Training guideline for use of propofol in gastrointestinal endoscopy

Global Trends of Gastrointestinal Endoscopy Anesthesia/Sedation: A Bibliometric Study (from 2001 to 2022)

Background

Gastrointestinal (GI) endoscopy becomes more and more common now in order to diagnose and treat GI diseases, and anesthesia/sedation plays an important role. We aim to discuss the developmental trends and evaluate the research hotspots using bibliometric methods for GI endoscopy anesthesia/sedation in the past two decades.

Methods

The original and review articles published from 2001 to December 2022 related to GI endoscopy anesthesia/sedation were extracted from the Web of Science database. Four different softwares (CiteSpace, VOSviewer, and Bibliometrix, Online Analysis Platform of Literature Metrology (Bibliometric)) were used for this comprehensive analysis.

Results

According to our retrieval strategy, we found a total of 3154 related literatures. Original research articles were 2855, and reviews were 299. There has been a substantial increase in the research on GI endoscopy anesthesia/sedation in recent 22 years. These publications have been cited 66,418 times, with a mean of 21.04 citations per publication. The US maintained a leading position in global research, with the largest number of publications (29.94%), and China ranked second (19.92%). Keyword burst and concurrence showed that conscious sedation, colonoscopy and midazolam were the most frequently occurring keywords.

Conclusion

Our research found that GI endoscopy anesthesia/sedation was in a period of rapid development and demonstrated the improvement of medical instruments and surgical options that had significantly contributed to the field of GI endoscopy anesthesia/sedation. The US dominates this field, and the selection and dosage of sedative regimens have always been the foci of disease research to improve comfort and safety, while adverse events and risks arouse attention gradually. In the past 20 years, hotspots mainly focus on upper gastrointestinal endoscopy, gastroscopy, and esophagogastroduodenoscopy. These data would provide future directions for clinicians and researchers regarding GI endoscopy anesthesia/sedation.

New sedatives and analgesic drugs for gastrointestinal endoscopic procedures

Procedural sedation has become increasingly common in endoscopy. Sedatives and analgesics induce anxiolysis and amnesia. In addition, an appropriate level of sedation is necessary for safe procedures including therapeutic endoscopy. Midazolam and propofol are the most commonly used drugs in sedative endoscopy. In recent years, the need to ascertain the safety and effectiveness of sedation has increased in practice. Therefore, new sedatives and analgesic drugs for optimal sedative endoscopy, have recently emerged. This article reviews the characteristics of sedatives and analgesics, and describes their clinical use in gastrointestinal endoscopy.

Creation and Implementation of a Hospitalist-Run Propofol Sedation Program

BACKGROUND

Pediatric hospitalists increasingly provide sedation outside the operating room. Given the large body of safety data available, propofol was identified as a beneficial addition to our hospitalist-run sedation service's medication repertoire. Currently, the training required for hospitalists to provide sedation is defined and determined locally by individual institutions.

METHODS

We convened a task force to develop and implement training for hospitalists in the use of propofol for deep sedation. After implementing training, we analyzed the outcome of patients receiving propofol for deep sedation for MRI, including the adverse event rate and successful completion rate. An adverse event was defined as a significant desaturation, persistent upper airway obstruction, laryngospasm, administration of neuromuscular blockade, conversion to anesthesia, call for additional backup, or if the procedure was not able to be completed. Successful completion was defined as any patient being able to complete the imaging study or procedure with sedation performed by a hospitalist physician.

RESULTS

Between September 2015 and September 2018, sedation services sedated 12 979 patients, 3929 of whom were deeply sedated with propofol. During this period, the trained hospitalists had an adverse event rate of 3.6% and a 98.9% rate of successful completion of all studies or procedures when using propofol for deep sedation.

CONCLUSION

With a comprehensive training program for hospitalists in the administration of propofol, we provided effective sedation for a selective population of patients. We now have a standard approach that uses credentialed hospitalists to train new faculty for propofol administration.

Outcomes of colonoscopy with non-anesthesiologist-administered propofol (NAAP): an equivalence trial

Background and study aims  Efficacy and safety of NAAP for gastrointestinal endoscopy have been widely documented, although there is no information about the outcomes of colonoscopy when the endoscopist supervises the sedation. In this context, the aim of this trial was to determine the equivalence of adenoma detection rate (ADR) in colorectal cancer (CRC) screening colonoscopies performed with non-anesthesiologist-administered propofol (NAAP) and performed with monitored anesthesia care (MAC). Patients and methods  This was a single-blind, non-randomized controlled equivalence trial that enrolled adults from a national CRC screening program (CRCSP). Patients were blindly assigned to undergo either colonoscopy with NAAP or MAC. The main outcome measure was the ADR in CRCSP colonoscopies performed with NAAP. Results  We included 315 patients per group. The median age was 59.76 ± 5.81 years; 40.5 % of patients were women. The cecal intubation rate was 97 %, 81.8 % of patients had adequate bowel preparation, withdrawal time was > 6 minutes in 98.7 %, and the median global exploration time was 24.25 ± 8.86 minutes (range, 8-70 minutes). The ADR was 62.9 % and the complication rate (CR) was 0.6 %. Analysis by intention-to-treat showed an ADR in the NAAP group of 64.13 % compared with 61.59 % in the MAC group, a difference (δADR) of 2.54 %, 95 %CI: -0.10 to 0.05. Analysis by per-protocol showed an ADR in the NAAP group of 62.98 %, compared with 61.94 % in the MAC group, δADR: 1.04 %, 95 %CI: -0.09 to 0.07. There was no difference in CR (NAAP: 0,63 vs. MAC: 0.63); P  = 1.0. Conclusions  ADR in colorectal cancer screening colonoscopies performed with NAAP was equivalent to that in those performed with MAC. Similarly, there was no difference in complication rates.

Anesthetic strategy for obese patients during gastroscopy: deep sedation or conscious sedation? A prospective randomized controlled trial

OBJECTIVE

This paper aims to compare the incidence of SpO₂ values < 95% and < 90% of the obese patients between conscious sedation and deep sedation and whether conscious sedation was superior to the deep sedation for obese patients during diagnostic gastroscopy.

METHODS

Obese patients undergoing diagnostic gastroscopy were randomly assigned to two different intervention groups: group CS (conscious sedation) or group DS (deep sedation). Group CS patients were managed by conscious sedation [Modified Observer Assessment of Alertness/Sedation (MOAA/S) at 4-5] protocol, and group DS patients were managed by deep sedation (MOAA/S at ≤ 2) protocol. Propofol and sufentanil (0.1 and 0.05 mg/kg) were, respectively, infused for sedation and analgesia in CS and DS protocols. The primary endpoints were to compare the incidence of SpO₂ values < 95% and < 90% of the patients between the two groups. The incidence of successful sedation, satisfaction scores of patients and endoscopist were assessed as secondary endpoints.

RESULTS

115 obese patients (59 in group CS and 56 in group DS) were enrolled in this study. The incidences of SpO₂ < 95% and < 90% in group CS (42.4% and 6.8%) were significantly lower than those in group DS (69.6% and 19.6%, with P = 0.003 and 0.041, respectively). The incidence of successful sedation was similar between groups (86.4% vs 89.3%, P = 0.641). Patient satisfaction scores and endoscopist satisfaction scores were both similar between groups (P = 0.548 and 0.171).

CONCLUSION

Conscious sedation with propofol and sufentanil (0.1 mg/kg) reduced the incidence of hypoxic events without affecting gastroscopy procedure and satisfaction compared with the deep sedation for obese patients during diagnostic gastroscopy.

TRIAL REGISTRATION

ChiCTR-1900024894; registration date, July 31, 2019. http://www.chictr.org.cn .

Safety of Outpatient Procedural Sedation Administered by Oral and Maxillofacial Surgeons: The Mayo Clinic Experience in 17,634 Sedations (2004 to 2019)

PURPOSE

The safety of the team anesthesia model routinely used by the specialty of oral and maxillofacial surgery has recently been called into question. The purpose of this article is to measure the frequency of adverse anesthetic events related to ambulatory surgical procedures performed under intravenous (IV) sedation by the Division of Oral and Maxillofacial Surgery at the Mayo Clinic during a 15-year period using the team anesthesia model.

MATERIALS AND METHODS

A retrospective cohort study was designed, and a sample of subjects identified undergoing IV sedation at Mayo Clinic from 2004 to 2019. The primary outcome variable of interest was the presence of anesthetic-related adverse events (AEs) consistent with the World Society of Intravenous Anesthesia International Sedation Task Force's intervention-based definitions of adverse anesthetic events. Additional covariates included patient age, gender, American Society of Anesthesiologists (ASA) score, type of surgical procedure performed, and the type/dosage of medications administered periprocedurally. Univariate logistic regression analysis was used to assess for associations between AEs and covariates.

RESULTS

The study identified 17,634 sedations administered to 16,609 unique subjects. In 17,634 sedations, 16 (0.1%) AEs and no subject deaths (0%) were identified. There were no statistically significant associations between AEs and age (hazard ratio [HR], 0.4; 95% confidence interval [95% CI], 0.2 to 1.3; P = .13); gender (HR, 0.9; 95% CI, 0.3 to 2.5; P = .87); ASA 2 classification (HR, 1.6; 95% CI, 0.6 to 4.5; P = .33); ASA 3 classification (HR, 1.3; 95% CI, 0.1 to 22.0; P = .86), or types of IV sedation medications administered during the procedure: fentanyl (HR, 0.4; 95% CI, 0.02 to 6.3; P = .5); midazolam (HR, 1.0; 95% CI, 0.2 to 4.3; P = .98); propofol (HR, 1.0; 95% CI, 0.3 to 3.5; P = .99); or ketamine (HR, 1.0; 95% CI, 0.1 to 7.3; P = .97).

CONCLUSIONS

The frequency of AEs (0.1%) and 0% mortality rate reported in this study demonstrate that the anesthesia team model used by oral and maxillofacial surgeons compares favorably to standardized intervention-based adverse anesthetic event outcomes reported by other nonanesthesiology specialties routinely performing outpatient procedural sedation.

Endoscopist-Directed Propofol as an Adjunct to Standard Sedation: A Canadian Experience

Background

Sedation practices vary widely by region. In Canada, endoscopist-directed administration of a combination of fentanyl and midazolam is standard practice. A minority of cases are performed with propofol.

Aims

To describe the safety of nonanaesthetist administered low-dose propofol as an adjunct to standard sedation.

Methods

This was a single-centre retrospective study of patients having undergone endoscopic procedures with propofol sedation between 2004 and 2012 in a teaching hospital in Montreal. Procedures were performed by gastroenterologists trained in Advanced Cardiovascular Life Support. Sedation was administered by intravenous bolus by a registered nurse, under the direction of the endoscopist. Outcomes of procedures were collected in the context of a retrospective chart review using the hospital's endoscopy database.

Results

Of patients undergoing endoscopies at our centre, 4930 patients received propofol as an adjunct to standard sedation with fentanyl and midazolam. Cecal intubation rate for colonoscopies (n = 2921) was 92.0%. Gastroscopies (n = 1614), flexible sigmoidoscopies (n = 28), endoscopic retrograde cholangiopancreatography (n = 331) and percutaneous endoscopic gastrostomy insertion (n = 36) had success rates, defined as successful completion of the procedure within anatomical limits, of 99.0, 96.4, 94.0 and 91.7%, respectively. The average dose of propofol used for each procedure was 34.5 ± 20.8 mg. Fentanyl was used in 67.4% of procedures at an average dose of 94.3 ± 17.5 mcg. Midazolam was used in 92.7% of cases at an average dose of 3.0 ± 0.7 mg. Reversal agents (naloxone or flumazenil) were used in 0.43% of the cases (n = 21). Patients who received propofol were discharged uneventfully within the usual postprocedure recovery time. One patient required sedation-related hospitalization. For patients having received propofol in addition to standard sedation agents, 99.6% experienced no adverse events. There were no mortalities.

Conclusion

The use of low-dose propofol as an adjunct to fentanyl and midazolam, administered by a registered nurse under the direction of the endoscopist was safe and effective in patients at our centre.

More than half of hypoxemia cases occurred during the recovery period after completion of esophagogastroduodenoscopy with planned moderate sedation

Guidelines advise precautionary measures for possible adverse events that may occur due to sedation during endoscopic procedures. To avoid complications, intraprocedural and postprocedural monitoring during recovery is considered important. However, since not many studies have reported on hypoxemia during the recovery period, findings for specific monitoring methods are insufficient. The aim of this retrospective study was to determine the incidence of hypoxemia during the recovery period using continuous central-monitoring by pulse oximetry and to characterize the hypoxemia cases. Among the 4065 consecutive esophagogastroduodenoscopy (EGD) procedures under planned moderate sedation, 84 (2.1%) procedures developed unexpected hypoxemia (SpO₂ ≤ 90%). Hypoxemia was observed during the procedure, at the end of the procedure, and during the recovery period in 21, 17, and 46 (1.1%) procedures, respectively. More than half of the hypoxemia cases occurred during the recovery period. Many hypoxemia cases were characterized by neither serious co-morbid illness nor low body mass index which have been reported as risk factors of hypoxemia. The lack of risk factors is no guarantee that hypoxemia will not occur. Therefore, continuous monitoring by pulse oximetry is more important during the recovery period and is recommended in all EGD procedures under planned moderate sedation.

Practice recommendations for the use of sedation in routine hospital-based colonoscopy

Objective

Although sedation improves patient experience during colonoscopy, there is great jurisdictional variability in sedative practices. The objective of this study was to develop practice recommendations for the use of moderate and deep sedation in routine hospital-based colonoscopy to facilitate standardisation of practice.

Design

We recruited 32 multidisciplinary panellists to participate in a modified Delphi process to establish consensus-based recommendations for the use of sedation in colonoscopy. Panel members participated in a values assessment survey followed by two rounds of anonymous online voting on preliminary practice recommendations. An inperson meeting was held between voting rounds to facilitate consensus-building. Consensus was defined as >60% agreement/disagreement with recommendation statements; >80% agreement/disagreement was considered indicative of strong consensus.

Results

Twenty-nine panellists participated in the values assessment survey. Panellists ranked all factors presented as important to the development of practice recommendations. The factor considered most important was patient safety. Patient satisfaction, procedural efficiency, and cost were considered less important. Strong consensus was achieved for all nine practice recommendations presented to the panel. These recommendations included that all endoscopists be able to perform colonoscopy with moderate sedation, that an endoscopist and a single trained nurse are sufficient for performing colonoscopy with moderate sedation, and that anaesthesia-provided deep sedation be used for select patients.

Conclusion

The recommendations presented in this study were agreed on by a multidisciplinary group and provide guidance for the use of sedation in routine hospital-based colonoscopy. Standardised sedation practices will promote safe, effective, and efficient colonoscopy for all patients.

Efficacy of novel sedation using the combination of dexmedetomidine and midazolam during endoscopic submucosal dissection for esophageal squamous cell carcinoma

BACKGROUND

Endoscopic submucosal dissection (ESD) is the preferred treatment for esophageal squamous cell carcinoma (ESCC). However, ESD can be difficult when patients move due to insufficient sedation. We conducted a prospective confirmatory single arm study to evaluate the efficacy of using dexmedetomidine (DEX) in combination with midazolam as a novel sedation for ESD.

METHODS

Endoscopic submucosal dissection was performed without intubation in 65 patients. The primary outcome was the proportion of patients who did not move or require restraint during ESD, compared to historical control of ESD performed under midazolam sedation. Secondary outcomes included the frequency of complications and self-report questionnaires from patients and endoscopists.

RESULTS

Restraint was not required in 97% of patients sedated using the combination of DEX and midazolam. Depressed respiration, low blood pressure, and bradycardia occurred in 23, 37, and 26% of patients, respectively. All patients recovered without severe complication. Occurrence of low blood pressure and bradycardia were higher, while respiratory depression was lower for the combination group than for the historical control group. The amount of midazolam used was significantly lower than in the control. Of note, 94% of patients had no painful sensations, with 3 reporting chest pain and 3 having a recollection of the procedure. Endoscopists were satisfied with the sedation in 94% of cases. All lesions were resected in en bloc fashion, without perforation.

CONCLUSIONS

The combination of DEX and midazolam provided effective sedation for ESD for ESCC.

Safety and Efficacy of Nonanesthesiologist-Administrated Propofol during Endoscopic Submucosal Dissection of Gastric Epithelial Tumors

Objective

There is no consensus regarding administration of propofol for performing endoscopic submucosal dissection (ESD) in patients with comorbidities. The aim of this study was to evaluate the safety and efficacy of propofol-induced sedation administered by nonanesthesiologists during ESD of gastric cancer in patients with comorbidities classified according to the American Society of Anesthesiologists (ASA) physical status.

Methods

Five hundred and twenty-two patients who underwent ESD for gastric epithelial tumors under sedation by nonanesthesiologist-administrated propofol between April 2011 and October 2017 at Dokkyo Medical University Hospital were enrolled in this study. The patients were divided into 3 groups according to the ASA physical status classification. Hypotension, desaturation, and bradycardia were evaluated as the adverse events associated with propofol. The safety of sedation by nonanesthesiologist-administrated propofol was measured as the primary outcome.

Results

The patients were classified according to the ASA physical status classification: 182 with no comorbidity (ASA 1), 273 with mild comorbidity (ASA 2), and 67 with severe comorbidity (ASA 3). The median age of the patients with ASA physical status of 2/3 was higher than the median age of those with ASA physical status of 1. There was no significant difference in tumor characteristics, total amount of propofol used, or ESD procedure time, among the 3 groups. Adverse events related to propofol in the 522 patients were as follows: hypotension (systolic blood pressure < 90 mmHg) in 113 patients (21.6%), respiratory depression (SpO₂ < 90%) in 265 patients (50.8%), and bradycardia (pulse rate < 50 bpm) in 39 patients (7.47%). There was no significant difference in the incidences of adverse events among the 3 groups during induction, maintenance, or recovery. No severe adverse event was reported. ASA 3 patients had a significantly longer mean length of hospital stay (8 days for ASA 1, 9 days for ASA 2, and 9 days for ASA 3, P = 0.003). However, the difference did not appear to be clinically significant.

Conclusions

Sedation by nonanesthesiologist-administrated propofol during ESD is safe and effective, even for at-risk patients according to the ASA physical status classification.

Judicial Precedent-Based Clinical Practice Guidelines of Propofol in Sedative Esthetic Surgery

BACKGROUND

Propofol is has been widely used for sedation in the field of esthetic surgery because of its favorable pharmacokinetic profile. Propofol sedation-induced side effects are rare. However, when present, they can be serious. The number of malpractice claims associated with propofol sedation has increased in recent years. This study aims to show which procedures lead to the most claims in the field of esthetic surgery through a review of Korean precedents.

METHODS

Thirteen precedent cases of propofol sedation in the field of esthetic surgery were collected between 2000 and 2016. We analyzed the type of procedure, administration route, anesthesia provider, complications, timing of damaging events, average indemnification, plaintiff's (patients) winning rate, ratio and the reason of limitation of liability and the key factors affecting the judgement in these cases.

RESULTS

Most plaintiffs were women, and in most cases (11/13, 73.3%), the times of the damaging events were in maintenance and the anesthesia provider was the surgeon. The most common complication related to propofol sedation was hypoxic brain damage. Among the 13 cases, 12 were won by the plaintiff. The mean claim settlement was 339,455,814 KRW (USD 301,792.15). The key factors affecting the judgement were administration method and staff, monitoring method, preparation of emergency kit, response to emergencies, transfer to a higher-level hospital, detailed medical recording about event and informed consent.

CONCLUSION

The number of claims owing to propofol sedation after esthetic surgery is increasing. Close monitoring during the operation, immediate reaction to an event and thorough medical records were main key factors that influenced the judgement. Preoperative explanation about the possibility of complications was important. The findings will help surgeons achieve high patient satisfaction and reduce liability concerns.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Italian Society of Digestive Endoscopy (SIED) position paper on the non-anaesthesiologist administration of propofol for gastrointestinal endoscopy

Propofol sedation by non-anesthesiologists in GI endoscopy, despite generally considered a safe procedure, is still a matter of debate. Benefits of propofol sedation include rapid onset of action, greater patient comfort and fast recovery with prompt discharge from the endoscopy unit. The use of propofol for sedation in GI endoscopy, preceded by dedicated training courses, has been approved by several anaesthesiologist and gastroenterologist societies but an Italian position paper taking into account the Italian law is lacking. In the present document, the Italian Society of Digestive Endoscopy (SIED) Sedation Group, on behalf of the SIED, presents a series of updated position statements concerning propofol sedation in GI endoscopy. The paper summarizes the advantages of propofol, how it should be administered and how patients should be monitored. Moreover, details concerning proper training of non-anaesthesiologist personnel involved in its use are provided. Protocols concerning propofol use s must be shared with the hospital's anaesthesiology staff and approved by the hospital's Executive Director.

Safety and Effectiveness of Endoscopist-Directed Nurse-Administered Sedation during Gastric Endoscopic Submucosal Dissection

BACKGROUND AND AIMS

Endoscopic submucosal dissection (ESD) is routinely performed in treating gastric neoplasia and requires long-term higher levels of sedation. Endoscopist-directed nurse-administered sedation (EDNAS) has not been well studied in ESD. This study aimed to evaluate the safety and effectiveness of EDNAS for ESD.

METHODS

Patients treated with ESD for gastric tumors between 2013 and 2015 were retrospectively collected. Patients were divided into a midazolam-treated group (M group) and a midazolam plus propofol-treated group (MP group). Clinical outcome, safety, effectiveness, adverse events of ESD, and adverse events of sedation were analyzed.

RESULTS

Of 209 collected patients, 83 were in the M group and 126 were in the MP group. Of all patients, 67 patients had the circulatory adverse event during the ESD procedure. Sedation method was the only significant risk factor (M versus MP: 2.17 (1.14-4.15), p = 0.019). In analysis of MP subgroups, 47 patients suffered an adverse event from sedation, and current smoking was the only significant association factor for adverse event (0.15 (0.03-0.68), p = 0.014).

CONCLUSIONS

In performing ESD, the effect of sedation is reduced in smoking patients. EDNAS may be acceptable for ESD under careful monitoring of vital sign and oxygen saturation.

Practice guidelines for propofol sedation by non-anesthesiologists: the Korean Society of Anesthesiologists Task Force recommendations on propofol sedation

In South Korea, as in many other countries, propofol sedation is performed by practitioners across a broad range of specialties in our country. However, this has led to significant variation in propofol sedation practices, as shown in a series of reports by the Korean Society of Anesthesiologists (KSA). This has led the KSA to develop a set of evidence-based practical guidelines for propofol sedation by non-anesthesiologists. Here, we provide a set of recommendations for propofol sedation, with the aim of ensuring patient safety in a variety of clinical settings. The subjects of the guidelines are patients aged ≥ 18 years who were receiving diagnostic or therapeutic procedures under propofol sedation in a variety of hospital classes. The committee developed the guidelines via a de novo method, using key questions created across 10 sub-themes for data collection as well as evidence from the literature. In addition, meta-analyses were performed for three key questions. Recommendations were made based on the available evidence, and graded according to the modified Grading of Recommendations Assessment, Development and Evaluation system. Draft guidelines were scrutinized and discussed by advisory panels, and agreement was achieved via the Delphi consensus process. The guidelines contain 33 recommendations that have been endorsed by the KSA Executive Committee. These guidelines are not a legal standard of care and are not absolute requirements; rather they are recommendations that may be adopted, modified, or rejected according to clinical considerations.

Training and Competency in Sedation Practice in Gastrointestinal Endoscopy

The practice of endoscopic sedation requires a thorough understanding of preprocedural assessment, sedation pharmacology, intraprocedure monitoring, adverse event management, and postprocedural care. The training process has become increasingly standardized and entails knowledge and practice-based components. The use of propofol in particular requires a higher level of structured training owing to its narrow therapeutic window. Simulation has increased opportunities for practice-based training in a controlled environment. After completion of training, the endoscopist must demonstrate competence in theoretical understanding and technical ability to administer sedation. Although individual institutions have certification processes, there is a lack of validated, standardized methods to confirm competence.

Application of clip traction in endoscopic submucosal dissection to the treatment of early esophageal carcinoma and precancerous lesions

BACKGROUND AND AIM

It is usually difficult to obtain a good view of the dissection plane during esophageal endoscopic submucosal dissection (ESD). Therefore, the aim of this study was to investigate the efficacy and safety of clip traction in ESD for the treatment of early esophageal carcinoma (EEC) or precancerous lesions.

METHODS

This is a case-matched comparative study. We selected 100 EEC patients who had undergone ESD. Fifty cases underwent ESD without clip traction (non-clip group), and 50 cases underwent ESD with clip traction (clip group). The patient-related variables, dissection time, data regarding muscularis propria injury, etc. were statistically analyzed.

RESULTS

ESD was successful in all cases without complication. There were no significant differences between the two groups with respect to age, gender, the longitudinal diameter of the lesions, etc. Wide visual field exposure of the submucosal tissue below the lesion was obtained by applying clip traction. The dissection time of ESD was shorter in the clip group than in the non-clip group [22.02 (6.77) min vs 26.48 (12.56); P = 0.018] when the extent of lesion was less than half of the circumference of the esophagus; otherwise, there was no difference between the two groups (P = 0.252). Moreover, the muscularis propria injuries in the clip group were obviously less than the non-clip group (10 vs 30 %, P = 0.007).

CONCLUSION

Clip traction can decrease the rate of muscularis propria injury and shorten the dissection time. It is recommended as a safe and effective auxiliary procedure for the treatment of esophageal ESD.

Sedation in hypoalbuminemic geriatric patients under spinal anesthesia in hip surgery. Midazolam or Propofol?

Objectives:

To compare midazolam and propofol sedation in hypoalbuminemic geriatric patients under spinal anesthesia in hip surgery with bispectral index monitoring.

Methods:

This prospective and randomized study was completed in the Department of Anesthesiology, Okmeydani Training and Research Hospital, Istanbul, Turkey between February 2013 and December 2014. Sixty patients undergoing elective hip surgery under spinal anesthesia in the geriatric age group with albumin levels below 3 g/dl were randomly divided into Group I and Group II. After administration of spinal block, Group I were given 0.05 mg/kg bolus midazolam, and then 0.02-0.1 mg/kg/hr dose infusion was begun. In Group II, 1 mg/kg bolus propofol was given within 10 minutes, and then 1-3 mg/kg/hr infusion was begun. The systolic arterial pressure, diastolic arterial pressure, mean arterial pressure, heart rate, peripheral oxygen saturation values, respiratory rate, and Wilson’s 5-stage sedation score were recorded at 15-minute intervals. At the end of the operation, the recovery time and surgeon satisfaction were recorded.

Results:

The recovery times for patients in Group I were found to be longer than in Group II (p<0.05). The respiration rate in patients in Group I at the start of surgery, 15th minute of surgery, and after surgery were lower than in Group II (p<0.05).

Conclusion:

We conclude that propofol is more reliable in terms of hemodynamic stability than midazolam, as it causes less respiratory depression and faster recovery in the propofol group.

Feasibility of deep sedation with a combination of propofol and dexmedetomidine hydrochloride for esophageal endoscopic submucosal dissection

BACKGROUND AND AIM

The aim of the present study was to evaluate the efficacy and safety of sedation with a combination of propofol (PF) and dexmedetomidine (DEX) compared with sedation with benzodiazepines in esophageal endoscopic submucosal dissection (ESD).

METHODS

We retrospectively reviewed clinical data for 40 consecutive patients who had undergone esophageal ESD at the Yokohama City University Hospital between July 2012 and August 2014. Of these patients, 20 were sedated with benzodiazepines (conventional group) and another 20 patients were sedated with a combination of PF and DEX (combination group). Parameters for efficacy and safety of sedation were evaluated by comparisons between the two groups.

RESULTS

Median procedural times in the combination group were shorter than those in the conventional group (61 min vs. 89 min, P = 0.03), and the percentage of patients who showed restlessness in the combination group was significantly lower than that in the conventional group (25% vs. 65%, P = 0.025). Incidences of hypotension and bradycardia in the combination group were higher than those in the conventional group (60% vs. 15%, P = 0.008, and 60% vs. 15%, P = 0.008, respectively).

CONCLUSION

This retrospective study suggests that a combination of PF and DEX may provide stable deep sedation with less body movement than benzodiazepines during esophageal ESD.

Morbidity and mortality of endoscopist-directed nurse-administered propofol sedation (EDNAPS) in a tertiary referral center

BACKGROUND AND STUDY AIMS

Endoscopist-Directed Nurse-Administered Propofol Sedation (EDNAPS) has been evaluated in community settings rather than tertiary referral centers.

PATIENTS AND METHODS

A hospital-wide prospectively collected database of Medical Emergency Team Calls (METCALL), emergency responses triggered by medically unstable patients, was reviewed. Responses that followed EDNAPS were extracted and compared with a prospectively entered database of all endoscopies performed using EDNAPS over the same period.

RESULTS

A total of 33,539 endoscopic procedures (16,393 gastroscopies, 17,146 colonoscopies) were performed on 27,989 patients using EDNAPS. Intravenous drugs included midazolam (0 - 5 mg), fentanyl (0 - 100 mcg), and propofol (10 - 420 mg). Of 23 METCALLs (18 gastroscopies and 5 colonoscopies), there were 16 with ASA scores of III or higher. Indications for gastroscopy were gastrointestinal (GI) hemorrhage (n = 11; 8 variceal, 3 nonvariceal), dysphagia (n = 5), PEG removal (n = 1), and dyspepsia (n = 1). Fifteen of 22 patients, including all of those who had a colonoscopy, made a full recovery and returned to the ward or were discharged home. In the gastroscopy group, seven were intubated and admitted to Intensive Care, of whom six were emergency cases for gastrointestinal bleeding (n = 4 variceal, n = 2 non variceal) and one in which the indication was PEG removal. Two deaths occurred in the intubated group.

CONCLUSIONS

In a tertiary referral center, EDNAPS for low-to-moderate risk (ASA ≤ 2) patients undergoing gastroscopy and colonoscopy is very safe. Gastroscopy is associated with greater anesthetic risk than colonoscopy and those with high ASA scores needing urgent endoscopy for upper gastrointestinal hemorrhage are at particular risk of cardiorespiratory decompensation.

Optimization of Deep Sedation with Spontaneous Respiration for Therapeutic Endoscopy Combining Propofol and Bispectral Index Monitoring

Background/Aims. This study aimed to establish optimal propofol anesthesia for therapeutic endoscopy, which has not been established. Methodology. We retrospectively investigated data on 89 patients who underwent upper-GI endoscopic submucosal dissection or endoscopic mucosal resection under anesthesia with propofol. Examined doses of propofol were changed according to efficacy and/or adverse events and classified into 5 periods. A bispectral index (BIS) monitor was used at Period 5 to decrease the incidence of adverse events caused by oversedation. The initial dose of propofol was administered after bolus injection of pethidine hydrochloride (0.5 mg/kg), and 1.0 mL of propofol was added every minute until the patients fell asleep. Continuous and bolus infusion were performed to maintain sedation. When the patient moved or an adverse event occurred, the maintenance dose examined was increased or decreased by 5 mL/h regardless of body weight. Results. Dose combinations (introduction : maintenance) and patient numbers for each period were as follows: Period 1 (n = 27), 0.5 mg/kg : 5 mg/kg/h; Period 2 (n = 11), 0.33 mg/kg : 3.3 mg/kg/h; Period 3 (n = 7), 0.5 mg/kg : 3.3 mg/kg/h; Period 4 (n = 14), 0.5 mg/kg : 2.5 mg/kg/h; Period 5 (n = 30), 0.5 mg/kg : 2.5 mg/kg/h, using BIS monitor. During Period 5, an adverse event occurred in 10.0% of patients, which was lower than that for Periods 1–4. Conclusions. Period 5 propofol anesthesia with BIS protocol could be safe and useful for therapeutic endoscopy under deep sedation with spontaneous respiration.

Efficacy and safety of a patient-positioning device (EZ-FIX) for endoscopic retrograde cholangiopancreatography

AIM

To assess the efficacy and safety of a patient-positioning device (EZ-FIX) for endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

A total of 105 patients were randomized to the EZ-FIX (n = 53) or non-EZ-FIX (n = 52) group in this prospective study. Midazolam and propofol, titrated to provide an adequate level of sedation during therapeutic ERCP, were administered by trained registered nurses under endoscopist supervision. Primary outcome measures were the total dose of propofol and sedative-related complications, including hypoxia and hypotension. Secondary outcome measures were recovery time and sedation satisfaction of the endoscopist, nurses, and patients.

RESULTS

There was no significant difference in the rate of hypoxia, but there was a statistical trend (EX-FIX group; n = 4, 7.55%, control group; n = 6, 11.53%, P = 0.06). The mean total dose of propofol was lower in the EZ-FIX group than in the non-EZ-FIX group (89.43 ± 49.8 mg vs 112.4 ± 53.8 mg, P = 0.025). In addition, the EZ-FIX group had a shorter mean recovery time (11.23 ± 4.61 mg vs 14.96 ± 5.12 mg, P < 0.001). Sedation satisfaction of the endoscopist and nurses was higher in the EX-FIX group than in the non-EZ-FIX group. Technical success rates of the procedure were 96.23% and 96.15%, respectively (P = 0.856). Procedure-related complications did not differ by group (11.32% vs 13.46%, respectively, P = 0.735).

CONCLUSION

Using EZ-FIX reduced the total dose of propofol and the recovery time, and increased the satisfaction of the endoscopist and nurses.

Usefulness of the thread-traction method in esophageal endoscopic submucosal dissection: randomized controlled trial

BACKGROUND AND AIM

To assess the usefulness of the thread-traction method (TT method) in esophageal endoscopic submucosal dissection (ESD).

METHODS

A total of 40 lesions that were scheduled to be treated by esophageal ESD were included in the study. The TT method was used for 20 lesions (group TT) and conventional ESD was used for 20 lesions (group C) after randomization. The hook-knife method was used in all cases. In group TT, after circumferential mucosal incision, a clip with thread was attached to the oral edge of the lesion.

RESULTS

ESD was carried out in all cases. Effective countertraction was created by the TT method, and it was possible to carry out an efficient dissection operation. Significant shortening of dissection time was achieved in group TT compared with group C (19.8 min vs 31.8 min, P = 0.044). Mean number of local injections during dissection was significantly less in group TT compared with that in group C (0.6 times vs 2.2 times, P < 0.001). As for the amount of local injection, group TT required significantly less compared with group C (2.6 mL vs 7.5 mL, P < 0.01). No complications were encountered.

CONCLUSION

The TT method in esophageal ESD was safe and contributed to shortening of dissection time. The TT method is expected to become widespread as a safe and useful procedure.

Non-anesthesiologist administrated propofol (NAAP) during endoscopic submucosal dissection for elderly patients with early gastric cancer

BACKGROUND

Propofol is rapidly increasing in use in many countries because endoscopists and patients report greater satisfaction with propofol than with conventional sedatives. However, propofol infusion during lengthy endoscopic procedures in elderly patients is still controversial. We investigated the safety of gastroenterologist-guided propofol sedation in elderly patients who underwent gastric endoscopic submucosal dissection (ESD) at a single center.

METHODS

We reviewed 121 medical records of patients who underwent gastric ESD. We compared retrospectively the details of propofol usage, hemodynamics, and re-sedation in the elderly group to those in a younger group.

RESULTS

No significant differences in patients' baseline characteristic including ASA classification between elderly and younger groups were shown. The average maintenance dose and total dose of propofol infusion could be similarly administrated in both groups. Seven adverse events (5.8 %) occurred at the time of propofol bolus injection. Although 3 cases (2.5 %) of hypotension (systolic blood pressure <80 mmHg), 8 cases (6.6 %) of desaturation (blood oxygen saturation <90 %) and 1 case (0.8 %) of bradycardia (pulse rate <40) were found during the maintenance of propofol infusion, there were no statistically significant differences in the elderly and younger groups. All events were immediately resolved without any intervention. No patients developed a re-sedated condition.

CONCLUSION

Gastroenterologist-guided propofol sedation during gastric ESD may be acceptable even in the elderly with ASA classification I/II under careful monitoring of vital signs and oxygen saturation.

Evaluation of Pharyngeal Function between No Bolus and Bolus Propofol Induced Sedation for Advanced Upper Endoscopy

This study aimed to assess pharyngeal function between no bolus and bolus propofol induced sedation during gastric endoscopic submucosal dissection. A retrospective study was conducted involving consecutive gastric cancer patients. Patients in the no bolus group received a 3 mg/kg/h maintenance dose of propofol after the initiation of sedation without bolus injection. All patients in the bolus group received the same maintenance dose of propofol with bolus 0.5 mg/kg propofol injection. Pharyngeal functions were evaluated endoscopically for the first 5 min following the initial administration of propofol. Fourteen patients received no bolus propofol induction and 13 received bolus propofol induction. Motionless vocal cords were observed in 2 patients (14%) in the no bolus group and 3 (23%) in the bolus group. Trachea cartilage was not observed in the no bolus group but was apparent in 6 patients (46%) in the bolus group (P < 0.01). Scope stimulated pharyngeal reflex was observed in 11 patients (79%) in the no bolus group and in 3 (23%) in the bolus group (P < 0.01). Propofol induced sedation without bolus administration preserves pharyngeal function and may constitute a safer sedation method than with bolus.

Endoscopist-directed propofol: pros and cons

Concerns about the safety of endoscopist-directed propofol (EDP) have been voiced that propofol should be given only by healthcare professionals trained in the administration of general anesthesia. Here we discuss the safety and drawbacks of EDP for routine endoscopic procedures. Currently, both diagnostic and therapeutic endoscopy are well tolerated and accepted by both patients and endoscopists due to the application of sedation in most clinics worldwide. Accordingly, propofol use is increasing in many countries. It is crucial for endoscopists to be very familiar with the use of propofol or a combination of drugs. However, the controversy regarding the administration of sedation by an endoscopist or an anesthesiologist continues. Until now, there have been no randomized control trials comparing sedation induced by propofol administered by an endoscopist or by an anesthesiologist. It might be difficult to perform this kind of study. For the convenience and safety of sedative endoscopy, it would be important that EDP be generally applied to endoscopic procedures, and for more safety, an anesthesiologist may automatically take care of particular patients at high risk of suffering from propofol side effects.

Preparation and patient evaluation for safe gastrointestinal endoscopy

Patient evaluation and preparation is the first and mandatory step to ensure safety and quality of endoscopic procedures. This begins and ends with identifying the patient, procedure type, and indication. Every patient has the right to be fully informed about risks and benefits of what is to be performed on them, and the medical personnel should respect the decision made by the patients. Thoroughly performed history taking and physical examination will guide the endoscopists to better stratify risk and plan sedation. Special attention should be given to higher-risk patients with higher-risk condition undergoing higher-risk procedures. Making preparations to monitor the patients and being ready to handle emergency situations throughout the endoscopic procedure are sine qua non to warrant safe endoscopy.

Recommended sedation and intraprocedural monitoring for gastric endoscopic submucosal dissection

Endoscopic submucosal dissection is associated with a longer treatment time and a higher risk of patient discomfort than conventional procedures. Adequate, safe sedation is therefore essential. Sedation can cause adverse effects such as hypoxemia and hypotension, requiring continuous intraoperative and postoperative monitoring of blood pressure, use of the electrocardiogram, and arterial blood oxygen saturation by pulse oximetry. A physician and a nurse solely responsible for sedating and monitoring the patient should be present during treatment.A combination of benzodiazepines and analgesics are generally used for sedation, but new sedatives such as propofol and dexmedetomidine hydrochloride are expected to be useful agents. Endoscopists should become more familiar with sedatives, analgesics, and emergency procedures in the future.

Cocktail sedation containing propofol versus conventional sedation for ERCP: a prospective, randomized controlled study

Background

ERCP practically requires moderate to deep sedation controlled by a combination of benzodiazepine and opiod. Propofol as a sole agent may cause oversedation. A combination (cocktail) of infused propofol, meperidine, and midazolam can reduce the dosage of propofol and we hypothesized that it might decrease the risk of oversedation. We prospectively compare the efficacy, recovery time, patient satisfactory, and side effects between cocktail and conventional sedations in patients undergoing ERCP.

Methods

ERCP patients were randomized into 2 groups; the cocktail group (n = 103) and the controls (n = 102). For induction, a combination of 25 mg of meperidine and 2.5 mg of midazolam were administered in both groups. In the cocktail group, a bolus dose of propofol 1 mg/kg was administered and continuously infused. In the controls, 25 mg of meperidine or 2.5 mg/kg of midazolam were titrated to maintain the level of sedation.

Results

In the cocktail group, the average administration rate of propofol was 6.2 mg/kg/hr. In the control group; average weight base dosage of meperidine and midazolam were 1.03 mg/kg and 0.12 mg/kg, respectively. Recovery times and patients’ satisfaction scores in the cocktail and control groups were 9.67 minutes and 12.89 minutes (P = 0.045), 93.1and 87.6 (P <0.001), respectively. Desaturation rates in the cocktail and conventional groups were 58.3% and 31.4% (P <0.001), respectively. All desaturations were corrected with temporary oxygen supplementation without the need for scope removal.

Conclusions

Cocktail sedation containing propofol provides faster recovery time and better patients’ satisfaction for patients undergoing ERCP. However, mild degree of desaturation may still develop.

Trial registration

ClinicalTrials.gov, NCT01540084

Anesthetic management for small bowel enteroscopy in a World Gastroenterology Organization Endoscopy Training Center

AIM

To study the anesthetic management of patients undergoing small bowel enteroscopy in the World Gastroenterology Organization (WGO) Endoscopy Training Center in Thailand.

METHODS

Patients who underwent small bowel enteroscopy during the period of March 2005 to March 2011 in Siriraj Gastrointestinal Endoscopy Center were retrospectively analyzed. The patients' characteristics, pre-anesthetic problems, anesthetic techniques, anesthetic agents, anesthetic time, type and route of procedure and anesthesia-related complications were assessed.

RESULTS

One hundred and forty-four patients underwent this procedure during the study period. The mean age of the patients was 57.6 ± 17.2 years, and most were American Society of Anesthesiologists (ASA) class II (53.2%). Indications for this procedure were gastrointestinal bleeding (59.7%), chronic diarrhea (14.3%), protein losing enteropathy (2.6%) and others (23.4%). Hematologic disease, hypertension, heart disease and electrolyte imbalance were the most common pre-anesthetic problems. General anesthesia with endotracheal tube was the anesthetic technique mainly employed (50.6%). The main anesthetic agents administered were fentanyl, propofol and midazolam. The mean anesthetic time was 94.0 ± 50.5 min. Single balloon and oral (antegrade) intubation was the most common type and route of enteroscopy. The anesthesia-related complication rate was relatively high. The overall and cardiovascular-related complication rates including hypotension in the older patient group (aged ≥ 60 years old) were significantly higher than those in the younger group.

CONCLUSION

During anesthetic management for small bowel enteroscopy, special techniques and drugs are not routinely required. However, for safety reasons anesthetic personnel need to optimize the patient's condition.

Incidence of propofol injection pain and effect of lidocaine pretreatment during upper gastrointestinal endoscopy

BACKGROUND/AIMS

Propofol has been used in the past for sedation in upper gastrointestinal (GI) endoscopic procedures. This study aimed to measure the incidence of propofol injection pain and evaluate the effect of lidocaine on pain caused during sedative upper GI endoscopic examinations.

METHODS

Subjects scheduled to undergo sedative diagnostic upper GI endoscopy were randomly assigned to lidocaine and placebo groups. Pretreatment with a bolus of 1% lidocaine 2 ml or normal saline 2 ml into the largest dorsal vein of the non-dominant hand was followed by propofol administration. Pain intensity was estimated by an examiner blinded to the group assignment using a four-point verbal rating scale. A score of 1-3 was regarded as pain.

RESULTS

A total of 121 patients (males, 69; age, 58.6 ± 12.1 years) completed the study; 61 and 60 subjects were randomly assigned to the lidocaine and placebo groups, respectively. The incidence of pain during upper GI endoscopy was 60%. The lidocaine group showed a lower incidence of pain than the placebo group (37.7% vs. 60.0%, P = 0.018). The lidocaine group perceived significantly less pain than the placebo group (median pain score, 0 vs. 1, P = 0.008). Only lidocaine pretreatment was an independently associated factor against pain perception (OR, 0.380; 95% CI, 0.177-0.815; P = 0.013).

CONCLUSIONS

Pretreatment using lidocaine was found to be effective in reducing propofol injection-induced pain. However, its usefulness for GI endoscopic procedures in daily clinical practice needs further evaluation because of the low intensity of pain.

Sedation and monitoring for gastrointestinal endoscopy: A nationwide web survey in Italy

BACKGROUND

Best strategy of sedation/analgesia in gastrointestinal (GI) endoscopy is still debated.

AIMS OF THE STUDY

To evaluate sedation and monitoring practice among Italian gastroenterologists and to assess their opinion about non-anaesthesiologist propofol administration.

METHODS

A 19-item survey was mailed to all 1192 members of the Italian Society of Digestive Endoscopy (SIED). For each respondent were recorded demographic data, medical specialty, years of practise and practise setting.

RESULTS

A total of 494 SIED members returned questionnaires, representing a response rate of 41.4%. The most employed sedation pattern was benzodiazepines for oesophagogastroduodenoscopies (EGDS) in 50.8% of procedures, benzodiazepines plus opioids for colonoscopy and enteroscopy in 39.5% and 35.3% of procedures, respectively, propofol for endoscopic retrograde colangiopancreatography (ERCP) and endoscopic ultrasound (EUS) in 42.3% and 35.6% of procedures, respectively. With regard to propofol use, 66% respondents stated that propofol was exclusively administered by anaesthesiologists. However, 76.9% respondents would consider non-anaesthesiologist propofol administration after appropriate training. Pulse oximetry is the most employed system for procedural monitoring. Supplemental O(2) is routinely administered by 39.3% respondents.

CONCLUSIONS

Use of sedation has become a standard practise during GI endoscopy in Italy. Pattern varies for each type of procedure. Pulse oximetry is the most employed system of monitoring. Administration of propofol is still directed by anaesthesiologists.

How best to approach endoscopic sedation?

Sedation is the drug-induced reduction of a patient's consciousness. The aim of sedation in endoscopic procedures is to increase the patient's comfort and to improve endoscopic performance, especially in therapeutic procedures. The most commonly used sedation regimen for conscious sedation in gastrointestinal endoscopy is still the combination of benzodiazepines with opioids. However, the use of propofol has increased enormously in the past decade and several studies show advantages of propofol over the traditional regimes in terms of faster recovery time. It is important to be aware that the complication rate of endoscopies increases when sedation is used; therefore, a thorough risk evaluation before the procedure and monitoring during the procedure must be performed. In addition, properly trained staff and emergency equipment should be available. The best approach to sedation in endoscopy is to choose a sedation regimen for the individual patient, tailored according to the clinical risk assessment and the anxiety level of the patient, as well as to the type of planned endoscopic procedure.

Propofol-based deep sedation for endoscopic retrograde cholangiopancreatography procedure in sick elderly patients in a developing country

INTRODUCTION

The aim of this study was to evaluate and compare the clinical efficacy of propofol-based deep sedation (PBDS) for endoscopic retrograde cholangiopancreatography (ERCP) procedure in sick (American Society of Anesthesiologists [ASA] physical status III-IV) and nonsick (ASA physical status I-II) elderly patients in a teaching hospital in Thailand.

METHODS

We undertook a retrospective review of the anesthesia or sedation service records of elderly patients who underwent ERCP procedures from October 2007 to September 2008. All patients were classified into two groups according to the ASA physical status. In group A, the patients had ASA physical status I-II, while in group B, the patients had ASA physical status III-IV. The primary outcome variable of the study was the successful completion of the procedure. The secondary outcome variables were sedation-related adverse events during and immediately after the procedure.

RESULTS

There were 158 elderly patients who underwent ERCP procedure by using PBDS during the study period. Of these, 109 patients were in group A and 49 patients were in group B. There were no significant differences in age, gender, weight, duration of ERCP, indication of procedure, and the mean dose of fentanyl, propofol, and midazolam between the two groups. All patients in both groups successfully completed the procedure except eight patients in group A and three patients in group B (P = 0.781). Overall, respiratory and cardiovascular adverse events in both groups were not significantly different. All adverse events were easily treated, with no adverse sequelae.

CONCLUSION

In the setting of a developing country, PBDS for ERCP procedure in sick elderly patients by trained anesthetic personnel with appropriate monitoring was safe and effective. The clinical efficacy of this technique in sick elderly patients was not different or worse than in nonsick elderly patients. Serious adverse events were rare in our population.

Efficacy of propofol sedation for endoscopic submucosal dissection (ESD): assessment with prospective data collection

OBJECTIVE

The indications for endoscopic treatment in early stage cancer of the digestive tract are expanding with the emergence and technical development of endoscopic submucosal dissection (ESD). ESD requires longer term stable sedation than conventional endoscopic procedures due to the necessity of meticulous control of the devices during the procedure. Propofol has a very short half-life and can be administered continuously, which is advantageous for long-term sedation. Propofol, thus, is likely to be useful for sedation during ESD.

METHODS

Fifty consecutive patients who underwent ESD for early gastric cancer with propofol sedation (Group P) and those with midazolam sedation (Group M) were included in this study. Cardiorespiratory suppression rate and the condition of arousal were compared between the groups. A questionnaire survey on the satisfaction of endoscopists, anesthesiologists, endoscopy nurses, and ward nurses with the use of propofol was also carried out.

RESULTS

Respiratory suppression was observed in 50% in Group M and in 20% in Group P (p<0.05). Hypotension was seen in 14% and 36% in Groups M and P, respectively (p<0.05). No sedation-related complications were encountered in either of the groups. Arousal rates 1 hour and 3 hours after the procedure were 23% and 60% in group M and 86% and 100% in Group P (p<0.05). As for the questionnaire survey, most respondents, in particular the ward nurses, supported the use of propofol.

CONCLUSION

Our data suggest that propofol is safe and useful during ESD as compared with midazolam.

Sedation during upper GI endoscopy in cirrhotic outpatients: a randomized, controlled trial comparing propofol and fentanyl with midazolam and fentanyl

BACKGROUND

Patients with liver cirrhosis frequently undergo diagnostic or therapeutic upper GI endoscopy (UGIE), and the liver disease might impair the metabolism of drugs usually administered for sedation.

OBJECTIVE AND SETTING

To compare sedation with a combination of propofol plus fentanyl and midazolam plus fentanyl in cirrhotic outpatients undergoing UGIE.

DESIGN

A prospective, randomized, controlled trial was conducted between February 2008 and February 2009.

MAIN OUTCOMES MEASUREMENTS

Efficacy (proportion of complete procedures using the initial proposed sedation scheme), safety (occurrence of sedation-related complications), and recovery time were measured.

RESULTS

Two hundred ten cirrhotic patients referred for UGIE were randomized to 2 groups: midazolam group (0.05 mg/kg plus fentanyl 50 μg intravenously) or propofol group (0.25 mg/kg plus fentanyl 50 μg intravenously). There were no differences between groups regarding age, sex, weight, etiology of cirrhosis, and Child-Pugh or American Society of Anesthesiologists classification. Sedation with propofol was more efficacious (100% vs 88.2%; P < .001) and had a shorter recovery time than sedation with midazolam (16.23 ± 6.84 minutes and 27.40 ± 17.19 minutes, respectively; P < .001). Complication rates were similar in both groups (14% vs 7.3%; P = .172).

LIMITATIONS

Single-blind study; sample size.

CONCLUSION

Both sedation schemes were safe in this setting. Sedation with propofol plus fentanyl was more efficacious with a shorter recovery time compared with midazolam plus fentanyl. Therefore, the former scheme is an alternative when sedating cirrhotic patients undergoing UGIE.

Propofol-Based Sedation Does Not Increase Rate of Complication during Percutaneous Endoscopic Gastrostomy Procedure

Objectives. To evaluate and compare the complication rate of sedation with or without propofol regimen for percutaneous endoscopic gastrostomy (PEG) in a hospital in Thailand. Subjects and Methods. A total of 198 patients underwent PEG procedures by using intravenous sedation (IVS) from Siriraj Hospital, Thailand from August 2006 to January 2009. The primary outcome variable was the overall complication rate. The secondary outcome variables were sedation and procedure related complications, and mortality rate. Results. After matching ASA physical status and indications of procedure, there were 92 PEG procedures in propofol based sedation group (A) and 20 PEG procedures in non-propofol based sedation group (B). All sedation was given by residents or anesthetic nurses directly supervised by staff anesthesiologist in the endoscopy room. There were no significant differences in patients' characteristics, sedation time, indication, complications, anesthetic personnel and mortality rate between the two groups. All complications were easily treated, with no adverse sequelae. Mean dose of fentanyl and midazolam in group A was significantly lower than in group B. Conclusion. Propofol-based sedation does not increase rate of complication during PEG procedure. Additionally, IVS of PEG procedure is relatively safe and effective when performed by physicians in training. Serious complications are none.

Safe and effective sedation in endoscopic submucosal dissection for early gastric cancer: a randomized comparison between propofol continuous infusion and intermittent midazolam injection

PURPOSE

Endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) generally takes longer to perform than conventional endoscopy and usually requires moderate/deep sedation with close surveillance for patient safety. The aim of this study was to compare the safety profiles and recovery scores propofol continuous infusion and intermittent midazolam (MDZ) injection as sedation for ESD.

METHODS

Sixty EGC patients scheduled for ESDs between August and November 2008 were included in this prospective study and randomly divided into a propofol (P-group, 28 patients) and an MDZ (M-group, 32 patients) group using an odd-even system. The P-group received a 0.8 mg/kg induction dose and a 3 mg/kg/h maintenance dose of 1% propofol using an infusion pump. All patients received 15 mg pentazocine at the start of the ESD and at 60-min intervals thereafter. We recorded and analyzed blood pressure, oxygen saturation and heart rate during and following the procedure and evaluated post-anesthetic recovery scores (PARS) and subsequent alertness scores.

RESULTS

The propofol maintenance and total dose amounts were (mean +/- standard deviation) 3.7 +/- 0.6 mg/kg/h and 395 +/- 202 mg, respectively. The mean total dose of MDZ was 10.3 +/- 4.5 mg. There were no cases of de-saturation <90% or hypotension <80 mmHg in either group. Alertness scores 15 and 60 min after the procedures were significantly higher in the P-group (4.9/4.9) than in the M-group (4.6/4.5; p < 0.05). The mean PARS 15 and 30 min after the ESDs were significantly higher in the P-group (9.6/9.9) than in the M-group (8.6/9.2; p < 0.01).

CONCLUSION

Based on our results, the ESDs for EGC performed under sedation using propofol continuous infusion were as safe as those performed using intermittent MDZ injection. Propofol-treated patients had a quicker recovery profile than those treated with MDZ. We therefore recommend the use of continuous propofol sedation for ESD, but sedation guidelines for the use of propofol are necessary.

A literature review of the safety and efficacy of using propofol for sedation in endoscopy

A 2007 survey of members of the Society of Gastroenterology Nurses and Associates identified a need for more evidence regarding sedation medications including propofol. Therefore, the Cochrane Database of Systematic Reviews, Cochrane Database of Randomized Clinical Trials, MEDLINE, CINAHL, EMBASE, and the National Guideline Clearinghouse (http://www.guideline.gov) databases were individually searched using the term propofol, limited to human, English, 2000-2009, review articles, and randomized clinical trials. A total of 46 resources contributed to this review, with emphasis on 16 studies ranging from retrospective chart reviews to double-blind, randomized controlled trials. Nonanesthesia personnel-administered propofol, including that administered by specially trained nurses under the supervision of an endoscopist, appears to be safe with minor, easily resolved, adverse events occurring in less than 1% of patients. These minor adverse events included four studies reporting hypoxemia requiring occasional intervention, three studies reporting hypotension, and two studies reporting bradycardia. No patients required tracheal intubation, and no deaths were reported.

Sedation and analgesia in gastrointestinal endoscopy: What’s new?

Various types of sedation and analgesia technique have been used during gastrointestinal endoscopy procedures. The best methods for analgesia and sedation during gastrointestinal endoscopy are still debated. Providing an adequate regimen of sedation/analgesia might be considered an art, influencing several aspects of endoscopic procedures: the quality of the examination, the patient’s cooperation and the patient’s and physician’s satisfaction with the sedation. The properties of a model sedative agent for endoscopy would include rapid onset and offset of action, analgesic and anxiolytic effects, ease of titration to desired level of sedation, rapid recovery and an excellent safety profile. Therefore there is an impulse for development of new approaches to endoscopic sedation. This article provides an update on the methods of sedation today available and future directions in endoscopic sedation.

Estudo comparativo de eficácia e segurança entre propofol e midazolam durante sedação para colonoscopia

OBJETIVO: Comparar a segurança e a eficácia do propofol com a do midazolam na sedação profunda durante colonoscopias. MÉTODOS: Sessenta e seis pacientes foram submetidos à colonoscopias e estudados prospectivamente. Um total de 50 pacientes recebeu 3,25 mg.kg-1 de peso de propofol. No grupo controle de 16 pacientes foi administrado 2,05 mg.kg-1 de peso de midazolam. A dose de manutenção foi titulada de acordo com a necessidade. Os parâmetros cardiovasculares e respiratórios observados foram a saturação de oxigênio, pressão arterial sistólica e diastólica e frequência cardíaca. Após o procedimento foi realizado um questionário sobre intercorrências como dor, desconforto e satisfação após a colonoscopia, utilizando uma escala visual de zero a dez. Foi aplicado o teste t de Student para a análise estatística. RESULTADOS: A amostra foi similar com relação às variáveis idade, peso, sexo e condição física. Houve diferença estatística significativa para os parâmetros saturação de oxigênio do sangue e pressão arterial sistólica entre os dois grupos. Não houve diferença estatística significativa para os parâmetros pressão arterial diastólica e pulso. Apesar das diferenças nos parâmetros cardiovasculares e respiratórios, não houve repercussões hemodinâmicas significativas. Não houve diferença estatística no parâmetro dor e satisfação. Os pacientes que apresentaram agitação (25%) no grupo midazolam, relataram mais desconforto (p=0,038). CONCLUSÃO: As variações nos parâmetros cardiovasculares e respiratórios, mesmo com diferenças significativas entre os grupos, não causaram repercussões clínicas significativas nos dois grupos, caracterizando a segurança na sedação profunda. A sedação com midazolam ou propofol não está associada a níveis de dor e satisfação diferentes entre os dois grupos. O grupo midazolan referiu significativamente mais desconforto que o grupo propofol.