Bispectral index monitoring during anesthesiologist-directed propofol and remifentanil sedation for endoscopic submucosal dissection: a prospective randomized controlled trial

Bispectral index monitoring for sedation in scheduled adult colonoscopy: A randomized controlled trial

BACKGROUND

Patients should be closely monitored during procedures under sedation outside the operating room, but it is unclear which type of monitoring is best. We investigated the efficacy and safety of BIS monitoring vs conventional monitoring for sedation during colonoscopy.

METHODS

We performed a double-blind clinical trial in 180 patients undergoing elective colonoscopy. Patients were randomized to 1) the BIS group or 2) a control group, in which sedation was monitored with a BIS monitor or the Ramsay Sedation Score, respectively. The primary outcome was the rate of sedation-induced adverse events in both groups. Secondary outcomes were the characteristics of patients who developed adverse events, and time during colonoscopy when these events occurred, propofol and remifentanil dosage, and patient satisfaction.

RESULTS

Univariate analysis showed fewer cardiopulmonary complications in the BIS group (41.11% vs 57.78% in controls; p = 0.02). Multivariate analysis found a significantly higher risk of adverse events in older patients (95% CI, 1.013-1.091; p = 0.0087) and in men (95% CI, 1.129-7.668; p = 0.0272). These events were observed at the hepatic flexure. No significant differences between propofol or remifentanil dosage, use of rescue medication, and patient satisfaction were observed between groups.

CONCLUSIONS

Our data suggest that BIS monitoring during sedation in scheduled colonoscopies reduces adverse respiratory events. Although its routine use in sedation does not appear to be warranted, clinicians should take steps to identify patients with a higher risk of complications who might benefit from this type of monitoring.

Feasibility and safety of deep sedation with propofol and remifentanil in spontaneous breathing during endoscopic retrograde cholangiopancreatography: an observational prospective study

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is an interventional procedure that requires deep sedation or general anaesthesia. The purpose of this prospective observational study was to assess the feasibility and safety of deep sedation in ERCP to maintain spontaneous breathing.

METHODS

This is a single-centre observational prospective cohort study conducted in a tertiary referral university hospital. All consecutive patients who needed sedation or general anaesthesia for ERCP were included from January 2021 to June 2021. Deep sedation was achieved and maintained by continuous infusion of an association of propofol and remifentanil. The primary endpoint was to assess the prevalence of major anaesthesia-related complications, such as arrhythmias, hypotension, gas exchange dysfunction, and vomiting (safety endpoint). Secondary endpoints were: (a) to assess the prevalence of signs of an insufficient level of sedation, such as movement, cough, and hiccups (feasibility endpoint): (b) time needed to achieve the target level of sedation and for recovery from anaesthesia. In order to do so we collect the following parameters: peripheral oxygen saturation, fraction of inspired oxygen, noninvasive systemic blood pressure, heart rate, number of breaths per minute, neurological functions with the use of the bispectral index to determine depth of anaesthesia, and partially exhaustive CO2 end pressure to continuously assess the ventilatory status. The collected data were analysed by several tests: Shapiro-Wilk, Student's t, Tuckey post-hoc, Wilcoxon rank-sum and Kruskall-Wallis ran. Statistical analysis was performed using Stata/BE 17.0 (StataCorp LLC).

RESULTS

114 patients were enroled. Eight patients were excluded because they did not meet the inclusion criteria. We found that all patients were hemodynamically stable: intraoperative mean systolic blood pressure was 139,23 mmHg, mean arterial pressure was on average 106,66 mmHg, mean heart rate was 74,471 bpm. The mean time to achieve the target level of sedation was 63 s, while the mean time for the awakening after having stopped drug infusion was 92 s.

CONCLUSIONS

During ERCP, deep sedation and analgesia using the association of propofol and remifentanil and maintaining spontaneous breathing are safe and feasible, allowing for a safe and quick recovery from anaesthesia.

Efficacy of capnographic and bispectral index monitoring on trans-oral therapeutic endoscopy: A prospective observational study

BACKGROUND AND AIM

Oral therapeutic and invasive endoscopy requires deep sedation to reduce patient distress due to prolonged examination and procedures. The usefulness of capnography and bispectral index (BIS) monitoring in the early hypoxia detection in oral therapeutic and invasive endoscopy has yet to be evaluated. This study aimed to investigate the clinical impact of capnography and BIS monitoring on hypoxic events during oral therapeutic and invasive endoscopic procedures.

METHODS

This is a prospective observational study. Trans-oral non-intubated therapeutic and/or invasive endoscopic procedures were performed with conventional monitoring (pulse oximetry, pulse, and blood pressure) as well as additional monitoring (BIS and end-tidal CO₂ concentration). Hypoxia is defined as oxygen saturation of <90% that lasts >15 s. The clinical impact of capnography and BIS monitoring on hypoxic events during oral therapeutic and invasive endoscopic procedures were investigated with the risk factors for hypoxia in each patient.

RESULTS

Patients with hypoxia had significantly more apneas detected using capnography than other patients. The multivariate analysis revealed the detected apnea by capnography as an independent risk factor for hypoxia (odds ratio: 3.48[95% confidence interval: 1.24-9.78], P = 0.02). The BIS was not significantly different as a risk factor for hypoxia; however, per-event analysis revealed significantly decreased BIS values over time in 3 min before hypoxic events.

CONCLUSIONS

Apnea detected by capnography was an independent predictor of hypoxia. The BIS value was not associated with hypoxia events; however, it showed a significant downward trend before hypoxia events.

Efficacy and safety of remifentanil for endoscopic ultrasound-guided tissue acquisition: a single center retrospective study

BACKGROUND

Remifentanil is a rapid onset and rapid recovery opioid. The combination of remifentanil and propofol for deep sedation decreases the incidents of movement, cough, and hiccup. We evaluated the efficacy and safety of remifentanil during endoscopic ultrasound-guided tissue acquisition.

METHODS

We retrospectively reviewed patients in whom endoscopic ultrasound-guided tissue acquisition was performed for solid mass lesions of the upper gastrointestinal tract and adjacent organs. All patients were premedicated with midazolam (2 mg), and target-controlled infusion of propofol, opioid, and Bispectral Index (BIS) monitoring were administered as necessary to maintain moderate-to-deep sedation. The opioids used were a bolus of alfentanil or remifentanil infusion. The discharge time, consumption of propofol and opioid, adverse events, diagnostic accuracy, and sensitivity and specificity for malignancy, were compared.

RESULTS

Tissue acquisition was achieved in 123 patients (alfentanil group, n = 64; remifentanil group, n = 59). The discharge time of the remifentanil group (16.5 ± 3.2 min) was significantly shorter than that of the alfentanil group (19.0 ± 4.9 min, P = 0.001). The consumption of propofol, adverse events, diagnostic accuracy, sensitivity, and specificity for malignancy in the alfentanil group were not significantly different from those in the remifentanil group.

CONCLUSIONS

Use of alfentanil or remifentanil for target-controlled infusion of propofol-BIS monitoring can provide good sedative and diagnostic quality for endoscopic ultrasound-guided tissue acquisition. However, remifentanil resulted in faster recovery than alfentanil.

Incidence rates, risk factors, and outcomes of aspiration pneumonia after gastric endoscopic submucosal dissection: A systematic review and meta-analysis

BACKGROUND AND AIM

The risk and prognosis of aspiration pneumonia (AP) after endoscopic submucosal dissection (ESD) are inconsistent among studies. We aim to estimate the incidence, risk factors, and outcome of AP in patients after gastric ESD.

METHODS

PubMed, EMBASE, Cochrane Library, and Web of Knowledge were searched for relevant articles from inception until April 2020. Data involving the incidence, risk factors, and outcomes were extracted. Pooled incidence, odds ratios (ORs), or standardized mean difference (SMD) and 95% confidence intervals (CIs) were calculated.

RESULTS

Forty records involving 48 674 subjects were finally included. The pooled incidence of AP after gastric ESD was 1.9% (95% CI, 1.2-2.7) via the double arcsine transformation method and 1.6% (1.1-2.5%) via the logit transformation method. Risk factors analyses revealed that old age (OR, 2.52; 95% CI, 1.99-3.18), comorbid pulmonary disease (2.49; 1.66-3.74), comorbid cerebrovascular disease (2.68; 1.05-6.85), remnant stomach (4.91; 1.83-13.14), sedation with propofol (2.51; 1.48-4.28), and long procedural duration (count data: 5.20, 1.25-21.7; measurement data: 1.01, 1.01-1.02) were related to the occurrence of AP. Patients with AP had a longer hospital stay (SMD, 0.56; 95% CI, 0.25-0.87) than those without AP.

CONCLUSIONS

About 1.9% (1.2-2.7%) of the patients who receive gastric ESD may develop AP, resulting in prolonged hospital stay. More attention should be paid in patients who are older; have comorbidities such as pulmonary diseases, cerebrovascular diseases, or gastric remnant; or require a long procedural duration or deep sedation with propofol.

The effect of pre-procedure anxiety on sedative requirements for sedation during upper gastrointestinal endoscopy

Objectives

Sedation for upper gastrointestinal endoscopy, commonly used for diagnosis and treatment of gastrointestinal diseases, has been increasing widespread. Sedative agent requirements during sedation or anesthesia can be affected by many factors such as age and sex. In the present study, we aimed to evaluate the effects of pre-procedural anxiety levels on sedative requirements during upper gastrointestinal endoscopy.

Material and Methods

300 patients between the ages of 18-70 years were studied. Baseline anxiety levels were measured before the procedure using Spielberger's State-Trait Anxiety Inventory (STAI) form X1. Propofol was administered to have BIS values between 65-85 during sedation. Doses of propofol, total procedure time, satisfaction of the patients and endoscopists and BIS values were recorded.

Results

Pre-procedural anxiety was 44 (40-48 [20-70]). We found significant correlations between pre-procedure anxiety and the usage of propofol (mg, mg/kg, mg/kg/dk) at BIS values between 65-85, [respectively, (p= 0.451, p <0.001), (p= 0.455, p <0.001), (p= 0.428, p <0.001)]. No correlation was found between pre-procedure anxiety and procedural or sedation complications (respectively p= 0.111, p= 0.424 and p= 0.408, p= 0.363). We found significant negative correlations between pre-procedure anxiety and the satisfaction of the patients/endoscopist [respectively, (p= -0.477, p <0.001), (p= -0.495, p <0.001)].

Conclusion

Based on the results of this study, we suggest that there is a significant association between the pre-procedural anxiety levels and use of sedative drugs in patients undergoing upper gastrointestinal endoscopy.

Pulmonary aspiration during procedural sedation: a comprehensive systematic review

Background

Although pulmonary aspiration complicating operative general anaesthesia has been extensively studied, little is known regarding aspiration during procedural sedation.

Methods

We performed a comprehensive, systematic review to identify and catalogue published instances of aspiration involving procedural sedation in patients of all ages. We sought to report descriptively the circumstances, nature, and outcomes of these events.

Results

Of 1249 records identified by our search, we found 35 articles describing one or more occurrences of pulmonary aspiration during procedural sedation. Of the 292 occurrences during gastrointestinal endoscopy, there were eight deaths. Of the 34 unique occurrences for procedures other than endoscopy, there was a single death in a moribund patient, full recovery in 31, and unknown recovery status in two. We found no occurrences of aspiration in non-fasted patients receiving procedures other than endoscopy.

Conclusions

This first systematic review of pulmonary aspiration during procedural sedation identified few occurrences outside of gastrointestinal endoscopy, with full recovery typical. Although diligent caution remains warranted, our data indicate that aspiration during procedural sedation appears rare, idiosyncratic, and typically benign.

Predictors of dysfunction and health-related quality of life in the flexion pattern subgroup of patients with chronic lower back pain: The STROBE study

Findings about predictors of chronic lower-back pain (CLBP) were inconsistent and inconclusive in previous studies because patients with CLBP are heterogeneous. Subgrouping patients with CLBP, according to a CLBP classification system, might thus clarify the research findings. CLBP in the direction of lumbar flexion movement, that is, the flexion pattern, is common in clinical situations. Therefore, the purpose of this study was to determine the predictors of dysfunction (pain, disability) and health-related quality of life in the flexion pattern subgroup of patients with CLBP.A cross-sectional study of prospectively collected data. One hundred eight subjects in the flexion pattern subgroup of CLBP. Thirteen variables were measured: the visual analog scale (VAS), the Oswestry Disability Index (ODI), the Short Form-36 (SF-36), the Beck Depression Inventory (BDI), hip internal rotation range of motion, hip flexion range of motion, knee extension range of motion, knee extension with dorsiflexion range of motion, ratio forward flexion, knee extension strength, hip extension strength, hip flexion strength, and lumbopelvic stability.The models for predictors of lower-back pain in the CLBP flexion pattern subgroup included knee extension and the BDI as predictor variables that accounted for 8.1% of the variance in the VAS (P < .05); predictors for disability included the BDI, age, and hip flexion strength, which accounted for 21.2% of the variance in the ODI (P < .05); predictors for health-related quality of life included the BDI, sex, knee extension with dorsiflexion range of motion, and age, which accounted for 38.8% of the variance in the SF-36 (P < .05) in multiple regression models with a stepwise selection procedure.The current results suggest that knee extension, the BDI, age, hip flexion strength, knee extension with dorsiflexion, and sex should be considered when determining appropriate prediction, prevention, and intervention in the flexion pattern subgroup of patients with CLBP.

Depth of anaesthesia monitoring during procedural sedation and analgesia: A systematic review and meta-analysis

OBJECTIVES

Processed electroencephalogram-based depth of anaesthesia monitoring devices provide an additional method to monitor level of consciousness during procedural sedation and analgesia. The objective of this systematic review was to determine whether using a depth of anaesthesia monitoring device improves the safety and efficacy of sedation.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Electronic databases (CENTRAL; Medline; CINAHL) were searched up to May 2015.

REVIEW METHODS

Randomised controlled trials that compared use of a depth of anaesthesia monitoring device to a control group who received standard monitoring during procedural sedation and analgesia were included. Study selection, data extraction and risk of bias assessment (Cochrane risk of bias tool) were performed by two reviewers. Safety outcomes were hypoxaemia, hypotension and adverse events. Efficacy outcomes were amount of sedation used, duration of sedation recovery and rate of incomplete procedures.

RESULTS

A total of 16 trials (2138 participants) were included. Evidence ratings were downgraded to either low or moderate quality due to study limitations and imprecision. Meta-analysis of 8 trials (766 participants) found no difference in hypoxaemia (RR 0.87; 95% CI=0.67-1.12). No statistically significant difference in hypotension was observed in meta-analysis of 8 trials (RR 0.96; 95% CI=0.54-1.7; 942 participants). Mean dose of propofol was 51mg lower for participants randomised to depth of anaesthesia monitoring (95% CI=-88.7 to -13.3mg) in meta-analysis of results from four trials conducted with 434 participants who underwent interventional endoscopy procedures with propofol infusions to maintain sedation. The difference in recovery time between depth of anaesthesia and standard monitoring groups was not clinically significant (standardised mean difference -0.41; 95% CI=-0.8 to -0.02; I²=86%; 8 trials; 809 participants).

CONCLUSIONS

Depth of anaesthesia monitoring did impact sedation titration during interventional procedures with propofol infusions. For this reason, it seems reasonable for anaesthetists to utilise a depth of anaesthesia monitoring device for select populations of patients if it is decided that limiting the amount of sedation would be beneficial for the individual patient. However, there is no need to invest in purchasing extra equipment or training staff who are not familiar with this technology (e.g. nurses who do not routinely use a depth of anaesthesia monitoring device during general anaesthesia) because there is no high quality evidence suggestive of clear clinical benefits for patient safety or sedation efficacy.

Bispectral Index Versus Standard Monitoring in Sedation for Endoscopic Procedures: A Systematic Review and Meta-Analysis

BACKGROUND

Bispectral index (BIS ) monitoring has been used as an objective measurement tool for sedation depth and has been proposed as a guidance to reduce the risk of intraprocedural over-sedation. However, the results of several studies evaluating the benefits of BIS monitoring for gastrointestinal endoscopy were not consistent.

AIMS

This meta-analysis aimed to assess the reduction in total consumption of administrated propofol and recovery time under BIS during gastrointestinal endoscopy.

METHODS

Electronic databases (MEDLINE, EMBASE, WEB of SCIENCE, and the Cochrane Central Register of Controlled Trials) were searched for articles published through March 2015. After screening, the reviewers extracted information on 11 randomized controlled trials. A total of 1039 patients (526 in BIS and 513 in non-BIS group) were included in this study.

RESULTS

Meta-analyses showed that the total propofol consumption (the pooled standardized mean difference [SMD]: -0.15, 95% confidence interval [CI]: -0.28 to -0.01) was significantly lower in the BIS group than in the non-BIS group, although mean propofol consumption was not significantly different. Recovery time (the pooled SMD: -0.04 [95% CI -0.46 to 0.38, P = 0.85]), procedure time (the pooled SMD: 0.13 [95% CI -0.03 to 0.29, P = 0.11]), adverse events, and satisfaction-related outcomes were not significantly superior in the BIS group when compared with the non-BIS group.

CONCLUSIONS

This first meta-analysis showed that BIS monitoring appears to be an effective and safe method for avoiding unnecessary administration of propofol and for providing adequate sedation during endoscopic procedures.