Sub-clinical hepatic encephalopathy in cirrhotic patients is not aggravated by sedation with propofol compared to midazolam: a randomized controlled study

Randomized controlled trial for endoscopy with propofol versus midazolam on psychometric tests and critical flicker frequency in people with cirrhosis

BACKGROUND AND AIM

People with cirrhosis are at increased risk of development of complications related to sedation. The aim of the present study was to compare the effects of sedation for upper gastrointestinal endoscopy (UGIE) with propofol and midazolam on psychometric tests and critical flicker frequency (CFF) in people with cirrhosis.

METHODS

A total of 127 people with cirrhosis were randomized into three groups: propofol group (n = 40), midazolam group (n = 42) and no sedation (n = 45). All patients underwent CFF test and combination of psychometry (number connection test-A and B [NCT-A,B]; digit symbol test [DST], line tracing test [LTT] and serial dotting test [SDT]) at baseline and at 2 h post-endoscopy. CFF was done at 30 min and repeated every 30 min for 2 h.

RESULTS

In the propofol group there was no deterioration in psychometry (NCT-A [55.6 ± 18.7 vs 56.4 ± 19.0 s], NCT-B [98.2 ± 35.1 vs 97.8 ± 34.6 s], DST [26.7 ± 5.7 vs 26.3 ± 5.3], LTT [112.9 ± 35.7 vs 113.7 ± 36.6 s], SDT [94.6 ± 34.1 vs 95.2 ± 34.5 s]). Significant deterioration from baseline (39.8 ± 2.9 Hz) was seen in CFF at 30 min (38.8 ± 2.3 Hz) and 1 h (39.2 ± 2.4 Hz), P = 0.01 but no difference thereafter. In the midazolam group, significant deterioration was observed on psychometry (NCT-A [56.0 ± 18.5 vs 60.4 ± 19.8 s], NCT-B [99.9 ± 29.1 vs 105.9.6 ± 30.3 s], DST [26.1 ± 4.7 vs 25.2 ± 4.3], LTT [129.1 ± 34.5 vs 132.9 ± 35.4 s], SDT [95.6 ± 34.2]). No deterioration was observed in psychometry and CFF in people with cirrhosis without sedation.

CONCLUSIONS

Propofol sedation for UGIE was associated with earlier recovery compared with midazolam, which causes deterioration of psychometric tests and CFF for a longer time in comparison with propofol.

Midazolam for sedation during diagnostic or therapeutic upper gastrointestinal endoscopy in cirrhotic patients

AIM

The objective of this study was to determine the frequency of clinically overt hepatic encephalopathy (HE) in cirrhotic patients undergoing diagnostic or therapeutic upper gastrointestinal endoscopy (UGE) who received midazolam for sedation.

METHODS

This was an interventional study carried out at Liaquat National Hospital, Karachi. Consecutive patients presenting to the service of a single consultant gastroenterologist for diagnostic or therapeutic UGE between January 2009 and January 2011, who fulfilled the inclusion and exclusion criteria, were prospectively recruited for the study. The administration of intravenous midazolam was carried out in an incremental manner, whereas pulse and oxygen saturation was monitored during every procedure. During the recovery period, the degree of alertness was measured at 2, 4, and 6 h by the resident using the observer's assessment of alertness and sedation score and time to full recovery was determined.

RESULTS

A total of 191 consecutive patients who underwent diagnostic or therapeutic UGE fulfilling the inclusion and exclusion criteria were recruited. The mean age was 51.30 ± 10.7 years, with an age range of 12-75 years. The majority of the patients were men (n=108, 56.5%), with 83 women (43.5%). A total of eight patients (4.2%) remained drowsy and developed clinically overt HE after the procedure on assessment at 2 and 4 h. However, all of these patients regained full consciousness at 6 h spontaneously. Among those eight patients who developed clinically overt HE, seven (87.5%) were Child-Pugh class C and one patient (12.5%) was Child-Pugh class B. Overt HE was significantly related to Child-Pugh class (P=0.005) and the dose of midazolam (P=0.02).

CONCLUSION

We concluded that intravenous midazolam can be used safely in cirrhotic patients of Child-Pugh class A and B undergoing UGE for conscious sedation, but caution should be exercised for patients with advanced liver disease.

Anesthetic considerations for the patient with liver disease

PURPOSE OF REVIEW

An increasing number of patients requiring surgery are presenting with chronic or end stage liver disease. The management of these patients demands anesthesiologists with in-depth knowledge of the consequences of hepatic dysfunction, the effects on other organs, the risk of surgery, and the impact of anesthesia.

RECENT FINDINGS

Chronic or end stage liver disease is associated with an increased risk of perioperative morbidity and mortality. It is essential to preoperatively assess possible hepatic encephalopathy, pleural effusions, hepatopulmonary syndrome, hepatopulmonary hypertension, hepatorenal syndrome, cirrhotic cardiomyopathy, and coagulation disorders. The application of two scoring systems, that is, Child-Turcotte-Pugh and model for end stage liver disease, helps to estimate the risk of surgery. The use of propofol is superior to benzodiazepines as intravenous narcotics. Although enflurane and halothane are discouraged for maintenance of anesthesia, all modern volatile anesthetics appear comparable with respect to outcome. Fentanyl, sufentanil, and remifentanil as opioids and cis-atracurium for relaxation may be the best choices in liver insufficency. Regional anesthesia is valuable for postoperative pain management.

SUMMARY

Current studies have employed different anesthetic approaches in the preoperative and intraoperative management in order to improve outcomes of patients with liver disease.

Management of critically-ill cirrhotic patients

Cirrhotic patients are prone to develop life-threatening complications that require emergency care and ICU admission. They can present specific decompensations related to cirrhosis such as variceal bleeding and hepatorenal syndrome (HRS) or other critical events also observed in the general population such as severe sepsis or septic shock. Clinical management of all these entities requires a specific approach in cirrhosis. Cirrhotic patients have a hyperdynamic circulation with high cardiac output and low systemic vascular resistance in the absence of infection. Circulatory dysfunction increases the susceptibility of critically-ill cirrhotic patients to develop multiple organ failure and attenuates vascular reactivity to vasopressor drugs. HRS, a severe functional renal failure occurring in patients with advanced cirrhosis and ascites, is also secondary to this circulatory dysfunction that leads to an extreme renal vasoconstriction. Moreover, hypotensive cirrhotic patients require a carefully balanced replacement of volemia, since overtransfusion increases portal hypertension and the risk of variceal bleeding and undertransfusion causes tissue hypoperfusion which increases the risk of multiple organ failure. Cirrhotic patients are also at a high risk for development of other bleeding complications and are more susceptible to nosocomial infections. This extreme complexity of critically-ill cirrhotic patients requires a specific medical approach that should be known by general intensivists since it has a negative impact on patient prognosis. This review will focus on the diagnostic approach and treatment strategies currently recommended in the critical care management of patients with cirrhosis.

Update of endoscopy in liver disease: More than just treating varices

The management of complications in liver disease is often complex and challenging. Endoscopy has undergone a period of rapid expansion with numerous novel and specialized endoscopic modalities that are of increasing value in the investigation and management of the patient with liver disease. In this review, relevant literature search and expert opinions have been used to provide a brief overview and update of the current endoscopic management of patients with liver disease and portal hypertension. The main areas covered are safety of endoscopy in patients with liver disease, the use of standard endoscopy for the treatment of varices and the role of new endoscopic modalities such as endoscopic ultrasound, esophageal capsule, argon plasma coagulation, spyglass and endomicroscopy in the investigation and treatment of liver-related gastrointestinal and biliary pathology. It is clear that the role of the endoscopy in liver disease is well beyond that of just treating varices. As the technology in endoscopy expands, so does the role of the endoscopist in liver disease.

Safety of propofol in cirrhotic patients undergoing colonoscopy and endoscopic retrograde cholangiography: results of a prospective controlled study

BACKGROUND AND AIMS

Safety of propofol sedation in patients with liver cirrhosis undergoing colonoscopy or endoscopic retrograde cholangiopancreatography (ERCP) remains to be studied. The aim of this study was to investigate whether the use of propofol is safe for endoscopic procedures more complex than gastroscopy in patients with liver cirrhosis in a prospective controlled study.

METHODS

Two hundred and fourteen consecutive patients, with or without cirrhosis, who underwent colonoscopy or ERCP with propofol sedation were recruited between January and June 2009. Administration of sedation was performed by anesthesiologists and outcome measures were recorded. Main outcomes were complication rates and recovery times.

RESULTS

Sixty-one (28.5%) cirrhotic patients and 153 (71.5%) noncirrhotic patients were included. The incidence of sedation-related complications did not significantly differ between the two populations (11.5 vs. 17.0%, respectively, P=0.31). The mean (±SD) dose of propofol administered (213±86 vs. 239±100 mg, P=0.07), the mean time to achieve adequate sedation (3.3±1.1 vs. 3.0±1.2 min, P=0.21), the mean total duration of the endoscopic procedure (24.5±10.6 vs. 27.4±11.8 min, P=0.08), the mean time to reach Observer's Assessment of Alertness and Sedation Scale 5 (17.2±4.4 vs. 18.4±5.6 min, P=0.15), the mean time from completion of the procedure to release (9.0±2.5 vs. 9.1±3.2 min, P=0.86), and the mean time to full recovery (42.2±7.3 vs. 42.3±7.8 min, P=0.88) were very similar between the two groups. The limitation of this study was lack of randomization, and a control group of cirrhotic patients using standard sedation with benzodiazepines and opioids.

CONCLUSION

Propofol deep sedation administered by an anesthesiologist with appropriate monitorings seems to be a safe procedure during colonoscopy or ERCP in cirrhotic patients.