Safer colonoscopy with patient-controlled analgesia and sedation with propofol and alfentanil

Comparison of patient-controlled analgesia and sedation (PCAS) with remifentanil and propofol versus total intravenous anesthesia (TIVA) with midazolam, fentanyl, and propofol for colonoscopy

BACKGROUND

Colonoscopy is a commonly performed gastroenterological procedure in patients associated with anxiety and pain. Various approaches have been used to provide sedation and analgesia during colonoscopy, including patient-controlled analgesia and sedation (PCAS). This study aims to evaluate the feasibility and efficiency of PCAS administered with propofol and remifentanil for colonoscopy.

METHODS

This randomized controlled trial was performed in an authorized and approved endoscopy center. A total of 80 outpatients were recruited for the colonoscopy studies. Patients were randomly allocated into PCAS and total intravenous anesthesia (TIVA) groups. In the PCAS group, the dose of 0.1 ml/kg/min of the mixture was injected after an initial bolus of 3 ml mixture (1 ml containing 3 mg of propofol and 10 μg of remifentanil). Each 1 ml of bolus was delivered with a lockout time of 1 min. In the TIVA group, patients were administered fentanyl 1 μg/kg, midazolam 0.02 mg/kg, and propofol (dosage titrated). Cardiorespiratory parameters and auditory evoked response index were continuously monitored during the procedure. The recovery from anesthesia was assessed using the Aldrete scale and the Observer's Assessment of Alertness/Sedation Scale. The Visual Analogue Scale was used to assess the satisfaction of patients and endoscopists.

RESULTS

No statistical differences were observed in the Visual Analogue Scale scores of the patients (9.58 vs 9.50) and the endoscopist (9.43 vs 9.30). A significant decline in the mean arterial blood pressure, heart rate, and auditory evoked response index parameters was recorded in the TIVA group (P < 0.05). The recovery time was significantly shorter in the PCAS group than in the TIVA group (P = 0.00).

CONCLUSION

The combination of remifentanil and propofol could provide sufficient analgesia, better hemodynamic stability, lighter sedation, and faster recovery in the PCAS group of patients compared with the TIVA group.

Randomised Study Comparing the use of Propofol Versus Dexmedetomidine as a Sedative Agent for Patients Presenting for Lower Gastrointestinal Endoscopy

Objectives::

Dexmedetomidine, the alpha 2 agonist sedative and an analgesic agent may be beneficial in sedation for endoscopic intervention. Our aim was to compare the use of dexmedetomidine versus the traditional use of propofol as a sedative agent for colonoscopies.

Methods::

This study included 100 patients presenting for elective colonoscopy under sedation with random and equal allocation of patients into two groups; group P, in which patients received propofol in a loading dose of 1.5 mg/kg and maintenance dose of 0.5 mg/kg/hr, and group D, in which patients received dexmedetomidine at a loading dose of 1ug/kg and maintenance dose of 0.5 ug/kg/hr. In addition to the demographic data, time to recovery, time of discharge, and endoscopist rating were measured. Also, the hemodynamic parameters were recorded, and also the incidence of postoperative complications.

Results::

The basic patients' characteristics, time to recovery, and time of discharge were comparable between the two groups. Moreover, the endoscopist did not significantly report more convenient procedure with one group over the other. Also, there was no significant difference in hemodynamic parameters or in the incidence of complications between the two studied groups. However the use of dexmedetomidine decreased the incidence of hypoxemia.

Conclusion::

The use of dexmedetomidine seems to have a similar effect to the use of propofol as a sedative agent for lower GIT endoscopy with the positive effect of dexmedetomidine in decreasing the incidence of perioperative hypoxemia.

Computer-Assisted and Patient-Controlled Sedation Platforms

As the number and complexity of endoscopic procedures increase, the role of sedation has been integral in patient and physician satisfaction. This article discusses the advances of computer-assisted and patient-controlled platforms. These computer-assisted and patient-controlled platforms use different anesthetics and analgesics, all with the intent of achieving improved consistency in the level of sedation, appropriate to the needs of patients, while also improving patient safety. These systems have been around for decades; however, few are approved for use in the United States, and several still require further study before broad clinical application.

Optimization of Deep Sedation with Spontaneous Respiration for Therapeutic Endoscopy Combining Propofol and Bispectral Index Monitoring. Gastroenterol Res Pract. 2015;2015:282149. [PMID: 26351450 PMCID: PMC4550768 DOI: 10.1155/2015/282149]

Background/Aims. This study aimed to establish optimal propofol anesthesia for therapeutic endoscopy, which has not been established. Methodology. We retrospectively investigated data on 89 patients who underwent upper-GI endoscopic submucosal dissection or endoscopic mucosal resection under anesthesia with propofol. Examined doses of propofol were changed according to efficacy and/or adverse events and classified into 5 periods. A bispectral index (BIS) monitor was used at Period 5 to decrease the incidence of adverse events caused by oversedation. The initial dose of propofol was administered after bolus injection of pethidine hydrochloride (0.5 mg/kg), and 1.0 mL of propofol was added every minute until the patients fell asleep. Continuous and bolus infusion were performed to maintain sedation. When the patient moved or an adverse event occurred, the maintenance dose examined was increased or decreased by 5 mL/h regardless of body weight. Results. Dose combinations (introduction : maintenance) and patient numbers for each period were as follows: Period 1 (n = 27), 0.5 mg/kg : 5 mg/kg/h; Period 2 (n = 11), 0.33 mg/kg : 3.3 mg/kg/h; Period 3 (n = 7), 0.5 mg/kg : 3.3 mg/kg/h; Period 4 (n = 14), 0.5 mg/kg : 2.5 mg/kg/h; Period 5 (n = 30), 0.5 mg/kg : 2.5 mg/kg/h, using BIS monitor. During Period 5, an adverse event occurred in 10.0% of patients, which was lower than that for Periods 1–4. Conclusions. Period 5 propofol anesthesia with BIS protocol could be safe and useful for therapeutic endoscopy under deep sedation with spontaneous respiration.

Intranasal dexmedetomidine in combination with patient-controlled sedation during upper gastrointestinal endoscopy: a randomised trial

BACKGROUND

Sedation using intranasal dexmedetomidine is a convenient and well-tolerated technique. This study evaluated the sedative efficacy of intranasal dexmedetomidine in combination with patient-controlled sedation (PCS) for upper gastrointestinal endoscopy.

METHODS

In this double-blind, randomised, controlled trial, 50 patients received either intranasal dexmedetomidine 1.5 μg/kg (dexmedetomidine group) or intranasal saline (placebo group) 1 h before the procedure. PCS with propofol and alfentanil was provided for rescue sedation. Additional sedative consumption, perioperative sedation scores using Observer's Assessment of Alertness/Sedation (OAA/S) scale, recovery, vital signs, adverse events and patient satisfaction were assessed.

RESULTS

Total consumption of PCS propofol and alfentanil was significantly less in the dexmedetomidine than placebo group with a mean difference of -13.8 mg propofol (95% confidence interval -27.3 to -0.3) and -34.5 μg alfentanil (95% confidence interval -68.2 to -0.7) at the completion of the procedure (P = 0.044). Weighted areas under the curve (AUCw ) of OAA/S scores were significantly lower in the dexmedetomidine group before, during and after procedures (P < 0.001, P = 0.024 and P = 0.041 respectively). AUCw of heart rate and systolic blood pressure were also significantly lower during the procedure (P = 0.007 and P = 0.022 respectively) with dexmedetomidine. There was no difference in recovery, side effects or satisfaction.

CONCLUSION

Intranasal dexmedetomidine with PCS propofol and alfentanil confers deeper perioperative clinical sedation with significantly less use of additional sedatives during upper gastrointestinal endoscopy.

Synergistic antinociceptive interactions between fospropofol and alfentanil in mice

BACKGROUND

Combination therapy, which provides the opportunity to achieve optimal analgesia with reduced side effects at lower drug doses, is a valid approach for the treatment of pain. The analgesic interaction between fospropofol and alfentanil has not been investigated till date. We sought to determine the nature of the interaction between fospropofol and alfentanil in mice models of the formalin test, hot-plate test and the tail-flick test.

METHODS

The effects of fospropofol, alfentanil and their combinations were examined in the formalin-induced paw inflammatory hyperalgesia, the hot-plate test and the tail-flick test in mice. In the three models, dose-response curves were established and their respective ED50 (50% effective dose) values were determined separately for each agent. Fixed-ratio combinations of fospropofol and alfentanil were tested for their combined antinociceptive effects, and the type of interaction was determined by the isobolographic analysis.

RESULTS

Fospropofol, alfentanil and their combination produced a dose-dependent decrease in the number of flinches during phase 1 of the formalin test. In the hot-plate test and in the tail-flick test, fospropofol, alfentanil and their combination significantly and dose dependently prolonged the latency of withdrawal. In the three models, isobolographic analysis revealed a significant synergistic interaction between fospropofol and alfentanil. The ED50 value for the drug combination was significantly lower than the theoretical additive value (p<0.05).

CONCLUSIONS

The results demonstrate that fospropofol and alfentanil provide synergistic antinociceptive interactions in the formalin, hot-plate, and tail-flick tests. The observed synergistic interaction between fospropofol and alfentanil are indicative of the effectiveness of the combination treatment in pain management and should be explored further in patients undergoing minor surgical procedures.

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

PURPOSE

Endoscopic submucosal dissection (ESD) is a technically difficult and lengthy procedure requiring optimal depth of sedation. The bispectral index (BIS) monitor is a non-invasive tool that objectively evaluates the depth of sedation. The purpose of this prospective randomized controlled trial was to evaluate whether BIS guided sedation with propofol and remifentanil could reduce the number of patients requiring rescue propofol, and thus reduce the incidence of sedation- and/or procedure-related complications.

MATERIALS AND METHODS

A total of 180 patients who underwent the ESD procedure for gastric adenoma or early gastric cancer were randomized to two groups. The control group (n=90) was monitored by the Modified Observer's Assessment of Alertness and Sedation scale and the BIS group (n=90) was monitored using BIS. The total doses of propofol and remifentanil, the need for rescue propofol, and the rates of complications were recorded.

RESULTS

The number of patients who needed rescue propofol during the procedure was significantly higher in the control group than the BIS group (47.8% vs. 30.0%, p=0.014). There were no significant differences in the incidence of sedation- and/or procedure-related complications.

CONCLUSION

BIS-guided propofol infusion combined with remifentanil reduced the number of patients requiring rescue propofol in ESD procedures. However, this finding did not lead to clinical benefits and thus BIS monitoring is of limited use during anesthesiologist-directed sedation.

Sedation-analgesia in elective colonoscopy: propofol-fentanyl versus propofol-alfentanil

BACKGROUND AND OBJECTIVES

Sedation-analgesia is recommended for comfortable colonoscopy procedures, which are invasive and can be painful. This study aimed to compare the combinations of propofol-alfentanil and propofol-fentanyl for sedation-analgesia in elective colonoscopy patients.

METHODS

This prospective and randomized study was planned in ASA I-II groups and included 80 patients between the ages of 18 and 65 years. Sedation-analgesia induction was performed as 1 μg.kg-1 fentanyl, 1 mg.kg-1 propofol in the propofol-fentanyl group (Group PF) and 10 μg.kg-1 alfentanil, 1 mg.kg-1 propofol in the propofol-alfentanil group (Group PA). Patients’ scores were limited to 3-4 values on the Ramsey Sedation Scale (RSS) by 0.5 mg.kg-1 bolus additional doses of propofol in sedation-analgesia maintenance. We recorded demographical data, heart rate, mean arterial pressure (MAP), oxygen saturation of hemoglobin (SpO2), RSS value, colonoscopy time, total dose of propofol, complications, recovery time, and discharge time, as well as colonoscopist and patient satisfaction scores.

RESULTS

MAP at the 15th minute in Group PA was signifi cantly higher than in Group PF (p = 0.037). Group PA’s beginning mean heart rate was higher than the mean heart rate at subsequent readings (p = 0.012, p = 0.002). The mean total propofol dose of Group PA was signifi cantly higher than the total dose of Group PF (p = 0.028). The mean recovery time of Group PA was signifi cantly longer than that of Group PF (p = 0.032).

CONCLUSION

Fentanyl provides better operative conditions and reduces the need for additional propofol doses. These advantages cause a shorter recovery time. Therefore, propofol-fentanyl is superior to the propofol-alfentanil for sedation-analgesia in colonoscopy.

Sedation-analgesia in elective colonoscopy: propofol-fentanyl versus propofol-alfentanil. Braz J Anesthesiol. 2013;63:352-357. [PMID: 24565243 DOI: 10.1016/j.bjane.2012.07.007]

BACKGROUND AND OBJECTIVES

Sedation-analgesia is recommended for comfortable colonoscopy procedures, which are invasive and can be painful. This study aimed to compare the combinations of propofol-alfentanil and propofol-fentanyl for sedation-analgesia in elective colonoscopy patients.

METHODS

This prospective and randomized study was planned in ASA I-II groups and included 80 patients between the ages of 18 and 65 years. Sedation-analgesia induction was performed as 1 μg.kg(-1) fentanyl, 1mg.kg(-1) propofol in the propofol-fentanyl group (Group PF) and 10 μg.kg(-1) alfentanil, 1mg.kg(-1) propofol in the propofol-alfentanil group (Group PA). Patients' scores were limited to 3-4 values on the Ramsey Sedation Scale (RSS) by 0.5mg.kg(-1) bolus additional doses of propofol in sedation-analgesia maintenance. We recorded demographical data, heart rate, mean arterial pressure (MAP), oxygen saturation of hemoglobin (SpO2), RSS value, colonoscopy time, total dose of propofol, complications, recovery time, and discharge time, as well as colonoscopist and patient satisfaction scores.

RESULTS

MAP at the 15(th) minute in Group PA was significantly higher than in Group PF (p = 0.037). Group PA's beginning mean heart rate was higher than the mean heart rate at subsequent readings (p = 0.012, p = 0.002). The mean total propofol dose of Group PA was significantly higher than the total dose of Group PF (p = 0.028). The mean recovery time of Group PA was significantly longer than that of Group PF (p = 0.032).

CONCLUSION

Fentanyl provides better operative conditions and reduces the need for additional propofol doses. These advantages cause a shorter recovery time. Therefore, propofol-fentanyl is superior to the propofol-alfentanil for sedation-analgesia in colonoscopy.

Randomized clinical trial of the effect of supplemental opioids in procedural sedation with propofol on serum catecholamines

OBJECTIVES

The objective was to assess the effect on stress biomarkers of supplemental opioid to a standard propofol dosing protocol for emergency department (ED) procedural sedation (PS). The hypothesis was that there is no difference in the change in serum catecholamines between PS using propofol with or without supplemental alfentanil.

METHODS

This was a randomized, nonblinded pilot study of adult patients undergoing PS in the ED for the reduction of fractures and dislocations. Patients with pain before the procedure were treated with intravenous (IV) morphine sulfate until their pain was adequately treated for at least 20 minutes before starting the procedure. Patients were randomized to receive either 10 μg/kg alfentanil followed by 1 mg/kg propofol, followed by 0.5 mg/kg every 3 minutes as needed, or propofol only, dosed in similar fashion without supplemental alfentanil. Doses, vital signs, nasal end-tidal CO2 (ETCO2), pulse oximetry, and bispectral electroencephalogram (EEG) analysis scores were recorded. Subclinical respiratory depression was defined as a change in ETCO2 > 10 mm Hg, an oxygen saturation of < 92% at any time, or an absent ETCO2 waveform at any time. Clinical events related to respiratory depression were noted during the procedure, including the addition of or increase in the flow rate of supplemental oxygen, the use of a bag-valve-mask apparatus, airway repositioning, or stimulation to induce breathing. Blood was drawn 1 minute prior to the administration of the medications for PS and again 1 minute after completion of the procedure for which the patient was sedated. Serum was tested for total catecholamines, epinephrine, norepinephrine, and dopamine. Postprocedure, patients were asked to report any pain perceived during the procedure. Data were analyzed using descriptive statistics, Wilcoxon rank sum tests, and chi-square tests, as appropriate.

RESULTS

Twenty patients were enrolled; 10 received propofol and 10 received propofol with alfentanil. No clinically significant complications were noted. Subclinical respiratory depression was seen in four of 10 (40%) patients in the propofol group and five of 10 (50%) patients in the propofol/alfentanil group (effect size = -10%, 95% confidence interval [CI] = -53% to 33%). There was no difference in the rate of clinical signs of respiratory depression between the two groups. Pain during the procedure was reported by two of 10 (20%) patients in the propofol group and five of 10 (50%) patients in the propofol/alfentanil group (effect size = -30%, 95% CI = -70% to 10%). Recall of some part of the procedure was reported by 0 of 10 (0%) patients in the propofol group and five of 10 (50%) of patients in the propofol/alfentanil group (effect size = -50%, 95% CI = -81% to -19%). There was no difference in the baseline or postprocedure catecholamine levels between the groups.

CONCLUSIONS

No difference in serum catecholamines was detected immediately after PS between patients who receive propofol with and without supplemental opioid in this small pilot study. PS using propofol only without supplemental opioid did not appear to induce markers of physiologic stress in this small pilot study.

Intermittent manually controlled versus continuous infusion of propofol for deep sedation during interventional endoscopy: a prospective randomized trial

INTRODUCTION

Beside the traditional, intermittent bolus application of propofol, continuous propofol infusion via infusion pump is an alternative procedure for deep sedation during long-lasting interventional endoscopy. However, up to now, there are no randomized comparisons for gastrointestinal endoscopy.

METHODS

One hundred patients (ERCP: n = 60, EUS: n = 40) were randomly assigned to receive intermittent bolus application ("bolus group") or continuous infusion ("perfusor group") of propofol sedation after induction with 3 mg midazolam for deep sedation. Patients in the bolus group received an initial propofol dose according to body weight (bw <70 kg: 40 mg; bw ≥ 70 kg 60 mg). In the perfusor group, bw-adapted, continuous propofol infusion (6 mg/kg) via the Injectomat 2000 MC (Fresenius-Kabi) was administered after an initial bolus of 1 mg/kg. Vital signs, dose of propofol, patient cooperation (VAS 1-10), sedation depth, and the recovery time as well as the quality of recovery were evaluated.

RESULTS

Total propofol dose in the bolus group 305 ± 155 mg (100-570 mg) and in the perfusor group 343 ± 123 mg (126-590 mg, p = 0.5) were comparable. Oxygen saturation below 90% was seen in four patients of each group, with no need for assisted ventilation. Arterial blood pressure <90 mmHg was documented in two patients in the bolus group and seven patients in the perfusor group (p = 0.16). Patients' cooperation was rated as good in both groups (bolus group, 9.1 ± 0.9; perfusor group, 8.9 ± 1; p = 0.17). Recovery time was significantly shorter in the bolus group compared with the perfusor group (19 ± 5 versus 23 ± 6 min, p < 0.001) whereas the quality of recovery was nearly identical in both groups.

CONCLUSION

Both sedation regimens allow nearly identical good controllability of propofol sedation. However, recovery time was significantly slower and hypotension was tended to occur more often in the perfusor group.

Sedation-associated hiccups in adults undergoing gastrointestinal endoscopy and colonoscopy

AIM: To investigate whether the incidence of hiccups in patients undergoing esophagogastroduodenoscopy (EGD) or same-day bidirectional endoscopy (EGD and colonoscopy; BDE) with sedation is different from those without sedation in terms of quantity, duration and typical onset time.

METHODS: Consecutive patients scheduled for elective EGD or same-day BDE at the gastrointestinal endoscopy unit or the health examination center were allocated to two groups: EGD without sedation (Group A) and BDE with sedation (Group B). The use of sedation was based on the patients’ request. Anesthesiologists participated in this study by administrating sedative drugs as usual. A single experienced gastroenterologist performed both the EGD and the colonoscopic examinations for all the patients. The incidence, duration and onset time of hiccups were measured in both groups. In addition, the association between clinical variables and hiccups were analyzed.

RESULTS: A total of 435 patients were enrolled in the study. The incidences of hiccups in the patients with and without sedation were significantly different (20.5% and 5.1%, respectively). The use of sedation for patients undergoing endoscopy was still significantly associated with an increased risk of hiccups (adjusted odds ratio: 8.79, P < 0.001) after adjustment. The incidence of hiccups in males under sedation was high (67.4%). The sedated patients who received 2 mg midazolam developed hiccups more frequently compared to those receiving 1 mg midazolam (P = 0.0028). The patients with the diagnosis of gastroesophageal reflux disease (GERD) were prone to develop hiccups (P = 0.018).

CONCLUSION: Male patients undergoing EGD or BDE with sedation are significantly more likely to suffer from hiccups compared to those without sedation. Midazolam was significantly associated with an increased risk of hiccups. Furthermore, patients with GERD are prone to develop hiccups.

Prospective description of coughing, hemodynamic changes, and oxygen desaturation during endoscopic sedation

BACKGROUND

Deep sedation is increasingly used for endoscopy. The impact of sedation level on hemodynamic status, oxygenation, and aspiration risk is incompletely described.

AIMS

To describe the incidence of intraprocedural cough, hemodynamic changes, oxygen desaturation, and their relationship to clinical factors and sedation level.

METHODS

Detailed prospective recordings of hemodynamic changes, oxygen desaturation, and cough during 757 nonemergent endoscopic procedures done under sedation using propofol, midazolam, and/or fentanyl.

RESULTS

Thirteen percent of patients had at least one cough and 3% had prolonged cough. Cough was more common in nonsmokers (P = 0.05), upper endoscopy (P < 0.0001), with propofol (P = 0.0008), longer procedures (P = 0.0001), and hiccups (P = 0.01). The association between supine positioning during colonoscopy and cough approached significance (P = 0.06). Oxygen desaturation was rare (4%) and associated only with deep sedation (P = 0.02). Mean systolic and diastolic blood pressure (BP) dropped by 7.3 and 5.6% respectively. Decreases in systolic BP were more common in whites (P = 0.03), males (P = 0.004), nonsmokers (P = 0.04), during colonoscopy (P < 0.0001), and in patients receiving midazolam and fentanyl (P = 0.01). Heart rate (HR) dropped >20% from baseline in 15% of patients and was more common during colonoscopy (P = 0.002). HR increased >20% in 20% of patients and was more common with coughing (P < 0.0001) and in younger patients (P = 0.0002). No patient required pharmacologic treatment of BP or HR.

CONCLUSIONS

We have described procedural predictors of cough that may help clinicians reduce the risk of aspiration during endoscopy. Hemodynamic changes during endoscopy are common but largely clinically insignificant.

Balanced propofol sedation administered by nonanesthesiologists: The first Italian experience

AIM: To assess the efficacy and safety of a balanced approach using midazolam in combination with propofol, administered by non-anesthesiologists, in a large series of diagnostic colonoscopies.

METHODS: Consecutive patients undergoing diagnostic colonoscopy were sedated with a single dose of midazolam (0.05 mg/kg) and low-dose propofol (starter bolus of 0.5 mg/kg and repeated boluses of 10 to 20 mg). Induction time and deepest level of sedation, adverse and serious adverse events, as well as recovery times, were prospectively assessed. Cecal intubation and adenoma detection rates were also collected.

RESULTS: Overall, 1593 eligible patients were included. The median dose of propofol administered was 70 mg (range: 40-120 mg), and the median dose of midazolam was 2.3 mg (range: 2-4 mg). Median induction time of sedation was 3 min (range: 1-4 min), and median recovery time was 23 min (range: 10-40 min). A moderate level of sedation was achieved in 1561 (98%) patients, whilst a deep sedation occurred in 32 (2%) cases. Transient oxygen desaturation requiring further oxygen supplementation occurred in 8 (0.46%; 95% CI: 0.2%-0.8%) patients. No serious adverse event was observed. Cecal intubation and adenoma detection rates were 93.5% and 23.4% (27.8% for male and 18.5% for female, subjects), respectively.

CONCLUSION: A balanced sedation protocol provided a minimalization of the dose of propofol needed to target a moderate sedation for colonoscopy, resulting in a high safety profile for non-anesthesiologist propofol sedation.

European Society of Gastrointestinal Endoscopy, European Society of Gastroenterology and Endoscopy Nurses and Associates, and the European Society of Anaesthesiology Guideline: Non-anaesthesiologist administration of propofol for GI endoscopy. Eur J Anaesthesiol. 2010;27:1016-1030. [PMID: 21068575 DOI: 10.1097/eja.0b013e32834136bf]

Propofol sedation by non-anaesthesiologists is an upcoming sedation regimen in several countries throughout Europe. Numerous studies have shown the efficacy and safety of this sedation regimen in gastrointestinal endoscopy. Nevertheless, this issue remains highly controversial. The aim of this evidence- and consensus-based set of guideline is to provide non-anaesthesiologists with a comprehensive framework for propofol sedation during digestive endoscopy. This guideline results from a collaborative effort from representatives of the European Society of Gastrointestinal Endoscopy (ESGE), the European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) and the European Society of Anaesthesiology (ESA). These three societies have endorsed the present guideline.The guideline is published simultaneously in the Journals Endoscopy and European Journal of Anaesthesiology.

Patient-controlled sedation with propofol and remifentanil for ERCP: a randomized, controlled study

BACKGROUND

Deep sedation with propofol and an opioid is commonly used for ERCP but is associated with increased risk and may require the presence of an anesthesiologist. Delivery of propofol and a short-acting, potent opioid analgesic remifentanil by patients to themselves (patient-controlled sedation, PCS) could be another option. Comparative studies with propofol PCS for ERCP are lacking.

OBJECTIVE

To compare PCS with propofol/remifentanil to anesthesiologist-managed propofol sedation.

DESIGN

Prospective, randomized, controlled human trial.

SETTING

University hospital.

PATIENTS

This study involved 80 patients presenting for elective ERCP.

INTERVENTION

Patients were randomized to PCS with propofol/remifentanil (PCS group) or anesthesiologist-managed propofol sedation (propofol infusion group). Sedation level was estimated every 5 minutes throughout the procedure by using Ramsay and Gillham sedation scores. The total amount of propofol was calculated at the end of the procedure. Endoscopist and patient satisfaction with the procedures was evaluated with a structured questionnaire.

MAIN OUTCOME MEASUREMENTS

Patient vital signs, amount of consumed propofol, sedation levels, and degree of endoscopist and patient satisfaction.

RESULTS

PCS was successful with 38 of 40 (95%) ERCP patients. In the PCS group, the mean (±standard deviation) level of sedation was markedly lighter and propofol consumption significantly smaller (175±98 mg) than in the propofol infusion group (249±138 mg) (P<.01). Degrees of patient and endoscopist satisfaction were equally high in both groups. All of the patients preferred the same sedation method should a repeat ERCP be required.

LIMITATIONS

Single-center study.

CONCLUSION

PCS with propofol/remifentanil is a suitable and well-accepted sedation method for ERCP. Anesthesiologist-managed propofol sedation with constant propofol infusion is associated with unnecessary deep sedation without any impact on the degree of patient or endoscopist satisfaction. Further larger-scale studies are needed to assess the safety of PCS in ERCP patients. (

CLINICAL TRIAL REGISTRATION NUMBER

NCT01079312.).

Randomized controlled trial of patient-controlled sedation for colonoscopy: Entonox vs modified patient-maintained target-controlled propofol

AIM

Propofol sedation is often associated with deep sedation and decreased manoeuvrability. Patient-maintained sedation has been used in such patients with minimal side-effects. We aimed to compare novel modified patient-maintained target-controlled infusion (TCI) of propofol with patient-controlled Entonox inhalation for colonoscopy in terms of analgesic efficacy (primary outcome), depth of sedation, manoeuvrability and patient and endoscopist satisfaction (secondary outcomes).

METHOD

One hundred patients undergoing elective colonoscopy were randomized to receive either TCI propofol or Entonox. Patients in the propofol group were administered propofol initially to achieve a target concentration of 1.2 μg/ml and then allowed to self-administer a bolus of propofol (200 μg/kg/ml) using a patient-controlled analgesia pump with a handset. Entonox group patients inhaled the gas through a mouthpiece until caecum was reached and then as required. Sedation was initially given by an anaesthetist to achieve a score of 4 (Modified Observer's Assessment of Alertness and Sedation Scale), and colonoscopy was then started. Patients completed an anxiety score (Hospital Anxiety and Depression questionnaire), a baseline letter cancellation test and a pain score on a 100-mm visual analogue scale before and after the procedure. All patients completed a satisfaction survey at discharge and 24 h postprocedure.

RESULTS

The median dose of propofol was 174 mg, and the median number of propofol boluses was four. There was no difference between the two groups in terms of pain recorded (95% confidence interval of the difference -0.809, 5.02) and patient/endoscopist satisfaction. There was no difference between the two groups in either depth of sedation or manoeuvrability.

CONCLUSION

Both Entonox and the modified TCI propofol provide equally effective sedation and pain relief, simultaneously allowing patients to be easily manoeuvred during the procedures.

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.

Sedation in digestive endoscopy: the Athens international position statements

BACKGROUND

Guidelines and practice standards for sedation in endoscopy have been developed by various national professional societies. No attempt has been made to assess consensus among internationally recognized experts in this field.

AIM

To identify areas of consensus and dissent among international experts on a broad range of issues pertaining to the practice of sedation in digestive endoscopy.

METHODS

Thirty-two position statements were reviewed during a 1 (1/2)-day meeting. Thirty-two individuals from 12 countries and four continents, representing the fields of gastroenterology, anaesthesiology and medical jurisprudence heard evidence-based presentations on each statement. Level of agreement among the experts for each statement was determined by an open poll.

RESULTS

The principle recommendations included the following: (i) sedation improves patient tolerance and compliance for endoscopy, (ii) whenever possible, patients undergoing endoscopy should be offered the option of having the procedure either with or without sedation, (iii) monitoring of vital signs as well as the levels of consciousness and pain/discomfort should be performed routinely during endoscopy, and (iv) endoscopists and nurses with appropriate training can safely and effectively administer propofol to low-risk patients undergoing endoscopic procedures.

CONCLUSIONS

While the standards of practice vary from country to country, there was broad agreement among participants regarding most issues pertaining to sedation during endoscopy.

Safe and effective sedation in endoscopic submucosal dissection for early gastric cancer: a randomized comparison between propofol continuous infusion and intermittent midazolam injection

PURPOSE

Endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) generally takes longer to perform than conventional endoscopy and usually requires moderate/deep sedation with close surveillance for patient safety. The aim of this study was to compare the safety profiles and recovery scores propofol continuous infusion and intermittent midazolam (MDZ) injection as sedation for ESD.

METHODS

Sixty EGC patients scheduled for ESDs between August and November 2008 were included in this prospective study and randomly divided into a propofol (P-group, 28 patients) and an MDZ (M-group, 32 patients) group using an odd-even system. The P-group received a 0.8 mg/kg induction dose and a 3 mg/kg/h maintenance dose of 1% propofol using an infusion pump. All patients received 15 mg pentazocine at the start of the ESD and at 60-min intervals thereafter. We recorded and analyzed blood pressure, oxygen saturation and heart rate during and following the procedure and evaluated post-anesthetic recovery scores (PARS) and subsequent alertness scores.

RESULTS

The propofol maintenance and total dose amounts were (mean +/- standard deviation) 3.7 +/- 0.6 mg/kg/h and 395 +/- 202 mg, respectively. The mean total dose of MDZ was 10.3 +/- 4.5 mg. There were no cases of de-saturation <90% or hypotension <80 mmHg in either group. Alertness scores 15 and 60 min after the procedures were significantly higher in the P-group (4.9/4.9) than in the M-group (4.6/4.5; p < 0.05). The mean PARS 15 and 30 min after the ESDs were significantly higher in the P-group (9.6/9.9) than in the M-group (8.6/9.2; p < 0.01).

CONCLUSION

Based on our results, the ESDs for EGC performed under sedation using propofol continuous infusion were as safe as those performed using intermittent MDZ injection. Propofol-treated patients had a quicker recovery profile than those treated with MDZ. We therefore recommend the use of continuous propofol sedation for ESD, but sedation guidelines for the use of propofol are necessary.

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.

Randomized clinical trial of propofol with and without alfentanil for deep procedural sedation in the emergency department

OBJECTIVES

The objectives were to compare the efficacy, occurrence of adverse events, and recovery duration of propofol with and without alfentanil for use in procedural sedation in the emergency department (ED).

METHODS

This was a randomized nonblinded prospective trial of adult patients undergoing procedural sedation for painful procedures in the ED. Patients with pain before the procedure were given intravenous (IV) morphine sulfate until their pain was adequately treated at least 20 minutes before starting the procedure. Patients received 1 mg/kg propofol either with or without a supplemental dose of 10 mug/kg alfentanil for deep procedural sedation. Doses, vital signs, nasal end-tidal CO(2) (ETCO(2)), pulse oximetry, and bispectral electroencephalographic (EEG) analysis scores were recorded. Subclinical respiratory depression was defined as a change in ETCO(2) of >10 mmHg, an oxygen saturation of <92% at any time, or an absent ETCO(2) waveform at any time. Clinical events related to respiratory depression were noted during the procedure, including the addition of or increase in the flow rate of supplemental oxygen, the use of a bag-valve mask apparatus, airway repositioning, or stimulation to induce breathing. After the procedure, patients were asked if they experienced pain during the procedure or had recall of the procedure.

RESULTS

A total of 150 patients were enrolled; 146 underwent sedation and were included in the analysis. Seventy-four patients received propofol, and 71 received propofol with alfentanil. No clinically significant complications were noted. Subclinical respiratory depression was seen in 24/74 patients in the propofol group and 30/71 patients in the propofol/alfentanil group (effect size = 9.8%, 95% CI = -5.8% to 25.5%). Clinical signs of respiratory depression included an increase in supplemental oxygen use in 25 of the 74 propofol patients and 31 of the 71 propofol/alfentanil patients (effect size 9.9%, 95% CI = -5.9% to 25.7%), the use of bag-valve mask apparatus in seven patients in the propofol group and 12 in the propofol/alfentanil group (effect size = 5.6%, 95% CI = -3.5% to 18.4%), airway repositioning in 13 propofol patients and 20 propofol/alfentanil patients (effect size = 10.6%, 95% CI = -3.0% to 24.2%), and stimulation to induce breathing in 11 propofol patients and 20 propofol/alfentanil patients (effect size = 13.3%, 95% CI = 0.1% to 26.5%). The total time of the procedure was longer for the alfentanil/propofol group (median = 11 minutes, range = 5-22 minutes) than for the propofol group (median = 9 minutes, range = 1 to 43 minutes; effect size = 1.93 minutes, 95% CI = 0.73 to 2.58, p = 0.02). Pain during the procedure was reported by 10 of the 74 patients in the propofol group and 7 of the 71 patients in the propofol/alfentanil group (effect size = 4.5%, 95% CI = -6.8% to 14.1%). Recall of some part of the procedure was reported by 12 patients in the propofol group and 9 in the propofol/alfentanil group (effect size = 3.5%, 95% CI = -7.9% to 15.0%). All procedures were successfully completed.

CONCLUSIONS

The use of supplemental alfentanil with propofol for procedural sedation did not result in a difference in reported pain or recall immediately after the procedure. There was an increase in the proportion of patients who required stimulation to induce respiration during the procedure in patients who received propofol with supplemental alfentanil. The addition of supplemental opioid to procedural sedation with propofol does not appear beneficial.

Propofol alone versus propofol in combination with meperidine for sedation during colonoscopy

BACKGROUND

Despite the increasing popularity of propofol for sedation in colonoscopy, the optimal regimen is still controversial. Both propofol alone and propofol in combination with meperidine are frequently used during colonoscopy, but the impact of adding meperidine has not been evaluated. This study aimed to investigate if adding meperidine to propofol offers any advantage in terms of patient tolerance, recovery time, and postcolonoscopy discomforts.

METHOD

Consecutive patients admitted to the physical checkup department of our hospital were randomized to receive either meperidine plus propofol (combination group, n=100) or propofol alone (propofol group, n=100) for sedated colonoscopy. The patients' tolerance and postcolonoscopy discomforts (pain, bloating, dizziness, and nausea/vomiting) were assessed with a 0-10 visual analog scale. The recovery times were assessed with 5-minute and 10-minute Aldrete scores.

RESULTS

The dose of propofol was less in the combination group than the propofol group (129.80+/-37.93 mg vs. 147.90+/-47.85, mean+/-SD, P=0.003). The endoscopists, anesthetists, and nurses all rated patients' tolerance in favor of the combination group than the propofol group (mean+/-SD, endoscopists, 9.17+/-1.23 vs. 8.49+/-1.60, P=0.001; anesthetists, 9.21+/-1.08 vs. 8.63+/-1.37, P=0.001; nurses, 9.18+/-1.34 vs. 8.71+/-1.47, P=0.019, respectively). Patients in the combination group recovered earlier than the placebo group (5-min Aldrete scores: 9.48+/-1.09 vs. 9.05+/-1.32, mean+/-SD, P=0.013; short intervals to speak: 4.29+/-4.05 min vs. 6.30+/-5.22 min, P=0.003; and departure: 18.62+/-5.28 min vs. 20.28+/-5.68 min, P=0.034). There was also less abdominal bloating in the combination group after colonoscopy (1.23+/-1.79 vs. 2.19+/-2.12, mean+/-SD, P=0.004). Incidences of hypoxemia, hypotension, and overall satisfaction scores were comparable between the 2 groups.

CONCLUSIONS

For sedated colonoscopy, propofol in combination with meperidine is better than propofol alone in improving patients' tolerance and recovery.

Propofol for sedation during colonoscopy

BACKGROUND

Propofol is increasingly used for sedation during colonoscopy, with many recent reports of randomized controlled trials (RCTs) and large non-randomized case series.

OBJECTIVES

The primary objective was to identify, analyze and summarize RCTs comparing the relative effectiveness, patient acceptance and safety of propofol for colonoscopy, to traditional sedatives (narcotics and/or benzodiazepines).The secondary objective was to synthesize the studies comparing propofol administration by anesthesiologists to that by non-anesthesiologists for sedation during colonoscopy.

SEARCH STRATEGY

We searched Medline, Cancerlit, EMBASE, CINAHL, LILACS, Biological Abstracts, Web of Science and the Cochrane Controlled Trials Registry database between January 1980 and June 2007; and conference proceeding abstracts for DDW, EUGW and ACG between 1990 and June 2007. There were no language restrictions.

SELECTION CRITERIA

Randomized controlled trials comparing use of propofol and traditional agents or administration of propofol by anesthesiologists to that by non-anesthesiologists for sedation during colonoscopy.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted the data. The data were pooled using the Cochrane Collaborations' methodology and statistical software RevMan 4.2.10.

MAIN RESULTS

Twenty studies met the inclusion criteria for the primary objective. Most studies included only healthy out-patients. Recovery and discharge times were shorter with use of propofol. There was higher patient satisfaction with use of propofol (OR for dissatisfaction 0.35, 95% CI 0.23, 0.53). There was no difference in procedure time, cecal intubation rate or complications. There was no difference in pain control with non- patient controlled sedation (PCS) use of propofol as compared to the traditional agents (OR 0.90; 95% CI 0.58, 1.39). Although there was higher patient satisfaction (OR for dissatisfaction 0.42, 95% CI 0.20, 0.89), the pain control was inferior with use of PCS use of propofol as compared to the use of traditional agents (OR 3.09; 95% CI 2.15, 4.46).There was only one study comparing administration of propofol by anesthesiologists to that by non-anesthesiologists for sedation during colonoscopy, with no difference in procedure time or patient satisfaction.

AUTHORS' CONCLUSIONS

Propofol for sedation during colonoscopy for generally healthy individuals can lead to faster recovery and discharge times, increased patient satisfaction without an increase in side-effects. More studies with standardized end-points are needed to compare propofol administration by anesthesiologists to that by non-anesthesiologists.

Propofol for sedation during colonoscopy

BACKGROUND

Propofol is increasingly used for sedation during colonoscopy, with many recent reports of randomized controlled trials (RCTs) and large non-randomized case series.

OBJECTIVES

The primary objective was to identify, analyze and summarize RCTs comparing the relative effectiveness, patient acceptance and safety of propofol for colonoscopy, to traditional sedatives (narcotics and/or benzodiazepines).The secondary objective was to synthesize the studies comparing propofol administration by anesthesiologists to that by non-anesthesiologists for sedation during colonoscopy.

SEARCH STRATEGY

We searched Medline, Cancerlit, EMBASE, CINAHL, LILACS, Biological Abstracts, Web of Science and the Cochrane Controlled Trials Registry database between January 1980 and June 2007; and conference proceeding abstracts for DDW, EUGW and ACG between 1990 and June 2007. There were no language restrictions.

SELECTION CRITERIA

Randomized controlled trials comparing use of propofol and traditional agents or administration of propofol by anesthesiologists to that by non-anesthesiologists for sedation during colonoscopy.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted the data. The data were pooled using the Cochrane Collaborations' methodology and statistical software RevMan 4.2.10.

MAIN RESULTS

Twenty studies met the inclusion criteria for the primary objective. Most studies included only healthy out-patients. Recovery and discharge times were shorter with use of propofol. There was higher patient satisfaction with use of propofol (OR for dissatisfaction 0.35, 95% CI 0.23, 0.53). There was no difference in procedure time, cecal intubation rate or complications. There was no difference in pain control with non- patient controlled sedation (PCS) use of propofol as compared to the traditional agents (OR 0.90; 95% CI 0.58, 1.39). Although there was higher patient satisfaction (OR for dissatisfaction 0.42, 95% CI 0.20, 0.89), the pain control was inferior with use of PCS use of propofol as compared to the use of traditional agents (OR 3.09; 95% CI 2.15, 4.46).There was only one study comparing administration of propofol by anesthesiologists to that by non-anesthesiologists for sedation during colonoscopy, with no difference in procedure time or patient satisfaction.

AUTHORS' CONCLUSIONS

Propofol for sedation during colonoscopy for generally healthy individuals can lead to faster recovery and discharge times, increased patient satisfaction without an increase in side-effects. More studies with standardized end-points are needed to compare propofol administration by anesthesiologists to that by non-anesthesiologists.

Propofol use by gastroenterologists-the European experience

The administration of propofol as a sedative in gastrointestinal endoscopies became very popular in many European countries during the last years. Nevertheless there are huge regional differences in the way that the drug is used. Switzerland, the country with highest propagation of gastroenterologist guided propofol sedation, serves as a case study of its safe use in daily practice. The experiences of this spread are summarized in this article.

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.

Midazolam and pethidine versus propofol and fentanyl patient controlled sedation/analgesia for upper gastrointestinal tract ultrasound endoscopy: a prospective randomized controlled trial

BACKGROUND AND OBJECTIVES

The aim of this prospective, randomized study was to compare the standard regimen of midazolam and pethidine administered by the gastroenterologist versus patient controlled sedation with a propofol-fentanyl mixture during upper gastrointestinal tract endoscopic ultrasonography. Our primary end-points were patient satisfaction and patient cooperation assessed by endoscopist.

METHODS

Fifty-four consecutive patients, undergoing endoscopic ultrasonography, received sedation with midazolam and pethidine (Group M: n=27) or propofol and fentanyl (Group P: n=27). Group M: pethidine 0.7mg/kg midazolam 0.04mg/kg before examination; boluses of same drugs if the sedation was insufficient plus a sham patient controlled sedation analgesia; Group P: propofol 17mg plus fentanyl 15microg before examination and a patient controlled sedation analgesia pump containing 170mg propofol plus 150microg fentanyl injecting 0.5ml every time the patient pressed the button (no "lock out"). Boluses of 1ml of the same mixture if the sedation was insufficient.

RESULTS

Group M: mean dosage of pethidine and midazolam 88.6 and 5mg, respectively. Group P: mean dosage of propofol and fentanyl 119.7mg and 106microg, respectively. Both groups were similar for duration and difficulty of the procedure, the grade of sedation (Observer's Assessment of Alertness/Sedation Score) and judgement by endoscopist and patient about cooperation and satisfaction. The only difference between groups was about the extra boluses administered during the procedure.

CONCLUSION

This study demonstrated that a patient controlled sedation analgesia with propofol and fentanyl is an effective and safe technique for upper gastrointestinal tract endoscopic ultrasonography procedures and results in a high level of satisfaction both for patients and operator.

Propofol sedation during endoscopic procedures: how much staff and monitoring are necessary?

BACKGROUND

Propofol has been shown to be safe for nonanesthetist use during GI endoscopy. However, published studies involved propofol administration by an additional nurse or used specialized patient monitoring or were carried out in tertiary hospitals.

OBJECTIVE

Considering the downward pressure on reimbursement for endoscopic procedures, we asked how much staff and monitoring is necessary for safe use of propofol.

SETTING

Two private gastroenterology practices.

PATIENTS AND DESIGN

A total of 27,061 endoscopic procedures (14,856 EGDs and 12,205 colonoscopies) were prospectively assessed regarding patient characteristics, American Society of Anesthesiologists (ASA) status, dosage of propofol, fall of oxygen saturation below 90%, need to increase nasal oxygen administration above 2 L/min, and need for assisted ventilation.

INTERVENTION

Propofol was administered by the endoscopy nurse supervised by the endoscopist. Patient monitoring consisted of only pulse oximetry and clinical assessment.

RESULTS

The mean propofol dose for EGD was 161 mg (range 50-650 mg). During colonoscopy patients received a mean propofol dose of 116 mg (30-500 mg) in addition to 25 mg of meperidine. Oxygen saturation fell below 90% (lowest 74%) in 623 procedures (2.3%), normalizing within less than 30 seconds by stimulating the patient and increasing the nasal oxygen flow to 4 to 10 L/min. Six patients (ASA III) required mask ventilation for less than 30 seconds. No endotracheal intubation was necessary.

LIMITATIONS

There was no further follow-up regarding adverse events after patient discharge from the endoscopy unit.

CONCLUSIONS

An endoscopy team, consisting of 1 physician endoscopist and 1 endoscopy nurse, can safely administer propofol sedation for GI endoscopy in a practice setting without additional staff or specialized monitoring.

Nurses' knowledge and skills in colonoscopy patients' pain management

AIM

This study aimed to describe the knowledge and skills of nurses in managing pain during colonoscopy procedures.

BACKGROUND

Colonoscopy is a procedure to diagnose diseases of the intestine, and patients consider it even painful. However, few studies have described patients' pain management during the colonoscopy procedure.

DESIGN

A quantitative survey design was used. The data were collected from colonoscopy nurses with a self-completed semi-structured questionnaire developed for the study.

METHODS

The hospitals performing colonoscopies in Finland, with the exception of the ones where the questionnaire was pilot-tested, were included in the study (n = 12). The optional sample was drawn by mailing questionnaires (n = 147) to endoscopy units to be filled in by three colonoscopy nurses during 2002. The response rate was 79% (n = 116).

RESULTS

The majority of nurses used versatile non-pharmacological methods of managing pain and had practice-based knowledge of pain management during the colonoscopy procedure, but pain education and the acquisition of new professional knowledge were rarely reported. Pain scales were not in use and ethical conversation was lacking among the endoscopy staff in most (95%) hospitals.

CONCLUSION

The study showed that colonoscopy nurses used numerous non-pharmacological methods, but only rarely acquired professional knowledge. There was a lack of pain scales and ethical conversation in the participating endoscopy units.

RELEVANCE TO CLINICAL PRACTICE

The results can be used to improve the treatment of pain during colonoscopy procedures and endoscopy nurses' education. Nurses should be motivated by education and ethical conversation. Future studies should aim to analyse patients' own evaluation of pain during the colonoscopy procedure. The applicability of the existing pain scales and non-pharmacological methods should be tested in practice.

Practice efficiency and economics: the case for rapid recovery sedation agents for colonoscopy in a screening population

GOAL

To determine rapidly acting agents' impact on practice efficiency and cost for outpatient colonoscopy in a screening population.

BACKGROUND

Propofol-mediated endoscopic sedation is popular due to rapid sedation onset and superior recovery profile compared with sedation with an opioid and benzodiazepine. There are few data on the impact of this type of sedation on the economics and efficiency of an endoscopy unit.

STUDY

A provider-perspective economic model assessed the ability of propofol and fospropofol disodium (Aquavan, GPI 15715, MGI Pharma) to increase practice efficiency and determined break-even costs based on current colonoscopy reimbursement levels. Reimbursement inputs by practice setting, costs, and recovery profiles-taken from published literature examining time to discharge-were used to populate the model. To measure robustness of model results to changes in base case inputs, sensitivity analyses were performed. Using a Monte Carlo simulation, inputs were varied simultaneously and randomly for 1000 iterations to determine 95% confidence intervals (CI) for break-even costs.

RESULTS

In the time to complete 1 colonoscopy with midazolam/meperidine, 1.76 colonoscopies can be completed with propofol and 1.91 colonoscopies can be completed with fospropofol disodium. This efficiency benefit produced a break-even cost for rapid recovery agents of $71.53 (95% CI: $38.39, $105.67) in a hospital outpatient clinic and $61.48 (95% CI: $41.33, $108.99) in an ambulatory surgical center. One-way sensitivity analyses indicated the break-even cost of these agents was most sensitive to operating costs and time to discharge ratio.

CONCLUSIONS

Rapid recovery agents for colonoscopy can improve practice efficiency and offer economic advantages over traditional sedation.

[Safety of propofol administration by the staff of a gastrointestinal endoscopy unit]

Deep sedation controlled by the staff of gastrointestinal endoscopy units is currently controversial. In the last few years, numerous studies have provided data supporting the safety of propofol use in these techniques. We present a large series of patients who underwent gastroscopy or colonoscopy under endoscopist-controlled deep sedation. A total of 875 procedures (297 gastroscopies and 578 colonoscopies) were included. In all procedures intravenous propofol with or without intravenous midazolam was administered. In gastroscopies, complications attributable to the sedation were found in only 6.7% of the patients, mostly due to desaturation, which was resolved without the need for intubation. In colonoscopies, complications were found in 11.2%, the most frequent being bradycardia and desaturation, none of which were serious. No association was found between the presence of complications and the propofol dose administered. In the group of patients undergoing colonoscopy, simultaneous midazolam administration allowed reduction of the propofol dose required to achieve deep sedation. In conclusion, propofol shows a good safety profile and excellent tolerance in patients undergoing gastroscopy and colonoscopy and can be administrated by the endoscopy team. At least in the case of colonoscopy, the associated use of midazolam allows the propofol dose to be decreased, thus, theoretically, reducing the drug's adverse effects.

Single use of fentanyl in colonoscopy is safe and effective and significantly shortens recovery time

BACKGROUND

Colonoscopy remains an uncomfortable examination and many patients prefer to be sedated. The aim of this study was to evaluate the efficacy and safety of intravenous administration of fentanyl in titrated doses compared with intravenous administration of the well-known midazolam in titrated doses.

METHODS

One hundred twenty-six patients scheduled for ambulatory colonoscopy were randomly assigned to receive either 25 mcg fentanyl (Fentanyl group, n = 66, 35 females, mean age = 61.5 years) and titrated up to 50 mcg or 2 mg midazolam (Midazolam group, n = 60, 33 females, mean age = 63.2 years) and titrated up to 5 mg. Patients graded discomfort on a scale from 0 to 4 and pain on a scale from 0 to 10. Success of the procedure, time to cecum, complications, and recovery time for each patient were independently recorded.

RESULTS

Mean discomfort scores were 0.4 in the Fentanyl group and 1.0 in the Midazolam group (p = 0.002). Similarly, mean scores for pain and anus to cecum time were lower in the Fentanyl group than in the Midazolam group [2.59 vs. 4.43 (p = 0.002) and 8.7 vs. 12.9 min (p = 0.012), respectively]. No adverse events were reported in the Fentanyl group, while in the Midazolam group a decrease in oxygen saturation was noted in 23/60 (35%) patients. Mean recovery time was 5.6 min in the Fentanyl group and 16 min in the Midazolam group (p = 0.014). Mean dosage was 36 mcg for fentanyl and 4.6 mg for midazolam.

CONCLUSION

Administration of fentanyl in low incremental doses is sufficient to achieve a satisfactory level of comfort during colonoscopy.

Nurse-administered propofol sedation: a review of current evidence

This article highlights a highly controversial practice issue referred to as nurse-administered propofol sedation, which affects registered nurses as well as advanced practice nurses in many different practice settings across the United States. Amid varied advice from professional organizations and state licensing boards, a thorough and systematic review of the current evidence provides insight into the question of safety associated with the practice. The evidence examined includes position statements from professional organizations and state boards, information from the United States Food and Drug Administration and the Joint Commission on Accreditation of Healthcare Organizations, and published research since 1999. The body of evidence demonstrates diverse positions; however, the empirical evidence in the author's opinion unanimously supports nurse-administered propofol sedation as a safe practice in nonintubated adult patients. Under research conditions, participants had a low incidence of untoward events and were adequately rescued with no intubations required and no deaths reported.

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.

Synergistic sedation with oral midazolam as a premedication and intravenous propofol versus intravenous propofol alone in upper gastrointestinal endoscopies in children: a prospective, randomized study

OBJECTIVES

The primary objective of the present study was to compare the required dose of intravenous (IV) propofol between group A (synergistic sedation with an oral dose of midazolam combined with IV propofol) and group B (IV propofol alone), in diagnostic upper gastrointestinal endoscopy (UGIE) in pediatric patients. The secondary objective was to compare the safety, the efficacy, the ease of IV line placement and the ease of separation from parents between the 2 groups.

METHODS

Fifty-four consecutive children (aged 3 y or older) who underwent UGIE were randomly assigned to 1 of the 2 medication regimens. Patients in group A (n = 26, mean age: 8.1 y) received midazolam (0.5 mg/kg) orally. Thirty minutes after the midazolam dose was given, repeated IV doses of propofol 0.5 mg/kg were administered titrated to achieve the level of deep sedation. Patients in group B (n = 28, mean age: 9 y) received IV propofol alone with the same methodology and sedation end point.

RESULTS

The mean dose (1.8 +/- 0.7 mg/kg) of propofol administered in group A patients was remarkably lower compared with that (2.9 +/- 0.9 mg/kg) of group B. Multivariate stepwise logistic regression analysis revealed that among sex, age, ASA grade and the type of sedation, the synergistic sedation was the only factor associated with the ease of IV line placement (chi(2) = 16.3, P < 0.001) and the ease of separation from parents (chi(2) = 41.6, P < 0.001). Additional multivariate stepwise logistic regression analysis revealed that among sex, age, ASA grade and the type of sedation, synergistic sedation was the only factor associated with a higher level of patient comfort (chi(2) = 35.5, P < 0.001). The recovery time was significantly shorter in group B patients (7.7 +/- 3.6 min) compared with that of group A (25.9 +/- 4.1 minutes) (P < 0.01). The 2 regimens were equally safe.

CONCLUSIONS

Our data suggest that synergistic sedation with an oral dose of midazolam combined with propofol may benefit the children who undergo UGIE with regard to lower mean dose of propofol used, easier IV line placement, easier separation from the parents, less pain induced by the IV line placement and greater patient comfort.

Effect-site targeted patient-controlled sedation with propofol: comparison with anaesthetist administration for colonoscopy

Patient-controlled sedation (PCS) allows patients to match their sedation requirement to perceived discomfort. The significant delay in onset of sedation may be overcome with effect-site steered target controlled infusion, but previously only trials in volunteers have been carried out. We therefore conducted a randomised, double-blind controlled trial comparing effect-site steered propofol PCS with anaesthetist-administered propofol sedation in 40 patients presenting for colonoscopy. The initial effect-site target in the PCS group was 0.8 microg.ml(-1), increment was 0.1 microg.ml(-1) and lockout was 3 min. Patient and endoscopist satisfaction and operating conditions were similar between the two groups. PCS patients were sedated more slowly (13 [7.1] vs. 3 [1.1] min; p < 0.0001) and less deeply (minimum BIS value: 71 [16] vs. 58 [15]; p = 0.13) than anaesthetist-administered propofol sedation patients. More of the latter patients were hypotensive, but all patients had similar recollection of events during the procedure and similar quality of recovery.

Significance of patient-controlled sedation during colonoscopy. Results from a prospective randomized controlled study

BACKGROUND

In France, general anesthesia is given to more than 90% of patients undergoing colonoscopy although in several countries sedation is limited to intolerant patients. This study was carried out to determine whether Patient-Controlled Sedation (PCS) could provide a lighter sedation than general anesthesia adapted to the patient's individual requirement.

METHODS

Patients aged from 18 to 80 scheduled for elective colonoscopy were prospectively randomized to receive either standard sedation (control group) or patient-controlled-sedation (PCS). In the control group, patients received a continuous infusion of propofol. Patients in the PCS group were connected to an infusion pump containing propofol and self-administered 20-mg boluses as often as they required. An anesthetist was present throughout the procedure. Patient satisfaction measured on a visual analog scale four hours after colonoscopy was the main outcome criterion.

RESULTS

From December 2002 to September 2003, 402 patients underwent elective colonoscopy, 173 of them were eligible and were asked to participate in the study. Seventy-two gave their informed consent and were prospectively randomized. The patients' mean satisfaction scores were not statistically different between the two groups: 84.7 mm (PCS group) vs. 91.5 mm (control group); P = 0.24. Mean doses of propofol (60 mg vs. 248 mg; P <0.001), depth of sedation and time before discharge (1.75 hours vs. 4.45 hours) were significantly lower for patients in the PCS group; nine of them (25.7%) did not use the pump and had total colonoscopy without sedation. There were no statistically significant differences between the two groups regarding total duration of colonoscopy (19.4 min (PCS) vs. 18 min (control)) difficulty and therapeutic procedures (biopsy or polypectomy). Two weeks after the procedure, 96.5% of patients in the PCS group were willing to repeat the examination under the same conditions vs. 72.5% of patients in the control group (P = 0.03).

CONCLUSIONS

Our results demonstrate that need of sedation is widely overestimated in France. A subset of our patients is willing to consider colonoscopy without general anesthesia. For them, PCS with propofol is an effective and very well accepted form of sedation.

Premedication with intravenous ketorolac trometamol (Toradol) in colonoscopy: a randomized controlled trial

OBJECTIVE

We conducted a prospective double-blinded placebo-controlled randomized trial to investigate the effect of ketorolac trometamol (KT) administered intravenously as premedication in colonoscopy.

METHODS

One hundred and forty patients undergoing colonoscopy were randomized to receive either 60 mg of KT (KT group (KTG), n=70) or placebo (normal saline group (NSG), n=70) intravenously as premedication 30 min prior to procedure. Patient-controlled sedation (PCS) was used as the mode of sedation. Outcome measures included patient self-assessed pain score in a 10-cm unscaled visual analog scale (VAS), endoscopist assessment of patient pain score in VAS, patient's willingness to repeat colonoscopy, administered and demanded doses of PCS, patient satisfaction score in VAS, and hemodynamic changes during and after the procedure.

RESULTS

The mean patient self-assessed pain score (SD) during procedure was significantly lower in KTG than NSG: 5.08 (2.74) vs 6.62 (2.45); p=0.001. The mean endoscopist assessment of patient pain score (SD) was significantly lower in KTG than NSG as well: 3.99 (2.80) vs 5.28 (2.71); p=0.006. More patients in KTG were willing to repeat procedure as compared with NSG (80.0%vs 57.1%; p=0.004). No significant difference was found in the administered and demanded doses of PCS, mean satisfactory scores and hemodynamic changes in both groups. No serious complication related to intravenous (IV) KT was noted.

CONCLUSIONS

Premedication with IV KT (Toradol) improves pain control during colonoscopy with no associated serious complications.

Propofol versus traditional sedative agents for gastrointestinal endoscopy: a meta-analysis

BACKGROUND & AIMS

Even though propofol has better recovery profile than traditional agents, its use is limited because of the perception of increased complication rates. Because an adequately powered trial comparing risk of propofol with traditional agents is lacking, we performed a meta-analysis of the current literature.

METHODS

We searched Medline (1966-October 2004), EMBASE (1980-October 2004), and Cochrane controlled trials registry. The following 4 cardiopulmonary complications were assessed: hypoxia, hypotension, arrhythmias, and apnea. Procedures were divided into 3 groups: esophagogastroduodenoscopy group, colonoscopy group, and endoscopic retrograde cholangiopancreatography/endoscopic ultrasonography group. Pooled odds ratios for complications were calculated for all the procedures combined and then separately for the 3 groups. Random effects models were used for 2-proportion comparisons.

RESULTS

Of the 90 citations identified, 12 original studies qualified for this meta-analysis and included 1161 patients. Of these, 634 received propofol, and 527 received midazolam, meperidine, and/or fentanyl. Most of the included studies were randomized trials of moderate quality and nonsignificant heterogeneity (Cochran Q = 4.81, P = .90). Compared with traditional sedative agents, the pooled odds ratio with the use of propofol for developing hypoxia or hypotension for all the procedures combined was 0.74 (95% confidence interval [CI], 0.44-1.24); for EGD, 0.85 (95% CI, 0.33-2.17); for colonoscopy, 0.4 (95% CI, 0.2-0.79); and for ERCP/EUS, 1.07 (95% CI, 0.38-3.01).

CONCLUSIONS

Propofol sedation during colonoscopy appears to have lower odds of cardiopulmonary complications compared with traditional agents, but for other procedures, the risk of complications is similar.

Comparison of alfetanil and ketamine in combination with propofol for patient-controlled sedation during fiberoptic bronchoscopy

BACKGROUND

During fiberoptic bronchoscopy, propofol, ketamine, benzodiazepines, and opiates are most commonly used, alone or in combination for sedation. The aim of this study was to compare the clinical efficacy of propofol/ketamine with propofol/alfentanil for patient-controlled sedation (PCS) during fiberoptic bronchoscopy.

METHOD

Patients undergoing fiberoptic bronchoscopy were randomly assigned to receive either propofol/alfentanil (PA group; n = 138) or propofol/ketamine (PK group; n = 138) via a patient-controlled analgesia (PCA) device for sedation and analgesia. Changes in blood pressure, heart rate (HR), and oxygen saturation were monitored. Degree of patient and bronchoscopist satisfaction was evaluated using a 10-cm visual analog scale (VAS) (0 = extremely uncomfortable to 10 = extremely comfortable).

RESULTS

After sedation, systolic arterial pressure (SAP) decreased in the PA group, but SAP was stable in the PK group. Compared with values immediately before starting bronchoscopy, SAP and HR increased during the procedure in both groups (P < 0.05). Patients in the PK group showed more satisfaction [(9.5 (6-10) vs. 9.0 (6-10)), P < 0.05] and amnesia (82% vs. 61%, P < 0.01). Despite these differences, the majority (greater than 90%) of the patients in both groups stated that they were comfortable during the procedure.

CONCLUSION

Our results show that although both techniques proved effective for sedation in patients undergoing fiberoptic bronchoscopy, ketamine is superior to alfentanil when used in combination with propofol because of the high patient satisfaction and amnesia.

Sedation and the technical performance of colonoscopy

The use of sedation for routine endoscopic procedures, including colonoscopy, varies widely across cultures. This variation in sedation practice is greater than any other culturally based variation in the technical performance of endoscopy. This article sequentially reviews the technical performance of colonoscopy in patients who undergo unsedated colonoscopy, sedation with narcotics and benzodiazepines, and deep sedation with propofol. For each of these approaches to colonoscopy, the advantages and disadvantages also are listed and discussed.

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.

Recent developments in patient-controlled analgesia

Patient-controlled analgesia (PCA) has become the gold standard for acute pain management since it was first introduced 20 years ago, and its merits have been discussed in quite a large number of publications. This review summarizes the more recent developments, such as new application devices and strategies, including intranasal, spinal, and regional PCA; patient-controlled sedation; experience with children and elderly people; and some data from chronic pain situations. Analyzing PCA literature from 2001 onwards confirms the author's long belief that the PCA principle ("WYNIWYG": what you need is what you get) was the most important aspect of a patient-controlled strategy, more or less independent of the type of drug or machine. Discovering this principle has changed the understanding of pain and suffering.