging and oxygen desaturation was significantly less in Group 2 and 3 compared to Group 1. MBP was more stable and recovery was faster in Group 3. Anesthetist's satisfaction was more with Group 2 and even more with Group 3. CONCLUSIONS The sedato-analgesic cocktail was superior to the conventional propofol-midazolam regimen, dexmedetomidine as add-on increased the efficacy and safety of sedate-analgesic cocktail. It reduces propofol requirement, helps to maintain the patient in a safe and more stable level of sedation and increases satisfaction of the anesthetist.
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Affiliation(s)
- Sandip Mukhopadhyay
- Department of Pharmacology, Christian Medical College, Ludhiana, Punjab, India
| | - Mausumi Niyogi
- Department of Anaesthesiology, Burdwan Medical College, Burdwan, India
| | - Joydip Sarkar
- Department of Gastroenterology, Kothari Medical Centre, Kolkata, India
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Ramkiran S, Iyer SS, Dharmavaram S, Mohan CVR, Balekudru A, Kunnavil R. BIS Targeted Propofol Sparing Effects of Dexmedetomidine Versus Ketamine in Outpatient ERCP: A Prospective Randomised Controlled Trial. J Clin Diagn Res 2015; 9:UC07-12. [PMID: 26155536 PMCID: PMC4484128 DOI: 10.7860/jcdr/2015/12435.5991] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Accepted: 04/02/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND Endoscopic Retrograde Cholangio Pancreatography (ERCP) is routinely performed under propofol sedation. Adjuvant drugs have improved the quality of propofol sedation while minimizing complications. The aim of the study was to compare the propofol consumption, recovery and hemodynamic profiles of dexmedetomidine versus ketamine against a placebo control with BIS targeted in the sedative range for outpatient ERCP procedures. MATERIALS AND METHODS The study comprised of 72 patients undergoing ERCP, who were randomly allocated into one of the 3 groups: Group Dexmedetomidine (n =24) receiving a bolus and infusion of dexmedetomidine (1μg/kg and 0.5μg/kg/hr); Group Ketamine (n = 24) receiving a bolus and infusion of ketamine (0.25mg/kg and 5μg/kg/min) and Group Control (n =24) receiving saline placebo as a bolus and infusion with variable propofol boluses administered in all groups targeting BiSpectral Index between 60-70. RESULTS The total propofol consumption was significantly lower in both Dexmedetomidine (162.5 ± 71.7 mg ) and Ketamine groups (158.3 ± 66.89 mg) when compared with Control group (255.83 ± 114.12 mg)(p=0.001) .Time taken (minutes) to achieve Modified Aldrette Score (MAS) >9 and Observer Assessment of Alertness and Sedation (OAAS) score >4 was significantly prolonged in Dexmedetomidine group (MAS 16.6 ± 3.18 and OAAS 16.67 ± 2.82) compared to Ketamine (MAS 10 ± 4.17 and OAAS 8.75 ± 3.68) and Control (MAS 7.5 ± 3.29 and OAAS 6.88 ± 2.47) (p<0.001). Hemodynamic profiles were comparable although patients in dexmedetomidine had a statistically significant lower heart rate (p<0.001) although without clinical significance. CONCLUSION Low dose ketamine with background propofol boluses resulted in lesser propofol consumption, with earlier recovery and favourable hemodynamics when compared with Dexmedetomidine and control group in outpatient ERCP.
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Affiliation(s)
- Seshadri Ramkiran
- Assistant Professor, Department of Anesthesiology and Pain, M.S. Ramaiah Medical College and Hospitals, M.S.R. Nagar, Bengaluru, Karanataka, India
| | - Sadasivan S. Iyer
- Assistant Professor, Department of Anesthesiology and Pain, M.S. Ramaiah Medical College and Hospitals, M.S.R. Nagar, Bengaluru, Karanataka, India
| | - Sudhindra Dharmavaram
- Assistant Professor, Department of Anesthesiology and Pain, M.S. Ramaiah Medical College and Hospitals, M.S.R. Nagar, Bengaluru, Karanataka, India
| | - Chadalavada Venkata Rama Mohan
- Professor And Head, Department of Anesthesiology and Pain, M.S. Ramaiah Medical College and Hospitals, M.S.R. Nagar, Bengaluru, Karanataka, India
| | - Avinash Balekudru
- Associate Professor, Department of Gastroenterology, M.S. Ramaiah Medical College and Hospitals, M.S.R. Nagar, Bengaluru, Karanataka, India
| | - Radhika Kunnavil
- Lecturer, Department of Community Medicine and Bio Statistics, M.S. Ramaiah Medical College and Hospitals, M.S.R. Nagar, Bengaluru, Karanataka, India
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Kawano S, Okada H, Iwamuro M, Kouno Y, Miura K, Inokuchi T, Kanzaki H, Hori K, Harada K, Hiraoka S, Kawahara Y, Yamamoto K. An effective and safe sedation technique combining target-controlled infusion pump with propofol, intravenous pentazocine, and bispectral index monitoring for peroral double-balloon endoscopy. Digestion 2015; 91:112-116. [PMID: 25677385 DOI: 10.1159/000369614] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 11/11/2014] [Indexed: 02/04/2023]
Abstract
BACKGROUND/AIMS Because peroral double-balloon endoscopy (DBE) is a time-consuming, painful procedure, sedation with analgesics, and/or anesthetics is generally required. The aim of this prospective study was to investigate the safety and efficacy of our sedation protocol for peroral DBE, which consisted of target-controlled infusion (TCI) anesthesia with propofol, an intravenous bolus of pentazocine, and bispectral index (BIS) monitoring. METHODS A total of 34 consecutive patients who underwent DBE by the oral approach were enrolled. Patients were primarily sedated with a continuous infusion of propofol and adjusted in accordance with the BIS levels. The bolus infusion of pentazocine was performed when the propofol infusion was insufficient. The primary outcome measure of this study was to ensure the safety and efficacy of this sedation technique. The secondary purpose was to identify the characteristics of the patient who required the bolus infusion of pentazocine. RESULTS Five patients (14.7%) required a reduction in the dose of propofol. However, no patient experienced any serious adverse events. All patients (100%) and 80.6% (25/31) of endoscopists answered that the sedation protocol was 'excellent' or 'enough' for peroral DBE. Eleven patients (32.3%) required a bolus injection of pentazocine. Age <60 years and a total procedure time of >70 min were significant risk-factors for pentazocine use. CONCLUSIONS A combination of propofol via TCI pump, bolus injection of pentazocine as needed, and BIS monitoring was a safe and effective procedure for peroral DBE. Reasonable satisfaction indices were obtained from both patients and endoscopists. Pentazocine was required for young patients and in cases with longer procedure times.
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Affiliation(s)
- Seiji Kawano
- Department of Endoscopy, Okayama University Hospital, Okayama, Japan
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Miyoshi H, Shimatani M, Kato K, Sumimoto K, Kurishima A, Kusuda T, Fukata N, Ikeura T, Takaoka M, Okazaki K. Transcutaneous monitoring of partial pressure of carbon dioxide during endoscopic retrograde cholangiopancreatography using a double-balloon endoscope with carbon dioxide insufflation under conscious sedation. Dig Endosc 2014; 26:436-41. [PMID: 23941285 DOI: 10.1111/den.12155] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Accepted: 07/05/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIM A double-balloon (DB) endoscope can be selectively inserted into the afferent loop to carry out endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy, allowing various types of endoscopic treatments for pancreaticobiliary diseases to be successfully carried out. In order to make such a lengthy procedure more comfortable and safe, sedatives and carbon dioxide (CO2 ) insufflation are widely used for gastrointestinal endoscopy. However, these techniques can increase the risk of CO2 retention. Recently, a new sensor for transcutaneous measurement of partial pressure of carbon dioxide (PCO2 ) has been introduced. The aim of the present study was to evaluate the changes in transcutaneous PCO2 (PtcCO2 ) during DB-ERCP with CO2 insufflation under conscious sedation and assess any complications related to sedation and CO2 insufflation. METHODS A total of 312 patients underwent DB-ERCP with CO2 insufflation at our hospital between March 2009 and December 2012. The patients were moderately sedated using midazolam with or without pentazocine. PtcCO2 was measured by a non-invasive sensor throughout DB-ERCP in all patients. RESULTS The mean peak PtcCO2 during the procedure was significantly higher than the mean PtcCO2 value before and after DB-ERCP. Body mass index, procedure time and dose of pentazocine were significantly higher in the CO2 retention group (peak PtcCO2 ≥ 50 mmHg). CO2 narcosis was observed in one case. CONCLUSIONS DB-ERCP with CO2 insufflation under conscious sedation might have the potential to increase the risk of CO2 retention. Hence, non-invasive and continuous PtcCO2 measurement is useful for early detection of hypercapnia.
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Affiliation(s)
- Hideaki Miyoshi
- Division of Gastroenterology and Hepatology, Kansai Medical University, Osaka, Japan
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Terui T, Inomata M. Administration of additional analgesics can decrease the incidence of paradoxical reactions in patients under benzodiazepine-induced sedation during endoscopic transpapillary procedures: prospective randomized controlled trial. Dig Endosc 2013; 25:53-9. [PMID: 23286257 DOI: 10.1111/j.1443-1661.2012.01325.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2012] [Accepted: 03/26/2012] [Indexed: 02/08/2023]
Abstract
AIM The aim of the present study was to evaluate the efficacy and safety of giving pentazocine as an analgesic with benzodiazepine during endoscopic retrograde cholangiopancreatography (ERCP). METHODS The paradoxical reactions (PR) incidence was evaluated as an indicator of usefulness. Transcutaneous arterial carbon dioxide tension (PtcCO(2) ) was evaluated as an indicator of safety. A total of 160 patients were enrolled. Subjects were randomly divided into two groups; group 1 sedated with midazolam only and group 2 sedated both with midazolam and pentazocine (7.5 mg). RESULTS The initial dosage introduced sedation before procedure was significantly higher in group 1. The occurrence rate of PR's in group 1 was significantly higher compared to that in group 2 (P = 0.0108). Although maximum PtcCO(2) observed during sedation did not differ between the two groups (48.7 ± 7.2, 50.3 ± 7.6 mmHg, respectively),maximum PtcCO(2) during the first 15 min after the start of sedation was significantly higher in group 2 than in group 1 (P = 0.0294). In multivariate analysis, procedure duration (odds ratio [OR] = 1.048) and midazolam dose (OR = 1.221) were predictive factors for PR. CONCLUSION The administration of pentazocine is significantly reduced the incidence of PR's in patients under midazolam induced sedation during ERCP.
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Affiliation(s)
- Torahiko Terui
- Department of Gastroenterology and Hepatology, Iwate Medical University, Morioka, Japan
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Wang D, Wang S, Chen J, Xu Y, Chen C, Long A, Zhu Z, Liu J, Deng D, Chen J, Tang D, Wang L. Propofol combined with traditional sedative agents versus propofol- alone sedation for gastrointestinal endoscopy: a meta-analysis. Scand J Gastroenterol 2013; 48:101-110. [PMID: 23110510 DOI: 10.3109/00365521.2012.737360] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To assess the efficacy and safety of sedation of propofol combined with traditional sedative agents (PTSA) for gastrointestinal endoscopy, we conducted a meta-analysis of randomized controlled trials (RCTs) comparing PTSA with propofol-alone sedation. MATERIAL AND METHODS RCTs comparing the effects of PTSA and propofol alone during gastrointestinal endoscopy were found on MEDLINE, the Cochrane Central Register of Controlled Trials, and EMBASE. Cardiopulmonary complications (i.e., hypoxia, hypotension, arrhythmia, and apnea), total dose of propofol used and amnesia were assessed. RESULTS Nine original RCTs investigating a total of 1,505 patients, of whom, 805 received PTSA sedation and 700 received propofol-alone sedation, met the inclusion criteria. Compared with propofol-alone sedation, the pooled relative risk with the use of PTSA sedation for developing hypoxia, hypotension, arrhythmias, and apnea for all the procedures combined was 0.93 (95% CI, 0.30-2.92), 1.32 (95% CI, 0.38-4.64), 2.61 (95% CI, 0.23-29.29) and 2.81 (95% CI, 0.27-29.07), with no significant difference between the groups. The pooled mean difference in total dose of propofol used was -40.01 (95% CI, -78.96 to -1.05), which showed a significant reduction with use of PTSA sedation. The pooled relative risk for amnesia was 0.97 (95% CI, 0.88-1.07), suggesting no significant difference between the groups. CONCLUSIONS PTSA sedation during gastrointestinal endoscopy could significantly reduce the total dose of propofol, but without benefits of lower risk of cardiopulmonary complications compared with propofol-alone sedation.
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Affiliation(s)
- Daorong Wang
- Department of Gastrointestinal Surgery, Subei People's Hospital of Jiangsu Province (Clinical Medical College of Yangzhou University), Yangzhou, PR China
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Angsuwatcharakon P, Rerknimitr R, Ridtitid W, Kongkam P, Poonyathawon S, Ponauthai Y, Sumdin S, Kullavanijaya P. Cocktail sedation containing propofol versus conventional sedation for ERCP: a prospective, randomized controlled study. BMC Anesthesiol 2012; 12:20. [PMID: 22873637 PMCID: PMC3434082 DOI: 10.1186/1471-2253-12-20] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2011] [Accepted: 08/03/2012] [Indexed: 03/03/2023] Open
Abstract
Background ERCP practically requires moderate to deep sedation controlled by a combination of benzodiazepine and opiod. Propofol as a sole agent may cause oversedation. A combination (cocktail) of infused propofol, meperidine, and midazolam can reduce the dosage of propofol and we hypothesized that it might decrease the risk of oversedation. We prospectively compare the efficacy, recovery time, patient satisfactory, and side effects between cocktail and conventional sedations in patients undergoing ERCP. Methods ERCP patients were randomized into 2 groups; the cocktail group (n = 103) and the controls (n = 102). For induction, a combination of 25 mg of meperidine and 2.5 mg of midazolam were administered in both groups. In the cocktail group, a bolus dose of propofol 1 mg/kg was administered and continuously infused. In the controls, 25 mg of meperidine or 2.5 mg/kg of midazolam were titrated to maintain the level of sedation. Results In the cocktail group, the average administration rate of propofol was 6.2 mg/kg/hr. In the control group; average weight base dosage of meperidine and midazolam were 1.03 mg/kg and 0.12 mg/kg, respectively. Recovery times and patients’ satisfaction scores in the cocktail and control groups were 9.67 minutes and 12.89 minutes (P = 0.045), 93.1and 87.6 (P <0.001), respectively. Desaturation rates in the cocktail and conventional groups were 58.3% and 31.4% (P <0.001), respectively. All desaturations were corrected with temporary oxygen supplementation without the need for scope removal. Conclusions Cocktail sedation containing propofol provides faster recovery time and better patients’ satisfaction for patients undergoing ERCP. However, mild degree of desaturation may still develop. Trial registration ClinicalTrials.gov, NCT01540084
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Affiliation(s)
- Phonthep Angsuwatcharakon
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, 10310, Thailand.
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Balanced propofol sedation versus propofol monosedation in therapeutic pancreaticobiliary endoscopic procedures. Dig Dis Sci 2012; 57:2113-21. [PMID: 22615018 DOI: 10.1007/s10620-012-2234-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2012] [Accepted: 05/02/2012] [Indexed: 12/18/2022]
Abstract
BACKGROUND Prolonged or complex endoscopic procedures are frequently performed under deep sedation. However, no studies of therapeutic ERCP have yet compared the use of balanced propofol sedation (BPS) to propofol alone, titrated to moderate levels of sedation. AIM This prospective, randomized, double-blind study was planned to compare the sedation efficacy and safety of BPS (propofol in combination with midazolam and fentanyl) and propofol monosedation in therapeutic ERCP and EUS. METHODS BPS, or propofol monosedation titrated to a moderate level of sedation, was performed by trained registered nurses under endoscopist supervision. The main outcome measurements included sedation efficacy focusing on recovery time, sedation safety, endoscopic procedure outcomes, and complications. RESULTS There were no significant differences in sedation efficacy, safety, procedure outcomes, and complications, with the exception of recovery time. Mean recovery time (standard deviation) was 18.37 (7.86) min in BPS and 13.4 (6.24) min in propofol monosedation (P < 0.001). In a safety analysis, cardiopulmonary complication rates related to BPS and propofol monosedation were 7.8 % (8/102) and 9.6 % (10/104), respectively (P = 0.652). No patient required assisted ventilation or permanent termination of a procedure in either group. Technical success of the endoscopic procedures was 96.3 and 97.2 %, respectively (P = 0.701). Endoscopic procedure-related complications and outcomes did not differ depending on sedation procedure. CONCLUSIONS Propofol monosedation by trained, registered sedation nurses under supervision resulted in a more rapid recovery time than BPS. There were no differences in the sedation safety, endoscopic procedure outcomes, and complications between BPS and propofol monosedation.
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Obesity as a risk factor for sedation-related complications during propofol-mediated sedation for advanced endoscopic procedures. Gastrointest Endosc 2011; 74:1238-47. [PMID: 22136773 PMCID: PMC4124898 DOI: 10.1016/j.gie.2011.09.006] [Citation(s) in RCA: 107] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2011] [Accepted: 09/01/2011] [Indexed: 12/13/2022]
Abstract
BACKGROUND There are limited data on the safety of anesthesia-assisted endoscopy by using propofol-mediated sedation in obese individuals undergoing advanced endoscopic procedures (AEPs). OBJECTIVE To study the association between obesity (as measured by body mass index [BMI]) and the frequency of sedation-related complications (SRCs) in patients undergoing AEPs. DESIGN Prospective cohort study. SETTING Tertiary referral center. PATIENTS A total of 1016 consecutive patients undergoing AEPs (BMI <30, 730 [72%]; 30-35, 159 [16%]; >35, 127 [12%]). INTERVENTION Monitored anesthesia sedation with propofol alone or in combination with benzodiazepines and/or opioids. MAIN OUTCOME MEASUREMENTS SRCs, airway maneuvers (AMs), hypoxemia, hypotension requiring vasopressors, and early procedure termination were compared across 3 groups. RESULTS There were 203 AMs in 13.9% of patients, hypoxemia in 7.3%, need for vasopressors in 0.8%, and premature termination in 0.6% of patients. Increasing BMI was associated with an increased frequency of AMs (BMI <30, 10.5%; 30-35, 18.9%; >35-26.8%; P < .001) and hypoxemia (BMI <30, 5.3%; 30-35, 9.4%; >35, 13.4%; P = .001); there was no difference in the frequency of need for vasopressors (P = .254) and premature termination of procedures (P = .401). On multivariable analysis, BMI (odds ratio [OR] 2.0; 95% CI, 1.3-3.1), age (OR 1.1; 95% CI, 1.0-1.1), and American Society of Anesthesiologists class 3 or higher (OR 2.4; 95% CI, 1.1-5.0) were independent predictors of SRCs. In obese individuals (n = 286), there was no difference in the frequency of SRCs in patients receiving propofol alone or in combination (P = .48). LIMITATIONS Single tertiary center study. CONCLUSIONS Although obesity was associated with an increased frequency of SRCs, propofol sedation can be used safely in obese patients undergoing AEPs when administered by trained professionals.
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Slagelse C, Vilmann P, Hornslet P, Hammering A, Mantoni T. Nurse-administered propofol sedation for gastrointestinal endoscopic procedures: first Nordic results from implementation of a structured training program. Scand J Gastroenterol 2011; 46:1503-9. [PMID: 22050137 DOI: 10.3109/00365521.2011.619274] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Proper training to improve safety of NAPS (nurse-administered propofol sedation) is essential. OBJECTIVE To communicate our experience with a training program of NAPS. MATERIALS AND METHODS In 2007, a training program was introduced for endoscopists and endoscopy nurses in collaboration with the Department of Anaesthesiology. During a 2.5-year period, eight nurses were trained. Propofol was given as monotherapy. The training program for nurses consisted of a 6-week course including theoretical and practical training whereas the training program for endoscopists consisted of 2.5 h of theory. Patients were selected based on strict criteria including patients in ASA (American Society of Anesthesiologists) group I-III. RESULTS 2527 patients undergoing 2.656 gastrointestinal endoscopic procedures were included. The patients were ASA group I, II and III in 34.7%, 56% and 9,3%, respectively. Median dose of propofol was 300 mg. No mortality was noted. 119 of 2527 patients developed short lasting hypoxia (4.7%); 61 (2.4%) needed suction; 22 (0.9%) required bag-mask ventilation and 8 (0.3%) procedures had to be discontinued. In 11 patients (0.4%), anesthetic assistance was called due to short lasting desaturation. 34 patients (1.3%) experienced a change in blood pressure greater than 30%. CONCLUSION NAPS provided by properly trained nurses according to the present protocol is safe and only associated with a minor risk (short lasting hypoxia 4.7%). National or international structured training programs are at present few or non-existing. The present training program has documented its value and is suggested as the basis for the current development of guidelines.
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Affiliation(s)
- Charlotte Slagelse
- Department of Endoscopy, Copenhagen University Hospital Gentofte, Hellerup, Denmark
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Abstract
Endoscopic Retrograde Cholangiopancreatography is used for both diagnostic and therapeutic purposes. It is relatively more complex than routine endoscopies and requires adequate patient sedation. Furthermore the patients often have co-morbidities. This article provides an overview of various anaesthetic drugs and the type of anaesthesiological support.
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Affiliation(s)
- H Kapoor
- Department of Anaesthesiology, Kokilaben Dhirubhai Ambani Hospital, Mumbai, India.
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Kuwatani M, Kawakami H, Hayashi T, Ishiwatari H, Kudo T, Yamato H, Ehira N, Haba S, Eto K, Kato M, Asaka M. Carbon dioxide insufflation during endoscopic retrograde cholangiopancreatography reduces bowel gas volume but does not affect visual analogue scale scores of suffering: a prospective, double-blind, randomized, controlled trial. Surg Endosc 2011; 25:3784-90. [PMID: 21656068 DOI: 10.1007/s00464-011-1789-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2011] [Accepted: 05/16/2011] [Indexed: 12/13/2022]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) and related procedures can cause abdominal pain and discomfort. Two clinical trials have indicated, using the visual analogue scale (VAS) score, that CO(2) insufflation during ERCP ameliorates the suffering of patients without complications, compared with air insufflation. However, differences in patient suffering between CO(2) and air insufflation after ERCP under deep conscious sedation have not been reported. We focused on the gas volume score (GVS) as an objective indicator of gas volume, and designed a multicenter, prospective, double-blind, randomized, controlled study with CO(2) and air insufflation during ERCP. METHODS Between March 2010 and August 2010, 80 patients who required ERCP were enrolled and evenly randomized to receive CO(2) insufflation (CO(2) group) or air insufflation (air group). ERCP and related procedures were performed under deep conscious sedation with fentanyl citrate or pethidine and midazolam or diazepam. The GVS was evaluated as the primary endpoint in addition to the VAS score as the secondary endpoint. RESULTS The GVS after ERCP and related procedures in the CO(2) group was significantly lower than that in the air group (0.14 ± 0.06 vs. 0.31 ± 0.11, P < 0.01), as well as the rate of increase in GVS ([GVS after - GVS before]/[GVS before ERCP and related procedures] × 100) (3.8 ± 5.9 vs. 21 ± 11.1%, P < 0.01). VAS scores 3 and 24 h after ERCP and related procedures were comparable between the CO(2) and air groups for abdominal pain, abdominal distension, and nausea. Additionally, VAS scores were not correlated with the GVS. CONCLUSIONS CO(2) insufflation during ERCP reduces GVS (bowel gas volume) but not the VAS score of suffering compared with air insufflation. Deep and sufficient sedation during ERCP and related procedures is important for the palliation of patients' pain and discomfort.
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Affiliation(s)
- Masaki Kuwatani
- Department of Gastroenterology, Hokkaido University Graduate School of Medicine, North 15, West 7, Kita-ku, Sapporo 060-8638, Japan
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European Society of Gastrointestinal Endoscopy, European Society of Gastroenterology and Endoscopy Nurses and Associates, and the European Society of Anaesthesiology Guideline: Non-anaesthesiologist administration of propofol for GI endoscopy. Eur J Anaesthesiol 2011; 27:1016-30. [PMID: 21068575 DOI: 10.1097/eja.0b013e32834136bf] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Propofol sedation by non-anaesthesiologists is an upcoming sedation regimen in several countries throughout Europe. Numerous studies have shown the efficacy and safety of this sedation regimen in gastrointestinal endoscopy. Nevertheless, this issue remains highly controversial. The aim of this evidence- and consensus-based set of guideline is to provide non-anaesthesiologists with a comprehensive framework for propofol sedation during digestive endoscopy. This guideline results from a collaborative effort from representatives of the European Society of Gastrointestinal Endoscopy (ESGE), the European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) and the European Society of Anaesthesiology (ESA). These three societies have endorsed the present guideline.The guideline is published simultaneously in the Journals Endoscopy and European Journal of Anaesthesiology.
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Ramchandani M, Reddy DN, Gupta R, Lakhtakia S, Tandan M, Darisetty S, Rao GV. Spiral enteroscopy: a preliminary experience in Asian population. J Gastroenterol Hepatol 2010; 25:1754-1757. [PMID: 21039837 DOI: 10.1111/j.1440-1746.2010.06420.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND AIM In spite of recent developments in the field of enteroscopy the small bowel remains the challenging organ to access. The spiral enteroscopy is a novel technique using a special over-tube (Endo-Ease Discovery SB) system for deep intubation of the small bowel. The aim of the present study was to evaluate the efficacy of spiral enteroscopy with an Olympus enteroscope (SIF Q 180) in an Asian subset of patients. METHODS Between January and March 2010, 11 patients underwent spiral enteroscopies. The indication for the procedure was obscure gastrointestinal bleeding in five patients, Crohn's disease in two, malabsorbtion syndrome in two, Peutz-Jeghers syndrome in one and Osler Weber Rendu disease in one patient. RESULTS Eleven patients (five male and six female) mean age 41.6 years (range 21-62 years) underwent spiral enteroscopy. Spiral enteroscopy advancement was successful in all patients. The average depth of insertion was 249 cm (range 120-400 cm) past the ligament of Treitz, and the average time for the procedure was 27.8 min (range 20-32 min). The findings included ulcers (n = 3), polyps (n = 1), arteriovenous malformation (n = 2), ulcer with stricture (n = 1), and lymphangiectasia (n = 1). No major complications were observed. CONCLUSION In conclusion, our initial experience with spiral enteroscopy shows that it is easy to perform, takes less time than balloon assisted enteroscopy and is relatively safe.
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Ramchandani M, Reddy DN, Gupta R, Lakhtakia S, Tandan M, Rao GV, Darisetty S. Diagnostic yield and therapeutic impact of single-balloon enteroscopy: series of 106 cases. J Gastroenterol Hepatol 2009; 24:1631-8. [PMID: 19686408 DOI: 10.1111/j.1440-1746.2009.05936.x] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM Single-balloon enteroscopy (SBE) is a novel method of balloon assisted enteroscopy which allows deep intubation of intestine and has therapeutic potential. This prospective study was done in a tertiary care center to evaluate the feasibility, complications, diagnostic and therapeutic yield of SBE in patients with suspected small bowel disorders. METHODS One hundred and six patients (mean age 40.1 years, range 12-76 years, 65 men) with suspected small bowel diseases underwent 131 SBE procedures between February 2007 and July 2008. RESULTS Indications for SBE included obscure gastrointestinal bleeding (OGIB) (40), chronic abdominal pain with abnormal imaging studies (34), chronic diarrhea (20), polyposis syndromes (11) and foreign body (1).The mean insertion depth was 255.8 +/- 84.5 cm beyond the duodenojejunal flexure by the oral route and 163 +/- 59.3 cm proximal to the ileocecal valve by the per anal approach. The mean duration of the procedure for antegrade and retrograde enteroscopy was 65.9 +/- 19.5 min and 72.3 +/- 18.3 min, respectively. Pan-enteroscopy was possible in 25% of cases (five of 20 cases in which total enteroscopy was attempted). Diagnostic yields in cases of OGIB, chronic abdominal pain and chronic diarrhea were 60%, 65% and 55%, respectively. Overall new diagnosis was established in 46% and the extent of known disease was assessed in 15% of cases. In 21% of patients, therapeutic interventions were carried out while surgical treatment was directed to 8.4% of the patients. No major complications were observed. CONCLUSION SBE is well tolerated and has good diagnostic yield, having a similar yield to previous double-balloon enteroscopy reports.
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Santosh D, Lakhtakia S, Gupta R, Reddy DN, Rao GV, Tandan M, Ramchandani M, Guda NM. Clinical trial: a randomized trial comparing fluoroscopy guided percutaneous technique vs. endoscopic ultrasound guided technique of coeliac plexus block for treatment of pain in chronic pancreatitis. Aliment Pharmacol Ther 2009; 29:979-84. [PMID: 19222416 DOI: 10.1111/j.1365-2036.2009.03963.x] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Coeliac plexus block (CPB) is a management option for pain control in chronic pancreatitis. CPB is conventionally performed by percutaneous technique with fluoroscopic guidance (PCFG). Endoscopic ultrasound (EUS) is increasingly used for CPB as it offers a better visualization of the plexus. There are limited data comparing the two modalities. AIM To compare the pain relief in chronic pancreatitis among patients undergoing CPB either by PCFG technique or by EUS guided technique. METHODS Chronic pancreatitis patients with abdominal pain requiring daily analgesics for more than 4 weeks were included. Fifty six consecutive patients (41 males, 15 females) participated in the study. EUSG-CPB was performed in 27 and PCFG-CPB in 29 patients. In both the groups, 10 mL of Bupivacaine (0.25%) and 3 mL of Triamcinolone (40 mg) were given on both sides of the coeliac artery through separate punctures. RESULTS Pre and post procedure pain scores were obtained using a 0-10 visual analogue scale. Improvement in pain scores was seen in 70% of subjects undergoing EUS-CPB and 30% in Percutaneous- block group (P = 0.044). CONCLUSIONS EUS-guided coeliac block appears to be better than PCFG-CPB for controlling abdominal pain in patients with chronic pancreatitis.
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Affiliation(s)
- D Santosh
- Department of Anesthesiology, Asian Institute of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India.
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Abstract
The range of drugs available to provide anesthesia for patients undergoing electroconvulsive therapy (ECT) is ever increasing. Initially, anesthetic agents were selected on the basis of their capacity not to antagonize the induced seizure. This was not always a simple task because almost all general anesthetic agents have "in built" antiepileptic activity. Nonbarbiturate agents such as propofol have been successfully used as alternatives to thiopental and methohexitone, but this drug too has antiepileptic properties. Most recently, opioid-like drugs such as remifentanil have been used, and there has been renewed interest in ketamine, a phencyclidine derivative. Attention has also focused on whether the anesthetic agent selected may affect the cognitive impairment seen after ECT. Studies in this area are limited, but early results suggest that agents such as ketamine may have particular benefit. This article reviews the current literature dealing with anesthesia and postoperative cognitive impairment in general and with regard to ECT in particular.
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