Utility of droperidol for conscious sedation in gastrointestinal endoscopic procedures

Administration of additional analgesics can decrease the incidence of paradoxical reactions in patients under benzodiazepine-induced sedation during endoscopic transpapillary procedures: prospective randomized controlled trial

AIM

The aim of the present study was to evaluate the efficacy and safety of giving pentazocine as an analgesic with benzodiazepine during endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

The paradoxical reactions (PR) incidence was evaluated as an indicator of usefulness. Transcutaneous arterial carbon dioxide tension (PtcCO(2) ) was evaluated as an indicator of safety. A total of 160 patients were enrolled. Subjects were randomly divided into two groups; group 1 sedated with midazolam only and group 2 sedated both with midazolam and pentazocine (7.5 mg).

RESULTS

The initial dosage introduced sedation before procedure was significantly higher in group 1. The occurrence rate of PR's in group 1 was significantly higher compared to that in group 2 (P = 0.0108). Although maximum PtcCO(2) observed during sedation did not differ between the two groups (48.7 ± 7.2, 50.3 ± 7.6 mmHg, respectively),maximum PtcCO(2) during the first 15 min after the start of sedation was significantly higher in group 2 than in group 1 (P = 0.0294). In multivariate analysis, procedure duration (odds ratio [OR] = 1.048) and midazolam dose (OR = 1.221) were predictive factors for PR.

CONCLUSION

The administration of pentazocine is significantly reduced the incidence of PR's in patients under midazolam induced sedation during ERCP.

Increase of paradoxical excitement response during propofol-induced sedation in hazardous and harmful alcohol drinkers

BACKGROUND

Paradoxical excitement response during sedation consists of loss of affective control and abnormal movements. Chronic alcohol abuse has been proposed as a predisposing factor despite lack of supporting evidence. Because alcohol and propofol have a common site of action, we postulated that paradoxical excitement responses during propofol-induced sedation occur more frequently in hazardous and harmful alcohol drinkers than in social or non-drinkers.

METHODS

One hundred and ninety patients undergoing orthopaedic knee joint surgery were enrolled in this prospective and observational study. Subjects were divided into Group HD (hazardous and harmful drinkers) or Group NHD (no hazardous drinkers) according to the alcohol use disorder identification test (AUDIT). In study 1, propofol infusion was adjusted to achieve the bispectral index at 70-80 using target-controlled infusion. In study 2, the target concentration of propofol was fixed at 0.8 (study 2/Low) or 1.4 μg ml(-1) (study 2/High). Paradoxical excitement responses were categorized by intensity into mild, moderate, or severe.

RESULTS

The overall incidence of paradoxical excitement response was higher in Group HD than in Group NHD in study 1 (71.4% vs 43.8%; P=0.022) and study 2/High (70.0% vs 34.5%; P=0.006) but not in study 2/Low. The incidence of moderate-to-severe response was significantly higher in Group HD of study 1 (28.6% vs 3.1%; P=0.0005) and study 2/High (23.3% vs 3.4%; P=0.029) with no difference in study 2/Low. Severe excitement response occurred only in Group HD of study 1 and study 2/High.

CONCLUSIONS

Paradoxical excitement occurred more frequently and severely in hazardous and harmful alcohol drinkers than in social drinkers during propofol-induced moderate-to-deep sedation, but not during light sedation.

The difficult-to-sedate patient in the endoscopy suite

More than 20 million endoscopic procedures are performed in the United States annually. More than 98% of these endoscopies are performed with sedation. This includes both diagnostic and therapeutic procedures. Sedation reduces a patient's anxiety and discomfort, often improving their satisfaction with the procedure. Sedation creates a relaxed patient and a relaxed procedure environment allowing for a successful endoscopic examination.

Prospective evaluation of adjunctive ketamine on sphincter of Oddi motility in humans

BACKGROUND AND AIM

Performance of sphincter of Oddi manometry (SOM) at endoscopic retrograde cholangio-pancreatogram (ERCP) is technically demanding and requires that the patient be well sedated. Droperidol is used as an adjunctive agent in patients who are difficult to sedate. Concerns regarding the safety profile of droperidol and its effects on sphincter of Oddi motility has resulted in the search for other potent sedative agents that do not influence SOM readings. Ketamine, a dissociative anesthetic, is increasingly being used as an adjunctive agent for conscious sedation. This study evaluates the effect of ketamine on sphincter of Oddi motility when used as an adjunctive sedative agent during ERCP.

PATIENTS AND METHODS

This is a prospective study of 30 consecutive patients undergoing SOM who were difficult to sedate and required adjunctive ketamine. Manometry was initially performed with intravenous administration of diazepam plus meperidine or a combination of diazepam plus meperidine and midazolam. After the initial two pull-throughs, 20 mg of ketamine was administered intravenously and the measurements were repeated 5 min later.

RESULTS

The basal pressures of the biliary sphincter and of the pancreatic sphincter were not significantly altered by ketamine. By using a definition for sphincter of Oddi dysfunction of a basal pressure >or=40 mmHg, concordance (normal vs abnormal) between the basal sphincter pressure before and after ketamine was seen in 28 patients (93%). Ketamine also did not lead to a difference in phasic wave amplitude, duration, or frequency. No complication was associated with ketamine use.

CONCLUSIONS

Ketamine at 20 mg did not significantly affect SOM parameters. Further studies are required to confirm our preliminary findings before ketamine can be added to the armamentarium of agents used for performance of sphincter of Oddi manometry.

A national study of cardiopulmonary unplanned events after GI endoscopy

BACKGROUND

Cardiopulmonary unplanned events (CUE) related to conscious sedation constitute a major proportion of GI endoscopy-associated complications.

OBJECTIVES

Our purpose was to study the incidence of CUE during GI endoscopy and to determine factors that may predict CUE.

DESIGN

Retrospective CORI (Clinical Outcomes Research Initiative) database review.

PATIENTS

Undergoing GI endoscopy under conscious sedation.

MAIN OUTCOME MEASUREMENT

CUE associated with GI endoscopy.

RESULTS

Data on 324,737 unique procedures (EGD, 140,692; colonoscopy, 174,255; ERCP, 6092; and EUS, 3698) performed with the patient under conscious sedation were analyzed. Unplanned events were reported in 1.4% of procedures; 0.9% were associated with CUE. Rates of CUE with EGD, colonoscopy, ERCP, and EUS were 0.6%, 1.1%, 2.1%, and 0.9%, respectively. Multiple logistic regression revealed patient age (odds ratio [OR] 1.02, 95% CI 1.01-1.02) and ASA class were significant predictors of CUE (OR compared with ASA I: ASA II 1.05, 95% CI 0.95-1.16; ASA III 1.8, 95% CI 1.6-2.0, ASA IV 3.2, 95% CI 2.5-4.1, ASA V 7.5; 95% CI 3.2-17.6). Inpatient procedures were associated with higher CUE (OR 1.5, 95% CI 1.3-1.7). Compared with universities, nonuniversity sites (OR 1.2, 95% CI 1.1-1.4) and Veterans Administration Medical Centers (OR 1.4, 95% CI 1.2-1.5) had significantly higher CUE. Use of supplemental oxygen during a procedure was associated with significantly more CUE (OR 1.2, 95% CI 1.1-1.3). Involvement of a trainee with a procedure was also associated with higher CUE (OR 1.3, 95% CI 1.1-1.4).

LIMITATIONS

Retrospective review of data entered voluntarily by endoscopists not trained on CORI data entry.

CONCLUSIONS

During GI endoscopy with conscious sedation, patient's age, higher ASA grade, inpatient status, trainee participation, and routine use of oxygen are associated with a higher incidence of CUE.

Prospective randomized trial evaluating ketamine for advanced endoscopic procedures in difficult to sedate patients

BACKGROUND

Adequate patient sedation is mandatory for advanced endoscopic procedures such as ERCP and EUS.

AIM

To evaluate the effectiveness and safety of ketamine in difficult to sedate patients undergoing advanced endoscopic procedures.

METHODS

This was a prospective, randomized trial of all patients undergoing ERCP or EUS who were not adequately sedated despite administration of meperidine 50 mg, midazolam 5 mg and diazepam 5 mg. Patients during endoscopy were then randomized to receive either intravenous ketamine (20 mg) every 5 min or continue to receive standard sedation using meperidine and diazepam.

RESULTS

Of 175 patients, 82 were randomized to receive ketamine and 93 standard sedatives. Compared with standard sedation, qualitative physician rating (P < 0.0001) and depth of sedation (P < 0.001) were superior in the ketamine group with shorter recovery times (P < 0.0001). Both patient discomfort and sedation-related technical difficulty were significantly less among patients randomized to receive ketamine (P < 0.0001). More patients in the standard sedation group were crossed-over to the ketamine group due to sedation failure (35.5 vs. 3.7%, P < 0.0001). Nine patients who received ketamine, developed adverse events that were managed conservatively.

CONCLUSIONS

Ketamine is a useful adjunct to conscious sedation in patients who are difficult to sedate. Its use Results in better quality and depth of sedation with shorter recovery times than patients sedated using benzodiazepines and meperidine alone. Further prospective studies evaluating the effectiveness and safety of ketamine for endoscopic sedation are needed.

Droperidol, when used for sedation during ERCP, may prolong the QT interval

BACKGROUND

Droperidol is a known effective adjunctive agent for sedation/analgesia during endoscopic procedures, particularly in patients who are difficult to sedate with narcotics and benzodiazepines alone. However, the Food and Drug Administration (FDA) warning about potential droperidol-related fatal cardiac arrhythmias, issued in December 2001, led to concern about its safety in current clinical practice.

OBJECTIVE

In this study, we evaluated the effects of droperidol on the Bazett's corrected QT interval (QTcB) administered to patients undergoing ERCP and frequency of cardiac arrhythmias.

DESIGN

We retrospectively reviewed the medical records of patients who, at our institute, underwent ERCP while under sedation/analgesia and who received droperidol. Our protocol for patients who are considered to be candidates for droperidol use includes obtaining an ECG before and 1 to 3 hours after the procedure.

RESULTS

From April 2002 to October 2004, 6292 ERCPs were performed, of which 3113 patients with normal baseline QTcB (2001 women, 1112 men) received droperidol. Mean dosages were 4.3 mg (range, 1.25-10 mg) in women and 4.5 mg (range, 1.25-13.75 mg) in men. A total of 233 patients (7.48%; 133 women, 100 men) developed QTcB prolongation. Mean increases of the QTcB above the upper limit of normal were 16 milliseconds in women (range, 1-194 milliseconds) and 22 milliseconds in men (range, 1-310 milliseconds). Of these, 15 patients (0.48%; 8 women, 7 men) had marked prolongation of the QTcB (defined QTcB, >500 milliseconds). No serious dysrhythmias occurred.

CONCLUSIONS

Droperidol at usual doses during sedation/analgesia may precipitate QTcB prolongation above the normal range. However, no QT-related arrhythmias were noted in this study. Clinically significant cardiac events are probably rare with droperidol, despite documented QTcB effects. Baseline electrocardiogram for excluding patients with prolonged baseline QTcB and 1 to 3 hours afterward monitoring appears adequate when using droperidol. The study is still too small to detect very infrequent arrhythmia events.

Diphenhydramine as an adjunct to sedation for colonoscopy: a double-blind randomized, placebo-controlled study

BACKGROUND

Intravenous benzodiazepines in combination with opiates are used to achieve moderate sedation for colonoscopy. Although effective, these agents have potential adverse effects, such as respiratory depression and hypotension. Diphenhydramine hydrochloride possesses central nervous system depressant effects that theoretically could provide a synergistic effect for sedating patients.

OBJECTIVE

The objective was to assess the efficacy of adding diphenhydramine hydrochloride as an adjunct to improve sedation and to reduce the amount of standard sedatives used during colonoscopy.

DESIGN

We conducted a prospective, randomized, double-blind, placebo-controlled study.

SETTING

The study was conducted in a university hospital with an active GI fellowship training program.

PATIENTS

The study group comprised 270 patients undergoing screening/diagnostic/therapeutic colonoscopy were enrolled.

INTERVENTIONS

Patients were randomized to receive either 50 mg of diphenhydramine or placebo, given intravenously 3 minutes before starting conscious sedation with intravenous midazolam and meperidine.

MAIN OUTCOME MEASUREMENTS

The main outcome measure was anesthetic effect as assessed by the endoscopy team and by the patient; quantity of adjunctive sedatives to achieve adequate sedation.

RESULTS

Of 270 patients, data were analyzed for 258 patients, with 130 patients in the diphenhydramine group and 128 patients in the placebo group. There was a 10.1% reduction in meperidine usage and 13.7% reduction in midazolam usage in favor of the diphenhydramine group. The mean evaluation scores as judged by the faculty, the fellows, and the nurses were statistically significant in favor of the diphenhydramine group. In addition, patient scores for overall sedation and pain level favored the group that received diphenhydramine.

CONCLUSIONS

Intravenous diphenhydramine given before initiation of standard sedation offers a significant benefit to conscious sedation for patients undergoing colonoscopy.

Prospective evaluation of droperidol on sphincter of Oddi motility

BACKGROUND

Droperidol increasingly is used as an effective adjunct for conscious sedation during endoscopic procedures. Given the concern for the effects of narcotics and benzodiazepines on sphincter of Oddi motility, and the potential difficulty in sedating patients undergoing sphincter of Oddi manometry, droperidol could be an ideal agent in this setting.

METHODS

Over a 43-month period, consecutive patients undergoing sphincter of Oddi manometry were studied prospectively. Sphincter of Oddi manometry was performed under general anesthesia in all but 10 patients. Standard retrograde pull-through techniques were used to examine the biliary and/or pancreatic sphincter, depending on the indication for sphincter of Oddi manometry. After the initial two pull-throughs, 5 mg of droperidol were given intravenously and measurements were repeated 5 minutes later.

RESULTS

A total of 55 patients were studied (42 women [76%], 13 men; mean age 43 years). The basal biliary sphincter pressures measured in 35 patients before and after droperidol were, respectively, 56 mm Hg and 48 mm Hg (p = 0.02); the basal pancreatic sphincter pressures measured in 22 patients before and after droperidol were, respectively, 92 mm Hg and 67 mm Hg (p = 0.29). By using a definition for sphincter of Oddi dysfunction of a basal pressure greater than 40 mm Hg, droperidol would have resulted in a change in diagnosis in 5 patients undergoing biliary manometry (one misclassified as sphincter of Oddi dysfunction, 4 misclassified as normal), and 6 patients undergoing pancreatic sphincter manometry (5 misclassified as sphincter of Oddi dysfunction, one misclassified as normal) (total 19% of procedures). No complication was associated with droperidol use.

CONCLUSIONS

Droperidol alters basal sphincter pressures, which in some patients was clinically significant and would have resulted in misclassification. Although safe and well tolerated, droperidol appears to have subtle but clinically significant effects on the sphincter of Oddi.

Effects of droperidol on the pancreatic and biliary sphincters

BACKGROUND

Performance of sphincter of Oddi manometry at ERCP is technically demanding and requires that the patient be well sedated. Droperidol is frequently administered when adequate sedation cannot be achieved with a benzodiazepine and meperidine. This study examined the effects of droperidol on the biliary and pancreatic sphincters.

METHODS

A total of 31 patients were prospectively evaluated by sphincter of Oddi manometry in the conventional retrograde fashion. Manometry was initially performed with intravenous administration of diazepam alone, diazepam plus meperidine or midazolam plus meperidine. Manometry was then repeated 5 minutes after droperidol was administered.

RESULTS

The basal pressure of the biliary sphincter and of the pancreatic sphincter were not significantly altered by droperidol. Concordance (normal vs. abnormal) between the basal sphincter pressure before and after droperidol was seen in 30 patients (97%). Droperidol also did not lead to a difference in phasic wave amplitude, duration, or frequency. Thirteen manometry tracings (42%) were judged as being qualitatively better after droperidol, whereas two (6.5%; </= p 0.001) were qualitatively better before droperidol administration.

CONCLUSIONS

Droperidol does not significantly affect sphincter of Oddi manometric parameters. It appears that it can be added to the armamentarium of agents needed for performance of sphincter of Oddi manometry. However, further study is needed to determine whether recent safety concerns with droperidol use are valid.

Guidelines for conscious sedation and monitoring during gastrointestinal endoscopy

This is one of a series of statements discussing the utilization of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this text. In preparing this guideline, a MEDLINE literature search was performed, and additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When little or no data exist from well-designed prospective trials, emphasis is given to results from large series and reports from recognized experts. Guidelines for appropriate utilization of endoscopy are based on a critical review of the available data and expert consensus. Further controlled clinical studies are needed to clarify aspects of this statement, and revision may be necessary as new data appear. Clinical consideration may justify a course of action at variance to these recommendations.

The role of esophagogastroduodenoscopy in the diagnosis and management of upper gastrointestinal disorders

Esophagogastroduodenoscopy has revolutionized the clinical management of upper gastrointestinal diseases. Millions of EGDs are performed annually in the United States for many indications, such as gastrointestinal bleeding, abdominal pain, dysphagia, or surveillance of premalignant lesions. Esophagogastroduodenoscopy is very safe, with a low risk of serious complications such as perforation, cardiopulmonary arrest, or aspiration pneumonia. It is a highly sensitive and specific diagnostic test, especially when combined with endoscopic biopsy. Esophagogastroduodenoscopy is increasingly being used therapeutically to avoid surgery. New endoscopic technology such as endosonography, endoscopic sewing, and the endoscopic videocapsule will undoubtedly extend the frontiers and increase the indications for endoscopy.

Sedation and analgesia

In the United States sedation and analgesia is the standard of practice when performing upper and lower gastrointestinal endoscopy. Many of these endoscopic procedures are performed in ambulatory endoscopy centers, including ambulatory surgery centers. This article reviews new Joint Commission on Accreditation of Healthcare Organizations standards for sedation and analgesia, drugs used for sedation and analgesia (including side effects), patient assessment and monitoring (before, during, and postprocedure), and discharge of patients from the ambulatory endoscopy center.

Routine droperidol pre-medication improves sedation for ERCP

BACKGROUND

Pre-medication with droperidol has been used to improve sedation during endoscopy, especially in patients with a history of alcohol or narcotic abuse. We studied whether routine use of droperidol pre-endoscopic retrograde cholangiopancreatography (ERCP) could improve patient and physician satisfaction with sedation.

METHODS

Sixty-seven patients undergoing routine ERCP were enrolled in this double-blind placebo-controlled study. Patients were given either parenteral normal saline solution or 5 mg of droperidol 15 minutes before the procedure. After the ERCP, several parameters of procedural sedation were scored on an ordinal scale by the endoscopist, the endoscopy nurse, and the recovered patient. In addition, a follow-up telephone call was made to the patient after 24 hours.

RESULTS

The mean procedural room time was similar in the two groups. Nearly 25% less meperidine and diazepam was used in the droperidol-treated patients, making the overall medication cost similar in both groups. The mean recovery room time was 113 minutes for the placebo group and 106 minutes for the droperidol group. Droperidol premedication significantly decreased post-procedure nausea and vomiting, reduced gagging at intubation, and decreased retching during the procedure. Droperidol also improved physician (p = 0.001), nurse (p = 0.001), and patient (p = 0.0001) impressions of overall sedation and decreased the need for physical restraint during the procedure. Droperidol significantly increased the number of patients with no memory of the procedure.

CONCLUSION

Droperidol improved overall patient, physician, and nurse satisfaction with sedation during ERCP. It also reduced post-ERCP nausea and vomiting without increasing recovery time or medication cost. Droperidol is recommended for routine pre-ERCP sedation. (Gastrointest Endosc 2000;52:362-6).

A randomized, double-blind study of the use of droperidol for conscious sedation during therapeutic endoscopy in difficult to sedate patients

BACKGROUND

Droperidol has been used in combination with narcotics and benzodiazepines to achieve conscious sedation. We performed a randomized, double-blind, study of droperidol in patients at risk for difficult sedation scheduled for therapeutic endoscopy.

METHODS

Patients with regular ethanol, narcotic, or benzodiazepine usage, suspected sphincter of Oddi dysfunction, or a history of difficult sedation were eligible for the study. Patients were randomized to receive either droperidol or placebo along with midazolam and meperidine as preprocedure sedation. Time to achieve sedation, interruptions due to undersedation, medication dosages, recovery time, and subjective assessments of sedation were recorded.

RESULTS

One hundred one patients were randomized. The droperidol group had significantly fewer procedure interruptions and observer ratings of difficulty with sedation and required significantly less midazolam (23%) and meperidine (16%) than the placebo group. There were no significant differences in time to achieve sedation, incomplete procedures, procedure length, recovery room time, or complications. There were significantly higher observer ratings of the quality of sedation for patients who received droperidol.

CONCLUSIONS

Droperidol is a useful adjunct to conscious sedation in patients who are difficult to sedate. Its use results in significantly fewer interruptions due to poor sedation and improved sedation ratings compared with sedation using midazolam and meperidine alone.

Completion of upper endoscopic procedures despite paradoxical reaction to midazolam: a role for flumazenil?

Paradoxical excitation after benzodiazepine administration is well described. Although it is relatively uncommon, its occurrence can severely impede or even prevent the performance of upper endoscopy. We describe three cases in which paradoxical reactions to midazolam responded so well to flumazenil administration that the procedure was successfully completed in each instance. We review the limited literature on this topic and suggest that flumazenil may have greater utility in the management of this particular problem than is considered at present.

A randomized double-blind placebo-controlled trial evaluating the cost-effectiveness of droperidol as a sedative premedication for EUS

BACKGROUND

Droperidol is a neuroleptic agent with anti-emetic properties that produces mild sedation, reduced anxiety, and a state of mental detachment and indifference to one's surroundings. Routine premedication with droperidol has been shown to improve sedation during esophagogastroduodenoscopy and endoscopic retrograde cholangiopancreatography. The purpose of this randomized double-blind placebo-controlled study was to determine whether premedication with droperidol improves sedation during routine upper endoscopic ultrasound (EUS) in a cost-effective manner.

METHODS

One hundred consecutive patients referred for EUS were randomly assigned to receive either 2.5 mg or 5 mg of droperidol or placebo before the procedure. After EUS, the physician, nurse, and recovered patient scored various parameters of procedural sedation.

RESULTS

In the group receiving 5 mg of droperidol there was significantly less gagging at intubation, less retching during the procedure, better patient cooperation, less need for physical restraint, and improved nurses' and physician's impression of sedation. Significantly less meperidine and less midazolam were required for sedation, making medication costs significantly lower in the group receiving 5 mg droperidol.

CONCLUSIONS

A 5 mg dose of droperidol given as premedication for routine upper EUS improves sedation during the procedure while significantly decreasing the overall cost of sedation.

Endoscopic retrograde cholangiopancreatography under general anesthesia: indications and results

BACKGROUND

Conscious sedation is usually used during endoscopic retrograde cholangiopancreatography (ERCP). Little is known about the indications and outcomes for ERCP in patients who cannot undergo conscious sedation and therefore require general anesthesia. We retrospectively evaluated the indications and outcome for patients undergoing ERCP who required general anesthesia at four teaching hospitals over a 2-year period.

METHODS

Of 1200 ERCPs performed over a 2-year period, 65 patients required general anesthesia. Retrospective chart analysis was undertaken to determine indications and outcomes of ERCP performed under general anesthesia. Eleven patients underwent sphincter of Oddi manometry.

RESULTS

The major indication for general anesthesia was substance abuse. Therapeutic intervention was successful in 45 of 48 patients; 6 of the 63 patients had complications, all mild and not related to the anesthesia. Sphincter of Oddi manometry was normal in 7 patients; 4 patients had elevated basal pressures.

CONCLUSIONS

ERCP under general anesthesia may be considered when conscious sedation fails to achieve a satisfactory level of sedation for a successful and safe ERCP. Procedure-related complication rates appear to be comparable if not lower with general anesthesia.

A randomized, prospective, double-blind comparison of midazolam (Versed) and emulsified diazepam (Dizac) for opioid-based, conscious sedation in endoscopic procedures

OBJECTIVE

We completed a prospective, randomized, double-blinded clinical trial to compare the quality of sedation with two benzodiazepines (emulsified diazepam and midazolam) for endoscopic procedures.

METHODS

Adult patients undergoing esophagogastroduodenoscopy or colonoscopy were eligible. Exclusion criteria included: drug allergies, altered mental status, untreated glaucoma, active pancreatitis, hyperlipidemia, resident physician training, or cases done outside the Endoscopy unit. Nurses began the sedation process by administering an opioid followed immediately by administering study drugs until patients were adequately sedated. At completion of the procedure, both the physician and the nurse rated whether the patient's sedation appeared to be adequate. In addition, before discharge, patients were asked to rate the quality of sedation.

RESULTS

A total of 111 patients were randomized to the emulsified diazepam group and 100 to the midazolam group. There was no difference in the physician's assessment of quality of sedation between the groups (p > 0.05). The length of time to sedation, total procedure time, and recovery time were similar between both groups. The estimated cost of using emulsified diazepam was approximately 50% less than that of midazolam, with an equal quality of sedation.

CONCLUSION

Neither the physicians, nurses, nor the patients could detect a difference between sedation produced by the drugs. We conclude that both drugs were equally effective for sedation for both upper and lower endoscopic procedures. Based on the results of this trial, we suggest that increased use of emulsified diazepam would markedly reduce the cost without altering the quality of sedation. The cost savings would be at least $50,000/yr at our institution.

The effect of droperidol on objective markers of patient cooperation and vital signs during esophagogastroduodenoscopy: a randomized, double-blind, placebo-controlled, prospective investigation

We investigated the effect of droperidol on objective markers of cooperation and vital signs in 140 patients undergoing elective diagnostic esophagogastroduodenoscopy. Procedure duration and the total doses of midazolam and meperidine required during the procedure were evaluated as objective markers of patient cooperation. The droperidol group comprised 66 patients and the placebo group 74 patients. Patient and procedure characteristics were similar for both groups. Droperidol produced a 10% reduction in procedure duration. Linear multiple regression modeling revealed droperidol to be a significant predictor of procedure duration (p = .036). Droperidol significantly reduced midazolam and meperidine requirements (p < .01). Nonetheless, four patients in the droperidol group received naloxone to reverse prolonged, excessive drowsiness. Droperidol produced a significant reduction in procedure-associated increase in pulse rate but did not exacerbate procedure-associated reduction in mean arterial pressure. Droperidol favorably influences markers of patient cooperation during elective, diagnostic esophagogastroduodenoscopy. However, the clinical significance of these changes is unclear.