Appropriate method of administration of propofol, fentanyl, and ketamine for patient-controlled sedation and analgesia during extracorporeal shock-wave lithotripsy

Efficacy of acupuncture for pain relief in patients receiving extracorporeal shock wave lithotripsy: a meta-analysis of randomized controlled studies

Background

This meta-analysis aimed at investigating the efficacy of acupuncture for pain relief in patients receiving extracorporeal shock wave lithotripsy (ESWL).

Methods

Randomized controlled trials comparing the efficacy of acupuncture with conventional treatments were retrieved from major electronic databases (e.g., MEDLINE, EMBASE, and Cochrane Library) until August 28, 2022. The primary outcome was the response rate (i.e., rate of pain relief), while secondary outcomes included stone-free rate, satisfaction rate, duration of ESWL, peri-/post-procedural pain score, and risk of adverse events.

Results

Thirteen eligible studies involving 1,220 participants published between 1993 and 2022 were analyzed. Pooled results indicated that acupuncture had a better response rate compared to conventional treatments (RR = 1.17, 95% CI: 1.06-1.3, p = 0.003, seven trials, n = 832). Despite no difference in ESWL duration (MD = 0.02 min, 95% CI: -1.53 to 1.57, p = 0.98, three trials, n = 141), stone-free rate (RR = 1.11, 95% CI: 1-1.25, p = 0.06, six trials, n = 498), and satisfaction rate (RR = 1.51, 95% CI: 0.92-2.47, p = 0.1, three trials, n = 334) between the two groups, the acupuncture group had a lower risk of adverse events (RR = 0.51, 95% CI: 0.33-0.79, p = 0.003, five trials, n = 327), peri- (MD = -1.91 points, 94% CI: -3.53 to -0.28, p = 0.02, four trials, n = 258 patient) and post-procedural (MD = -1.07, 95% CI: -1.77 to -0.36, p = 0.003, four trials, n = 335) pain score.

Conclusion

The results of this meta-analysis showed that the use of acupuncture in patients receiving ESWL was associated with a higher pain relief rate and a lower risk of adverse events, suggesting feasibility of its use in this clinical setting.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier: CRD42022356327.

A single‐sided trans‐nasal catheter for smooth and efficient oxygen delivery can improve the safety in patients undergoing pancreato‐biliary endoscopy under intravenous sedation: A randomized trial

Background

Pancreato‐biliary endoscopic procedures often need to be performed under deep intravenous sedation. The patients are at an increased risk of respiratory depression influenced by the anatomical dead space of the upper respiratory system. We aimed to evaluate the benefit of oxygen delivery through a single‐sided trans‐nasal catheter (TC) for patients undergoing pancreato‐biliary endoscopy.

Methods

Oxygen supplementation during the procedure was provided either by insertion of a single‐sided TC or insertion of a conventional nasal catheter (NC). A prospective, single‐blind, randomized controlled study was conducted in two groups.

Results

The number of patients who indicated a decrease in the peripheral transcutaneous oxygen saturation (SpO2; desaturation) was significantly lower in the TC group than in the counterpart (8/58; 13.8% vs. 26/58; 44.8% p < 0.001). The efficient oxygen delivery in the safe range was better conserved in the TC group than in the NC one. There was no adverse effect on both groups. The maximum SpO2 while the endoscopic procedure was significantly higher in the TC group (99.7% vs. 99.3% p = 0.016) and the minimum SpO2 was also significantly higher in the same group (97.7% vs. 94.1% p < 0.0001), which meant that the efficient oxygen delivery was better maintained in TC group than the NC group.

Conclusions

A single‐sided TC placed in the pharynx in patients undergoing pancreato‐biliary endoscopy prepares a superior condition of the patients for venous sedation, maintained hyper‐oxygen saturation and a relatively higher SpO2 level to be maintained in limited conditions to reduce the dead space with acceptable tolerance, as compared to the placement of a conventional NC.

Comparison of Different Analgesic Techniques for Pain Relief During Extracorporeal Shock Wave Lithotripsy: a Double-blind, Randomized Clinical Trial

Background:

Most patients experience some degree of pain during extracorporeal shock waves lithotripsy (ESWL).

Aim:

The aim of this study was to evaluate the effect of target-controlled infusion (TCI) of remifentanil or sufentanil and patient-controlled analgesia (PCA) with sufentanil or morphine for pain relief during ESWL.

Materials and Methods:

In a double blind, randomized clinical trial, a total of 60 patients who were scheduled for elective ESWL, randomly assigned into four groups (A, B, C and D). Patients in group A and B received remifentanil and sufentanil with TCI, respectively. Also, patients in group C and D received sufentanil and morphine with PCA, respectively. All patients in four groups were assessed about the intensity of their pain with Visual Analogue Scale (VAS) in three phases; the discharge of the waves (phase A), during breaking the stones (phase B) and the end of the procedure (phase C).

Results:

Patients in morphine PCA group experienced highest pain intensity in all stages, but patients in remifentanil TCI group experienced lowest pain intensity during lithotripsy. Remifentanil/TCI group experienced the lowest pain in B and C phases and the sufentanil/TCI group had the lowest pain only in the phase A. There was no significant difference in the occurrence of complications in all four groups.

Conclusion:

The current study demonstrates that efficacy of TCI pump in the reduction of pain during ESWL is superior to the PCA pump. Among the drugs that used in this study, remifentanil has more effective in pain management in the all phases during ESWL. We believe that using remifentanil/TCI should strongly be considered to clinicians in ESWL units.

The effect of midazolam premedication on patient satisfaction during fiberoptic bronchoscopy under patient-controlled sedation

BACKGROUND

Patient-controlled sedation (PCS) with propofol is a safe and effective method of attenuating discomfort during fiberoptic bronchoscopy. The purpose was to evaluate the usefulness of midazolam in addition to PCS for fiberoptic bronchoscopy.

METHODS

We randomly assigned 155 patients undergoing diagnostic bronchoscopy to two groups. Group M (n = 79) received 0.03 mg/kg of midazolam for premedication while group P (n = 76) received a loading dose (0.05 ml/kg) of PCS solution composed of 200 mg (20 ml) of propofol and 1 mg (2 ml) of alfentanil. Both groups received the PCS solution 0.2 ml/kg/hr with a bolus of 1 ml and a lockout time of 1 min. Vital signs, pulmonologist satisfaction, patient satisfaction and amnesia were evaluated.

RESULTS

After the insertion of the bronchoscope, there was a slight decrease of SpO2 and an increase of blood pressure and heart rate in both groups with no significant differences between the two groups. The group P required more bolus injections (1.6 +/- 1.7 in the group M vs 2.5 +/- 2.2 in group P; P < 0.05). There was no difference in the satisfaction of pulmonologists, but the satisfaction of patients was higher in the group M (P < 0.05). More patients in the group P (93%) remembered the procedure than in the group M (70%) (P < 0.05).

CONCLUSIONS

PCS is an effective method for sedating patients undergoing fiberoptic bronchoscopy and midazolam provides more patient satisfaction and amnesia.

Low-dose ketamine in addition to propofol for procedural sedation and analgesia in the emergency department

OBJECTIVE

To evaluate the efficacy and safety of low-dose intravenous ketamine in addition to intravenous propofol for procedural sedation and analgesia in the emergency department (ED).

DATA SOURCES

Articles were identified using PubMed (1949-February 2007), MEDLINE (1966-February 2007), EMBASE (1980-February 2007), BioMed Central (to February 2007), the Cochrane Library (to February 2007), International Pharmaceutical Abstracts, and Google Scholar (until February 2007). Reference citations from retrieved publications were also reviewed. Search terms included ketamine, propofol, ketamine-propofol, ketofol, combination, sedation, procedural sedation, conscious sedation, and emergency department.

STUDY SELECTION AND DATA EXTRACTION

All articles on prospective procedural sedation that were published or translated into English and that compared combination ketamine-propofol with an appropriate comparator group were included. Clinically relevant safety endpoints included the frequency of significant hemodynamic and respiratory compromise warranting medical intervention, nausea, vomiting, and emergence reactions. Time until hospital discharge criteria were met and patient satisfaction scores were efficacy endpoints of interest.

DATA SYNTHESIS

Of the 11 trials included in this review, most had small sample sizes and were conducted in non-ED settings. The ketamine-propofol combination demonstrated no additional efficacy over propofol in terms of time to discharge. Although fewer patients given the ketamine-propofol combination experienced significant hemodynamic and respiratory compromise, need for active interventions, including fluid or vasopressor administration, supplemental oxygen, or assisted ventilation did not differ between groups. Patients who received higher doses of adjuvant ketamine reported an increased incidence of nausea, vomiting, and emergence reactions following the procedure. Few studies reported patient satisfaction scores postprocedure, and effect of ketaminepropofol on time-to-discharge criteria met was inconclusive.

CONCLUSIONS

At this time, insufficient clinical evidence exists to recommend the routine use of low-dose ketamine with propofol for procedural sedation in the ED setting.