Physician-Administered Office Anesthesia

Continued midazolam versus diphenhydramine in difficult-to-sedate patients: a randomized double-blind trial

BACKGROUND AND AIMS

Current guidelines recommend diphenhydramine in patients undergoing endoscopy who are not adequately sedated with a benzodiazepine and opioid combination. Because this practice has not been adequately assessed, we performed a randomized, double-blind trial comparing diphenhydramine with continued midazolam in such patients.

METHODS

Patients undergoing elective colonoscopy with moderate sedation were eligible. Sedation was measured with the Modified Observer's Assessment of Alertness/Sedation (MOAA/S) score with adequate sedation defined as 3 on a 0- to 5-point scale. Patients not adequately sedated with midazolam 5 mg and fentanyl 100 μg were randomly assigned to diphenhydramine 25 mg versus continued midazolam 1.5 mg. Adequacy of sedation was assessed 3 minutes after each study medication dose. If MOAA/S was 4 to 5, study medication was repeated, to a maximum of 3 doses. The primary endpoint was adequate sedation.

RESULTS

The planned enrollment of 200 patients (100 in each study group) was attained. Adequate sedation was achieved less often with diphenhydramine than midazolam (27% vs 65%, difference = -38%; 95% CI, -50% to -24%; P < .0001). After study medications were completed, more patients required additional medication for sedation or analgesia with diphenhydramine versus midazolam (84% vs 68%, P = .008), whereas the time to discharge from the recovery unit was similar (134 vs 129 minutes). Treatment effect was consistent across subgroups including age ≤55, substance abuse, benzodiazepine use, opioid use, and psychiatric medication use.

CONCLUSIONS

Endoscopists performing moderate sedation should continue midazolam rather than switching to diphenhydramine in patients who do not achieve adequate sedation with usual doses of midazolam and an opioid. (Clinical trial registration number: NCT01769586.).

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.

Reducing the Incidence of Hematoma Requiring Surgical Evacuation following Male Rhytidectomy: A 30-Year Review of 985 Cases

BACKGROUND

The reported incidence of hematoma following male rhytidectomy ranges from 7.9 to 12.9 percent. In 1976, it was demonstrated that postoperative hypertension is a key etiologic factor in hematoma formation and postoperative use of Thorazine was recommended to control blood pressure. This study analyzes the incidence of hematoma after male rhytidectomy at one institution after a strict and aggressive perioperative blood pressure control regimen was initiated.

METHODS

From 1982 to 2002, 985 patients with a mean age of 61 years (range, 49 to 72 years) underwent rhytidectomy. Thirty-six patients required surgical evacuation of expanding hematoma after rhytidectomy. Operative procedures were performed by more than 100 different plastic surgery attending surgeons, residents, and fellows.

RESULTS

The overall incidence of hematoma during this study period was 4.24 percent. Age, medical history, medications, type of anesthesia, rhytidectomy technique and combination of procedures, and length of operation were not independent risk factors for determining who was more likely to develop a hematoma. Thirty-three percent of the patients requiring surgical evacuation had systolic blood pressure greater than 150 mmHg and diastolic blood pressure greater than 90 mmHg preoperatively, intraoperatively, and postoperatively. Over a 30-year period, the incidence of hematoma requiring surgical evacuation has decreased from 8.7 percent to 3.97 percent after initiation of a strict perioperative blood pressure control regimen.

CONCLUSION

Despite the lower incidence of hematoma following male rhytidectomy today as compared with 30 years ago, the incidence in men (3.97 percent) remains higher than that in women (1 to 3 percent).

Hairline lowering during foreheadplasty

Many patients seeking rejuvenation of their foreheads have high hairlines and are troubled by the prospect that surgery will worsen the deformity. Hairline elevation occurs in both coronal and endoscopic foreheadplasty techniques and is at least part of the reason that many surgeons do not always recommend these procedures when otherwise indicated. Although a pretrichial "hairline" incision prevents hairline retro-displacement, it results in forehead shortening only and not true hairline lowering. When a pretrichial incision is used in combination with a posterior scalp advancement flap, however, true hairline lowering is possible. Experience with this technique encompasses 27 procedures performed over a 5-year period. Patients ranged in age from 35 to 71 years. A significant improvement was demonstrable in all cases and corresponded with a high degree of patient satisfaction. No serious complications were seen. A high hairline must be recognized as the source of both a disproportionate and aged appearance. The ability to lower the hairline and place it in a more proportionate, youthful relationship with the rest of the face adds a new dimension to foreheadplasty equal to or greater in importance to an overall improved appearance as other maneuvers typically performed during the procedure. For many patients, the benefits of hairline lowering far outweigh the trade-off of a more anteriorly situated, and possibly more visible, scar.

Evaluation of the safety and efficacy of deep sedation for electrophysiology procedures administered in the absence of an anesthetist

Several procedures performed in the electrophysiology laboratory (EP lab) require surgical manipulation and are lengthy. Patients undergoing such procedures usually receive general anesthesia or deep sedation administered by an anesthesiologist. In 536 consecutive procedures performed in the EP lab, we assessed the safety and efficacy of deep sedation administered under the direction of an electrophysiologist and in the absence of an anesthetist. Patients were monitored with pulse oximetry, noninvasive blood pressure recordings, and continuous ECGs. The level of consciousness and vital signs were evaluated at 5-minute intervals. Deep sedation was induced in 260 patients using midazolam, phenergan, and meperidine, then maintained with intermittent dosing of meperidine at the following mean doses: midazolam 0.031 +/- 0.024 mg/kg; phenergan 0.314 +/- 0.179 mg/kg; and meperidine 0.391 +/- 0.167 mg/kg per hour. In the remaining 276 patients, deep sedation was induced with midazolam and fentanyl and maintained with a continuous infusion of fentanyl at a mean dose of 2.054 +/- 1.43 micrograms/kg per hour. Fourteen patients experienced a transient reduction in oxygen saturation that was readily reversed following administration of naloxone. An additional 11 patients desaturated secondary to partial airway obstruction, which resolved after repositioning the head and neck. Fourteen patients experienced hypotension with fentanyl. All but one returned to baseline blood pressures following an infusion of normal saline. No patient required intubation and no death occurred. Only three patients had recollection of periprocedure events. No patient remembered experiencing pain with the procedure. Hospital stays were not prolonged as a result of the sedation used.

IN CONCLUSION

(1) deep sedation during EP procedures can be administered safely under the guidance of the electrophysiologist without an anesthetist present; (2) the drugs used should be readily reversible in case of respiratory depression; and (3) this approach may reduce the overall cost of the procedures in the EP lab, maintaining adequate patient comfort.