Patient-controlled analgesia for conscious sedation during endoscopic retrograde cholangiopancreatography: a randomized controlled trial

Patient-Controlled Sedation Versus Clinician-Administered Sedation for Endoscopic Retrograde Cholangiopancreatography: A Systematic Review

Patient-controlled sedation (PCS) has been explored as a sedation method in endoscopic retrograde cholangiopancreatography (ERCP), yet a comprehensive review article on this topic is lacking. We performed a systematic review to compare PCS against clinician-administered sedation. The primary objectives are to compare the sedative dosage used and the sedation depth, while secondary objectives are to compare sedation failure rates, clinician intervention rates, and patient satisfaction. A systematic literature search was conducted on MEDLINE, EMBASE, and the Cochrane Library Database using the terms "ERCP," "Sedation," "Patient-controlled," and related terms. Randomized controlled trials comparing PCS against clinician-administered sedation in adults undergoing ERCP were included. Articles without English full texts were excluded. Studies were reviewed by 2 independent reviewers. The Cochrane Risk of Bias tool was used for quality assessment of individual included trials. This systematic review is registered in the International Prospective Register of Systematic Reviews (CRD42020198647). A total of 2619 articles were identified from the literature search. A total of 2615 articles were excluded based on the exclusion criteria. Four articles (comprised of 4 independent trials involving 425 patients) were included in analysis. When compared with clinician-administered sedation, PCS in ERCP may lead to lower propofol dosage used and lower sedation depth. The sedation failure rates appear to be higher in PCS, whereas lower rates of airway maneuvers are required. No significant difference was observable for patient satisfaction rates between PCS and clinician-administered sedation. The included studies demonstrated unclear to high risk of bias, particularly in randomization, incomplete outcome data, and outcome measurement. PCS appears to be a feasible option for sedation in ERCP. Nonetheless, large-scale, high-quality trials will be required before PCS can be regularly implemented in ERCP.

Anesthesia for endoscopic retrograde cholangiopancreatography: target-controlled infusion versus standard volatile anesthesia

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is a technique used both for diagnosis and for the treatment of biliary and pancreatic diseases. ERCP has some anesthetic implications and specific complications. The primary outcome aim was to compare two protocols in terms of time of extubation. We also compared anesthetic protocols in terms of hemodynamic and respiratory instability, antispasmodics needs, endoscopist satisfaction, and recovery room stay.

METHODS

Patients were randomized into two groups standard anesthesia group (Gr: SA) in whom induction was done by propofol, fentanyl and cisatracurium and maintenance was done by a mixture of oxygen, nitrousoxide (50%:50%) and sevoflurane; and intravenous anesthesia group to target concentration (Gr: TCI) in whom induction and maintenance of anesthesia were done with propofol with a target 0.5-2 μg/mL, and remifentanil with a target of 0.75-2 ng/mL.

RESULTS

90 patients were included. Extubation time was shorter in Gr: TCI, 15±2.6 vs. 27.4±7.1 min in Gr: SA (P<0.001). The incidence of hypotension was higher in GrL: SA (P=0.009). Satisfaction was better in Gr: TCI (P=0.003). Antispasmodic need was higher in Gr: SA (P=0.023). Six patients in Gr: SA group had desaturation in post-anesthesia care unit (PACU) versus one patient from Gr: TCI (P=0.049). Patients in Gr: TCI had shorter PACU stay 40.2±7.3 vs. 58.7±12.4 min (P<0.001).

CONCLUSION

The use of TCI mode allows better optimization of general anesthesia technique during ERCP.

Efficacy and Safety of Propofol-Mediated Sedation for Outpatient Endoscopic Retrograde Cholangiopancreatography (ERCP)

BACKGROUND AND AIMS

Propofol sedation for endoscopy may result in a rapid and unpredictable progression from deep sedation to general anesthesia, leading to potential complications. We investigated the incidence and predictors of sedation-related adverse events (SAEs) in nonintubated patients who underwent outpatient ERCP procedures with propofol sedation.

METHODS

We conducted a retrospective study of patients who underwent propofol sedation for ERCP procedures. Patients were sedated using propofol in combination with low-dose opiates. Data collected included patient demographics, American Society of Anesthesiologists (ASAs) physical status, and procedure times. SAE includes hypoxia (pulse oximetry <90 %), hypotension (systolic blood pressure <90 mmHg), and conversation to endotracheal intubation. Factors associated with SAEs were examined by univariate analysis and multivariate regression analysis (MVA).

RESULTS

A total of 3041 patients were evaluated. The median BMI was 25.2 kg/m(2), and the median ASA score was 3. The mean (±SD) duration of the procedures was 59 ± 23 min. Hypoxia requiring airway manipulation occurred in 28 % (n = 843) patients and hypotension requiring vasopressors in 0.4 % (n = 12). Forty-nine (1.6 %) patients required endotracheal intubation as a result of food in the stomach. Procedures underwent early termination in 8 (0.3 %) cases due to sedation-related hypotension (n = 5) and refractory laryngospasm (n = 3). Six patients were admitted after the ERCP for aspiration pneumonia as a result of sedation. Patients who developed SAE were older, had a higher mean BMI, and had longer mean procedure durations. On MVA, older age (p = 0.003), female sex (p = 0.001), BMI (p = 0.02), and ASA class ≥3 (p = 0.01) independently predicted SAEs.

CONCLUSIONS

Propofol can be used safely and effectively as a sedative agent for patients undergoing ERCPs when administered by trained professionals. Age, female sex, BMI, and ASA class ≥3 are independent predictors of SAEs.

Patient-controlled sedation with propofol and remifentanil for ERCP: a randomized, controlled study

BACKGROUND

Deep sedation with propofol and an opioid is commonly used for ERCP but is associated with increased risk and may require the presence of an anesthesiologist. Delivery of propofol and a short-acting, potent opioid analgesic remifentanil by patients to themselves (patient-controlled sedation, PCS) could be another option. Comparative studies with propofol PCS for ERCP are lacking.

OBJECTIVE

To compare PCS with propofol/remifentanil to anesthesiologist-managed propofol sedation.

DESIGN

Prospective, randomized, controlled human trial.

SETTING

University hospital.

PATIENTS

This study involved 80 patients presenting for elective ERCP.

INTERVENTION

Patients were randomized to PCS with propofol/remifentanil (PCS group) or anesthesiologist-managed propofol sedation (propofol infusion group). Sedation level was estimated every 5 minutes throughout the procedure by using Ramsay and Gillham sedation scores. The total amount of propofol was calculated at the end of the procedure. Endoscopist and patient satisfaction with the procedures was evaluated with a structured questionnaire.

MAIN OUTCOME MEASUREMENTS

Patient vital signs, amount of consumed propofol, sedation levels, and degree of endoscopist and patient satisfaction.

RESULTS

PCS was successful with 38 of 40 (95%) ERCP patients. In the PCS group, the mean (±standard deviation) level of sedation was markedly lighter and propofol consumption significantly smaller (175±98 mg) than in the propofol infusion group (249±138 mg) (P<.01). Degrees of patient and endoscopist satisfaction were equally high in both groups. All of the patients preferred the same sedation method should a repeat ERCP be required.

LIMITATIONS

Single-center study.

CONCLUSION

PCS with propofol/remifentanil is a suitable and well-accepted sedation method for ERCP. Anesthesiologist-managed propofol sedation with constant propofol infusion is associated with unnecessary deep sedation without any impact on the degree of patient or endoscopist satisfaction. Further larger-scale studies are needed to assess the safety of PCS in ERCP patients. (

CLINICAL TRIAL REGISTRATION NUMBER

NCT01079312.).

Clinical efficacy of dexmedetomidine alone is less than propofol for conscious sedation during ERCP

BACKGROUND

Propofol is an accepted method of sedation for an ERCP and generally achieves deep sedation rather than conscious sedation, and dexmedetomidine has sedative properties of equivalent efficacy.

OBJECTIVE

To examine the hypothesis that dexmedetomidine is as effective as propofol combined with fentanyl for providing conscious sedation during an ERCP.

DESIGN AND SETTING

Randomized, blind, double-dummy clinical trial.

PATIENTS

Twenty-six adults, American Society of Anesthesiologists status I to III, underwent an ERCP.

INTERVENTIONS

Patients were randomized to receive either propofol (n = 14) (target plasma concentration range 2-4 microg/mL) combined with fentanyl 1 microg/kg, or dexmedetomidine (n = 12) 1 microg/kg for 10 minutes, followed by 0.2 to 0.5 microg/kg/min. Additional sedatives were used if adequate sedation was not achieved at the maximum dose allowed.

MAIN OUTCOMES MEASUREMENTS

The sedation level was assessed by the Richmond alertness-sedation scale and the demand for additional sedatives. Furthermore, heart rate, blood pressure, oxygen saturation, and respiratory rate were continuously assessed.

RESULTS

The relative risk (RR) was 2.71 (95% CI, 1.31-5.61) and the number of patients that needed to be treated (NNT) was 1.85 (95% CI, 1.19-4.21) to observe one additional patient with drowsiness 15 minutes after sedation in the dexmedetomidine group. Also, the RR was 9.42 (95% CI, 1.41-62.80), and the NNT was 1.42 (95% CI, 1.0-2.29) to require additional analgesic. However, there was also a greater reduction in blood pressure, a lower heart rate, and greater sedation after the procedure.

CONCLUSIONS

Dexmedetomidine alone was not as effective as propofol combined with fentanyl for providing conscious sedation during an ERCP. Furthermore, dexmedetomidine was associated with greater hemodynamic instability and a prolonged recovery.

Anaesthetic considerations during endoscopic retrograde cholangiopancreatography

Endoscopic retrograde cholangiopancreatography has evolved from being a simple diagnostic procedure, performed under proceduralist-administered sedation, to a therapeutic one involving increasingly complex techniques that require a high degree of patient cooperation. The anaesthetist has become a vital member of the team. Many of the patients are medically unfit for surgery. Sedation or general anaesthesia is generally indicated for the increasingly complex, long and painful procedures being performed. Although there is very little published evidence of specific anaesthetic techniques in this area, knowledge of these problems allows the anaesthetist to select an appropriate technique to provide safe and effective anaesthesia.

Patient-controlled analgesia and sedation in gastrointestinal endoscopy

Variations in pain threshold, drug tolerance, and visceral sensitivity among patients make it difficult to anticipate the appropriate dose of sedation for gastrointestinal endoscopy. Propofol was recently introduced for sedation in endoscopy and has a rapid onset and offset of action, making it an ideal substance for patient-controlled administration. Several controlled trials have demonstrated that during colonoscopy, patient-controlled application of propofol alone or in combination with various opioids is effective,safe, and yields high patient satisfaction. Target-controlled infusion of propofol has shown encouraging results for prolonged upper endoscopy procedures like endoscopic retrograde cholangio pancreatography.

Patient-controlled versus nurse-administered sedation with propofol during colonoscopy. A prospective randomized trial

OBJECTIVES

Patient-controlled sedation (PCS) with propofol, is well tolerated and reduces recovery time and staff required during endoscopic interventions. "Who" administers the drug proves economically crucial. With the aim of maintaining safety, medical quality, and patient satisfaction, this study investigates PCS versus nurse-administered propofol sedation (NAPS) in a cohort of consecutive patients.

METHODS

One hundred and fourteen patients, aged 22-90 yr, undergoing only colonoscopy participated in this prospective randomized trial. Patients were randomly assigned to either PCS or NAPS. If patients declined randomization for different reasons of reluctance to PCS they were assigned to a standard nurse-sedated control group. All patients received pethidine presedation for analgesia. Visual analogue scales followed patient anxiety level, tolerability, pain, and satisfaction, and endoscopist's assessment of the procedure.

RESULTS

Given the choice, 35% of the patients who were rather younger and more anxious declined randomization to PCS. The mean total dose of propofol needed in this group was higher, but the patients had a tendency to rate the global tolerance and the pain of the examination as less comfortable compared to the two randomized groups. Self-administration of propofol created a significantly different drug profile and higher medication costs. With regard to the safety parameters there was no difference between PCS and NAPS. In their global assessments, the patients and endoscopists tended to prefer NAPS.

CONCLUSIONS

Individual patient characteristics and attitudes toward self-control are crucial for PCS. While being a viable option for patients who are able and willing to handle, this technique is not applicable in a considerable portion of everyday patients.

Safer colonoscopy with patient-controlled analgesia and sedation with propofol and alfentanil

BACKGROUND

The aim of this study was to assess the efficacy of patient-controlled analgesia and sedation with propofol/alfentanil for colonoscopy compared with continuous drug infusion and conventional nurse-administered medication.

METHODS

One hundred fifty patients undergoing colonoscopy on an outpatient basis were randomly assigned to 1 of 3 medication regimens. To maintain blinding, all patients were connected to an infusion pump. Group I patients could self-administer boluses of 4.8 mg propofol and 125 microg alfentanil without restriction. Group II patients received a continuous infusion with 0.048 mg/kg propofol and 0.12 microg/kg alfentanil per minute. Group III patients received intravenous premedication with 0.035 mg/kg midazolam and 0.35 mg/kg meperidine.

RESULTS

There were no differences between the groups with respect to pain (visual analogue scale) and procedure time. Patient-controlled analgesia and sedation with propofol/alfentanil (group I) resulted in less of an increase in the transcutaneous partial pressure of carbon dioxide (p = 0.0004) during colonoscopy and less of a decrease in mean arterial blood pressure (p = 0.0021) during recovery, as well as more complete recovery (p = 0.0019) after 45 minutes compared with conventional administration of midazolam/meperidine. Furthermore, patient-controlled analgesia and sedation yielded a higher degree of patient satisfaction than continuous infusion of propofol/alfentanil (p = 0.0033) or nurse-administered midazolam/meperidine (p = 0.0094).

CONCLUSIONS

Patient-controlled administration of propofol and alfentanil for colonoscopy may provide a better margin of safety than conventional administration of midazolam and meperidine and results in a higher level of patient satisfaction and shorter recovery.

Effect of magnetic endoscope imaging on colonoscopy performance: a randomised controlled trial

BACKGROUND

Colonoscopy can be technically challenging because of unpredictable colonoscope looping. Without imaging, straightening the colonoscope is sometimes difficult since the endoscopist has to guess where the tip is. Magnetic endoscope imaging (MEI), a new non-radiographical technique for picturing the colonoscope shaft in real time, could facilitate loop straightening and thus improve performance.

METHODS

We assessed trainees and endoscopists with much experience of routine outpatient colonoscopy. In group 1, trainees examined 113 consecutive patients. MEI views were recorded in all examinations, but procedures were randomised to be done by two trainees, either with the endoscopist and endoscopy assistants viewing the imager display (n=58), or without the imager view (n=55). In group 2, two skilled endoscopists were randomised (as with group 1) to undertake consecutive examinations (n=183) either with (n=92) or without (n=91) the MEI view. MEI views of all procedures were analysed retrospectively.

FINDINGS

In both groups, intubation times were shorter (median 11.8 min [4.3-31.5] vs 15.3 min [4-67] [group 1]; 8.0 min [2.6-40.8] vs 9.3 min [2.5-52.6] [group 2]) and number of attempts at straightening the colonoscope fewer (median 5 [0-20] vs 12 [0-57] [group 1]; 7 [0-55] vs 10 [0-80] [group 2]), when the endoscopist was able to see the imager view. In group 1, colonoscopy completion rates were also higher (100% [58] vs 89% [49]) and duration of looping was reduced (median 3 min [0-18.8] vs 5.4 min [0-44.5]) when the imager could be seen. Abdominal hand pressure was more effective when the endoscopist and endoscopy assistant could see the imager view.

INTERPRETATION

MEI significantly improves performance of colonoscopy, particularly when used by trainees, or by experts in technically difficult cases; loops were straightened or controlled effectively, resulting in quick intubation times and high completion rates.

Patient-controlled analgesia for conscious sedation during colonoscopy: a randomized controlled study

BACKGROUND

The aim of this study was to assess whether patient-controlled anesthesia (PCA) can improve patient tolerance for colonoscopy. We compared baseline sedation and analgesia with baseline sedation and PCA.

METHODS

Fifty-six consecutive patients were alternatively allocated to 1 of 2 groups: either to control group (n = 28) to receive standard sedation (meperidine and midazolam as baseline and additional doses of meperidine administered by the anesthesiologist) or to a PCA group (n = 28) to receive the same baseline premedication but additional analgesia with meperidine being self-administered. Cardiopulmonary parameters were recorded and tolerance for the examination was evaluated by a numeric rating scale, 0 meaning "no pain" and 10 meaning "maximal pain."

RESULTS

Patients' mean pain score (on a scale of 0 to 10) was 4.85 +/- 3.74 for the PCA group and 5.30 +/- 3.53 (not significant) for the control group. Physicians' assessment of patient tolerance registered a lower numeric rating score than patients' assessment. The duration of the procedure was slightly longer in the PCA group. None of the patients experienced a decline in oxygen saturation below 90%; a decrease in expiratory carbon dioxide during the examination was noted in both groups of patients, particularly during the first minutes of the examination. Mean additional sedation per patient in the PCA group was slightly higher, but not significantly different.

CONCLUSIONS

Our results suggest that patient-controlled analgesia during colonoscopy is as effective as standard sedation with respect to patient tolerance and safety of the examination.

Anesthesia and sedation in the endoscopy suite? (influences and options)

Advances in technology and pharmacology have enabled gastrointestinal endoscopists to expand the diagnostic and therapeutic capabilities of the specialty. Research into the impact of the endoscopy environment on patient stress, acknowledgement of the various patient coping styles, development and deployment of procedural preparative programs and information streamlining have been shown to be of value in decreasing anxiety and reducing sedative requirements. Being aware of procedure-related stressors, and factors associated with complications, allows us to tailor our sedation or anesthesia plan to the individual patient.