Propofol in the endoscopy suite: an anesthesiologist's perspective

Ciprofol versus propofol for sedation in gastrointestinal endoscopy: protocol for a systematic review and meta-analysis

INTRODUCTION

Painless gastrointestinal endoscopy is being increasingly practised in the clinical field. The management and choice of sedation are important during the endoscopy procedure to reduce patient discomfort and facilitate high disease detection rates. Ciprofol is principally an agonist of the γ-aminobutyric acid type A receptor; it comprises the active ingredient HSK3486, which is similar to the currently used intravenous anaesthetic propofol in clinical practice. A systematic review and meta-analysis comparing ciprofol and propofol will be conducted to assess their efficacy and safety during endoscopy. Before starting the study, we describe the specific protocol of this systematic review.

METHODS AND ANALYSIS

This protocol was prepared in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols 2015. The following databases will be searched: Embase, Cochrane Library, PubMed, Web of Science, Chinese Biomedical Literature Service System, China National Knowledge Infrastructure, Wanfang Database, China Science and Technology Journal Database and a clinical trial registry. The database search strategy will adopt a combination of subject words and free words. Randomised controlled trials related to ciprofol use for sedation during gastrointestinal endoscopy will also be included. Based on the inclusion and exclusion criteria, two researchers will independently screen the articles and extracted data. Following the qualitative evaluation of each study, analysis will be conducted using Review Manager software.

ETHICS AND DISSEMINATION

The protocol for this systematic review and meta-analysis involves no individual patient data; thus, ethical approval is not required. This will be the first meta-analysis to assess the sedation efficacy of ciprofol and provide evidence to clinicians for decision-making. The results will be disseminated through conference presentations and publications in peer-review journals related to this field.

PROSPERO REGISTRATION NUMBER

CRD42022370047.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The comparison of propofol and midazolam for bronchoscopy: A meta-analysis of randomized controlled studies

BACKGROUND

Propofol and midazolam are widely used for the sedation of bronchoscopy. This systematic review and meta-analysis is conducted to compare the efficacy of propofol and midazolam for bronchoscopy.

METHODS

The databases including PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases are systematically searched for collecting the randomized controlled trials (RCTs) regarding the efficacy of propofol and midazolam for bronchoscopy.

RESULTS

This meta-analysis has included 4 RCTs. Compared with midazolam intervention in patients undergoing bronchoscopy, propofol intervention is associated with remarkably reduced recovery time [standard mean difference (SMD) = -0.74; 95% confidence interval (95% CI) = -1.04 to -0.45; P < .00001], but demonstrates no significant impact on operation time (SMD = -0.01; 95% CI = -0.16 to 0.13; P = .87), induction time (SMD = -0.58; 95% CI = -1.19 to 0.03; P = .06), lowest oxyhemoglobin saturation (SpO2, SMD = 0.24; 95% CI = -0.09 to 0.58; P = .15), SpO2 <90% [risk ratio (RR) = 1.02; 95% CI = 0.82-1.25; P = .88), and major arrhythmias (RR = 0.56; 95% CI = 0.26-1.19; P = .13).

CONCLUSION

Propofol sedation is able to reduce recovery time and shows similar safety compared with midazolam sedation during bronchoscopy.

Age correlates with hypotension during propofol-based anesthesia for endoscopic retrograde cholangiopancreatography

OBJECTIVE

Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure used for diagnostic and therapeutic purposes. Most of the patients may feel pain, anxiety, and discomfort during this procedure, so conscious sedation is usually used during ERCP. General anesthesia would be considered if conscious sedation fails to achieve the requirement of the endoscopists. Several studies showed that propofol-based sedation could provide a better recovery profile. However, propofol has a narrow therapeutic window and complications may occur beyond this window. The present study aimed to find out the complications and the associated risk factors during ERCP procedure under propofol-based deep sedation.

METHODS

We retrospectively reviewed data from anesthetic and procedure records of the patients who underwent ERCP under propofol-based deep sedation from January 2006 to July 2010 at Far Eastern Memorial Hospital, Taipei, Taiwan. All propofol-based deep sedations were conducted by anesthesiologists. The incidence of complications was determined and the independent risk factors identified by the multivariable logistic regression model.

RESULT

Propofol-based deep sedation was provided for 552 patients who received ERCP procedure. The majority of the patients were male, the mean age was 60 ± 16 years and American Society of Anesthesiologists physical status II-III. Almost 30% of patients experienced hypotension during the procedure, although no mortality or morbidity was associated with this complication. Sex, age, anesthetic time, American Society of Anesthesiologists status, hypertension, and arrhythmia were significantly different (p < 0.05) between patients with hypotension and without hypotension during the procedure. Multivariable logistic regression identified sex and age to be the independent predictors of hypotension.

CONCLUSION

Hypotension was the most frequent anesthetic complication during procedure under propofol-based deep sedation, but this method was safe and effective under appropriate monitoring. Age is the strongest predictor of hypotension and therefore propofol-based deep sedation should be conducted with caution in the elderly.

The potential regimen of target-controlled infusion of propofol in flexible bronchoscopy sedation: a randomized controlled trial

OBJECTIVES

Target-controlled infusion (TCI) provides precise pharmacokinetic control of propofol concentration in the effect-site (Ce), eg. brain. This pilot study aims to evaluate the feasibility and optimal TCI regimen for flexible bronchoscopy (FB) sedation.

METHODS

After alfentanil bolus, initial induction Ce of propofol was targeted at 2 μg/ml. Patients were randomized into three titration groups (i.e., by 0.5, 0.2 and 0.1 μg/ml, respectively) to maintain stable sedation levels and vital signs. Adverse events, frequency of adjustments, drug doses, and induction and recovery times were recorded.

RESULTS

The study was closed early due to significantly severe hypoxemia events (oxyhemoglobin saturation <70%) in the group titrated at 0.5 μg/ml. Forty-nine, 49 and 46 patients were enrolled into the 3 respective groups before study closure. The proportion of patients with hypoxemia events differed significantly between groups (67.3 vs. 46.9 vs. 41.3%, p = 0.027). Hypotension events, induction and recovery time and propofol doses were not different. The Ce of induction differed significantly between groups (2.4±0.5 vs. 2.1±0.4 vs. 2.1±0.3 μg/ml, p = 0.005) and the Ce of procedures was higher at 0.5 μg/ml titration (2.4±0.5 vs. 2.1±0.4 vs. 2.2±0.3 μg/ml, p = 0.006). The adjustment frequency tended to be higher for titration at 0.1 μg/ml but was not statistically significant (2 (0∼6) vs. 3 (0∼6) vs. 3 (0∼11)). Subgroup analysis revealed 14% of all patients required no further adjustment during the whole sedation. Comparing patients requiring at least one adjustment with those who did not, they were observed to have a shorter induction time (87.6±34.9 vs. 226.9±147.9 sec, p<0.001), a smaller induction dose and Ce (32.5±4.1 vs. 56.8±22.7 mg, p<0.001; 1.76±0.17 vs. 2.28 ±0.41, p<0.001, respectively), and less hypoxemia and hypotension (15.8 vs.56.9%, p = 0.001; 0 vs. 24.1%, p = 0.008, respectively).

CONCLUSION

Titration at 0.5 μg/ml is risky for FB sedation. A subgroup of patients required no more TCI adjustment with fewer complications. Further studies are warranted to determine the optimal regimen of TCI for FB sedation.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01101477.

The use of propofol as a sedative agent in gastrointestinal endoscopy: a meta-analysis

OBJECTIVES

To assess the efficacy and safety of propofol sedation for gastrointestinal endoscopy, we conducted a meta-analysis of randomized controlled trials (RCTs) comparing propofol with traditional sedative agents.

METHODS

RCTs comparing the effects of propofol and traditional sedative agents during gastrointestinal endoscopy were found on MEDLINE, the Cochrane Central Register of Controlled Trials, and EMBASE. Cardiopulmonary complications (i.e., hypoxia, hypotension, arrhythmia, and apnea) and sedation profiles were assessed.

RESULTS

Twenty-two original RCTs investigating a total of 1,798 patients, of whom 912 received propofol only and 886 received traditional sedative agents only, met the inclusion criteria. Propofol use was associated with shorter recovery (13 studies, 1,165 patients; WMD -19.75; 95% CI -27.65, 11.86) and discharge times (seven studies, 471 patients; WMD -29.48; 95% CI -44.13, -14.83), higher post-anesthesia recovery scores (four studies, 503 patients; WMD 2.03; 95% CI 1.59, 2.46), better sedation (nine studies, 592 patients; OR 4.78; 95% CI 2.56, 8.93), and greater patient cooperation (six studies, 709 patients; WMD 1.27; 95% CI 0.53, 2.02), as well as more local pain on injection (six studies, 547 patients; OR 10.19; 95% CI 3.93, 26.39). Effects of propofol on cardiopulmonary complications, procedure duration, amnesia, pain during endoscopy, and patient satisfaction were not found to be significantly different from those of traditional sedative agents.

CONCLUSIONS

Propofol is safe and effective for gastrointestinal endoscopy procedures and is associated with shorter recovery and discharge periods, higher post-anesthesia recovery scores, better sedation, and greater patient cooperation than traditional sedation, without an increase in cardiopulmonary complications. Care should be taken when extrapolating our results to specific practice settings and high-risk patient subgroups.

Propofol combined with traditional sedative agents versus propofol- alone sedation for gastrointestinal endoscopy: a meta-analysis

OBJECTIVE

To assess the efficacy and safety of sedation of propofol combined with traditional sedative agents (PTSA) for gastrointestinal endoscopy, we conducted a meta-analysis of randomized controlled trials (RCTs) comparing PTSA with propofol-alone sedation.

MATERIAL AND METHODS

RCTs comparing the effects of PTSA and propofol alone during gastrointestinal endoscopy were found on MEDLINE, the Cochrane Central Register of Controlled Trials, and EMBASE. Cardiopulmonary complications (i.e., hypoxia, hypotension, arrhythmia, and apnea), total dose of propofol used and amnesia were assessed.

RESULTS

Nine original RCTs investigating a total of 1,505 patients, of whom, 805 received PTSA sedation and 700 received propofol-alone sedation, met the inclusion criteria. Compared with propofol-alone sedation, the pooled relative risk with the use of PTSA sedation for developing hypoxia, hypotension, arrhythmias, and apnea for all the procedures combined was 0.93 (95% CI, 0.30-2.92), 1.32 (95% CI, 0.38-4.64), 2.61 (95% CI, 0.23-29.29) and 2.81 (95% CI, 0.27-29.07), with no significant difference between the groups. The pooled mean difference in total dose of propofol used was -40.01 (95% CI, -78.96 to -1.05), which showed a significant reduction with use of PTSA sedation. The pooled relative risk for amnesia was 0.97 (95% CI, 0.88-1.07), suggesting no significant difference between the groups.

CONCLUSIONS

PTSA sedation during gastrointestinal endoscopy could significantly reduce the total dose of propofol, but without benefits of lower risk of cardiopulmonary complications compared with propofol-alone sedation.

Difficult colonoscopies in the propofol era

BACKGROUND

To study the relationship between endoscopic practice and adverse events during colonoscopy under standard deep sedation induced and monitored by an anesthetist.

METHODS

We investigated the routine activity of an endoscopy center at the Padova University teaching hospital. We considered not only endoscopic and cardiorespiratory complications, but also the need to use high-dose propofol to complete the procedure, and the inability to complete the procedure. Variables relating to the patient's clinical conditions, bowel preparation, the endoscopist's and the anesthetist's experience, and the duration of the procedure were input in the model.

RESULTS

617 procedures under deep sedation were performed with a 5% rate of adverse events. The average dose of propofol used was 2.6 ± 1.2 mg/kg. In all, 14 endoscopists and 42 anesthetists were involved in the procedures. The logistic regression analysis identified female gender (OR=2.3), having the colonoscopy performed by a less experienced endoscopist (OR=1.9), inadequate bowel preparation (OR=3.2) and a procedure lasting longer than 17.5 minutes (OR=1.6) as the main risk factors for complications. An ASA score of 2 carried a 50% risk reduction (OR=0.5).

DISCUSSION AND CONCLUSIONS

Our model showed that none of the variables relating to anesthesiological issues influenced which procedures would prove difficult.

Feasibility of bispectral index-guided propofol infusion for flexible bronchoscopy sedation: a randomized controlled trial

OBJECTIVES

There are safety issues associated with propofol use for flexible bronchoscopy (FB). The bispectral index (BIS) correlates well with the level of consciousness. The aim of this study was to show that BIS-guided propofol infusion is safe and may provide better sedation, benefiting the patients and bronchoscopists.

METHODS

After administering alfentanil bolus, 500 patients were randomized to either propofol infusion titrated to a BIS level of 65-75 (study group) or incremental midazolam bolus based on clinical judgment to achieve moderate sedation. The primary endpoint was safety, while the secondary endpoints were recovery time, patient tolerance, and cooperation.

RESULTS

The proportion of patients with hypoxemia or hypotensive events were not different in the 2 groups (study vs. control groups: 39.9% vs. 35.7%, p = 0.340; 7.4% vs. 4.4%, p = 0.159, respectively). The mean lowest blood pressure was lower in the study group. Logistic regression revealed male gender, higher American Society of Anesthesiologists physical status, and electrocautery were associated with hypoxemia, whereas lower propofol dose for induction was associated with hypotension in the study group. The study group had better global tolerance (p<0.001), less procedural interference by movement or cough (13.6% vs. 36.1%, p<0.001; 30.0% vs. 44.2%, p = 0.001, respectively), and shorter time to orientation and ambulation (11.7±10.2 min vs. 29.7±26.8 min, p<0.001; 30.0±18.2 min vs. 55.7±40.6 min, p<0.001, respectively) compared to the control group.

CONCLUSIONS

BIS-guided propofol infusion combined with alfentanil for FB sedation provides excellent patient tolerance, with fast recovery and less procedure interference.

TRIAL REGISTRATION

ClinicalTrials. gov NCT00789815.

Sedation, analgesia, and monitoring

Endoscopic procedures are common and sedation is frequently used to minimize anxiety and discomfort, reduce the potential for physical injury during the procedure, and improve overall patient tolerability and satisfaction. In this article, the authors review the variety of options for sedation and analgesia available to the gastroenterologist or surgical endoscopist.

Comparison of propofol deep sedation versus moderate sedation during endosonography

BACKGROUND

The purposes of this study are: (1) to prospectively evaluate clinically relevant outcomes including sedation-related complications for endoscopic ultrasound (EUS) procedures performed with the use of propofol deep sedation administered by monitored anesthesia care (MAC), and (2) to compare these results with a historical case-control cohort of EUS procedures performed using moderate sedation provided by the gastrointestinal (GI) endoscopist.

MATERIALS AND METHODS

Patients referred for EUS between January 1, 2001 and December 31, 2002 were enrolled. Complication rates for EUS using MAC sedation were observed and also compared with a historical case-control cohort of EUS patients who received meperidine/midazolam for moderate sedation, administered by the GI endoscopist. Logistic regression analysis was used to isolate possible predictors of complications.

RESULTS

A total of 1,000 patients underwent EUS with propofol sedation during the period from January 1, 2001 through December 31, 2002 (mean age 64 years, 53% female). The distribution of EUS indications based on the primary area of interest was: 170 gastroduodenal, 92 anorectal, 508 pancreaticohepatobiliary, 183 esophageal, and 47 mediastinal. The primary endpoint of the study was development of sedation-related complications occurring during a performed procedure. A total of six patients experienced complications: duodenal perforation (one), hypotension (one), aspiration pneumonia (one), and apnea requiring endotracheal intubation (three). The complication rate with propofol was 0.60%, compared with 1% for the historical case-control (meperidine/midazolam moderate sedation) group.

CONCLUSIONS

There does not appear to be a significant difference between complication rates for propofol deep sedation with MAC and meperidine/midazolam administered for moderate sedation.

Propofol sedation for upper gastrointestinal endoscopy in patients with liver cirrhosis as an alternative to midazolam to avoid acute deterioration of minimal encephalopathy: a randomized, controlled study

OBJECTIVE

Midazolam sedation for upper gastrointestinal (GI) endoscopy exacerbates minimal hepatic encephalopathy (HE) in patients with liver cirrhosis, therefore an alternative drug regimen for these patients is warranted. The aim of this randomized, controlled study was to assess whether the use of the short-acting propofol as a sedative for GI endoscopy could prevent the exacerbation of minimal HE in patients with liver cirrhosis.

MATERIAL AND METHODS

The study comprised patients with liver cirrhosis without clinical HE who had undergone upper GI endoscopy for therapeutic purposes (intended variceal band ligation). Sixty patients were randomly assigned into two groups to receive propofol (n=40) or midazolam (n=20) for upper GI endoscopy. The study groups were matched for age, gender and Child-Pugh score. All patients completed number connecting tests (NCTs), as well as a porto-systemic encephalopathy (PSE) syndrome test before and at 2 h after completion of the endoscopic procedure. Time needed to fulfill the tests was documented. Baseline results of the psychomotor test batteries were compared with the post-interventional evaluations. Data were also compared with the results of a healthy control group (n=20) that did not undergo endoscopic sedation. Recovery time and quality (score system) were evaluated.

RESULTS

The differences in the NCT times before and after sedation (median delta NCT, midazolam group, 11 s (95% CI, -1.2 to 16.1 s) versus the propofol group, -9.5 s (95% CI, -15.7 to -4.6 s), p=0.002) and in the PSE scores (median delta PSE, midazolam group, -1 (95% CI, -1.5 to 0.2) versus the propofol group, 1 (95% CI, 0.5 to 1.5), p=0.0009) differed significantly between the two groups. In addition, the recovery time and quality in patients receiving propofol were significantly improved compared with in the midazolam group (7.8+/-2.9 min versus 18.4+/-6.7 min, 6.1+/-1.1 versus 8.2+/-1.3, both p<0.001).

CONCLUSIONS

The study demonstrates that propofol sedation for upper GI endoscopy does not cause acute deterioration of minimal hepatic encephalopathy and is associated with improved recovery in patients with liver cirrhosis. Propofol should be recommended for these patients as an alternative to midazolam.

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.

Monitored anesthesia care (MAC) sedation: clinical utility of fospropofol

Fospropofol, a phosphorylated prodrug version of the popular induction agent propofol, is hydrolyzed in vivo to release active propofol, formaldehyde, and phosphate. Pharmacodynamic studies show fospropofol provides clinically useful sedation and EEG/bispectral index suppression while causing significantly less respiratory depression than propofol. Pain at the injection site, a common complaint with propofol, was not reported with fospropofol; the major patient complaint was transitory perianal itching during the drug's administration. Although many clinicians believe fospropofol can safely be given by a registered nurse, the FDA mandated that fospropofol, like propofol, must be used only in the presence of a trained anesthesia provider.

Mask adaptor--a novel method of positive pressure ventilation during propofol deep sedation for upper GI endoscopy

BACKGROUND

Propofol dosages required for upper GI endoscopy are often high enough to pose serious risks of respiratory depression. Stopping the procedure and bag ventilating a patient until the propofol wears off may be a safer management because traditional mask ventilation is not available.

OBJECTIVE

We introduce the mask adaptor for upper GI endoscopy (MAUGE), a new method of positive pressure ventilation during upper GI endoscopy, and assessed its feasibility and safety.

DESIGN

Subjects received propofol 1.5 to 2.5 mg/kg injection followed by repeated doses of 20 to 30 mg if necessary.

SETTING

Tertiary hospital.

PATIENTS

Thirty patients, American Society of Anesthesiologists class I to III, undergoing upper GI endoscopy and requesting sedation.

INTERVENTIONS

After connecting the MAUGE to the anesthetic ventilation circuit and mask, the endoscope was inserted into the patient's digestive tract through the channel for endoscopes in the MAUGE and through the mask. Oxygen was supplied to the respiratory tract through the channel for gas in the MAUGE and through the mask by using positive pressure ventilation by bag-valve-mask ventilation.

MAIN OUTCOME MEASUREMENTS

Heart rate, noninvasive blood pressure, end-tidal carbon dioxide tension, oxygen saturation, respiratory waveform.

RESULTS

Oxygen saturation was more than 95% throughout the endoscopy in all patients. Positive ventilation was achieved in all patients and consistent with thoracic wall movement and respiratory waveforms shown by capnography.

LIMITATIONS

The MAUGE cannot seal the respiratory tract. Patients in high risk for aspiration should not be considered candidates for using the MAUGE.

CONCLUSIONS

By use of the MAUGE, positive pressure ventilation was efficaciously achieved, and desaturation and carbon dioxide retention were effectively avoided during the upper GI endoscopy procedure.

Understanding modes of moderate sedation during gastrointestinal procedures: a current review of the literature

Recommendations for routine screening for colorectal cancer with colonoscopy are likely to substantially increase the demand for provision of sedation for these procedures. Because of this burgeoning caseload and associated economic constraints, it is unlikely that anesthesiologists will be available for all such procedures, particularly those involving average-risk patients. Thus, sedative agents that can be safely administered by nonanesthesiologists, appropriately trained in monitoring and managing the patient's airway, are desperately needed. New concepts in sedation for colonoscopy include enhanced mechanisms for drug delivery such as patient-controlled sedation/analgesia and target-controlled infusion, along with the development of new drugs such as a modified cyclodextrin-based formulation of propofol and fospropofol disodium (Aquavan Injection), a water-soluble prodrug of propofol.

Risk factors for cardiopulmonary events during propofol-mediated upper endoscopy and colonoscopy

BACKGROUND

Propofol-mediated sedation for endoscopy is popular because of its rapid onset and recovery profile.

AIM

To examine procedure-specific occurrence and risk factors for cardiopulmonary events during propofol-mediated upper endoscopy (EGD) and colonoscopy.

DESIGN

A cohort study using the Clinical Outcomes Research Initiative database was used to determine the frequency of cardiopulmonary events. Clinical Outcomes Research Initiative consisted of 69 practice sites comprising 593 US endoscopists. Multivariate logistic regression analysis used variables, such as age, ASA classification and propofol administration by monitored anaesthesia care or gastroenterologist-administered propofol to determine the risk of cardiopulmonary events.

RESULTS

The overall cardiopulmonary event rate for 5928 EGDs and 11 683 colonoscopies was 11.7/1000 cases. For colonoscopy, ascending ASA classification was associated with an increased risk. Monitored anaesthesia care was associated with a decreased adjusted relative risk (0.5, 95% CI: 0.36-0.72). ASA I and II patients receiving monitored anaesthesia care for EGD exhibited a significantly lower relative risk (ARR 0.29, 95% CI: 0.14-0.64). For subjects with ASA class III or greater, there was no difference in the risk between monitored anaesthesia care and gastroenterologist-administered propofol.

CONCLUSIONS

There are procedure-specific risk factors for cardiopulmonary events during propofol-mediated EGD and colonoscopy. These should be taken into account during future prospective comparative trials.

Efficacy of bispectral monitoring as an adjunct to nurse-administered propofol sedation for colonoscopy: a randomized controlled trial

BACKGROUND AND AIMS

Bispectral (BIS) monitoring provides an objective, non-invasive measure of the level of consciousness in sedated patients. BIS has been shown to lag behind the level of sedation during induction and emergence of sedation with propofol. In this study, we sought to determine whether BIS is a useful adjunctive maneuver to registered nurse-administered propofol sedation (NAPS) as measured by reductions in recovery time and doses of propofol administered.

METHODS

A randomized controlled trial of 102 outpatients presenting for colonoscopy was performed. BIS values were recorded continuously in all subjects. Patients were randomized to receive NAPS with BIS visible to nurse and endoscopist versus BIS invisible to nurse and endoscopist. In phase 1 (47 patients), the nurse and endoscopist team were instructed to consider BIS (when visible) as only adjunctive information with regard to titrating sedation. In phase 2 (55 patients), the nurse endoscopist team was instructed to use BIS as the primary endpoint for titration of sedation, and to target BIS to greater than 60 (60-70 is deep sedation).

RESULTS

In phase 1, the mean (SD) BIS value from scope-in (SI) to scope-out (SO) for BIS was 59.3 (9.9) and was not different from controls at 59.9 (10.1; p= 0.82). The mean (SD) propofol dose (mg/min) was 15.8 (5.6) and 17.2 (6.2) for BIS and controls, respectively (p= 0.45). The mean (SD) recovery time with BIS visible in phase 1 was 20.6 min (5.5) versus 19.2 min (4.5) in controls (p= 0.34). In phase 2, the mean (SD) BIS from SI to SO in those randomized to have BIS visible was 64.1 (5.4) versus 63.1 (8.5) in controls (p= 0.58). The mean (SD) dose of propofol (mg/min) was 16.1 (11.2) and 16.4 (12.3) for BIS and control groups, respectively (p= 0.92). The mean (SD) recovery time in phase 2 with BIS visible was 18.7 (3.5) versus 20.1 (5.6) in controls (p= 0.27).

CONCLUSIONS

BIS did not lead to reductions in mean propofol dose or recovery time when used as an adjunct to NAPS for colonoscopy, or when used as the primary target for sedation. No clinically important role for BIS monitoring as an adjunct to NAPS has yet been established.

Age effect on efficacy and side effects of two sedation and analgesia protocols on patients going through cardioversion: a randomized clinical trial

BACKGROUND

Cardioversion (CV), a painful procedure, requires sedation and analgesia. Although several sedation agents currently are in use for CV, data on age-specific efficacy and side effects of midazolam and propofol have been limited.

OBJECTIVES

To compare the efficacy and side effects of midazolam and propofol in patients of two different age groups, younger than 65 years and 65 years and over, who were going through CV.

METHODS

Seventy consented patients with CV indications caused by atrial fibrillation were included in this clinical trial. The participants were placed into four groups by using a stratified randomization method: patients aged younger than 65 years who were receiving midazolam (n = 12) or propofol (n = 11) and patients 65 years and over who were receiving midazolam (n = 25) or propofol (n = 22). Medications were administered by slow intermittent bolus injections. During CV, time to reach Ramsay Sedation Scale level 5 (RSS-5; induction time); time to reach RSS-2 (recovery time); and side effects including desaturation, apnea, and changes in hemodynamic parameters were recorded by a person blinded to the patient treatment allocation.

RESULTS

Mean induction time was similar in all four groups. Mean recovery time (min +/- SD) was shorter in both propofol groups when compared with both midazolam groups: 18.8 (+/- 4.06) and 40.33 (+/- 20.8) in the group younger than 65 years and 18.2 (+/- 5.12) and 54.2 (+/- 20.85) in the group 65 years or older, respectively (p < 0.001). Older participants in each medication group needed less medication than younger patients. There were no hemodynamic differences between the groups. Desaturation was higher in both midazolam groups as compared with individuals in the age-matched propofol groups (both p < 0.05). Patient reactions were less in propofol groups with similar joules during CV procedures than were those in the midazolam groups.

CONCLUSIONS

Propofol appears to be a better choice for CV sedation in elders because of its short recovery time, fewer side effects, and its more comfortable sedative effect.

Clinical analysis of propofol deep sedation for 1,104 patients undergoing gastrointestinal endoscopic procedures: A three year prospective study

AIM: To analyze the hemodynamic and respiratory effects of propofol on patients undergoing gastroscopy and colonoscopy.

METHODS: In this prospective study, conducted over a period of three years, 1,104 patients referred for a same day GI endoscopy procedure were analyzed. All patients were given a propofol bolus (0.5-1.5 mg/kg). Arterial blood pressure (BP) was monitored at 3 min intervals and heart rate and oxygen saturation (SpO₂) were recorded continuously by pulse oximetry. Analyzed data acquisition was carried out before, during, and after the procedure.

RESULTS: A statistically significant reduction in mean arterial pressure was demonstrated (P <0.001) when compared to pre-intervention values, but severe hypotension, defined as a systolic blood pressure below 60 mmHg, was noted in only 5 patients (0.5%). Oxygen saturation decreased from 96.5% to 94.4 % (P<0.001). A critical decrease in oxygen saturation (<90%) was documented in 27 patients (2.4%).

CONCLUSION: Our results showed that propofol provided good sedation with excellent pain control, a short recovery time and no significant hemodynamic side effects if carefully titrated. All the patients (and especially ASA III group) require monitoring and care of an anesthesiologist.

Sedative Drug Requirements during Bronchoscopy Are Higher in Cystic Fibrosis after Lung Transplantation

BACKGROUND

We noted that patients with cystic fibrosis tended to need higher doses of sedatives during bronchoscopy. We undertook this study to assess the sedative drug doses administered during bronchoscopy in lung transplant recipients and to assess if there is a change in the dosage requirements over time following lung transplantation.

METHODS

In all, 773 transbronchial biopsy procedures performed via flexible bronchoscopy were analyzed in 140 consecutive lung transplant recipients. Conscious sedation was achieved with intermittent boluses of intravenous midazolam and fentanyl. Intravenous propofol boluses of 10 to 30 mg were administered when optimal sedation was not achieved with midazolam doses of 0.20 to 0.25 mg/kg and fentanyl 2 to 2.5 micrograms/kg.

RESULTS

Mean doses of midazolam and fentanyl administered were 0.15+/-0.07 mg/kg (range 0.02 to 0.44 mg/kg) and 1.8+/-0.8 micrograms/kg (range 0.1 to 6.67 micrograms/kg) respectively. Midazolam and fentanyl doses administered to patients with cystic fibrosis were the highest compared to those with other disease types (P<0.0001). Examining the sedative doses administered over time following transplantation, there was a significant linear (P<0.001) and quadratic (P=0.0023) effect of time for midazolam and a significant linear (P=0.003) and a trend (P=0.08) for a quadratic effect for fentanyl. Propofol was effectively used in seven lung transplant recipients in whom adequate sedation could not be achieved with high doses of midazolam and fentanyl.

CONCLUSIONS

There is an increase in sedative drug requirement with time for both midazolam and fentanyl after transplantation, which is significantly higher in patients with cystic fibrosis.

Sedation with propofol for routine ERCP in high-risk octogenarians: a randomized, controlled study

OBJECTIVES

Adequate patient sedation is mandatory for diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP). In this respect it is known that the short-acting anesthetic propofol offers certain potential advantages for sedation during ERCP, but there are no controlled studies concerning the feasibility and safety of propofol sedation in elderly, high-risk patients.

METHODS

One hundred and fifty consecutive patients aged >or=80 yr with high comorbidity (ASA score >or=III: 91 %), randomly received midazolam plus meperidine (n = 75) or propofol alone (n = 75) for sedation during ERCP. Vital signs were continuously monitored and procedure-related parameters, recovery time, and quality as well as patients' cooperation and tolerance of the procedure were assessed.

RESULTS

Clinically relevant changes in vital signs were observed at comparable frequencies with a temporary oxygen desaturation (<90%) occurring in eight patients in the propofol-group and seven patients receiving midazolam/meperidine (n.s.). Hypotension was documented in two patients in the propofol group and one patient receiving midazolam/meperidine. Propofol provided a significantly better patient cooperation than midazolam/meperidine (p < 0.01), but the procedure tolerability was rated nearly the same by both groups. Mean recovery time was significantly shorter in the propofol group (22 +/- 7 min vs 31 +/- 8 min for midazolam/meperidine (p < 0.01)) while the recovery score was significantly higher under propofol (8.3 +/- 1.2 vs 6.1 +/- 1.1(p < 0.01)). During recovery a significant lower number of desaturation events (<90%) were observed in the propofol group (12%) than in the midazolam/meperidine group (26%, p < 0.01).

CONCLUSION

Under careful monitoring the use of propofol for sedation during ERCP is superior to midazolam/meperidine even in high-risk octogenarians.

Efficiency issues in sedation and monitoring

Sedation and monitoring are key elements of the endoscopy process. There continues to be intense study of better methods for sedation and monitoring to improve the endoscopic "experience" for both patient and physicians alike. Our current practices will likely change in the future with technologic advances (monitoring) and expansion of our pharmacologic armamentarium (sedation).

Target-controlled propofol infusion during monitored anesthesia in patients undergoing ERCP

BACKGROUND

A target-controlled infusion system automatically adjusts the rate of infusion of propofol to maintain a desired (target) concentration. The aim of this study was to determine whether administration of propofol with a target-controlled infusion system could improve the sedation of patients undergoing ERCP.

METHODS

A total of 205 consecutive patients undergoing ERCP were sedated by using a propofol target-controlled infusion system by an anesthesiologist. The target plasma concentration of propofol ranged from 2 to 5 microg/mL. A bolus dose of fentanyl (50-100 mcg) was administered if signs of insufficient analgesia were observed at the maximum target concentration of propofol allowed. The technical difficulty of ERCP was graded on a scale from 1 (least difficult) to 5 (most difficult).

RESULTS

The mean dosages of propofol and fentanyl administered were 465 (245) mg and 59 (23) mcg, respectively. The total dose of propofol administered and the mean duration of ERCP were related to the degree of difficulty of the procedure. No severe complication was observed; mean time to discharge was 31 (12) minutes. Time to discharge was not influenced by the difficulty of ERCP or by the total dose of propofol administered.

CONCLUSIONS

A target-controlled infusion system for administration of propofol provides safe and effective sedation during ERCP. Further studies are needed to determine the cost-effectiveness and the safety profile for infusion of propofol with a target-controlled infusion system by a nonanesthesiologist during ERCP.

Infection control and its application to the administration of intravenous medications during gastrointestinal endoscopy

Several infection control practices and procedures crucial to the prevention of disease transmission in the health care setting are reviewed and discussed. Emphasis is placed on the importance of infection control to gastrointestinal endoscopy. Recommendations that minimize the risk of nosocomial infection during the preparation, handling, and administration of intravenous medications, particularly propofol, are provided. These recommendations include the labeling of predrawn syringes; use of sterile single-use syringes, needles, and administration sets for each patient; and, whenever feasible, administration of intravenous medications promptly after opening their prefilled syringes or after opening their ampoules or vials and filling the sterile syringes.

Update and review of moderate and deep sedation

The administration of sedation/analgesia to allow patients to tolerate diagnostic or therapeutic procedures and tests is a fact of life. Approximately 200,000,000 such sedations are administered every year in the United States. Any morbidity or mortality associated with sedation is likely to be deemed avoidable. There will never be adequate resources or personnel so that trained anesthesia providers administer all sedations, and there probably is no need for such an approach. Clinicians from many specialties now safely and effectively administer sedation. With attention to updated guidelines and concepts, as outlined in this article, the safety and efficacy of sedation/analgesia can and should be excellent.

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.

Review article: registered nurse-administered propofol sedation for endoscopy

Propofol has several attractive properties that render it a potential alternative sedative agent for endoscopy. Compared with meperidine and midazolam, it has an ultra-short onset of action, short plasma half-life, short time to achieve sedation, faster time to recovery and discharge, and results in higher patient satisfaction. Shorter times to achieve sedation enhance efficiency in the endoscopy unit. Multiple studies have documented the safe administration of propofol by non-anaesthesiologists. Administration by registered nurses is more cost-effective than administration by anaesthesiologists. However, the administration of propofol by a registered nurse supervised only by the endoscopist is controversial because the drug has the potential to produce sudden and severe respiratory depression. More information is needed on how training nurses and endoscopists should proceed to give propofol, as well as the optimal level of monitoring to ensure the safety of nurse-administered propofol.

Technical performance of colonoscopy in patients sedated with nurse-administered propofol

OBJECTIVES

Nurse-administered propofol has gained attention as a safe and effective means of sedation for patients undergoing endoscopic procedures. However, little is known about the effect of propofol on the technical performance of colonoscopy.

METHODS

Three separate studies were conducted. In the first study, we reviewed procedure notes from consecutive colonoscopies performed by a single experienced endoscopist at our hospital endoscopy unit on patients sedated with either nurse-administered propofol (n = 162) or midazolam/narcotic (n = 164). In the second study, 100 eligible colonoscopy outpatients were randomized to receive either nurse-administered propofol (n = 50) or midazolam/fentanyl (n = 50). In both studies, the measured parameters included visualization of the cecum, time required to reach the cecum, repositioning of the patient, and the application of abdominal counterpressure. In a third study, we reviewed the rate of cecal intubation and colonic perforation in the first 2357 patients in our unit receiving nurse-administered propofol.

RESULTS

In the retrospective comparative study, there was no difference in the cecal intubation rate in those receiving propofol (99.4%) compared to those receiving midazolam/narcotic (97%; p= 0.1), and three of five failed cecal intubations in the latter group resulted from obstructing masses. Patients sedated with propofol were repositioned less frequently compared to those receiving midazolam/narcotic (3.7%vs 26.2%) (p < 0.0001). Abdominal pressure was employed in 9.9% of patients sedated with propofol compared to 19.5% (p= 0.01) of those given midazolam/narcotic. The mean time to reach the cecum was lower in the propofol group than in the midazolam/narcotic group (4.6 min vs 6.0 min, p= 0.002). In the prospective randomized study, the endoscopist intubated the cecum in all 100 patients. Patients in the propofol group were repositioned less frequently than those in the midazolam/fentanyl group (2%vs 24%, respectively, p= 0.001). The number of cases requiring abdominal counterpressure was not significantly different between the propofol and midazolam/fentanyl groups (12%vs 24%, respectively, p= 0.1). The mean time to reach the cecum in the propofol group (3.2 min) was similar to that in the midazolam/fentanyl group (3.8 min, p= 0.08). Among the first 2357 patients in our unit undergoing colonoscopy with nurse-administered propofol, the rate of complete colonoscopy was 99.2% and there were no perforations.

CONCLUSION

Nurse-administered propofol sedation is safe and simplifies the technical performance of colonoscopy compared to midazolam/narcotic sedation.

Nurse-administered propofol versus midazolam and meperidine for upper endoscopy in cirrhotic patients

OBJECTIVES

Upper GI endoscopy is often performed in patients with chronic liver disease to screen for esophageal and gastric varices. Propofol is currently under evaluation as an alternative to the combination of midazolam and meperidine for sedation during endoscopic procedures. The purpose of this study was to compare nurse-administered propofol to midazolam and meperidine for sedation in patients with chronic liver disease undergoing diagnostic upper GI endoscopy.

METHODS

Twenty outpatients who had known chronic liver disease (Child-Pugh class A or B) and were undergoing variceal screening were randomized to receive propofol or midazolam plus meperidine for sedation. Administration of sedation was performed by a registered nurse and supervised by the endoscopist. Outcome measures studied were induction and recovery times, efficacy and safety of sedation, patient satisfaction, and return to baseline function.

RESULTS

The mean dose of propofol and meperidine/midazolam administered was 203 mg (SD 43.7, range 150-280) and 71.3 mg (SD 17.7, range 50-100)/5.3 mg (SD 0.9, range 3.0-6.0), respectively. The mean time to achieve adequate sedation was 3.6 min (SD 1.2) for the propofol group in comparison to 7.3 min (SD 2.8) for the meperidine/midazolam group (p<0.05). Procedure times between the groups were similar: propofol, 3.9 min (SD 1.9); midazolam/meperidine, 2.7 min (SD 0.8) (p=0.11). The level of sedation achieved by the propofol group was greater (p=0.0001). Time to full recovery was faster in the propofol group: 34.9 min (SD 10.3) versus 51.6 min (SD 18.4) (p<0.05). The mean time to reach a maximal level of alertness on the Observer's Assessment of Alertness and Sedation Scale for the propofol group was 15 min (SD 3.6) versus 29 min (SD 10.5) (p=0.001). Although both groups recorded a high level of satisfaction, patients receiving propofol expressed greater overall mean satisfaction with the quality of their sedation at the time of discharge (p<0.05), and reported a return to baseline function sooner in the majority of cases. Propofol achieved comparable levels of efficacy and safety to meperidine/midazolam in our study group. Both were well tolerated with minimal complications.

CONCLUSIONS

Propofol sedation administered by registered nurses in the setting of adequate patient monitoring is efficacious and well tolerated in patients with liver disease who are undergoing variceal screening by upper endoscopy. Patients were more satisfied with the quality of sedation, and return to baseline function was usually sooner compared to results achieved with midazolam/meperidine. Propofol offers advantages over meperidine/midazolam in cirrhotic patients.

Propofol for endoscopic sedation: A protocol for safe and effective administration by the gastroenterologist

BACKGROUND

There is increasing interest in the use of propofol, an ultrashort-acting hypnotic agent, for sedation during endoscopic examinations. A protocol was developed for administration of propofol, combined with small doses of midazolam and meperidine, for endoscopic sedation under the direction of a gastroenterologist. Initial experience with using this protocol is described.

METHODS

A total of 819 consecutive endoscopic examinations under sedation with propofol, midazolam, and meperidine (or fentanyl), in adherence with the sedation protocol, were reviewed retrospectively.

RESULTS

There were 638 colonoscopies and 181 EGDs; 89% of patients were classified as American Society of Anesthesiologists (ASA) class I or II. Mean dosages of medications were: propofol 63 (33.5) mg, meperidine 48 (7.2) mg, and midazolam 1 (0.12) mg. The dose of propofol was inversely correlated with age and ASA class, and positively correlated with patient weight and duration of examination. Hypotension (>20 mm Hg decline in either systolic or diastolic blood pressure) developed in 218 (27%) patients, and hypoxemia (oxygen saturation <90%) developed in 75 (9%). All episodes of hypotension and hypoxemia were transient, and no patient required administration of a pharmacologic antagonist or assisted ventilation. The average time for recovery after colonoscopy and after EGD was, respectively, 25 minutes and 28 minutes. All EGDs and 98% of colonoscopies were completed successfully.

CONCLUSIONS

On the basis of this initial experience, it is believed that propofol, potentiated by small doses of midazolam and meperidine, can be safely and effectively administered under the direction of a gastroenterologist. Additional research will be necessary to determine whether propofol is superior to the current methods of sedation.

Safety of propofol for conscious sedation during endoscopic procedures in high-risk patients-a prospective, controlled study

OBJECTIVES

Propofol, a rapidly-acting hypnotic agent, is increasingly being used for endoscopic sedation. Serious adverse effects, including respiratory and cardiovascular depression, make many endoscopists reluctant to use propofol in critically ill patients. This study characterizes propofol's safety profile in consecutive high-risk patients (American Society of Anesthesiologists [ASA] classes III and IV) compared with matched subjects (ASA classes I and II).

METHODS

During a 19-month period, 1370 at risk-patients were sedated with propofol, of whom 47% (614 ASA III, 28 ASA IV) were age matched with 642 consecutive patients of the same gender and age assigned to ASA classes I and II and undergoing the same endoscopic procedures (395 gastroscopies, 201 colonoscopies, 14 combined). Registered nurses performed all sedations by propofol dose titration while carefully monitoring arterial oxygen saturation, heart rate, and blood pressure.

RESULTS

No major complications occurred among the critically ill patients. There was, however, an increased risk for a short relevant oxygen desaturation (<90%) of 3.6% for ASA III and IV versus 1.7% for ASA I and II (p = 0.036). In four versus one case, short mask ventilation was necessary. Also, a greater proportion of patients showed a > or =5% oxygen saturation decrease. There was no pronounced influence on arterial pressure or heart rate and no perforations in 336 colonoscopies.

CONCLUSIONS

With careful monitoring, propofol sedation during GI endoscopies is safe, even for high-risk patients. Considering their higher comorbidity and tendency toward oxygen desaturation, they need particularly careful monitoring, and the required dose is, on mean, 10-20% lower than in ASA classes I and II.

Conscious sedation with propofol in elderly patients: a prospective evaluation

AIM

To characterize the safety of endoscopic procedures and propofol use as administered by nurses in a cohort of elderly patients.

METHODS

During 19 months all endoscopy patients > 70 years were eligible for this prospective observational study. Patients were assigned to group A (70-85 years) or group B (> 85 years). Records from all patients < 70 years treated during the same period served as controls. Specially trained nurses administered the propofol and monitored for complications (decrease in the peripheral oxygen saturation, mean arterial pressure or heart rate).

RESULTS

There were 1435 endoscopic procedures in group A and 351 in group B. There was no procedure or sedation-related mortality, nor a significantly greater need for emergency intervention than in the control group. Two patients required short mask ventilation but recovered without sequelae. Compared with younger patients, there was a significant increase in risk for a short oxygen desaturation < 90% and a decrease in oxygen saturation > 5%. Arterial hypotension occurred significantly more often in the control group than among the aged patients.

CONCLUSIONS

This present study documents that gastrointestinal endoscopic procedures are safe and well tolerated even in the very elderly. Nurse-administered propofol is a safe and reasonable sedation method in these patients.

Risk stratification and safe administration of propofol by registered nurses supervised by the gastroenterologist: a prospective observational study of more than 2000 cases

BACKGROUND

Conscious sedation is standard for GI endoscopy. Propofol increasingly is used as an alternative drug to avoid unwanted effects of the commonly used benzodiazepines. Although propofol in the hands of nonanesthesiologists is still controversial, this study characterized the safety profile of propofol administered by nurses under supervision of the gastroenterologist.

METHODS

All patients undergoing any endoscopic procedure between September 2000 and December 2001 in the gastroenterology department of an academic tertiary medical center were eligible for inclusion in this prospective observational study. Sedation was voluntary. Demographic data, type of endoscopic procedure, and clinical features were recorded. A structured personal history led to a 5-class risk stratification based on the criteria of the American Society of Anesthesiologists. A total of 3475 procedures were performed in 2574 patients using propofol administered by registered nurses.

RESULTS

No major complications occurred because of the use of propofol, but overall decreases in the mean values for oxygen saturation (-2%), arterial pressure (-18%), and pulse rate (-10%) were observed. Severe respiratory depression requiring intervention occurred in less than 0.3% of all patients given propofol.

CONCLUSION

The administration of propofol by registered nurses, with careful monitoring under the supervision of the gastroenterologist, is safe for conscious sedation during GI endoscopic procedures.

Gastroenterologist-administered propofol versus meperidine and midazolam for advanced upper endoscopy: a prospective, randomized trial

BACKGROUND & AIMS

Propofol is increasingly used for gastrointestinal endoscopy because of its rapid recovery profile. There has been no prospective, randomized comparison of gastroenterologist-administered propofol to meperidine and midazolam for endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography. Additionally, its cost-effectiveness has not been studied.

METHODS

Seventy-five randomized patients received either gastroenterologist-administered propofol (n = 38) or meperidine/midazolam (n = 37) for endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography. Monitoring with capnography allowed for rapid titration of propofol at the earliest signs of respiratory depression. Visual analogue scales measured tolerance and satisfaction. A cost-effectiveness analysis was performed by using return to baseline for both activity and food intake 24 hours after the procedure as the effectiveness measure.

RESULTS

The groups had similar physiological outcomes and satisfaction. Patients receiving propofol had shorter recovery times (P < 0.001) and a higher recovery of both baseline activity level and dietary intake 24 hours after the procedure (P = 0.028). With incremental cost-effectiveness analysis, gastroenterologist-administered propofol cost an additional $403.00 per additional patient at 100% of baseline for both activity level and food intake when compared with standard sedation and analgesia. Sensitivity analysis indicated that the only model in which propofol administration would become the dominant strategy was with its administration by a registered nurse.

CONCLUSIONS

Gastroenterologist-administered propofol using monitoring with capnography is similar to meperidine/midazolam for both physiological outcomes and patient/endoscopist satisfaction. Propofol leads to significantly improved recovery of baseline activity and food intake 24 hours after the procedure. Our model suggests that propofol would be more cost-effective than meperidine and midazolam for endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography if registered nurse administration were possible.

Safety of propofol administered by registered nurses with gastroenterologist supervision in 2000 endoscopic cases

OBJECTIVES

Propofol has certain advantages over benzodiazepines plus narcotics as sedation for endoscopy. In a few centers, propofol has reportedly been used in endoscopic procedures and administered by nurses supervised by gastroenterologists without attendance by anesthesiologists or nurse anesthetists.

METHODS

As part of our continuous quality improvement program, we prospectively recorded the doses of propofol and adverse reactions to the drug in our initial 2000 cases. In all cases propofol was administered by nurses who were supervised by gastroenterologists, with no involvement by an anesthesia specialist.

RESULTS

The 2000 cases included 2222 procedures. There were five episodes of oxygen desaturation to <85%, four of which seemed to be related to excessive administration of propofol and were treated by brief (< 1 min) periods of mask ventilation. No patient required endotracheal intubation or hospital admission, or suffered long-term sequelae from propofol administration. There were no perforations in 977 colonoscopies.

CONCLUSIONS

Propofol can be given safely by appropriately trained nurses under supervision by endoscopists. Technology that allows immediate detection of apnea would likely further improve its safety.

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.

Gastrointestinal bleeding in the elderly

Among patients with acute gastrointestinal bleeding, older age is associated with an increased rate of comorbidity, greater medication use, and atypical clinical presentations. The aging of the population makes the evaluation and management of gastrointestinal bleeding in the elderly a special and increasingly common clinical challenge. The unique features and common causes of upper and lower gastrointestinal bleeding in the elderly are reviewed. Important management issues considered include hemodynamic resuscitation; anticoagulation; and medical, surgical, and endoscopic therapy.

Gastroenterologist-administered propofol for therapeutic upper endoscopy with graphic assessment of respiratory activity: a case series

BACKGROUND

Traditional methods of sedation and analgesia for advanced endoscopic procedures can be inadequate and frequently prolong recovery room observation. Propofol is a rapidly acting agent that produces an excellent hypnotic state, but its use is typically limited to anesthesiologist-assisted cases because of the inadequacy of current monitoring standards to reliably detect early stages of respiratory depression.

METHODS

Ten patients undergoing advanced upper endoscopic procedures (endoscopic retrograde cholangiopancreatography, endoscopic ultrasound, esophageal stent placement) received a propofol infusion under the control of a second qualified gastroenterologist with advanced cardiac life support skills. Graphic assessment of respiratory activity was made by using a sidestream carbon dioxide detecting cannula. Patient satisfaction was measured with a 100 mm visual analog scale. Recovery scores were measured by standardized scoring of discharge criteria.

RESULTS

Monitoring with graphic assessment of respiratory activity detected early phases of respiratory depression, resulting in a timely decrease in the propofol infusion without significant hypoxemia, hypercapnia, hypotension, or arrhythmias. Satisfaction scores were extremely high (median score 92 of 100) and 9 of 10 patients met discharge criteria at 15 minutes after discontinuation of the propofol infusion.

CONCLUSIONS

With the use of monitoring by graphic assessment of respiratory activity, propofol infusion by a second qualified gastroenterologist for prolonged upper endoscopic procedures is safe and results in high levels of patient satisfaction with rapid recovery times.

Sedation for endoscopy

A review of the recent literature reveals an increasing published opinion in favour of unsedated endoscopy. However, recent studies show that the majority of US patients are unwilling or unable to tolerate this. In order for there to be a shift towards unsedated endoscopy, physicians will have to change patients' expectations. The indications for diagnostic and therapeutic endoscopic procedures continue to expand, involving increasingly complex techniques that require a high degree of patient cooperation. There is still a need to refine the sedative regimen for these cases.