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Deng J, Yu YF, Tang ZG, Lei HJ, Tan CC. Efficacy and safety of low-dose esketamine for painless gastrointestinal endoscopy in adults: a systematic evaluation and meta-analysis. Front Pharmacol 2024; 15:1364546. [PMID: 38645560 PMCID: PMC11026590 DOI: 10.3389/fphar.2024.1364546] [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: 01/02/2024] [Accepted: 02/26/2024] [Indexed: 04/23/2024] Open
Abstract
Object: The benefits of low-dose esketamine for painless gastrointestinal endoscopy remain unclear. As such, the present study aimed to investigate the efficacy and safety of low-dose esketamine for this procedure. Methods: Seven common databases were searched for clinical studies investigating low-dose esketamine for painless gastrointestinal endoscopy. Subsequently, a meta-analysis was performed to synthesize and analyze the data extracted from studies fulfilling the inclusion criteria. Results: Meta-analysis revealed that, compared with propofol, low-dose esketamine in combination with propofol significantly reduced recovery time by 0.56 min (mean difference [MD] -0.56%, 95% confidence interval (CI) -1.08 to -0.05, p = 0.03), induction time by 9.84 s (MD -9.84, 95% CI -12.93 to -6.75, p < 0.00001), propofol dosage by 51.05 mg (MD -51.05, 95% CI -81.53 to -20.57, p = 0.01), and increased mean arterial pressure by 6.23 mmHg (MD 6.23, 95% CI 1.37 to 11.08, p = 0.01). Meanwhile, low-dose esketamine reduced injection pain by 63% (relative risk [RR] 0.37, 95% CI 0.28 to 0.49, p < 0.00001), involuntary movements by 40% (RR 0.60, 95% Cl 0.42 to 0.85, p < 0.005), choking by 42% (RR 0.58, 95% Cl 0.38 to 0.88, p = 0.01), bradycardia by 68% (RR 0.32, 95% Cl 0.18 to 0.58, p = 0.0002), hypotension by 71% (RR 0.29, 95% Cl 0.21 to 0.40, p < 0.00001), respiratory depression by 63% (RR 0.37, 95% 0.26 to 0.51, p < 0.00001), additional cases of propofol by 53% (RR 0.47, 95% Cl 0.29 to 0.77, p = 0.002), and increased hypertension by 1000% (RR 11.00, 95% Cl 1.45 to 83.28, p = 0.02). There were no significant differences in mean heart rate, mean oximetry saturation, delirium, dizziness, vomiting, tachycardia, and hypoxemia. Subgroup analyses revealed that, compared with other dose groups, 0.25 mg/kg esketamine afforded additional benefits in recovery and induction time, mean arterial pressure, involuntary movements, hypoxemia, and respiratory depression. Conclusion: Low-dose esketamine was found to be safe and effective for providing anesthesia during gastrointestinal endoscopy, with 0.25 mg/kg identified as the optimal dose within the dosage ranges examined. However, caution should be exercised when administering this drug to patients with inadequate preoperative blood pressure control.
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Affiliation(s)
- Juan Deng
- Digestive Endoscopy Center, The First Hospital of Hunan University of Chinese Medicine, Changsha, China
- Department of Anesthesiology, The Third Hospital of Changsha, Changsha, China
| | - Yun-Feng Yu
- Digestive Endoscopy Center, The First Hospital of Hunan University of Chinese Medicine, Changsha, China
| | - Zheng-Guo Tang
- Department of Anesthesiology, The Third Hospital of Changsha, Changsha, China
| | - Hua-Juan Lei
- Digestive Endoscopy Center, The First Hospital of Hunan University of Chinese Medicine, Changsha, China
| | - Chuan-Chuan Tan
- Digestive Endoscopy Center, The First Hospital of Hunan University of Chinese Medicine, Changsha, China
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Goudra B, Gouda G, Mohinder P. Recent Developments in Drugs for GI Endoscopy Sedation. Dig Dis Sci 2020; 65:2781-2788. [PMID: 31916088 DOI: 10.1007/s10620-020-06044-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 01/01/2020] [Indexed: 12/20/2022]
Abstract
Providing sedation for patients undergoing gastrointestinal (GI) endoscopy continues to be a debated topic in both anesthesia and gastroenterology circles. Sedation approaches are widely varied across the globe. While propofol administration is embraced by more endoscopists and patients, its administration evolves controversy. Whereas trained nurses and gastroenterologists are allowed to administer propofol for GI endoscopy sedation in Europe and Asia, it is the sole privilege of anesthesia providers in the USA. However, the costs of anesthesia providers are significant and threaten to derail the screening colonoscopy practice. Efforts were made by both drug and device manufacturers to find alternatives. Fospropofol was one such effort that did not live up to the expectations due to respiratory depressant properties that were similar to propofol. Use of a new tool to administer propofol in the form of Sedasys® was the next experiment that tried to find alternative to anesthesia providers. The device did not succeed due to inadequate sedation. The latest effort is remimazolam, a new benzodiazepine that has quicker recovery profile. In the interim, many drug combinations such as propofol-dexmedetomidine and propofol-ketamine are improving the safety without compromising the quality of sedation. This review attempts to discuss the new drug innovations and drug combinations of existing sedatives for the benefit of readers.
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Affiliation(s)
- Basavana Goudra
- Perelman School of Medicine, Hospital of the University of Pennsylvania, 680 Dulles, 3400 Spruce Street, Philadelphia, PA, 19104, USA.
| | - Gowri Gouda
- Burrel College of Osteopathic Medicine, 3501 Arrowhead Drive, Las Cruces, NM, 88001, USA
| | - Preet Mohinder
- Department of Anesthesiology, Washington University in Saint Louis, 660 South Euclid Avenue, St Louis, MO, 63110, USA
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Sajid MS, Caswell J, Bhatti MI, Sains P, Baig MK, Miles WFA. Carbon dioxide insufflation vs conventional air insufflation for colonoscopy: a systematic review and meta-analysis of published randomized controlled trials. Colorectal Dis 2015; 17:111-23. [PMID: 25393051 DOI: 10.1111/codi.12837] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2014] [Accepted: 08/06/2014] [Indexed: 12/16/2022]
Abstract
AIM Conventional air insufflation (AI) may cause prolonged abdominal bloating, excessive abdominal pain and discomfort during colonoscopy. Carbon dioxide may be an acceptable alternative to avoid these complications. The object of this study was to evaluate systematically the effectiveness of carbon dioxide insufflation (CI) for colonoscopy compared with AI. METHOD Randomized controlled trials (RCTs) comparing the effectiveness of CI with that of AI during colonoscopy were retrieved from medical electronic databases and combined analysis was performed using the RevMan statistical package. The combined outcome of dichotomous and continuous variables was expressed as an odds ratio (OR) and standardized mean difference (SMD). RESULTS Twenty-one RCTs comprising 3607 patients were included in the study. There was statistically significant heterogeneity among included studies. CI showed a significant trend towards reduced procedural pain [SMD -1.34; 95% confidence interval (95% CI) -2.23 to -0.45; z = 2.96; P < 0.003] and also postprocedural pain at 1 h (SMD -1.11; 95% CI -1.83 to -0.38; z = 2.97; P < 0.003), 6 and 24 h (OR 0.44; 95% CI 0.23-0.85; z = 2.44; P < 0.01). CI was associated with faster caecal intubation (SMD -0.20; 95% CI -0.37 to -0.02; z = 2.23; P < 0.03) but the caecal intubation rate was similar (P = 0.59) in both colonic insufflation techniques . CONCLUSION CI seems to have clinical advantages over AI for colonoscopy with regard to pain during and after the procedure.
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Affiliation(s)
- M S Sajid
- Department of General, Endoscopic and Laparoscopic Colorectal Surgery, Western Sussex Hospitals NHS Trust, Worthing Hospital, Worthing, West Sussex
| | - J Caswell
- Department of General, Endoscopic and Laparoscopic Colorectal Surgery, Western Sussex Hospitals NHS Trust, Worthing Hospital, Worthing, West Sussex
| | - M I Bhatti
- Department of General and Colorectal Surgery, Queen Elizabeth Hospital, King's Lynn NHS Foundation Trust, King's Lynn, Norfolk, UK
| | - P Sains
- Department of General, Endoscopic and Laparoscopic Colorectal Surgery, Western Sussex Hospitals NHS Trust, Worthing Hospital, Worthing, West Sussex
| | - M K Baig
- Department of General, Endoscopic and Laparoscopic Colorectal Surgery, Western Sussex Hospitals NHS Trust, Worthing Hospital, Worthing, West Sussex
| | - W F A Miles
- Department of General and Colorectal Surgery, Queen Elizabeth Hospital, King's Lynn NHS Foundation Trust, King's Lynn, Norfolk, UK
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Gurbulak B, Uzman S, Kabul Gurbulak E, Gul YG, Toptas M, Baltali S, Anil Savas O. Cardiopulmonary safety of propofol versus midazolam/meperidine sedation for colonoscopy: a prospective, randomized, double-blinded study. IRANIAN RED CRESCENT MEDICAL JOURNAL 2014; 16:e19329. [PMID: 25763217 PMCID: PMC4329962 DOI: 10.5812/ircmj.19329] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Revised: 08/06/2014] [Accepted: 09/01/2014] [Indexed: 12/12/2022]
Abstract
Background: Different levels of pharmacological sedation ranging from minimal to general anesthesia are often used to increase patient tolerance for a successful colonoscopy. However, sedation increases the risk of respiratory depression and cardiovascular complications during colonoscopy. Objectives: We aimed to compare the propofol and midazolam/meperidine sedation methods for colonoscopy procedures with respect to cardiopulmonary safety, procedure-related times, and patient satisfaction. Patients and Methods: This was a prospective, randomized, double-blinded study, in which 124 consecutive patients undergoing elective outpatient diagnostic colonoscopies were divided into propofol and midazolam/meperidine sedation groups (n: 62, m/f ratio: 26/36, mean age: 46 ± 15 for the propofol group; n: 62, m/f ratio: 28/34, mean age: 49 ± 15 for the midazolam/meperidine group) by computer-generated randomization. The frequency of cardiopulmonary events (hypotension, bradycardia, hypoxemia), procedure-related times (duration of colonoscopy, time to cecal intubation, time to ileal intubation, awakening time, and time to hospital discharge) and patients’ evaluation results (pain assessment, quality of sedation, and recollection of procedure) were compared between the groups. Results: There were no statistically significant differences between the two groups with respect to demographic and clinical characteristics of the patients, the frequency of hypotension, hypoxemia or bradycardia, cecal and ileal intubation times, and the duration of colonoscopy. The logistic regression analysis indicated that the development of cardiopulmonary events was not associated with the sedative agent used or the characteristics of the patients. The time required for the patient to be fully awake and the time to hospital discharge was significantly longer in the propofol group (11 ± 8 and 37 ± 11 minutes, respectively) than the midazolam/meperidine group (8 ± 6 and 29 ± 12 minutes, respectively) (P = 0.009 and P < 0.001, respectively). The patient satisfaction rates were not significantly different between the groups; however, patients in the propofol group experienced more pain than patients in the midazolam/meperidine group (VAS score: 0.31 ± 0.76 vs. 0 ± 0; P = 0.002). Conclusions: Midazolam/meperidine and propofol sedation for colonoscopy have similar cardiopulmonary safety profiles and patient satisfaction levels. Midazolam/meperidine can be preferred to propofol sedation due to a shorter hospital length of stay and better analgesic activity.
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Affiliation(s)
- Bunyamin Gurbulak
- Department of General Surgery, Arnavutkoy State Hospital, Istanbul, Turkey
| | - Sinan Uzman
- Department of Anesthesiology and Reanimation, Haseki Training and Research Hospital, Istanbul, Turkey
- Corresponding Author: Sinan Uzman, Department of Anesthesiology and Reanimation, Haseki Training and Research Hospital, Istanbul, Turkey. Tel: +90-5055645271, Fax: +90-2125294453, E-mail:
| | - Esin Kabul Gurbulak
- Department of General Surgery, Sisli Etfal Training and Research Hospital, Istanbul, Turkey
| | - Yasar Gokhan Gul
- Department of Anesthesiology and Reanimation, Arnavutkoy State Hospital, Istanbul, Turkey
| | - Mehmet Toptas
- Department of Anesthesiology and Reanimation, Haseki Training and Research Hospital, Istanbul, Turkey
| | - Sevim Baltali
- Department of Anesthesiology and Reanimation, Arnavutkoy State Hospital, Istanbul, Turkey
| | - Osman Anil Savas
- Department of General Surgery, Haseki Training and Research Hospital, Istanbul, Turkey
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Eberl S, Polderman JAW, Preckel B, Kalkman CJ, Fockens P, Hollmann MW. Is "really conscious" sedation with solely an opioid an alternative to every day used sedation regimes for colonoscopies in a teaching hospital? Midazolam/fentanyl, propofol/alfentanil, or alfentanil only for colonoscopy: a randomized trial. Tech Coloproctol 2014; 18:745-52. [PMID: 24973875 DOI: 10.1007/s10151-014-1188-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Accepted: 02/19/2014] [Indexed: 01/30/2023]
Abstract
BACKGROUND We investigated the satisfaction of patients and endoscopists and concurrently safety aspects of an "alfentanil only" and two clinically routinely used sedation regimes in patients undergoing colonoscopy in a teaching hospital. METHODS One hundred and eighty patients were prospectively randomized in three groups: M (midazolam/fentanyl), A (alfentanil), and P (propofol/alfentanil); M and A were administered by an endoscopy nurse, P by an anesthesia nurse. Interventions, heart rate, saturation, electrocardiogram, noninvasive blood pressure, and expiratory CO₂ were monitored using video assistance. After endoscopy, patients and gastroenterologists completed questionnaires about satisfaction. RESULTS A high level of satisfaction was found in all groups, with patients in group P being more satisfied with their sedation experience (median 1.75, p < 0.001). Gastroenterologist satisfaction varied not significantly between the three alternatives. Patients in group A felt less drowsy, could communicate more rapidly than patients in both other groups, and met discharge criteria immediately after the end of the procedure. Respiratory events associated with sedation were observed in 43% patients in group M, 47% in group P, but only 13% in group A (p < 0.001). CONCLUSIONS These results suggest that alfentanil could be an alternative for sedation in colonoscopy even in the setting of a teaching hospital. It results in satisfied patients easily taking up information, and recovering rapidly. Although one might expect to observe more respiratory depression with an "opioid only" sedation technique without involvement of anesthesia partners, respiratory events were less frequent than when other methods were used.
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Affiliation(s)
- S Eberl
- Department of Anesthesiology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands,
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Wang HL, Ye F, Liao WF, Xia B, Zheng GR. Unsedated versus sedated gastrointestinal endoscopy: A questionnaire investigation in Wuhan, central China. ACTA ACUST UNITED AC 2013; 33:857-861. [DOI: 10.1007/s11596-013-1211-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Revised: 10/26/2013] [Indexed: 12/17/2022]
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