Propofol sedation with a target-controlled infusion pump in elderly patients undergoing ERCP

Safety and tolerability outcomes of nonanesthesiologist-administered propofol using target-controlled infusion in routine GI endoscopy

BACKGROUND AND AIMS

Nonanesthesiologist-administered propofol (NAAP) is increasingly accepted, but data are limited on drug administration using target-controlled infusion (TCI) in clinical practice. TCI adjusts the drug infusion based on patient-specific parameters, maintaining a constant drug dose to reduce the risk of adverse events (AEs) because of drug overdosing and to enhance patient comfort. The aims of this study were to assess the rate of AEs and to evaluate patient satisfaction with NAAP using TCI in a retrospective cohort of 18,302 procedures.

METHODS

Low-risk patients (American Society of Anesthesiologists score I and II) undergoing outpatient GI endoscopic procedures, including EGDs and colonoscopies, were sequentially enrolled at IRCCS San Raffaele Hospital (Milan, Italy) between May 2019 and November 2021.

RESULTS

Data from 7162 EGDs and 11,140 colonoscopies were analyzed. Mean patient age was 59.1 ± 14.8 years, and mean body mass index was 24.9 ± 3.7 kg/m2. The male-to-female ratio was equal at 8798 (48.1%):9486 (51.9%). AEs occurred in 240 procedures (1.3%) out of the total cohort, with no differences between EGDs and colonoscopies (100 [1.4%] and 140 [1.2%], respectively; P = .418). Most patients (15,875 [98.9%]) indicated they would likely repeat the procedure with the same sedation protocol. Age (odds ratio, 1.02; 95% confidence interval, 1.01-1.03; P < .008) was the only independent factor associated with overall AEs.

CONCLUSIONS

NAAP using TCI is an effective and safe sedation method for routine endoscopy. The proper propofol dosage based on individual patients and the presence of trained operators are crucial for NAAP sedation management.

A prospective, randomized, single-blinded study comparing the efficacy and safety of dexmedetomidine and propofol for sedation during endoscopic retrograde cholangiopancreatography

BACKGROUND

Balanced propofol sedation is extensively used in endoscopic retrograde cholangiopancreatography (ERCP), but sedation-related adverse events (SRAEs) are common. In various clinical settings, the combination of dexmedetomidine with opioids and benzodiazepines has provided effective sedation with increased safety. The aim of this investigation was to compare the efficacy and safety of dexmedetomidine and propofol for sedation during ERCP.

METHODS

Forty-one patients were randomly divided into two groups: the dexmedetomidine (DEX) group and the propofol (PRO) group. Patients in the DEX group received an additional bolus of 0.6 μg kg-1 dexmedetomidine followed by a dexmedetomidine infusion at 1.2 μg kg-1 h-1, whereas the PRO group received 1-2 mg kg-1 of propofol bolus followed by a propofol infusion at 2-3 mg kg-1 h-1. During ERCP, the primary outcome was the incidence of hypoxemia (SpO2 < 90% for > 10 s). Other intraoperative adverse events were also recorded as secondary outcomes, including respiratory depression (respiratory rate of < 10 bpm min-1), hypotension (MAP < 65 mmHg), and bradycardia (HR < 45 beats min-1).

RESULTS

The incidence of hypoxemia was significantly reduced in the DEX group compared to the PRO group (0% versus 28.6%, respectively; P = 0.032). Patients in the PRO group exhibited respiratory depression more frequently than patients in the DEX group (35% versus 81%, respectively; P = 0.003). There were no significant differences in terms of hypotension and bradycardia episodes between groups. During the procedures, the satisfaction scores of endoscopists and patients, as well as the pain and procedure memory scores of patients were comparable between groups.

CONCLUSION

In comparison with propofol, dexmedetomidine provided adequate sedation safety with no adverse effects on sedation efficacy during ERCP.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR2200061468, 25/06/2022.

Safety and efficacy of a low-dose combination of midazolam, alfentanil, and propofol for deep sedation of elderly patients undergoing ERCP

BACKGROUND

Proper sedation of patients, particularly elderly individuals, who are more susceptible to sedation-related complications, is of significant importance in endoscopic retrograde cholangiopancreatography (ERCP). This study aims to assess the safety and efficacy of a low-dose combination of midazolam, alfentanil, and propofol for deep sedation in elderly patients undergoing ERCP, compared to a group of middle-aged patients.

METHODS

The medical records of 610 patients with common bile duct stones who underwent elective ERCP under deep sedation with a three-drug regimen, including midazolam, alfentanil, and propofol at Shandong Provincial Third Hospital from January 2023 to September 2023 were retrospectively reviewed in this study. Patients were categorized into three groups: middle-aged (50-64 years, n = 202), elderly (65-79 years, n = 216), and very elderly (≥ 80 years, n = 192). Intraoperative vital signs and complications were compared among these groups.

RESULTS

The three groups showed no significant difference in terms of intraoperative variation of systolic blood pressure (P = 0.291), diastolic blood pressure (P = 0.737), heart rate (P = 0.107), peripheral oxygen saturation (P = 0.188), bispectral index (P = 0.158), and the occurrence of sedation-related adverse events including hypotension (P = 0.170) and hypoxemia (P = 0.423).

CONCLUSION

The results suggest that a low-dose three-drug regimen consisting of midazolam, alfentanil, and propofol seems safe and effective for deep sedation of elderly and very elderly patients undergoing ERCP procedures. However, further studies are required to verify these findings and clarify the benefits and risks of this method.

Comparing sedation protocols for endoscopic retrograde cholangiopancreatography (ERCP): A retrospective study

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.

Benefits of remimazolam as an anesthetic sedative for older patients: A review

Owing to the decreased levels of receptors in the peripheral and central nervous systems, the functions of various organ systems decline in older patients. When administering anesthesia to older patients, it is necessary to consider the effects of medication on the homeostatic balance. Remimazolam, a new benzodiazepine, was recently developed as an anesthetic drug that has shown promise in clinical anesthesia application owing to its molecular structure, targets, pharmacodynamics, and pharmacokinetic characteristics. Remimazolam exhibits a rapid onset and metabolism, with minor effects on liver and kidney functions. Moreover, the drug has a specific antagonist, flumazenil. It is safer to use in older patients than other anesthetic sedatives and has been widely used since its introduction. Comparisons of the pharmacokinetics, metabolic pathways, effects on target organs, and hemodynamics of different drugs with those of commonly used anesthetic sedative drugs are useful to inform clinical practice. This article elaborates on the benefits of remimazolam compared with those of other anesthetic sedatives for sedation in older patients to demonstrate how it offers a new option for anesthetics in older patients. In cases involving older patients with increased clinical complexities or very old patients requiring anesthesia, remimazolam can be selected as the preferred anesthetic sedative, as outlined in this review.

Patient-Reported Quality of Recovery after Sedation for Endoscopy in the Elderly

INTRODUCTION

Although sedation is critical in minimizing discomforts in patients, conflicting data regarding the safety of sedation among the elderly population exist. This prospective study aimed to compare the quality of recovery (QoR) from gastrointestinal endoscopy performed under sedation between elderly and younger patients.

METHODS

We included 177 patients aged 40-64 (group 1, n = 66), 65-79 (group 2, n = 76), and ≥80 (group 3, n = 35) years. QoR was assessed 1 day after the procedure using the quality of recovery 15 (QoR-15) questionnaire, which is a 15-item questionnaire with scores ranging from 0 to 150. Patient demographic, procedural, and sedation data were collected, and neurocognitive function was assessed before and a day after sedation.

RESULTS

Groups 1 and 3 differed according to the Mini-Cog test and 3-word memory test performed before the procedure (p < 0.001). QoR-15 scores between groups were not different (139 ± 19 group 1, 141 ± 17 group 2, and 147 ± 26 group 3; p > 0.05). Patients in groups 3 and 2 were administered lower doses of propofol and midazolam than those in group 1. The incidence of oxygen desaturation (SaO2 <90% for >30 s) was lower in groups 1 and 2 than in group 3 (p = 0.01).

CONCLUSIONS

As indicated by the QoR-15 questionnaire, the QoR from sedation was not significantly different between the study groups.

Dynamic prediction of hypoxemia risk at different time points based on preoperative and intraoperative features: machine learning applications in outpatients undergoing esophagogastroduodenoscopy

BACKGROUND

Hypoxemia often occurs in outpatients undergoing anesthesia-assisted esophagogastroduodenoscopy (EGD). However, there is a scarcity in tools to predict the hypoxemia risk. We aimed to solve this problem by developing and validating machine learning (ML) models based on preoperative and intraoperative features.

METHODS

All data were retrospectively collected from June 2021 to February 2022. The most appropriate predictive features were selected by the least absolute shrinkage and selection operator, which were incorporated and modelled by 4 ML algorithms. The area under the precision-recall curve (AUPRC) was used as the main evaluation metric to select the best models, and the selected models were compared with the STOP-BANG score. Their predictive performance was visually interpreted by SHapley Additive exPlanations. The primary endpoint of this study was hypoxemia during the procedure, defined as at least one reading of pulse oximetry < 90% without probes misplacement from the anesthesia induction beginning to the end of EGD, while the secondary endpoint was hypoxemia during induction, from the induction beginning to the start of endoscopic intubation.

RESULTS

Of 1160 patients in the derivation cohort, 112 patients (9.6%) developed intraoperative hypoxemia, of which 102 (8.8%) occurred during the induction period. In temporal and external validation, no matter whether based on preoperative variables or still based on preoperative plus intraoperative variables, our models showed excellent predictive performance for the two endpoints, significantly better than STOP-BANG score. In the model interpretation section, preoperative variables (airway assessment indicators, pulse oximeter oxygen saturation and BMI) and intraoperative variables (the induced propofol dose) made the highest contribution to the predictions.

To our knowledge, our ML models were the first to predict hypoxemia risk, which achieved excellent overall predictive ability integrating various clinical indicators. These models have the potential to become an effective tool for adjusting sedation strategies flexibly and reducing the workload of anesthesiologists.KEY MESSAGESThis study is the first model employing ML methods based on preoperative and preoperative plus intraoperative variables for predicting the risk of hypoxemia during induction and the whole EGD procedure respectively.Our four models achieved satisfactory predictive performance and outperformed STOP-BANG score in terms of AUPRC in the temporal and external validation cohorts respectively.We found that the relevant variables of airway assessment should be fully taken into account when analyzing the risk factor of hypoxemia, and the effect of patients' age on their hypoxemia risk should be considered in conjunction with the propofol dose.

Effect of Esketamine Added to Propofol Sedation on Desaturation and Hypotension in Bidirectional Endoscopy: A Randomized Clinical Trial

Importance

Propofol sedation is widely used for endoscopic procedures, but it poses risks of hemodynamic and respiratory depression. The addition of esketamine as an adjuvant may reduce propofol requirements and associated adverse events.

Objective

To evaluate the effects of low-dose esketamine added to propofol-based sedation on desaturation and hypotension during same-visit bidirectional endoscopy.

Design, Setting, and Participants

This multicenter, double-blind, placebo-controlled randomized clinical trial assessed patients from 3 teaching hospitals in China who were scheduled for same-visit bidirectional endoscopy between February 8 and November 30, 2022, and randomly assigned to receive esketamine or normal saline (placebo).

Interventions

After induction of sedation with 0.1 μg/kg of sufentanil and 0.5 mg/kg of propofol, patients in the esketamine group received 0.15 mg/kg of intravenous esketamine, whereas patients in the placebo group received an equivalent volume of saline. Sedation was achieved through propofol titration.

Main Outcomes and Measures

The primary outcome was the composite of desaturation and hypotension during the procedures. Secondary outcomes included desaturation, hypotension, propofol requirements, postprocedure pain and fatigue, nausea or vomiting, dizziness or headache, hallucination or nightmare, endoscopist satisfaction, and patient satisfaction.

Results

Among the 663 initially enrolled patients, 660 completed the study (median [IQR] age, 48 [36-57] years; 355 [53.8%] female), with 331 randomized to the esketamine group and 329 to the placebo group. The administration of esketamine compared with placebo significantly reduced the incidence of the composite outcome of desaturation and hypotension (8.2% vs 21.0%; difference, -12.8 percentage points; odds ratio [OR], 0.34; 95% CI, 0.21-0.54; P < .001). Additionally, esketamine led to significantly lower incidences of desaturation (OR, 0.36; 95% CI, 0.18-0.72; false discovery rate q = .01) and hypotension (OR, 0.33; 95% CI, 0.18-0.60; q < .001) and reduced propofol requirements (difference, -58.9 mg; 95% CI, -65.7 to -52.2 mg; q < .001), without significant effects on other secondary outcomes.

Conclusions and Relevance

In this randomized clinical trial of patients undergoing same-visit bidirectional endoscopy, the administration of low-dose esketamine resulted in an approximately 61% reduction in the incidence of desaturation and hypotension, accompanied by decreased propofol requirements. These findings support the use of esketamine as an adjuvant to propofol-based sedation in endoscopic procedures.

Trial Registration

Chinese Clinical Trial Registry Identifier: ChiCTR2200055938.

The efficacy of non-anesthesiologist-administered propofol sedation with a target-controlled infusion system during double-balloon endoscopic retrograde cholangiopancreatography

BACKGROUND

The sedation method used during double-balloon endoscopic retrograde cholangiopancreatography (DB-ERCP) differs among countries and/or facilities, and there is no established method. This study aimed to evaluate the efficacy of non-anesthesiologist-administered propofol (NAAP) sedation using a target-controlled infusion (TCI) system during DB-ERCP.

METHODS

This retrospective study was conducted between May 2017 and December 2020 at an academic center. One hundred and fifty-six consecutive patients who underwent DB-ERCP were sedated by gastroenterologists using diazepam (n = 77) or propofol with a TCI system (n = 79), depending on the period. The primary endpoint was a comparison of poor sedation rates between the two groups. Poor sedation was defined as a condition requiring the use of other sedative agents or discontinuation of the procedure. Secondary endpoints were sedation-related adverse events and risk factors for poor sedation.

RESULTS

Poor sedation occurred significantly more often in the diazepam sedation group (diazepam sedation, n = 12 [16%] vs. propofol sedation, n = 1 [1%]; P = 0.001). Vigorous body movements (3 or 4) (diazepam sedation, n = 40 [52%] vs. propofol sedation, n = 28 [35%]; P = 0.038) and hypoxemia (< 85%) (diazepam sedation, n = 7 [9%] vs. propofol sedation, n = 1 [1%]; P = 0.027) occurred significantly more often in the diazepam sedation group. In the multivariate analysis, age < 70 years old (OR, 10.26; 95% CI, 1.57-66.98; P = 0.015), BMI ≥ 25 kg/m2 (OR, 11.96; 95% CI, 1.67-85.69; P = 0.014), and propofol sedation (OR, 0.06; 95% CI, 0.01-0.58; P = 0.015) were associated factors for poor sedation.

CONCLUSIONS

NAAP sedation with the TCI system during DB-ERCP was safer and more effective than diazepam sedation.

A randomized, controlled clinical trial comparing remimazolam to propofol when combined with alfentanil for sedation during ERCP procedures

STUDY OBJECTIVE

In many countries, the combination of propofol and opioid is used as the preferred sedative regime during ERCP. However, the most serious risks of propofol sedation are oxygen deficiency and hypotension. Compared to midazolam, remimazolam has a faster onset and offset of hypnotic effect, as well as cardiorespiratory stability, and to achieve widespread acceptance for procedural sedation, remimazolam must replace propofol which is the most commonly used for procedural sedation. The objective of this study was to compare the safety and efficacy profiles of the remimazolam and propofol when combined with alfentanil for sedation during ERCP procedures.

DESIGN

A randomized, controlled, single-center trial.

SETTING

The Endoscopic Centre of Tianjin Nankai Hospital, China.

PATIENTS

518 patients undergoing elective ERCP under deep sedation.

INTERVENTIONS

Patients scheduled for ERCP were randomly assigned to be sedated with either a combination of remimazolam-alfentanil or propofol-alfentanil.

MEASUREMENTS

The primary outcome was the prevalence of hypoxia, which was defined as SpO₂ < 90% for >10 s. Other outcomes were the need for airway maneuver, procedure, and sedation-related outcomes and side effects (e.g., nausea, vomiting, and cardiovascular adverse events).

MAIN RESULTS

A total of 518 patients underwent randomization. Of these, 250 were assigned to the remimazolam group and 255 to the propofol group. During ERCP, 9.6% of patients in the remimazolam group showed hypoxia, while in the propofol group, 15.7% showed hypoxia (p = 0.04). The need for airway maneuvering due to hypoxia was significantly greater in the propofol group (p = 0.04). Furthermore, patients sedated with remimazolam had a lower percentage of hypotension than patients sedated with propofol (p < 0.001). Patients receiving remimazolam sedation expressed higher satisfaction scores and were recommended the same sedation for the next ERCP. The procedure time in the remimazolam group was much longer than in the propofol group due to the complexity of the patient's disease, which resulted in a longer sedation time.

CONCLUSION

During elective ERCP, patients administered with remimazolam showed fewer respiratory depression events under deep sedation with hemodynamic advantages over propofol when administered in combination with alfentanil.

An interpretable artificial neural network model for predicting hypoxemia via an online tool in adult (18-64) patients during esophagogastroduodenoscopy

Background

The hypoxemia risk in adult (18-64) patients treated with esophagogastroduodenoscopy (EGD) under sedation often poses a dilemma for anesthesiologists. We aimed to establish an artificial neural network (ANN) model to solve this problem, and introduce the Shapley additive explanations (SHAP) algorithm to further improve the interpretability.

Methods

The relevant data of patients underwent routine anesthesia-assisted EGD were collected. Elastic network was used to filter the optimal features. Airway-ANN and Basic-ANN models were established based on all collected indicators and remaining variables excluding airway assessment indicators, respectively. The performance of Basic-ANN, Airway-ANN and STOP-BANG was evaluated by the area under the precision-recall curve (AUPRC) on temporal validation set. The SHAP was used for revealing the predictive behavior of our best model.

Results

999 patients were eventually included. The AUPRC value of Airway-ANN model was significantly higher than Basic-ANN model in the temporal validation set (0.532 vs 0.429, P < 0.05). And the performance of both two ANN models was significantly better than that of STOP-BANG score (both P < 0.05). The Airway-ANN model was deployed to the cloud (http://njfh-yxb.com.cn:2022/airway_ann).

Conclusion

Our online interpretable Airway-ANN model achieved satisfying ability in identifying the hypoxemia risk in adult (18-64) patients undergoing EGD.

Application effects of remimazolam and propofol on elderly patients undergoing hip replacement

Objective

To explore the anesthetic and analgesic effects of remimazolam and propofol in elderly patients undergoing hip replacement and their effects on respiratory and circulatory systems, stress and cognitive function.

Methods

Sixty elderly patients undergoing elective hip replacement in the hospital were selected as the research subjects, and they were divided into the remimazolam group and the propofol group according to the admission sequence of patients. The remimazolam group was anesthetized with remimazolam, and the propofol group was anesthetized with propofol. The anesthesia-related indicators, perioperative pain degree [Visual Analogue Scale (VAS)], circulatory indicators [heart rate, mean arterial pressure (MAP)] before anesthesia (T₀), immediately before laryngeal mask insertion (T₁), at 5 min after laryngeal mask insertion (T₂), at 30 min after laryngeal mask insertion (T₃) and at 5 min after laryngeal mask removal (T₄), stress response indicators (plasma epinephrine, norepinephrine, cortisol) before anesthesia induction and at 24 h and 72 h after surgery, cognitive function [Mini-Mental State Examination (MMSE)] and adverse reactions were compared between the two groups.

Results

Among the 60 enrolled patients, only 1 case was excluded due to withdrawal, thus 30 cases in the remimazolam group and 29 cases in the propofol group were included. There were statistically significant differences in the heart rate, MAP, plasma epinephrine, norepinephrine, cortisol and VAS score in the two groups from the aspects of interaction effect and time-point effect (P < 0.05). The heart rate and MAP at T₁, T₂ and T₃ in the two groups were significantly decreased compared with those at T₀, but the heart rate and MAP in the remimazolam group at T₁, T₂ and T₃ were significantly higher than those in the propofol group (P < 0.05). There were no statistical differences in the anesthesia time, awakening time and extubation time between the remimazolam group and the propofol group (P > 0.05). The levels of plasma epinephrine, norepinephrine and cortisol in the two groups were significantly higher at 24 h and 72 h after surgery than those before anesthesia induction, and the above levels were significantly lower in the remimazolam group than those in the propofol group (P < 0.05). The VAS scores at each time point in the two groups were significantly reduced compared to before surgery, but there was no statistically significant difference between the two groups after surgery (P > 0.05). The MMSE scores of the two groups were significantly lower at 1 d and 3 d after surgery compared with those before anesthesia induction, but the score in the remimazolam group was significantly higher than that in the propofol group (P < 0.05). In addition, the incidence rates of adverse reactions were significantly lower in the remimazolam group compared to the propofol group (P < 0.05).

Conclusion

Compared with propofol, remimazolam can achieve equivalent anesthetic and analgesic effects in elderly patients undergoing hip replacement. However, the latter one can significantly relieve respiratory and circulatory suppression, stress response and cognitive dysfunction, with good safety.

Trial registration

This single-center, prospective, RCT has completed the registration of the Chinese Clinical Trial Center at 31/12/2021 with the registration number ChiCTR2100055039.

Effectiveness of single loading dose of dexmedetomidine combined with propofol for deep sedation of endoscopic retrograde cholangiopancreatography (ERCP) in elderly patients: a prospective randomized study

Background

Endoscopic retrograde cholangiopancreatography (ERCP) is an advanced endoscopic procedure and requires deep sedation. Deep sedation with dexmedetomidine for the respiratory drive preserved has become popular in recent years. However, the use of dexmedetomidine in elderly patients is controversial because its adverse events are more common. The objective of this study was to investigate the effectiveness of a single loading dose of dexmedetomidine combined with propofol for deep sedation of ERCP in elderly patients.

Methods

In this prospective randomized trial, 49 elderly patients undergoing ERCP were randomly allocated to the dexmedetomidine (DEX) or propofol (PRO) groups. The single loading dose of dexmedetomidine was set at 0.5 μg/kg at the start of anesthesia induction and loading for 10 min. The primary outcome was the cumulative dose of propofol. Secondary outcomes included time to awake, the frequency of airway interventions, and hemodynamics.

Results

The intraoperative cumulative dose of propofol was lower in the DEX group (111.0 ± 12.6 μg/kg/min) than the PRO group (143.7 ± 23.4 μg/kg/min) (P < 0.001). There was no statistically significant difference in the time to awake between the two groups. The incidence of artificial airway interventions and hypotension in the PRO group (36%, 60%) were significantly higher than those in the DEX group (4.2%, 16.7%) (P = 0.011, P = 0.003, respectively). In addition, the occurrence of bradycardia increased significantly in the DEX group (58.3%) compared with the PRO group (12%) (P < 0.001).

Conclusions

The single loading dose of dexmedetomidine combined with propofol can reduce propofol consumption and artificial airway intervention and provide better hemodynamic stability than propofol for deep sedation in elderly patients during ERCP.

Trial registration

www.chictr.org.cn (Registration number ChiCTR1900028069, Registration date 10/12/2019).

Impact of intravenous and topical lidocaine on clinical outcomes in patients receiving propofol for gastrointestinal endoscopic procedures: a meta-analysis of randomised controlled trials

BACKGROUND

The efficacy of i.v. or topical lidocaine as an anaesthesia adjunct in improving clinical outcomes in patients receiving gastrointestinal endoscopic procedures under propofol sedation remains unclear.

METHODS

Electronic databases (MEDLINE, EMBASE, and Cochrane Library) were searched for RCTs comparing the clinical outcomes with or without lidocaine application (i.v. or topical) in patients receiving propofol for gastrointestinal endoscopic procedures from inception to 29 March 2021. The primary outcome was propofol dosage, while secondary outcomes included procedure time, recovery time, adverse events (e.g. oxygen desaturation), post-procedural pain, and levels of endoscopist and patient satisfaction.

RESULTS

Twelve trials (1707 patients) published between 2011 and 2020 demonstrated that addition of i.v. (n=7) or topical (n=5) lidocaine to propofol sedation decreased the level of post-procedural pain (standardised mean difference [SMD]=-0.47, 95% confidence interval [CI]: -0.8 to -0.14), risks of gag events (risk ratio [RR]=0.51, 95% CI: 0.35-0.75), and involuntary movement (RR=0.4, 95% CI: 0.16-0.96). Subgroup analysis demonstrated that only i.v. lidocaine reduced propofol dosage required for gastrointestinal endoscopic procedures (SMD=-0.83, 95% CI: -1.19 to -0.47), increased endoscopist satisfaction (SMD=0.75, 95% CI: 0.21-1.29), and shortened the recovery time (SMD=-0.83, 95% CI: -1.45 to -0.21). Intravenous or topical lidocaine did not affect the incidence of oxygen desaturation (RR=0.72, 95% CI: 0.41-1.24) or arterial hypotension (RR=0.6, 95% CI: 0.22-1.65) and procedure time (SMD=0.21, 95% CI: -0.09 to 0.51).

CONCLUSION

This meta-analysis demonstrated that i.v. or topical lidocaine appears safe to use and may be of benefit for improving propofol sedation in patients undergoing gastrointestinal endoscopic procedures. Further large-scale trials are warranted to support our findings.

Controversies in ERCP: Indications and preparation

The aim of the series of papers on controversies of biliopancreatic drainage procedures is to discuss the pros and cons of the varying clinical practices and techniques in ERCP and EUS for drainage of biliary and pancreatic ducts. The first part focuses on indications, clinical and imaging prerequisites before ERCP, sedation options, post-ERCP pancreatitis (PEP) prophylaxis, and other related technical topics. In the second part, specific procedural ERCP-techniques including precut techniques and its timing as well as management algorithms are discussed. In addition, controversies in EUS-guided bile duct and pancreatic drainage procedures are under preparation.

Efficacy of an Oxycodone-Propofol Combination versus a Fentanyl-Propofol Combination in Conscious Sedation during Therapeutic Endoscopic Retrograde Cholangiopancreatography in Elderly Patients

BACKGROUND

With a rapidly aging population, the need for endoscopic retrograde cholangiopancreatography (ERCP) is increasing. The commonly used sedation anesthesia in ERCP is a combination of propofol and fentanyl, even though fentanyl may cause some adverse reactions such as respiratory depression.

OBJECTIVES

This study aimed to evaluate the efficacy of oxycodone combined with propofol versus fentanyl combined with propofol for sedation anesthesia during ERCP.

METHODS

A total of 193 patients aged from 65 to 80 years undergoing ERCP were enrolled and randomized into two groups: an "oxycodone combined with propofol" group (group OP, n = 97) and a "fentanyl combined with propofol" group (group FP, n = 96). The rate of perioperative adverse events as well as the recovery time, patients' satisfaction, and endoscopists' satisfaction were noted.

RESULTS

There was no difference in the frequency of hypotension or bradycardia between the two groups, but there were more episodes of desaturation (SpO2 <90% for >10 s in 8.3%), postoperative nausea (7.3%), and vomiting (5.2%) in group FP than in group OP. Patients' satisfaction in group FP was lower than that in group OP. The recovery time was longer in group FP than in group OP.

CONCLUSIONS

Oxycodone combined with propofol was effective in ERCP, with a low incidence of perioperative adverse events.