Fentanyl and diazepam in endoscopy of the upper gastrointestinal tract

Meperidine for patients expected to have poor tolerance to esophagogastroduodenoscopy: A double-blind, randomized, controlled study

Background

Anxious patients and those with poor tolerance to previous esophagogastroduodenoscopy (EGD) usually have poor tolerance for EGD.

Aims

To investigate the effect of meperidine on these patients during EGD.

Methods

A total of 110 patients undergoing diagnostic EGD were randomized to receive either meperidine (n = 55) or placebo (n = 55) before EGD. The primary outcome was patient discomfort scores during esophageal intubation.

Results

Patients in the meperidine group reported less discomfort during esophageal intubation (median score of 5.0 and interquartile range (IQR) 1.5-7.0) compared with the control (median score of 6.0, IQR 5.0-8.5, P = .003). Patients in the meperidine group had better tolerance during the procedure (median score of 2 (IQR 1.0-3.0) versus 3 (IQR 1.0-4.0), P = .048), and the endoscopists reported higher overall satisfaction scores (median score of 9 (IQR 7.0-9.0) versus 8 (IQR 7.0-9.0), P = .043). There was significantly less increase in heart rate and blood pressure during the procedure in the meperidine group than in the placebo group (23 bpm (IQR 9-32) versus 30 bpm (IQR 18-52); P = .006); (7 mmHg (IQR 1-14) versus 18 mmHg (IQR 2-30); P = .008). Connect-the-numbers test showed comparable results before and after EGD between the two groups.

Conclusion

For patients expected to have poor tolerance during EGD, meperidine reduced discomfort, decreased cardiovascular distress, and improved endoscopist satisfaction, without adverse effects on their psychomotor function after the procedure.

Removing Meperidine from the Health-System Formulary—Frequently Asked Questions

Meperidine is FDA-approved for relieving moderate to severe pain and has been widely used since its introduction in the 1930s. However, the drug is no longer considered a first-line analgesic. Many clinicians recommend that meperidine be removed from health-systems or that its use be restricted, due to concerns about adverse reactions, drug interactions, and normeperidine neurotoxicity. In addition, clinical evidence shows that meperidine has no advantage over other opioids for biliary colic or pancreatitis. The formulary status of meperidine has been extensively discussed at University of Utah Hospitals and Clinics. The Pharmacy and Therapeutics Committee has been working with hospital staff to assess the impact of either removing meperidine from the formulary, or limiting its use. The Drug Information Service developed this document to help pharmacists respond to prescribers' questions and to alleviate the prescribers' concerns about these changes. Information is provided comparing meperidine with other opioids, including dosage equivalency, pharmacodynamics, pharmacokinetics, cost, adverse effects, and drug interactions. Where available, alternatives to meperidine are suggested for various indications.

A systematic review and meta-analysis of randomized, controlled trials of moderate sedation for routine endoscopic procedures

BACKGROUND

Numerous agents are available for moderate sedation in endoscopy.

OBJECTIVE

Our purpose was to compare efficacy, safety, and efficiency of agents used for moderate sedation in EGD or colonoscopy.

DESIGN

Systematic review of computerized bibliographic databases for randomized trials of moderate sedation that compared 2 active regimens or 1 active regimen with placebo or no sedation.

PATIENTS

Unselected adults undergoing EGD or colonoscopy with a goal of moderate sedation.

MAIN OUTCOME MEASUREMENTS

Sedation-related complications, patient assessments (satisfaction, pain, memory, willingness to repeat examination), physician assessments (satisfaction, level of sedation, patient cooperation, examination quality), and procedure-related efficiency outcomes (sedation, procedure, or recovery time).

RESULTS

Thirty-six studies (N = 3918 patients) were included. Sedation improved patient satisfaction (relative risk [RR] = 2.29, range 1.16-4.53) and willingness to repeat EGD (RR = 1.25, range 1.13-1.38) versus no sedation. Midazolam provided superior patient satisfaction to diazepam (RR = 1.18, range 1.07-1.29) and less frequent memory of EGD (RR = 0.57, range 0.50-0.60) versus diazepam. Adverse events and patient/physician assessments were not significantly different for midazolam (with or without narcotics) versus propofol except for slightly less patient satisfaction (RR = 0.90, range 0.83-0.97) and more frequent memory (RR = 3.00, range 1.25-7.21) with midazolam plus narcotics. Procedure times were similar, but sedation and recovery times were shorter with propofol than midazolam-based regimens.

LIMITATIONS

Marked variability in design, regimens tested, and outcomes assessed; relatively poor methodologic quality (Jadad score </=3 in 23/36 trials).

CONCLUSIONS

Moderate sedation provides a high level of physician and patient satisfaction and a low risk of serious adverse events with all currently available agents. Midazolam-based regimens have longer sedation and recovery times than does propofol.

Review article: premedication and intravenous sedation for upper gastrointestinal endoscopy

Upper gastrointestinal endoscopy can be performed without intravenous sedation but the evidence suggests that, in the United Kingdom and United States, most patients and endoscopists prefer that some form of premedication is given. Intravenous diazepam or midazolam are used by the majority of endoscopists. In the UK, the ratio of diazepam to midazolam users is approximately 2:1, while in the USA more endoscopists are now using midazolam. Midazolam is approximately twice as potent as diazepam but, when allowance is made for this, there is probably little or no difference in the propensity of the two drugs to produce respiratory depression. The antegrade amnesic effect of midazolam is significantly superior to that of diazepam. A benzodiazepine/narcotic combination can achieve a smoother and more rapid induction with less gagging and choking, but the incidence of adverse outcomes--particularly respiratory depression--is increased significantly. Over 50% of the deaths that are associated with upper gastrointestinal endoscopy are due to cardiopulmonary problems. Hypoxia is very common if measured using non-invasive monitoring equipment, such as a pulse oximeter. Methods of preventing oxygen desaturation and thus, by inference, most cardiac arrhythmias associated with endoscopy are discussed, as is the role of flumazenil, the new benzodiazepine antagonist.

The safety of fentanyl use in the emergency department

Fentanyl citrate is a synthetic narcotic 1,000 times as potent as meperidine. It produces minimal hemodynamic effects and is characterized by a rapid onset of sedation and analgesia, a relatively short duration of action (approximately 30 to 40 minutes), and rapid reversal with opiate antagonists. These properties make fentanyl an ideal drug for emergency department use. The safety of fentanyl use in an adult ED population has not previously been studied. We retrospectively reviewed the charts of 841 patients who received fentanyl at the University of Cincinnati Center for Emergency Care between January 1985 and June 1988. The study population included 497 (59%) men and 344 (41%) women, with an average age of 33 years. The average dose of fentanyl was 180 micrograms (range, 25 to 1,400 micrograms). Six patients (1%) experienced mild side effects including nausea (one), emesis (two), urticaria (one), and pruritus (two). Nine patients (1%) developed more serious complications including six cases (0.7%) of respiratory depression and three cases (0.4%) of hypotension. Two of 183 patients (1%) who received midazolam and two of nine patients (22%) who received haloperidol developed respiratory depression. Four of the six patients with respiratory depression and two of the three patients with hypotension were intoxicated. All of the complications were transient, and none resulted in hospitalization. We conclude that fentanyl is a safe drug for use in the ED. To maximize safety, we recommend careful dosing and titration, close patient monitoring, and the availability of naloxone hydrochloride and resuscitation equipment.(ABSTRACT TRUNCATED AT 250 WORDS)

Upper gastrointestinal endoscopy without sedation: a prospective study of 2000 examinations

Various drugs are used for sedation prior to upper gastrointestinal endoscopy, some with undesirable side effects. In an attempt to avoid these side effects, 2000 upper diagnostic gastrointestinal endoscopies were performed in a period of 4 years between 1982 and 1986, without any sedation, using Olympus GIF-Q and GIF-P3 gastroscopes. Anxiety, ease of introduction of gastroscope, tolerance of the procedure, and the overall success of the procedure were assessed. Most patients were calm (81.2%); 94.4% had an easy introduction of the gastroscope, 80.3% tolerated the procedure well; and 94.2% of the endoscopies were completely successful. There were no complications, and only four examinations failed (0.2%). Sedation had to be used (intravenous diazepam) in 32 patients due to excessive anxiety and an inability to introduce the gastroscope and in three children under 10 years (1.6%). The average time needed to complete an endoscopy without sedation was found to be 9.5 min, nearly half of the average time needed before this study when sedation was routinely given. It is concluded that upper gastrointestinal endoscopy without sedation can be a safe, quick, well-tolerated procedure.