BIS Targeted Propofol Sparing Effects of Dexmedetomidine Versus Ketamine in Outpatient ERCP: A Prospective Randomised Controlled Trial

Comparative Efficacy and Safety of Anesthetic and Sedative Regimens for Endoscopic Retrograde Cholangiopancreatography: A Network Meta-Analysis

INTRODUCTION

This study evaluates the efficacy and safety of various anesthetic and sedative regimens for endoscopic retrograde cholangiopancreatography (ERCP) procedures.

METHODS

A systematic search was conducted across PubMed, Web of Science, Scopus, and Embase to identify randomized controlled trials (RCTs) published until March 2024. Primary outcomes included procedure time, patient satisfaction, oxygen saturation (SpO2), incidence of SpO2 below 90%, and adverse events. The analysis was performed using R software, analyzing continuous outcomes with mean differences and dichotomous outcomes with risk ratios.

RESULTS

42 RCTs were included. Combination therapies such as remifentanil plus tramadol and propofol plus midazolam plus pethidine demonstrated significantly shorter procedure times. Propofol plus oxycodone yielded higher patient satisfaction. Oxygenation results indicated that propofol plus fentanyl, oxycodone, and ketamine improved SpO2. Propofol plus oxycodone (RR <0.01), dexmedetomidine plus fentanyl (RR <0.01), propofol plus nalbuphine (RR = 0.01), Mg sulfate plus propofol (RR = 0.01), and propofol plus fentanyl (RR = 0.02) showed a significant lower rate of patients with SpO2 below 90% compared to propofol. Midazolam plus pethidine plus dexmedetomidine (RR = 0.01), propofol plus oxycodone (RR = 0.09), and dexmedetomidine plus fentanyl (RR = 0.2) exhibited lower rates of adverse events compared to propofol.

CONCLUSION

This study provides comprehensive evidence to guide clinical decision-making and optimize anesthetic management for ERCP procedures.

INTRODUCTION

This study evaluates the efficacy and safety of various anesthetic and sedative regimens for endoscopic retrograde cholangiopancreatography (ERCP) procedures.

METHODS

A systematic search was conducted across PubMed, Web of Science, Scopus, and Embase to identify randomized controlled trials (RCTs) published until March 2024. Primary outcomes included procedure time, patient satisfaction, oxygen saturation (SpO2), incidence of SpO2 below 90%, and adverse events. The analysis was performed using R software, analyzing continuous outcomes with mean differences and dichotomous outcomes with risk ratios.

RESULTS

42 RCTs were included. Combination therapies such as remifentanil plus tramadol and propofol plus midazolam plus pethidine demonstrated significantly shorter procedure times. Propofol plus oxycodone yielded higher patient satisfaction. Oxygenation results indicated that propofol plus fentanyl, oxycodone, and ketamine improved SpO2. Propofol plus oxycodone (RR <0.01), dexmedetomidine plus fentanyl (RR <0.01), propofol plus nalbuphine (RR = 0.01), Mg sulfate plus propofol (RR = 0.01), and propofol plus fentanyl (RR = 0.02) showed a significant lower rate of patients with SpO2 below 90% compared to propofol. Midazolam plus pethidine plus dexmedetomidine (RR = 0.01), propofol plus oxycodone (RR = 0.09), and dexmedetomidine plus fentanyl (RR = 0.2) exhibited lower rates of adverse events compared to propofol.

CONCLUSION

This study provides comprehensive evidence to guide clinical decision-making and optimize anesthetic management for ERCP procedures.

Efficacy and safety of sedation with dexmedetomidine in adults undergoing gastrointestinal endoscopic procedures: systematic review and meta-analysis of randomized controlled trials

Background: The sedative role of dexmedetomidine (DEX) in gastrointestinal endoscopic procedures is unclear. We performed this systematic review and meta-analysis to assess the efficacy and safety of sedation with DEX during gastrointestinal endoscopic procedures with a view to providing evidence-based references for clinical decision-making. Methods: The PubMed, Embase, Cochrane Library, Web of Science, and ClinicalTrials.gov databases were searched for randomized controlled trials (RCTs) that compared DEX with different sedatives comparators (such as propofol, midazolam, and ketamine) for sedation in a variety of adult gastrointestinal endoscopic procedures from inception to 1 July 2022. Standardized mean difference (SMD) and weighted mean difference (WMD) with 95% confidence interval (CI) or pooled risk ratios (RR) with 95% CI were used for continuous outcomes or dichotomous outcomes, respectively, and a random-effect model was selected regardless of the significance of the heterogeneity. Results: Forty studies with 2,955 patients were assessed, of which 1,333 patients were in the DEX group and 1,622 patients were in the control (without DEX) group. The results suggested that the primary outcomes of sedation level of DEX are comparable to other sedatives, with similar RSS score and patient satisfaction level, and better in some clinical outcomes, with a reduced risk of body movements or gagging (RR: 0.60; 95% CI: 0.37 to 0.97; p = 0.04; I2 = 68%), and a reduced additional requirement for other sedatives, and increased endoscopist satisfaction level (SMD: 0.41; 95% CI: 0.05 to 0.77; p = 0.03; I2 = 86%). In terms of secondary outcomes of adverse events, DEX may benefit patients in some clinical outcomes, with a reduced risk of hypoxia (RR:0.34; 95% CI: 0.20 to 0.55; p < 0.0001; I2 = 52%) and cough (RR: 0.25; 95% CI: 0.12 to 0.54; p = 0.0004; I2 = 0%), no significant difference in the risk of hypotension, while an increased risk of bradycardia (RR: 3.08; 95% CI: 2.12 to 4.48; p < 0.00001; I2 = 6%). Conclusion: This meta-analysis indicates that DEX is a safe and effective sedative agent for gastrointestinal endoscopy because of its benefits for patients in some clinical outcomes. Remarkably, DEX is comparable to midazolam and propofol in terms of sedation level. In conclusion, DEX provides an additional option in sedation for gastrointestinal endoscopic procedures. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/#searchadvanced.

Dexmedetomidine or midazolam in combination with propofol for sedation in endoscopic retrograde cholangiopancreatography: a randomized double blind prospective study

Introduction

Interventional endoscopic procedures, such as endoscopic retrograde cholangiopancreatography (ERCP), often require sedation during the procedure. The most commonly used drugs for this purpose are midazolam and propofol, which are used as sedative and hypnotic agents with minimal analgesic potential.

Aim

To compare the analgesic sedative effects of midazolam-propofol and dexmedetomidine-propofol combinations and their influence on hemodynamic and respiratory variables in patients undergoing ERCP.

Material and methods

Forty adult patients aged 20-78 and undergoing ERCP were randomized to two groups. Patients were premedicated with midazolam (0.05 mg/kg 10 min before the procedure) in group M and with dexmedetomidine (1 μg/kg for 10 min) in group D. Propofol was used for maintenance. The sedation level was monitored using the bispectral index (BIS) to maintain a score between 70 and 80. Hemodynamic and respiratory variables, recovery time and adverse events were recorded.

Results

The hemodynamic and respiratory variables were similar in both groups. Total propofol consumption was significantly lower in the dexmedetomidine group (208.5 ±80.0 vs. 154.5 ±66.7 mg; p = 0.011). The recovery period was shorter in group D (time to achieve the Aldrete score 9 was 9.4 ±2.1 vs. 6.6 ±1.1 min; p < 0.001). Changes in hemodynamic and respiratory variables and adverse events were not different between the two groups.

Conclusions

We found a shorter recovery time and comparable sedative and adverse effects with the dexmedetomidine-propofol combination compared with the midazolam-propofol combination. Dexmedetomidine in combination with propofol may be a safe and useful alternative for sedation for ERCP patients.

Comparative Evaluation of Dexmedetomidine versus Midazolam as Premedication to Propofol Anesthesia in Endoscopic Retrograde Cholangiopancreatography

Background:

Endoscopic retrograde cholangiopancreatography (ERCP) is used to diagnose and treat pancreaticobiliary diseases. It is a potentially uncomfortable procedure that needs to be performed under conscious sedation. Safe and effective sedation protocol is the need of an hour.

Aims:

This study aims to evaluate the requirement of propofol using midazolam and dexmedetomidine as premedication for ERCP. The degree of comfort experienced by endoscopist and the patients was also assessed.

Materials and Methods:

A total of sixty patients were enrolled in a randomized, assessor-blinded study in the age group of 40–80 years, American Society of Anesthesiologists physical class II–III undergoing elective ERCP procedures. They were divided into two groups of 30 each. Group D (n = 30): Dexmedetomidine (100 μg/mL + 18 mL saline) loading dose at 1 μg/kg intravenous (IV) over 10 min followed by 0.5 μg/kg/h infusion, and Group M (n = 30): Midazolam at 0.05 mg/kg IV bolus over 10 min followed by normal saline infusion under hemodynamic monitoring. Satisfaction scores, total propofol requirement, and complications such as gagging, restlessness, agitation, postoperative nausea and vomiting were noted and analyzed statistically.

Statistical Analysis:

Statistical analysis was performed using SSPS 17.0 software (SPSS Inc., 233 South Wacker Drive, Chicago, USA). The Chi-square test was applied for nonparametric data and parametric numerical data, unpaired t-test for intergroup comparison, and repeated measures ANOVA for intragroup comparison. Results were expressed as a mean ± standard deviation. Value of P < 0.05 was considered statistically significant and <0.001 as highly significant.

Results:

Surgeons and patients were more satisfied and comfortable along with less requirement of propofol in the dexmedetomidine group. The incidence of complications was also less in the dexmedetomidine group as compared to that of midazolam group.

Conclusion:

Both dexmedetomidine and midazolam can be safely administered as an anesthetic adjuvant to propofol for short procedures like ERCP's. Dexmedetomidine provided intense and better sedation quality along with lesser requirement of propofol doses. Moreover, it provided stable hemodynamic conditions and good recovery characteristics as compared to midazolam group.

Efficacy of a Dexmedetomidine-Remifentanil Combination Compared with a Midazolam-Remifentanil Combination for Conscious Sedation During Therapeutic Endoscopic Retrograde Cholangio-Pancreatography: A Prospective, Randomized, Single-Blinded Preliminary Trial

BACKGROUND

Dexmedetomidine as a conscious sedative exhibits both analgesia and respiratory sparing effects.

AIMS

We evaluated and compared the sedative effect and the safety of a dexmedetomidine-remifentanil (DR) regimen with a midazolam-remifentanil (MR) combination during the endoscopic retrograde cholangio-pancreatography (ERCP) requiring conscious sedation.

METHODS

One-hundred and ninety-eight patients were randomized and divided into two groups. A bolus of midazolam (0.05 mg kg^-1) was injected intravenously for MR group, and dexmedetomidine (1 μg kg^-1) was pumping for 10 min for DR group. Next, an initial loading dose of 1 μg kg^-1 and 0.05-0.2 μg kg^-1 min^-1 of remifentanil was administered in all patients. Hemodynamic and respiratory changes, Ramsay Sedation Scale, Visual Analogue Scale, endoscopist and patient satisfaction were assessed. Furthermore, adverse events as well as recovery time and discharge time were rated.

RESULTS

Patient satisfaction scores were significantly higher in the DR group compared with MR group. The occurrence of desaturation was statistically higher, and the operation time was longer in the MR group. Although no statistically significant values could be determined between the two groups about amnesia and need of additional drug, the DR group was found to require a significantly reduced amount of extra midazolam. Furthermore, nausea during catheterization of oropharynx was found to be more pronounced in the DR group.

CONCLUSIONS

The dexmedetomidine-remifentanil protocol provided a parallel sedative efficacy and improved respiratory sparing effects. The higher patient satisfaction scores potentially offer a more reproducible ERCP quality. Adding dexmedetomidine to remifentanil can be used safely as a conscious sedation method during ERCP.

Effect of different doses of dexmedetomidine on hemodynamic and respiratory parameters in elderly patients undergoing endoscopic retrograde cholangiopancreatography

AIM

To investigate the effect of different doses of dexmedetomidine on hemodynamic and respiratory parameters in elderly patients undergoing endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

From August 2015 to July 2017, 104 elderly patients who underwent ERCP at our hospital were randomly divided into a control group (n = 26), a low-dose group (n = 26), a middle-dose group (n = 26), and a high-dose group (n = 26). The control group was given fentanyl, and the low-, middle-, and high-dose groups were intravenously injected with dexmedetomidine at 0.4, 0.7, and 1 μg/kg, respectively. Propofol dosage, operative time, time to recovery, hemodynamic and respiratory parameters [respiratory rate (RR), heart rate (HR), diastolic blood pressure (DBP), and systolic blood pressure (SBP)] at different time points [preoperative (T0), fentanyl or dexmedetomidine infusion completion (T1), duodenal endoscopy into the esophagus (T2)], serum cortisol (Cor) level, and incidence of adverse reactions in the four groups were recorded.

RESULTS

There was a significant difference in the dosage of propofol among the four groups (P < 0.05). There was no significant difference in operative time or time to recovery among the four groups. In the middle-dose group, the dosage of propofol was less than those of the other groups (P < 0.05). There was no significant difference in DBP, SBP, HR, or RR at T0 among the four groups, but there was a significant difference among the four groups in DBP, SBP, HR, and RR at T1 and T2 (P < 0.05); the amplitude of each index in the middle-dose group was significantly lower than that of the other groups (P < 0.05). There was no significant difference in the levels of serum Cor among the four groups at T0, but there was a significant difference in serum Cor levels among the four groups at T1 and T2 (P < 0.05). The increase of serum Cor in the middle-dose group was significantly smaller than that of the other groups (P < 0.05). There was a significant difference in the incidence of adverse reactions among the four groups (P < 0.05), and the incidence of adverse reactions in the control group was higher than that of the other three groups (P < 0.05).

CONCLUSION

Anesthesia with a moderate dose of dexmedetomidine in ERCP can reduce the dosage of propofol, has no impact on operative time and time to recovery, and can avoid the influence on hemodynamics and respiratory conditions in elderly patients, with little stress response, few adverse reactions, and high safety.

Sedative and Analgesic Effects of Propofol-Fentanyl Versus Propofol-Ketamine During Endoscopic Retrograde Cholangiopancreatography: A Double-Blind Randomized Clinical Trial

Background

Endoscopic retrograde cholangiopancreatography (ERCP) is a painful procedure that requires analgesia and sedation.

Objectives

In this study, we compared the analgesic and sedative effects of propofol-ketamine versus propofol-fentanyl in patients undergoing ERCP.

Methods

In this clinical trial, 72 patients, aged 30 - 70 years old, who were candidates for ERCP were randomly divided into two groups. Before the start of ERCP, both groups received midazolam 0.5 - 1 mg. The intervention group (PK) received ketamine 0.5 mg/kg, and the control group (PF) received fentanyl 50 - 100 micrograms. All patients received propofol 0.5 mg/kg in a loading dose followed by 75 mcg/kg/minute in an infusion. The patients, the anesthesiologist, and the endoscopist were unaware of the medication regimen. Sedation and analgesia quality (based on a VAS), blood pressure, respiratory rate, heart rate, arterial oxygen saturation, recovery time (based on Aldrete scores), and endoscopist and patient satisfation were recorded.

Results

The sedative effects were equal in the two groups (P > 0.05), but the analgesic effects were higher in the PF group than in the PK group (P < 0.05). The PK group had higher blood pressure levels in the eighth minute. Respiratory rate, heart rate, and arterial oxygen saturation showed no significant differences between the groups (P > 0.05). Endoscopist satisfaction, patient satisfaction, and recovery time showed no significant differences between the two groups (P > 0.05).

Conclusions

The results showed that the sedative effect of propofol-ketamine was equal to the propofol-fentanyl combination during ERCP. To prevent respiratory and hemodynamic complications during ERCP, the propofol-ketamine combination should be used in patients with underlying disease.

Dexmedetomidine in gastrointestinal endoscopic procedures

Gastrointestinal endoscopy is the gold standard in the examination and the treatment of the diseases of gastrointestinal system, but the disadvantage of being painful process. At this point the sedative and analgesic agents may be important. Dexmedetomidine is a new sedoanalgesic agent which is alternative to benzodiazepines and opioids. It has analgesia, amnesia, sedative and anxiolytic properties. The use of dexmedetomidine as the sole anesthetic agent and as the adjuvant analgesic agent has been published but has not been approved because of the inconsistency of efficacy and safety. The author has been collected the published papers in the literature. This article is aimed to describe the use of dexmedetomidine in various gastrointestinal endoscopic procedures.