Propofol patient-controlled sedation during hip or knee arthroplasty in elderly patients

Patient-controlled sedation in orthopedic surgery under regional anesthesia: a new approach in procedural sedation

BACKGROUND AND OBJECTIVES

Regional anesthesia is a commonly used technique in orthopedic procedures. Sedation should reduce the patient's anxiety and fear while increasing regional anesthesia quality. This study evaluated the hemodynamic changes, level of sedation, both patients' and surgeons' levels of satisfaction and potential side effects in patient-controlled sedation using propofol.

METHODS

This randomized clinical trial studied sixty ASA physical class I-III patients scheduled for total knee replacement surgery under combined spinal-epidural anesthesia. Patients in Group P (n = 30) received propofol via a patient-controlled analgesia device with the following settings: intravenous propofol bolus dose 400 μg.kg(-1), 5-minute lockout interval and no basal infusion. In Group S, we infused saline 150 using the same settings. To determine the level of sedation, we used BIS and Observer's Assessment of Alertness/ Sedation Scale. For all patients, we recorded the number of requests. As the fi nal evaluation, we scored surgeons' and patients' satisfaction on 4-point scales.

RESULTS

Both BIS values and OAA/S scores were lower in Group P than in Group S. Patients' satisfaction was higher in Group P, although there was no significant difference with respect to surgeons' satisfaction between the groups. The number of requests for sedation was significantly higher in Group S. However, most requests were considered unsuccessful.

CONCLUSION

This study suggests that patient-controlled sedation with propofol can be used efficiently in orthopedic procedures.

Recent advances in patient-controlled sedation

PURPOSE OF REVIEW

Advances in minimally invasive procedures have resulted in an increased demand for procedural sedation. Patient-controlled sedation (PCS) has been in clinical use for almost 20 years, but has not been reviewed in over 10 years.

RECENT FINDINGS

Advances in microprocessor technology, increased demand for procedural sedation in a cost-conscious environment, and the availability of readily titratable pharmacologic agents together stimulated the development of alternative sedation practices. Continued research into the neurobiology of pain perception and the placebo effect has also played a role. PCS and patient-maintained sedation, primarily with propofol, have emerged as intriguing clinical alternatives to traditional sedation based in part on extensions of traditional PCA models.

SUMMARY

PCS has been applied to a wide variety of procedures, but systems that can be applied 'off-the-shelf' are not easy to tune. New approaches to PCS may address these limitations. Better understanding of the psychology of sedation may lead to better patient acceptance of PCS.

Pain and psychiatry: a critical analysis and pharmacological review

Pain is one of the most difficult medical problems to diagnose and treat and can be a common symptom of several psychiatric disorders. Pain-related issues are heterogeneous and often underestimated or misinterpreted, with the result that psychiatric interventions, which might have been beneficial from the outset, are often delayed or requested only as a last measure. Several problems arise from the definition, classification and assessment of pain, when documented according to the different scales which are commonly used, since these attempt to cover a multitude of analytical requirements, without really succeeding. An area of constant debate regards the connection between pain and various psychiatric disorders, and the difficulty in the classification of pain disorders within the currently existing framework. The pharmacological treatment of pain is complex and implies a variety of different compounds, from opioids to psychotropic medications like antidepressants and anticonvulsivants.

This paper explores the mutual and reciprocal influence between pain and psychiatric disorders reviewing the latest developments in the definition, assessment and treatment of pain, with special emphasis on the impact of pain on psychiatric disorders (and vice versa), and on the use of psychotropic drugs in the treatment of pain syndromes.

Comparison of alfetanil and ketamine in combination with propofol for patient-controlled sedation during fiberoptic bronchoscopy

BACKGROUND

During fiberoptic bronchoscopy, propofol, ketamine, benzodiazepines, and opiates are most commonly used, alone or in combination for sedation. The aim of this study was to compare the clinical efficacy of propofol/ketamine with propofol/alfentanil for patient-controlled sedation (PCS) during fiberoptic bronchoscopy.

METHOD

Patients undergoing fiberoptic bronchoscopy were randomly assigned to receive either propofol/alfentanil (PA group; n = 138) or propofol/ketamine (PK group; n = 138) via a patient-controlled analgesia (PCA) device for sedation and analgesia. Changes in blood pressure, heart rate (HR), and oxygen saturation were monitored. Degree of patient and bronchoscopist satisfaction was evaluated using a 10-cm visual analog scale (VAS) (0 = extremely uncomfortable to 10 = extremely comfortable).

RESULTS

After sedation, systolic arterial pressure (SAP) decreased in the PA group, but SAP was stable in the PK group. Compared with values immediately before starting bronchoscopy, SAP and HR increased during the procedure in both groups (P < 0.05). Patients in the PK group showed more satisfaction [(9.5 (6-10) vs. 9.0 (6-10)), P < 0.05] and amnesia (82% vs. 61%, P < 0.01). Despite these differences, the majority (greater than 90%) of the patients in both groups stated that they were comfortable during the procedure.

CONCLUSION

Our results show that although both techniques proved effective for sedation in patients undergoing fiberoptic bronchoscopy, ketamine is superior to alfentanil when used in combination with propofol because of the high patient satisfaction and amnesia.

Recent developments in patient-controlled analgesia

Patient-controlled analgesia (PCA) has become the gold standard for acute pain management since it was first introduced 20 years ago, and its merits have been discussed in quite a large number of publications. This review summarizes the more recent developments, such as new application devices and strategies, including intranasal, spinal, and regional PCA; patient-controlled sedation; experience with children and elderly people; and some data from chronic pain situations. Analyzing PCA literature from 2001 onwards confirms the author's long belief that the PCA principle ("WYNIWYG": what you need is what you get) was the most important aspect of a patient-controlled strategy, more or less independent of the type of drug or machine. Discovering this principle has changed the understanding of pain and suffering.

Patient-controlled versus nurse-administered sedation with propofol during colonoscopy. A prospective randomized trial

OBJECTIVES

Patient-controlled sedation (PCS) with propofol, is well tolerated and reduces recovery time and staff required during endoscopic interventions. "Who" administers the drug proves economically crucial. With the aim of maintaining safety, medical quality, and patient satisfaction, this study investigates PCS versus nurse-administered propofol sedation (NAPS) in a cohort of consecutive patients.

METHODS

One hundred and fourteen patients, aged 22-90 yr, undergoing only colonoscopy participated in this prospective randomized trial. Patients were randomly assigned to either PCS or NAPS. If patients declined randomization for different reasons of reluctance to PCS they were assigned to a standard nurse-sedated control group. All patients received pethidine presedation for analgesia. Visual analogue scales followed patient anxiety level, tolerability, pain, and satisfaction, and endoscopist's assessment of the procedure.

RESULTS

Given the choice, 35% of the patients who were rather younger and more anxious declined randomization to PCS. The mean total dose of propofol needed in this group was higher, but the patients had a tendency to rate the global tolerance and the pain of the examination as less comfortable compared to the two randomized groups. Self-administration of propofol created a significantly different drug profile and higher medication costs. With regard to the safety parameters there was no difference between PCS and NAPS. In their global assessments, the patients and endoscopists tended to prefer NAPS.

CONCLUSIONS

Individual patient characteristics and attitudes toward self-control are crucial for PCS. While being a viable option for patients who are able and willing to handle, this technique is not applicable in a considerable portion of everyday patients.

Safer colonoscopy with patient-controlled analgesia and sedation with propofol and alfentanil

BACKGROUND

The aim of this study was to assess the efficacy of patient-controlled analgesia and sedation with propofol/alfentanil for colonoscopy compared with continuous drug infusion and conventional nurse-administered medication.

METHODS

One hundred fifty patients undergoing colonoscopy on an outpatient basis were randomly assigned to 1 of 3 medication regimens. To maintain blinding, all patients were connected to an infusion pump. Group I patients could self-administer boluses of 4.8 mg propofol and 125 microg alfentanil without restriction. Group II patients received a continuous infusion with 0.048 mg/kg propofol and 0.12 microg/kg alfentanil per minute. Group III patients received intravenous premedication with 0.035 mg/kg midazolam and 0.35 mg/kg meperidine.

RESULTS

There were no differences between the groups with respect to pain (visual analogue scale) and procedure time. Patient-controlled analgesia and sedation with propofol/alfentanil (group I) resulted in less of an increase in the transcutaneous partial pressure of carbon dioxide (p = 0.0004) during colonoscopy and less of a decrease in mean arterial blood pressure (p = 0.0021) during recovery, as well as more complete recovery (p = 0.0019) after 45 minutes compared with conventional administration of midazolam/meperidine. Furthermore, patient-controlled analgesia and sedation yielded a higher degree of patient satisfaction than continuous infusion of propofol/alfentanil (p = 0.0033) or nurse-administered midazolam/meperidine (p = 0.0094).

CONCLUSIONS

Patient-controlled administration of propofol and alfentanil for colonoscopy may provide a better margin of safety than conventional administration of midazolam and meperidine and results in a higher level of patient satisfaction and shorter recovery.

Patient-controlled sedation with propofol for colonoscopy

BACKGROUND

Patient-controlled sedation (PCS) allows the patient to titrate the dosage of sedative drugs according to need.

METHODS

To compare the efficacy of PCS by using propofol with anesthetist-administered midazolam during colonoscopy, 88 patients were randomized to receive either intravenous midazolam 0.05 mg/kg bolus (1 mg increments as required) or propofol PCS (0.3 mg/kg bolus, zero lockout). Heart and respiratory rates, blood pressure, and oxygen saturation were monitored. Patient cooperation, endoscopist satisfaction, and level of sedation were scored. Patient satisfaction was assessed by questionnaire. To correct for multiple testing of data, statistical significance was asserted only for individually stated p values with p < 0.01.

RESULTS

Oxygen saturation and hemodynamics were stable in both groups. Better patient cooperation (good vs. minimal; p = 0.008) and higher endoscopist satisfaction (very good vs. good; p = 0.001) were achieved with PCS. Although more sedated intraoperatively (sedation score 4 vs. 2; p = 0.03 for a single test of hypothesis; correction for multiple testing of data removes this significance), patients in the propofol PCS group were more alert by 30 minutes and discharged earlier (mean and SD times were 43.3 [12.1] min compared with 61.0 [29.7] min; p = 0.001.) More patients in the PCS group (86 vs. 6l%; p < 0.001) were satisfied with their overall level of comfort.

CONCLUSION

PCS with propofol is effective and results in high patient satisfaction and faster discharge.

Sedation for vitreoretinal surgery: a comparison of anaesthetist-administered midazolam and patient-controlled sedation with propofol

Local anaesthesia is increasingly being used for vitreoretinal surgery, but the optimal technique for sedation remains unclear. Anaesthetist-administered midazolam, which is often used, was compared in this study to patient-controlled sedation with propofol in 43 patients undergoing 50 vitreoretinal procedures. A variety of patient, anaesthetist and surgical endpoints were measured. There were no significant outcome differences between the two agents except that midazolam produced more amnesia for the local anaesthetic eye block. However, several outcomes and the observations in patients who experienced both agents showed a trend in favour of propofol for intraoperative sedation. We conclude that both approaches are safe and that patient-controlled sedation with propofol is at least as satisfactory as anaesthetist-administered midazolam.

Propofol anesthesia for outpatient oral and maxillofacial surgery

Propofol is a sedative-hypnotic intravenous anesthetic agent that has gained wide use in outpatient oral and maxillofacial surgery since its clinical introduction in 1985. Propofol has several therapeutic advantages that make it an excellent choice for use in all phases of general anesthesia and conscious sedation. It is associated with minimal side effects, a controllable anesthetic state, and rapid recovery. This review of propofol discusses its pharmacologic character, administration, and side effects and presents anesthetic drug interaction information and comparisons.

[Patient-controlled sedation with propofol for extracorporeal shock wave lithotripsy]

OBJECTIVE

Evaluation of patient-controlled sedation with propofol for extracorporeal shock wave lithotripsy (ESWL) using an EDAP LT01 lithotriptor.

STUDY DESIGN

Prospective clinical study.

PATIENTS

Fifty consecutive patients, ASA I or II, aged 18-65 years.

METHODS

Patients received 50 mg of propofol five minutes before ESWL, then they self-administered 50 mg bolus doses of propofol with a ten minutes lock-out interval. Pain (1-100 mm VAS) and sedation (four points scale) were assessed every five minutes. Patient satisfaction was recorded at the end of the procedure. Pharmacokinetic simulation was done with the Marsh's data set.

RESULTS

Three patients were excluded. Patients received a mean propofol dose of 147 +/- 68 mg during the procedure with a mean duration of 47 +/- 8 minutes. The median of the higher sedation scores was 2 (drowsy) and mean maximal VAS was 40 +/- 20 mm (10-70). No complications were recorded. Thirty-nine patients (83%) were satisfied or very satisfied by patient-controlled sedation.

CONCLUSION

Patient-controlled sedation with propofol is a safe and efficient mode of administration of an hypnotic agent for ESWL.

Advances in regional anaesthesia and pain management

Advances in regional anaesthesia to date have made it one of the safest modalities for surgical anaesthesia and pain management. Continued refinement and development of new block techniques and approaches enhance the potential for block success, rapid postoperative recovery and patient safety. This will benefit both patient care and the health care economy.