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Liou JY, Wang HY, Kuo IT, Tsou MY, Chang WK, Ting CK. A New Method for Comprehensive Analysis of Benzodiazepine, Opioid, and Propofol Interactions and Dose Selection Rationales in Gastrointestinal Endoscopy Sedation. Anesth Analg 2025; 140:1168-1177. [PMID: 39908199 DOI: 10.1213/ane.0000000000007263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2025]
Abstract
BACKGROUND The aim of this study was to explore a new method for determining optimal dosing regimens for combinations of propofol, midazolam, and an opioid to achieve rapid on- and off-set of deep sedation. METHODS We simulated 16 published dosing regimens using a well-validated pharmacodynamic model. The study was divided into 2 parts. First, the regimen that best provided deep sedation and rapid recovery was selected. A deep sedation-time area-under-the-curve (AUC) method was used to compare published dosing regimens; a higher AUC indicated better sedation and faster recovery. Second, subgroup analysis of the best-performing dosing regimen was undertaken better to understand how each drug affected patient recovery. RESULTS The AUC method identified a combination of midazolam 1 mg, alfentanil 500 µg, and propofol target infusion effect-site concentration (Ce) 2 µg mL -1 as the optimal regimen ( P < .01). Propofol correlated with high probability of sedation and increased AUC (R 2 = 0.53), whereas midazolam had a significant impact on time to return of consciousness (R 2 = 0.86). Subgroup analysis indicated that regimens consisting of a fixed dose of alfentanil and either 5 µg mL -1 Ce propofol, or 1 mg midazolam with 3-5 µg mL -1 Ce of propofol, or 2 mg midazolam with 2 µg mL -1 Ce propofol provided adequate sedation and rapid recovery. Midazolam >3 mg greatly prolonged recovery. CONCLUSIONS This study used a clinically relevant method and model simulation to determine suitable sedation regimens for use in gastrointestinal endoscopy. A balanced propofol, midazolam, and an opioid should be used. The AUC method was capable of providing objective assessments for model selection.
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Affiliation(s)
- Jing-Yang Liou
- From the Department of Anesthesiology, Taipei Veterans General Hospital and School of Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan
- Department of Biomedical Engineering, National Yang-Ming Chiao Tung University, Taipei, Taiwan
| | - Hsin-Yi Wang
- From the Department of Anesthesiology, Taipei Veterans General Hospital and School of Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan
- Department of Biomedical Sciences and Engineering, National Central University, Taoyuan City, Taiwan
| | - I-Ting Kuo
- From the Department of Anesthesiology, Taipei Veterans General Hospital and School of Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan
- Department of Biomedical Engineering, National Yang-Ming Chiao Tung University, Taipei, Taiwan
| | - Mei-Yung Tsou
- Department of Anesthesiology, Cardinal Tien Hospital, New Taipei City, Taiwan
- School of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan
- Department of Anesthesiology, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Weng-Kuei Chang
- From the Department of Anesthesiology, Taipei Veterans General Hospital and School of Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan
| | - Chien-Kun Ting
- From the Department of Anesthesiology, Taipei Veterans General Hospital and School of Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan
- Institute of Emergency and Critical Care Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan
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Xie G, Estevez M, Heybati K, Vogt M, Smith M, Moshe C, Chan J, Kumbhari V, Chadha R. Single-agent versus combination regimens containing propofol: a retrospective cohort study of recovery metrics and complication rates in a hospital-based endoscopy suite. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2025; 75:844602. [PMID: 40023496 PMCID: PMC11951190 DOI: 10.1016/j.bjane.2025.844602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2024] [Revised: 01/29/2025] [Accepted: 01/31/2025] [Indexed: 03/04/2025]
Abstract
BACKGROUND Anesthesiologists are often tasked with overseeing sedation in non-surgical settings. We aim to determine whether adding adjuvant sedatives to propofol affects the recovery times and complication rates after endoscopy. METHODS We conducted a retrospective cohort study of adults (≥18) who received propofol while undergoing esophagogastroduodenoscopy (EGD) and/or colonoscopy (COL) at a large academic institution over a four-year period. Patients receiving propofol alone were compared against patients receiving propofol in combination with midazolam, fentanyl, ketamine, or dexmedetomidine. The primary outcome was PACU length of stay, adjusted for age, sex, and ASA Score. Secondary outcomes included incidence of PACU postoperative nausea and vomiting, hypoxemia (SpO2 < 90%), bradycardia (HR < 60 bpm), and escalation of care (hospital admission), reported in adjusted odds ratios and their 95% confidence intervals. RESULTS Across the study period, 28,532 cases were included. Colonoscopies performed under propofol+fentanyl sedation were associated with significantly longer PACU LOS compared to propofol alone. Adjusted mean PACU LOS was significantly longer in patients receiving adjuvant fentanyl, compared to propofol alone (p < 0.01) and propofol + dexmedetomidine (p < 0.01). Patients receiving propofol alone exhibited a 9.4% incidence of bradycardia, 16.0% hypoxia, 0.89% PONV, and 0.40% hospitalization. Adjuvant fentanyl use was associated with higher odds of hypoxia across all procedure types (p < 0.05). Adjuvant dexmedetomidine was associated with higher rates of bradycardia, but lower rates of hypoxia, PONV, and hospitalization (p < 0.05). CONCLUSIONS With the exception of fentanyl, combining propofol with other sedatives was not associated with longer recovery times. The incidence of complications differed significantly with the use of adjuvant fentanyl or dexmedetomidine.
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Affiliation(s)
- Guozhen Xie
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, USA
| | - Maria Estevez
- Clinical Studies Unit, Mayo Clinic Jacksonville, FL, USA
| | - Kiyan Heybati
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, USA
| | - Matthew Vogt
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Michael Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Jacksonville, FL, USA
| | - Christine Moshe
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Jacksonville, FL, USA
| | - Johanna Chan
- Department of Gastroenterology and Hepatology, Mayo Clinic Jacksonville, FL, USA
| | - Vivek Kumbhari
- Department of Gastroenterology and Hepatology, Mayo Clinic Jacksonville, FL, USA
| | - Ryan Chadha
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Jacksonville, FL, USA.
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Xie G, Estevez M, Heybati K, Vogt M, Smith M, Moshe C, Chan J, Kumbhari V, Chadha R. Outcomes of anesthesia-supported versus endoscopist-driven sedation modalities: a retrospective cohort study. Gastrointest Endosc 2025:S0016-5107(25)00048-3. [PMID: 39880215 DOI: 10.1016/j.gie.2025.01.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2024] [Revised: 12/09/2024] [Accepted: 01/19/2025] [Indexed: 01/31/2025]
Abstract
BACKGROUND AND AIMS The use of anesthesia has become commonplace in many procedural settings. The goal of this study is to compare sedation modalities used by endoscopists and anesthesiologists in the endoscopy suite, particularly with respect to recovery time and adverse events. METHODS We conducted a retrospective cohort study including adults (≥18 years of age) undergoing outpatient EGD and/or colonoscopy at Mayo Clinic in Jacksonville, Florida between October 1st, 2018 and December 31st, 2022. Cases were classified as using propofol only, propofol ± adjuvants (PA; including dexmedetomidine, ketamine, fentanyl, and midazolam), general anesthesia (GA) with endotracheal tube, or fentanyl/midazolam (FM) only. The primary outcome was length of stay (LOS) in the postanesthesia care unit (PACU), and secondary outcomes included the incidence of postoperative nausea and vomiting (PONV), hypoxemia (Spo2 risk 90%), bradycardia (heart rate <60 bpm), and escalation of care (hospital admission). RESULTS The analysis included 56,361 cases. Among patients who received FM sedation, the mean PACU LOS was 52.01, 49.68, and 53.24 minutes for EGD, colonoscopy, and combined procedures, respectively. This was significantly higher than the mean PACU LOS for GA (44.65, 41.41, and 41.92 minutes, respectively), for PA (32.35, 35.75, and 33.42 minutes, respectively), and for propofol (31.63, 32.61, and 33.29 minutes, respectively; P < .0001). Of patients receiving FM, 8.39% experienced bradycardia, 6.12% experienced hypoxia, 0.24% experienced PONV, and 0.05% were hospitalized. These were substantially lower than the rates for other sedation groups, and odds ratios were significantly lower than 1.00 (P < .05) in 30 of 36 comparisons across procedural, sedative, and outcome categories. CONCLUSIONS Sedation achieved with FM correlated with a lower rate of adverse events but a significantly longer PACU LOS compared with propofol, PA, or GA.
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Affiliation(s)
- Guozhen Xie
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Maria Estevez
- Clinical Studies Unit, Mayo Clinic, Jacksonville, Florida, USA
| | - Kiyan Heybati
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthew Vogt
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Christine Moshe
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Johanna Chan
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Vivek Kumbhari
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Ryan Chadha
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida, USA.
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Murakami K, Horita S, Tsuyuki M, Moriyasu A. Perioperative changes in anxiety and comfort in third molar extraction patients sedated with midazolam. Oral Maxillofac Surg 2025; 29:31. [PMID: 39806035 DOI: 10.1007/s10006-024-01326-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2024] [Accepted: 12/28/2024] [Indexed: 01/16/2025]
Abstract
PURPOSE This study aimed to analyze changes in anxiety and comfort levels at each perioperative stage during third molar extraction under single-agent intravenous midazolam sedation, and to clarify how these conditions at each perioperative stage affect postoperative satisfaction. PATIENTS AND METHOD 115 who requested extraction of 1 ~ 4 third molars under single-agent intravenous midazolam sedation were targeted. These patients were administered a questionnaire survey one week after surgery. The questionnaire's five items (Anxiety before surgery, Comfort during surgery, Comfort after surgery, Amnesia, and Satisfaction) were evaluated using a visual analog scale (VAS). We investigated the correlation between each of the eight parameters which added age, operation time, and total amount of midazolam, to the VAS score. Furthermore, we compared each eight parameters according to the number of extracted wisdom teeth and sex differences. RESULTS Regarding the correlation among each parameter, low preoperative anxiety were weak and positively correlated with reduced operation time reduced midazolam dosage, and an increase in postoperative comfort. All parameters influenced the patient's satisfaction level. Those levels were significantly affected by preoperative reassurance (r = 0.4402, p < 0.01), postoperative comfort (r = 0.5522, p < 0.01) amnesia (r = 0.5741, p < 0.01), and intraoperative comfort (r = 0.7578, p < 0.01). Each parameter had no significant difference depending on the number of teeth extracted. In comparison between men and women, only preoperative reassurance was significantly lower in women than in men (p<0.05). CONCLUSION AND RELEVANCE This sedation effectively managed preoperative anxiety and improved postoperative satisfaction. To obtain good sedative condition, Preoperative anxiolytics are recommended. This sedation is considered particularly effective in women.
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Affiliation(s)
- Kazuhiro Murakami
- Department of Oral and Maxillofacial Surgery, Nara Medical University, 840, Shijo-Cho, 634-8522, Kashihara, Nara, Japan.
| | - Satoshi Horita
- Department of Oral and Maxillofacial Surgery, Nara Medical University, 840, Shijo-Cho, 634-8522, Kashihara, Nara, Japan
| | - Motokatsu Tsuyuki
- Department of Oral and Maxillofacial Surgery, Nara Medical University, 840, Shijo-Cho, 634-8522, Kashihara, Nara, Japan
| | - Akihito Moriyasu
- Department of Oral and Maxillofacial Surgery, Nara Medical University, 840, Shijo-Cho, 634-8522, Kashihara, Nara, Japan
- Department of Internal Medicine, Hattori Memorial Hospital, 4244 Kanmaki, 639-0214, Kamimaki-cho, Kitakatsuragi-gun, Nara, Japan
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Wu X, Zhang L, Zhou Z, Qi L, Liu Y, Du X, Ma L, Ji X. The Efficacy and Safety Profile of Balanced Propofol Sedation for Bronchoscopy. Ther Clin Risk Manag 2024; 20:849-860. [PMID: 39691941 PMCID: PMC11649497 DOI: 10.2147/tcrm.s495253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2024] [Accepted: 12/03/2024] [Indexed: 12/19/2024] Open
Abstract
Purpose We conducted a prospective, real-world study to evaluate the efficacy and safety of balanced propofol sedation (BPS) in bronchoscopy and identify an advantageous sedation regimen for such procedures. Patients and Methods The participants were placed in four groups based on their sedation regimen (exposure factor): the M-S group (midazolam + sufentanil for traditional sedation), R-S group (remimazolam + sufentanil for traditional sedation), M-S-P group (midazolam + sufentanil + propofol for BPS), and R-S-P group (remimazolam + sufentanil + propofol for BPS). The primary outcomes included satisfaction metrics (satisfaction of the patients, endoscopic physicians, and nurses) and follow-up questionnaires. The secondary outcomes included time metrics (induction time, recovery time, and discharge time), dosage metrics (induction dose, maintenance dose, and total dose of each sedative), completion rate of sedation, intraprocedural dose, and frequency of lidocaine spray in the airway, and incidence of adverse reactions. Results In total, 418 subjects were included in this study. Compared to traditional sedation, both BPS groups significantly increased the satisfaction of patients, endoscopic physicians, and nurses (P < 0.05) and reduced the incidence of intraprocedural wakefulness (P < 0.05). Additionally, induction and recovery of the BPS group were rapid, with high sedation completion rates and no increase in the incidence of intraprocedural and postprocedural adverse reactions (P < 0.05). The RSP group was better than the MSP group in terms of various time metrics and postprocedural adverse reactions. Conclusion BPS can be safely and effectively applied during bronchoscopy, with remimazolam and sufentanil combined with a small dose of propofol being an optimal medication regimen.
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Affiliation(s)
- Xinyu Wu
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, People’s Republic of China
| | - Lina Zhang
- Department of Anesthesiology, Qingdao Municipal Hospital, Qingdao, Shandong, People’s Republic of China
| | - Zangong Zhou
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, People’s Republic of China
| | - Lijie Qi
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, People’s Republic of China
| | - Yinhuan Liu
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, People’s Republic of China
| | - Xuebin Du
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, People’s Republic of China
| | - Lixia Ma
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, People’s Republic of China
| | - Xiangyu Ji
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, People’s Republic of China
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Xu JH, Tan HL, Zhang LN, Zhou ZG, Yuan L, Kong LX, Song MQ, Qi LJ, Ji XY. Transcutaneous Electrical Acupoint Stimulation Combined with Moderate Sedation of Remimazolam Tosilate in Gastrointestinal Endoscopy: A Prospective, Randomized, Double-Blind, Placebo-Controlled Clinical Trial. Pain Ther 2024; 13:919-936. [PMID: 38890239 PMCID: PMC11254895 DOI: 10.1007/s40122-024-00618-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Accepted: 05/20/2024] [Indexed: 06/20/2024] Open
Abstract
INTRODUCTION Further clinical validation is required to determine whether transcutaneous electrical acupoint stimulation (TEAS) can replace opioids and be used in combination with remimazolam for sedation during gastrointestinal endoscopy. METHODS A total of 108 outpatients who underwent diagnostic gastrointestinal endoscopy were randomly divided into three groups: fentanyl plus remimazolam group (group C), TEAS plus remimazolam group (group E), and placebo-TEAS plus remimazolam group (group P). The assessments of patient satisfaction, physician satisfaction, and pain scale score during the examination constituted the primary endpoints of the study. The secondary endpoints were the time of recovery, recovery of normal behavioral function and discharge, incidence of adverse reactions, and dose of remimazolam. RESULTS Compared with group C, group E had a greater median score for patient satisfaction at follow-up and a slightly lower median score for physician satisfaction. The pain score of group E was slightly greater than that of group C, but the difference was not significant. However, in group C, the incidence of hypoxemia, the rate of nausea and the severity of vertigo were greater, and the number of patients discharged and resuming normal behavioral function was greater than those in the other two groups. The dose of remimazolam in group C and group E was less than that in group P. CONCLUSIONS TEAS combined with moderate sedation of remimazolam can provide an ideal sedative effect, which preferably suppresses discomfort caused by gastrointestinal endoscopy and has fewer sedation-related complications. TRIAL REGISTRATION ID: NCT05485064; First registration (29/07/2022); Last registration (02/11/2022) (Clinical Trials.gov).
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Affiliation(s)
- Jian-Han Xu
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Hai-Ling Tan
- Department of Pharmacy, Qingdao Municipal Hospital, Qingdao, 266071, China
| | - Li-Na Zhang
- Department of Anesthesiology, Qingdao Municipal Hospital, Qingdao, 266071, China.
| | - Zan-Gong Zhou
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Li Yuan
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Ling-Xin Kong
- Department of Rehabilitation Physiotherapy, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Ming-Quan Song
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Li-Jie Qi
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xiang-Yu Ji
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, China.
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Chen B, Lu L, Zhai J, Hua Z. Effect of moderate versus deep sedation on recovery following outpatient gastroscopy in older patients: a randomized controlled trial. Surg Endosc 2024; 38:1273-1282. [PMID: 38102399 DOI: 10.1007/s00464-023-10642-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 12/03/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND Although gastrointestinal endoscopy with sedation is increasingly performed in older patients, the optimal level of sedation remains open to debate. In this study, our objective was to compare the effects of moderate sedation (MS) and deep sedation (DS) on recovery following outpatient gastroscopy in elderly patients. METHODS In this randomized, partially blinded, controlled trial, we randomly divided 270 patients older than 60 years who were scheduled for elective outpatient gastroscopy into the MS or DS group based on the Modified Observer's Assessment of Alertness/Sedation (MOAA/S) scale. The primary outcome was the duration of stay in the post-anesthesia care unit (PACU). Secondary outcomes included the duration of the total hospital stay, frequency of retching, bucking, and body movements during the examination, endoscopist and patient satisfaction, and sedation-associated adverse events during the procedure. RESULTS A total of 264 patients completed the study, of whom 131 received MS and 133 received DS. MS was associated with a shorter PACU stay [16.15 ± 9.01 min vs. 20.02 ± 11.13 min, P < 0.01] and total hospital stay [27.32 ± 9.86 min vs. 30.82 ± 12.37 min, P < 0.05], lesser hypoxemia [2.3% (3/131) vs. 12.8% (17/133), P < 0.01], use of fewer vasoactive drugs (P < 0.001), and more retching (P < 0.001). There was no difference in the incidence of bucking and body movements or endoscopist and patient satisfaction between the two groups. CONCLUSION Compared to deep sedation, moderate sedation may be a preferable choice for American Society of Anesthesiologists (ASA) Grade I-III elderly patients undergoing outpatient gastroscopies, as demonstrated by shorter PACU stays and total hospital stays, lower sedation-associated adverse events, and similar levels of endoscopist and patient satisfaction.
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Affiliation(s)
- Bing Chen
- Department of Anesthesiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, No. 1 Dahua Road, DongDan, Beijing, 100730, People's Republic of China
| | - Lin Lu
- Department of Anesthesiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, No. 1 Dahua Road, DongDan, Beijing, 100730, People's Republic of China
| | - Jie Zhai
- Department of Anesthesiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, No. 1 Dahua Road, DongDan, Beijing, 100730, People's Republic of China
| | - Zhen Hua
- Department of Anesthesiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, No. 1 Dahua Road, DongDan, Beijing, 100730, People's Republic of China.
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Kojima Y, Oiwa D. Ultrasound-Guided Selective Glossopharyngeal Nerve Block for Severe Gag Reflex During Dental Treatment: A Report of Two Cases. Cureus 2024; 16:e54725. [PMID: 38524059 PMCID: PMC10961151 DOI: 10.7759/cureus.54725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2024] [Indexed: 03/26/2024] Open
Abstract
The ultrasound-guided selective glossopharyngeal nerve block (UGSGNB) has been developed as an approach to overcome the drawbacks of the conventional glossopharyngeal nerve block. The UGSGNB may be performed when a gag reflex occurs during dental treatment. Case 1 involved a 67-year-old man with a medical history of cervical spondylosis and dilated cardiomyopathy. Dental treatment with conscious sedation and the UGSGNB was performed three times. Case 2 involved a 25-year-old woman who was scheduled for dental treatment under general anesthesia because of dental phobia and gagging. Because the patient experienced severe tooth pain and desired urgent treatment, anesthesia was induced with intravenous sedation and the UGSGNB. In both cases, treatments were completed without intraoperative gagging or any complications. Our observations indicate that the UGSGNB can suppress the gag reflex during dental treatment; it may allow surgeons to avoid inducing general anesthesia and deep sedation in patients with a severe gag reflex.
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Affiliation(s)
- Yuki Kojima
- Department of Dental Anesthesiology, Asahi General Hospital, Asahi, JPN
| | - Daisuke Oiwa
- Department of Dental Anesthesiology and Perioperative Management, Hinode Makomanai Dental Hospital, Sapporo, JPN
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Manivannan A, Madani S, Woodall M, McKelvey G, Kemper S. Propofol Sedation in Pediatric Upper Endoscopy: A Study of Pharmacodynamics and the Effects of Gastroenterologists, Anesthesiologists, and Supervised Participants on the Procedure Time and Sedation Time. Cureus 2024; 16:e54841. [PMID: 38533143 PMCID: PMC10964119 DOI: 10.7759/cureus.54841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2024] [Indexed: 03/28/2024] Open
Abstract
Background and aims Propofol combined with fentanyl is a commonly used sedative for pediatric upper endoscopies (UEs). The primary aim was to study the association between propofol dose and procedure and sedation time. The secondary aims were to assess the pharmacodynamics of propofol use with fentanyl and evaluate if gastroenterologists' and anesthesiologists' years of experience or the presence of supervised participants (such as students, residents, and fellows) have any influence on the procedure and sedation time. Methods A retrospective study was performed at the Children's Hospital of Michigan on patients under 18 years who underwent UEs with propofol sedation with fentanyl over a two-year period. Results A correlation was found between the propofol amount used expressed per body mass index (BMI)/body surface area (BSA), procedure time, and sedation time (p < 0.0001). Throat pain was the most common post-procedural adverse event (4.48%). The impact of psychoactive drugs on these events was not statistically significant, but attention-deficit/hyperactivity disorder (ADHD) medication use was related to increased post-procedural pain complaints. The use of prescribed psychoactive medications was associated with larger propofol dose usage (p = 0.007) without a significant increase in sedation time. Individual gastroenterologists, their years of experience, and the presence of supervised participants were associated with different procedure times (p <0.0001, <0.0001, 0.01). Fellow participation was associated with a 1.11-minute procedure time increase (p = 0.04). Individual anesthesiologists, their years of experience, and the presence of supervised participants were associated with different sedation times (p <0.0001, <0.0001, 0.01). Conclusion We found a novel correlation between propofol dosing expressed by the BMI/BSA and sedation time. The UE procedure time and sedation time are associated with individual gastroenterologists and anesthesiologists, their years of experience, and the presence of supervised participants.
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Affiliation(s)
| | - Shailender Madani
- Pediatric Gastroenterology, Children's Hospital of Michigan, Troy, USA
| | - Michael Woodall
- Pediatrics, NorthShore/Endeavor Health Medical Group, Evanston, USA
| | | | - Sharon Kemper
- Pediatric Anesthesiology, Children's Hospital of Michigan, Detroit, USA
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Chiang C, Teng WN, Chiang TY, Huang CL, Lin SP, Chang WK, Ting CK. True intratracheal oxygen concentration delivered by SentriO Oxy™ masks under various respiratory conditions: a bench study. J Clin Monit Comput 2023; 37:1489-1495. [PMID: 37828296 PMCID: PMC10651707 DOI: 10.1007/s10877-023-01076-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 09/03/2023] [Indexed: 10/14/2023]
Abstract
SentriO Oxy™ is a newly available, Food and Drug Administration-approved oxygenation mask system that provides high oxygenation, even on low-flow (5-10 L/min) oxygen. This study aimed to accurately measure the intratracheal fraction of inspired oxygen (FiO2) using SentriO Oxy™ masks under relatively low oxygen flow rates. A manikin-ventilator-test lung simulation system was used. We measured FiO2 at the level of the carina, 5 minutes after applying 45 different respiratory parameter combinations using SentriO Oxy™ masks. Tidal volume (TV) was set to 300, 500, and 700 mL; respiratory rate (RR) was set to 8, 12, 16, 20, and 24 breaths per minute; and oxygen flow rate was set to 6, 8, and 10 L/min. Our hypothesis was that FiO2 would be proportional to the difference between oxygen flow rate and minute ventilation. FiO2 measured by smaller TV, lower RR, or higher oxygen flows revealed a significantly higher value, confirming our hypothesis. In addition, using linear regression analysis, we found that TV, RR, and oxygen flow were all significant factors influencing the measured FiO2. Our experiment proposed two prediction equations considering the oxygen flow rate, TV, and RR. The results of our study may provide information and prediction of FiO2 for clinicians to use SentriO Oxy™ masks during sedative anesthetic procedures under low oxygen flow rates.
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Affiliation(s)
- Cheng Chiang
- Department of Anesthesiology, Taipei Veterans General Hospital and National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wei-Nung Teng
- Department of Anesthesiology, Taipei Veterans General Hospital and National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ting-Yun Chiang
- Department of Anesthesiology, Taipei Veterans General Hospital and National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chao-Lan Huang
- Department of Anesthesiology, Taipei Veterans General Hospital and National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shi-Pin Lin
- Department of Anesthesiology, Taipei Veterans General Hospital and National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wen-Kuei Chang
- Department of Anesthesiology, Taipei Veterans General Hospital and National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chien-Kun Ting
- Department of Anesthesiology, Taipei Veterans General Hospital and National Yang Ming Chiao Tung University, Taipei, Taiwan.
- Institute of Emergency and intensive care medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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11
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Liou JY, Kuo IT, Chang WK, Ting CK, Tsou MY. Pharmacodynamic modeling of moderate sedation and rationale for dosing using midazolam, propofol and alfentanil. BMC Pharmacol Toxicol 2023; 24:3. [PMID: 36647160 PMCID: PMC9843845 DOI: 10.1186/s40360-023-00642-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 01/03/2023] [Indexed: 01/18/2023] Open
Abstract
PURPOSE Regulations have broadened to allow moderate sedation administration for gastrointestinal endoscopy by non-anesthesia personnel. The line between moderate and deep sedation is ambiguous. Deep sedation offers patient comfort as well as greater safety concerns. Unintended deep sedation can occur if drug interactions are overlooked. We present a pharmacodynamic model for moderate sedation using midazolam, alfentanil and propofol. The model is suitable for training and devising rationales for appropriate dosing. METHODS The study consists of two parts: modeling and validation. In modeling, patients scheduled for esophagogastroduodenoscopy (EGD) or colonoscopy sedation are enrolled. The modified observer's assessment of alertness/sedation (MOAA/S) score < 4 is defined as loss of response to represent moderate sedation. Two patient groups receiving bronchoscopy or endoscopic retrograde cholangiopancreatography (ERCP) are used for validation. Model performance is assessed by receiver operating characteristic (ROC) curves and area under the curve (AUC). Simulations are performed to demonstrate how the model is used to rationally determine drug regimen for moderate sedation. RESULTS Interaction between propofol and alfentanil is stronger than the other pairwise combinations. Additional synergy is observed with three drugs. ROC AUC is 0.83 for the modeling group, and 0.96 and 0.93 for ERCP and bronchoscopy groups respectively. Model simulation suggests that 1 mg midazolam, 250 µg alfentanil and propofol maximally benefits from drug interactions and suitable for moderate sedation. CONCLUSION We demonstrate the accurate prediction of a three-drug response surface model for moderate sedation and simulation suggests a rational dosing strategy for moderate sedation with midazolam, alfentanil and propofol.
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Affiliation(s)
- Jing-Yang Liou
- grid.278247.c0000 0004 0604 5314Department of Anesthesia, Taipei Veterans General Hospital, Taipei Veterans General Hospital, No.201, Sec. 2, Shipai Rd., Beitou District, 11217 Taipei, Taiwan ,grid.260539.b0000 0001 2059 7017Department of Biomedical Engineering, National Yang-Ming Chiao Tung University, Taipei, Taiwan ,grid.260539.b0000 0001 2059 7017School of Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan
| | - I-Ting Kuo
- grid.278247.c0000 0004 0604 5314Department of Anesthesia, Taipei Veterans General Hospital, Taipei Veterans General Hospital, No.201, Sec. 2, Shipai Rd., Beitou District, 11217 Taipei, Taiwan ,grid.260539.b0000 0001 2059 7017Department of Biomedical Engineering, National Yang-Ming Chiao Tung University, Taipei, Taiwan
| | - Weng-Kuei Chang
- grid.278247.c0000 0004 0604 5314Department of Anesthesia, Taipei Veterans General Hospital, Taipei Veterans General Hospital, No.201, Sec. 2, Shipai Rd., Beitou District, 11217 Taipei, Taiwan ,grid.260539.b0000 0001 2059 7017School of Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan
| | - Chien-Kun Ting
- grid.278247.c0000 0004 0604 5314Department of Anesthesia, Taipei Veterans General Hospital, Taipei Veterans General Hospital, No.201, Sec. 2, Shipai Rd., Beitou District, 11217 Taipei, Taiwan ,grid.260539.b0000 0001 2059 7017Department of Biomedical Engineering, National Yang-Ming Chiao Tung University, Taipei, Taiwan ,grid.260539.b0000 0001 2059 7017School of Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan ,grid.260539.b0000 0001 2059 7017Institute of Emergency and Critical Care Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Mei-Yung Tsou
- grid.278247.c0000 0004 0604 5314Department of Anesthesia, Taipei Veterans General Hospital, Taipei Veterans General Hospital, No.201, Sec. 2, Shipai Rd., Beitou District, 11217 Taipei, Taiwan ,grid.260539.b0000 0001 2059 7017School of Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan
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12
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Simulation-Based Gastrointestinal Endoscopy Sedations: A Novel Validation to Multidrug Pharmacodynamic Modeling. Pharmaceutics 2022; 14:pharmaceutics14102056. [PMID: 36297491 PMCID: PMC9610933 DOI: 10.3390/pharmaceutics14102056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 09/15/2022] [Accepted: 09/20/2022] [Indexed: 11/16/2022] Open
Abstract
Pharmacodynamic models have described the interactions between anesthetics. Applying the models to clinical practice is still problematic due to inherent limitations: 1. modeling conditions are different from practice. 2. One model can only describe one endpoint. To tackle these, we propose a new method of model validation for recovery and intraprocedural sedation adequacy with a three-drug pharmacodynamic model using six published clinical studies that contain midazolam, opioid, and propofol. Mean drug dose, intraprocedural sedation level, procedure, and recovery time are extracted from each study. Simulated drug regimens are designed to best approximate study conditions. A published deep sedation model is used for simulation. Model-predicted recovery time and intraprocedural sedation scores are compared with the original clinical study outcomes. The model successfully predicted recovery times in eight out of nine regimens. Lower doses of midazolam are associated with faster recovery. Model prediction of intraprocedural sedation level was compatible with the clinical studies in five out of seven regimens. The three-drug pharmacodynamic model describes the course of gastrointestinal endoscopy sedations from clinical studies well. Model predictions are consistent with the results from clinical studies. The approach implies that large scale validation can be performed repeatedly.
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Jang JM, Park SB, Yoon JY, Kwak MS, Cha JM. Gastrointestinal and non-gastrointestinal complication rates associated with diagnostic esophagogastroduodenoscopy under sedation. Medicine (Baltimore) 2022; 101:e29266. [PMID: 35583537 PMCID: PMC9276211 DOI: 10.1097/md.0000000000029266] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 04/20/2022] [Indexed: 01/04/2023] Open
Abstract
Esophagogastroduodenoscopy (EGD) under sedation may result in gastrointestinal (GI) and non-GI complications. However, no previous studies have reported 30-day GI and non-GI complications after diagnostic EGD under sedation.We conducted a retrospective, observational study of 30-day GI and non-GI complication rates after outpatient diagnostic EGD under sedation in subjects ≥18 years between January 2012 and December 2017 based on a common data model database. Thirty-day complication rates were compared with EGD under sedation or not, type of sedation drugs (midazolam only vs midazolam/propofol) and age groups (18-64 year vs ≥65 year) for GI (bleeding and perforation) and non-GI complications (pneumonia, acute myocardial infarction, congestive heart failure and cerebral stroke).In total, 39,910 were performed with sedation (midazolam only, n = 16,033 and midazolam/propofol, n = 23,864) and 22,894 were performed without sedation. Elderly patients significantly favored EGD without sedation (P < .01). GI and non-GI complication rates were similar between EGD under sedation and without sedation (all P > .1) except for acute myocardial infarction rate, which was significantly higher in EGD without sedation than EGD under sedation (1.7/10,000 vs 0.3/10,000 persons, P = .043). All GI and non-GI complications were also similar between the midazolam/propofol and midazolam only groups as well as between young and old patients (all P > .1).Outpatient diagnostic EGD under sedation has an excellent safety profile. In addition, it can be safely performed with midazolam only or midazolam/propofol and in young and old patients.
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Affiliation(s)
- Ji Min Jang
- Division of Gastroenterology, Department of Internal Medicine, Kyung Hee University Hospital at Gang Dong, Seoul, Korea
| | - Su Bee Park
- Division of Gastroenterology, Department of Internal Medicine, Kyung Hee University Hospital at Gang Dong, Seoul, Korea
| | - Jin Young Yoon
- Division of Gastroenterology, Department of Internal Medicine, Kyung Hee University Hospital at Gang Dong, Seoul, Korea
- Division of Gastroenterology, Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, Korea
| | - Min Seob Kwak
- Division of Gastroenterology, Department of Internal Medicine, Kyung Hee University Hospital at Gang Dong, Seoul, Korea
- Division of Gastroenterology, Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, Korea
| | - Jae Myung Cha
- Division of Gastroenterology, Department of Internal Medicine, Kyung Hee University Hospital at Gang Dong, Seoul, Korea
- Division of Gastroenterology, Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, Korea
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14
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Nam JH, Jang DK, Lee JK, Kang HW, Kim BW, Jang BI, the Committees of Quality Management and Conscious Sedation of Korean Society of Gastrointestinal Endoscopy. Propofol Alone versus Propofol in Combination with Midazolam for Sedative Endoscopy in Patients with Paradoxical Reactions to Midazolam. Clin Endosc 2022; 55:234-239. [PMID: 34634857 PMCID: PMC8995981 DOI: 10.5946/ce.2021.126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 05/14/2021] [Accepted: 05/19/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND/AIMS The efficacy of propofol in gastrointestinal endoscopy for patients with midazolam-induced paradoxical reactions remains unclarified. This study aimed to compare the efficacy and safety of propofol-based sedation in patients who previously experienced paradoxical reactions. METHODS This was a prospective, single-blinded, randomized controlled pilot study. Participants with a history of paradoxical reactions to midazolam during a previous esophagogastroduodenoscopy were recruited and randomly assigned to group I (propofol monosedation) or group II (combination of propofol and midazolam). The primary endpoint was the occurrence of a paradoxical reaction. RESULTS A total of 30 participants (mean age, 54.7±12.6 years; male, 19/30) were randomly assigned to group I (n=16) or group II (n=14). There were no paradoxical reactions in group I, but there were two in group II, without a significant difference (p=0.209). The mean dose of propofol was higher in group I than in group II (p=0.002). Meanwhile, the procedure and recovery times did not differ between groups. CONCLUSION Propofol-based sedation was safe and effective for patients who experienced paradoxical reactions to midazolam. However, caution is needed because few cases of paradoxical reaction again can happen in group II in which midazolam was readministered.
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Affiliation(s)
- Ji Hyung Nam
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Dong Kee Jang
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Jun Kyu Lee
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Hyoun Woo Kang
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Byung-Wook Kim
- Department of Internal Medicine, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
| | - Byung Ik Jang
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - the Committees of Quality Management and Conscious Sedation of Korean Society of Gastrointestinal Endoscopy
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
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15
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Vargo JJ. Endoscopist-directed nurse-administered balanced propofol sedation for ASA class III patients: A safety net for a tough balancing act? Gastrointest Endosc 2021; 94:131-132. [PMID: 33994210 DOI: 10.1016/j.gie.2021.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 03/06/2021] [Indexed: 12/11/2022]
Affiliation(s)
- John J Vargo
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
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16
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Kanogawa N, Ogasawara S, Ooka Y, Inoue M, Wakamatsu T, Yokoyama M, Maruta S, Unozawa H, Iwanaga T, Sakuma T, Fujita N, Koroki K, Kanzaki H, Maeda T, Kobayashi K, Kiyono S, Nakamura M, Kondo T, Saito T, Motoyama T, Suzuki E, Nakamoto S, Tawada A, Chiba T, Arai M, Kanda T, Maruyama H, Kato J, Takemura R, Nozaki‐Taguchi N, Shiroh I, Yokosuka O, Kato N. Propofol versus midazolam for sedation during radiofrequency ablation in patients with hepatocellular carcinoma. JGH Open 2021; 5:273-279. [PMID: 33553667 PMCID: PMC7857294 DOI: 10.1002/jgh3.12483] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 12/10/2020] [Accepted: 12/11/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIM Standardization of the sedation protocol during radiofrequency ablation (RFA) in patients with hepatocellular carcinoma (HCC) is needed. This randomized, single-blind, investigator-initiated trial compared clinical outcomes during and after RFA using propofol and midazolam, respectively, in patients with HCC. METHODS Few- and small-nodule HCC patients (≤3 nodules and ≤3 cm) were randomly assigned to either propofol or midazolam. Patient satisfaction was assessed using a 100-mm visual analog scale (VAS) (1 mm = not at all satisfied, 100 mm = completely satisfied). Sedation recovery rates 1, 2, 3, and 4 h after RFA were evaluated based on Modified Observer's Assessment of Alertness/Sedation (MOAA/S) scores; full recovery was defined as a MOAA/S score of 5. RESULTS Between July 2013 and September 2017, 143 patients with HCC were enrolled, and 135 patients were randomly assigned to the treatment group. Compared with midazolam, propofol exhibited similar median procedural satisfaction (propofol: 73.1 mm, midazolam: 76.9 mm, P = 0.574). Recovery rates 1 and 2 h after RFA were higher in the propofol group than in the midazolam group. Meanwhile, recovery rates observed 3 and 4 h after RFA were similar in the two groups. The safety profiles during and after RFA were almost identical in the two groups. CONCLUSION Patient satisfaction was almost identical in patients receiving propofol and midazolam sedation during RFA. Propofol sedation resulted in reduced recovery time compared with midazolam sedation in patients with HCC. The safety profiles of both propofol and midazolam sedation during and after RFA were acceptable.
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Affiliation(s)
- Naoya Kanogawa
- Department of Gastroenterology, Graduate School of MedicineChiba UniversityChibaJapan
| | - Sadahisa Ogasawara
- Department of Gastroenterology, Graduate School of MedicineChiba UniversityChibaJapan
- Translational Research and Development CenterChiba University HospitalChibaJapan
| | - Yoshihiko Ooka
- Department of Gastroenterology, Graduate School of MedicineChiba UniversityChibaJapan
| | - Masanori Inoue
- Department of Gastroenterology, Graduate School of MedicineChiba UniversityChibaJapan
| | - Toru Wakamatsu
- Department of Gastroenterology, Graduate School of MedicineChiba UniversityChibaJapan
| | - Masayuki Yokoyama
- Department of Gastroenterology, Graduate School of MedicineChiba UniversityChibaJapan
| | - Susumu Maruta
- Department of Gastroenterology, Graduate School of MedicineChiba UniversityChibaJapan
| | - Hidemi Unozawa
- Department of Gastroenterology, Graduate School of MedicineChiba UniversityChibaJapan
| | - Terunao Iwanaga
- Department of Gastroenterology, Graduate School of MedicineChiba UniversityChibaJapan
| | - Takafumi Sakuma
- Department of Gastroenterology, Graduate School of MedicineChiba UniversityChibaJapan
| | - Naoto Fujita
- Department of Gastroenterology, Graduate School of MedicineChiba UniversityChibaJapan
| | - Keisuke Koroki
- Department of Gastroenterology, Graduate School of MedicineChiba UniversityChibaJapan
| | - Hiroaki Kanzaki
- Department of Gastroenterology, Graduate School of MedicineChiba UniversityChibaJapan
| | - Takahiro Maeda
- Department of Gastroenterology, Graduate School of MedicineChiba UniversityChibaJapan
| | - Kazufumi Kobayashi
- Department of Gastroenterology, Graduate School of MedicineChiba UniversityChibaJapan
| | - Soichiro Kiyono
- Department of Gastroenterology, Graduate School of MedicineChiba UniversityChibaJapan
| | - Masato Nakamura
- Department of Gastroenterology, Graduate School of MedicineChiba UniversityChibaJapan
| | - Takayuki Kondo
- Department of Gastroenterology, Graduate School of MedicineChiba UniversityChibaJapan
| | - Tomoko Saito
- Department of Gastroenterology, Graduate School of MedicineChiba UniversityChibaJapan
| | - Tenyu Motoyama
- Department of Gastroenterology, Graduate School of MedicineChiba UniversityChibaJapan
| | - Eiichiro Suzuki
- Department of Gastroenterology, Graduate School of MedicineChiba UniversityChibaJapan
| | - Shingo Nakamoto
- Department of Gastroenterology, Graduate School of MedicineChiba UniversityChibaJapan
| | - Akinobu Tawada
- Department of Gastroenterology, Graduate School of MedicineChiba UniversityChibaJapan
- Department of Medical Oncology, Graduate School of MedicineChiba UniversityChibaJapan
| | - Tetsuhiro Chiba
- Department of Gastroenterology, Graduate School of MedicineChiba UniversityChibaJapan
| | - Makoto Arai
- Department of Gastroenterology, Graduate School of MedicineChiba UniversityChibaJapan
- Department of Medical Oncology, Graduate School of MedicineChiba UniversityChibaJapan
| | - Tatsuo Kanda
- Department of Gastroenterology, Graduate School of MedicineChiba UniversityChibaJapan
- Division of Gastroenterology and Hepatology, Department of MedicineNihon University School of MedicineTokyoJapan
| | - Hitoshi Maruyama
- Department of Gastroenterology, Graduate School of MedicineChiba UniversityChibaJapan
- Department of GastroenterologyJuntendo University School of MedicineTokyoJapan
| | - Jun Kato
- Department of Gastroenterology, Graduate School of MedicineChiba UniversityChibaJapan
| | - Ryo Takemura
- Clinical and Translational Research CenterKeio University HospitalTokyoJapan
| | | | - Isono Shiroh
- Departmetn of Anesthesiology, Graduate School of MedicineChiba UniversityChibaJapan
| | - Osamu Yokosuka
- Department of Gastroenterology, Graduate School of MedicineChiba UniversityChibaJapan
| | - Naoya Kato
- Department of Gastroenterology, Graduate School of MedicineChiba UniversityChibaJapan
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Kim JH, Byun S, Choi YJ, Kwon HJ, Jung K, Kim SE, Park MI, Moon W, Park SJ. Efficacy and Safety of Etomidate in Comparison with Propofol or Midazolam as Sedative for Upper Gastrointestinal Endoscopy. Clin Endosc 2020; 53:555-561. [PMID: 32229801 PMCID: PMC7548146 DOI: 10.5946/ce.2019.210] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 02/04/2020] [Accepted: 02/04/2020] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND/AIMS In this study, we compared the efficacy and safety of etomidate with those of propofol or midazolam for the maintenance of sedation during endoscopy. METHODS The study enrolled patients who underwent sedative endoscopy in our hospital and divided them into three groups. Patients in each group were administered midazolam as induction therapy and were subsequently administered either midazolam (M + M group), propofol (M + P group), or etomidate (M + E group) as maintenance medication. The primary outcome was overall cardiovascular and respiratory adverse events. RESULTS In total, 105 patients who underwent sedative endoscopic examination were enrolled. The outcomes related to the procedure and sedation were not significantly different among the groups. Overall cardiovascular and respiratory adverse events were observed in 9 patients (25.7%) in the M + M group, 8 patients (23.5%) in the M + P group, and 10 patients (27.8%) in the M + E group. The logistic regression analysis revealed that etomidate use was not an independent risk factor for overall cardiovascular and respiratory adverse events. CONCLUSION The outcomes following the use of etomidate for maintenance after induction with midazolam for sedation in upper gastrointestinal endoscopy were not inferior to those following midazolam or propofol use from the perspectives of safety and efficacy.
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Affiliation(s)
- Jae Hyun Kim
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Sanghwan Byun
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Youn Jung Choi
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Hye Jung Kwon
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Kyoungwon Jung
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Sung Eun Kim
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Moo In Park
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Won Moon
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Seun Ja Park
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
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Delgado AADA, de Moura DTH, Ribeiro IB, Bazarbashi AN, dos Santos MEL, Bernardo WM, de Moura EGH. Propofol vs traditional sedatives for sedation in endoscopy: A systematic review and meta-analysis. World J Gastrointest Endosc 2019; 11:573-588. [PMID: 31839876 PMCID: PMC6885729 DOI: 10.4253/wjge.v11.i12.573] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 08/17/2019] [Accepted: 09/11/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Propofol is commonly used for sedation during endoscopic procedures. Data suggests its superiority to traditional sedatives used in endoscopy including benzodiazepines and opioids with more rapid onset of action and improved post-procedure recovery times for patients. However, Propofol requires administration by trained healthcare providers, has a narrow therapeutic index, lacks an antidote and increases risks of cardio-pulmonary complications. AIM To compare, through a systematic review of the literature and meta-analysis, sedation with propofol to traditional sedatives with or without propofol during endoscopic procedures. METHODS A literature search was performed using MEDLINE, Scopus, EMBASE, the Cochrane Library, Scopus, LILACS, BVS, Cochrane Central Register of Controlled Trials, and The Cumulative Index to Nursing and Allied Health Literature databases. The last search in the literature was performed on March, 2019 with no restriction regarding the idiom or the year of publication. Only randomized clinical trials with full texts published were included. We divided sedation therapies to the following groups: (1) Propofol versus benzodiazepines and/or opiate sedatives; (2) Propofol versus Propofol with benzodiazepine and/or opioids; and (3) Propofol with adjunctive benzodiazepine and opioid versus benzodiazepine and opioid. The following outcomes were addressed: Adverse events, patient satisfaction with type of sedation, endoscopists satisfaction with sedation administered, dose of propofol administered and time to recovery post procedure. Meta-analysis was performed using RevMan5 software version 5.39. RESULTS A total of 23 clinical trials were included (n = 3854) from the initial search of 6410 articles. For Group I (Propofol vs benzodiazepine and/or opioids): The incidence of bradycardia was not statistically different between both sedation arms (RD: -0.01, 95%CI: -0.03-+0.01, I 2: 22%). In 10 studies, the incidence of hypotension was not statistically difference between sedation arms (RD: 0.01, 95%CI: -0.02-+0.04, I 2: 0%). Oxygen desaturation was higher in the propofol group but not statistically different between groups (RD: -0.03, 95%CI: -0.06-+0.00, I 2: 25%). Patients were more satisfied with their sedation in the benzodiazepine + opioid group compared to those with monotherapy propofol sedation (MD: +0.89, 95%CI: +0.62-+1.17, I 2: 39%). The recovery time after the procedure showed high heterogeneity even after outlier withdrawal, there was no statistical difference between both arms (MD: -15.15, 95%CI: -31.85-+1.56, I 2: 99%). For Group II (Propofol vs propofol with benzodiazepine and/or opioids): Bradycardia had a tendency to occur in the Propofol group with benzodiazepine and/or opioid-associated (RD: -0.08, 95%CI: -0.13--0.02, I 2: 59%). There was no statistical difference in the incidence of bradycardia (RD: -0.00, 95%CI: -0.08-+0.08, I 2: 85%), desaturation (RD: -0.00, 95%CI: -0.03-+0.02, I 2: 44%) or recovery time (MD: -2.04, 95%CI: -6.96-+2.88, I 2: 97%) between sedation arms. The total dose of propofol was higher in the propofol group with benzodiazepine and/or opiates but with high heterogeneity. (MD: 70.36, 95%CI: +53.11-+87.60, I 2: 61%). For Group III (Propofol with benzodiazepine and opioid vs benzodiazepine and opioid): Bradycardia and hypotension was not statistically significant between groups (RD: -0.00, 95%CI: -0.002-+0.02, I 2: 3%; RD: 0.04, 95%CI: -0.05-+0.13, I 2: 77%). Desaturation was evaluated in two articles and was higher in the propofol + benzodiazepine + opioid group, but with high heterogeneity (RD: 0.15, 95%CI: 0.08-+0.22, I 2: 95%). CONCLUSION This meta-analysis suggests that the use of propofol alone or in combination with traditional adjunctive sedatives is safe and does not result in an increase in negative outcomes in patients undergoing endoscopic procedures.
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Affiliation(s)
- Aureo Augusto de Almeida Delgado
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403000, Brazil
| | - Diogo Turiani Hourneaux de Moura
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403000, Brazil
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Igor Braga Ribeiro
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403000, Brazil
| | - Ahmad Najdat Bazarbashi
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Marcos Eduardo Lera dos Santos
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403000, Brazil
| | - Wanderley Marques Bernardo
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403000, Brazil
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Julián Gómez L, Fuentes Coronel A, López Ramos C, Ochoa Sangrador C, Fradejas Salazar P, Martín Garrido E, Conde Gacho P, Bailador Andrés C, García-Alvarado M, Rascarachi G, Castillo Trujillo R, Rodríguez Gómez SJ. A clinical trial comparing propofol versus propofol plus midazolam in diagnostic endoscopy of patients with a low anesthetic risk. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2019; 110:691-698. [PMID: 30318893 DOI: 10.17235/reed.2018.5289/2017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND OBJECTIVES propofol and midazolam are two of the most commonly used sedatives in upper gastrointestinal endoscopy (UGE). The objective of this study was to evaluate these two sedation regimens administered to patients who underwent an UGE with regard to security, efficiency, quality of exploration and patient response. PATIENTS AND METHODS a prospective, randomized and double-blind study was performed which included 83 patients between 18 and 80 years of age of a low anesthetic risk (ASA - American Society of Anesthesiologists- I-II) who underwent a diagnostic UGE. Patients were randomized to receive sedation with either placebo plus propofol (group A) or midazolam plus propofol (group B). RESULTS in group A, 42 patients received a placebo bolus (saline solution) and on average up to 115 mg of propofol in boluses of 20 mg. In group B, 41 patients received 3 mg of midazolam and an average of up to 83 mg of propofol in boluses of 20 mg. There were no significant differences in the adverse effects observed in either group and all adverse events were treated conservatively. The patients in group B (midazolam plus propofol) entered the desired sedated state more quickly with no variation in the overall time of the exploration. The quality of the endoscopic evaluation was similar in both groups and the patients were equally satisfied regardless of the sedatives they received. CONCLUSIONS the use of midazolam plus propofol as a sedative does not affect the overall exploration time, a lower dose of propofol can be used and it is as safe as administering propofol as a monotherapy while providing the same level of both exploration quality and patient approval.
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Chen L, Liang X, Tan X, Wen H, Jiang J, Li Y. Safety and efficacy of combined use of propofol and etomidate for sedation during gastroscopy: Systematic review and meta-analysis. Medicine (Baltimore) 2019; 98:e15712. [PMID: 31096522 PMCID: PMC6531275 DOI: 10.1097/md.0000000000015712] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Sedation with etomidate or propofol alone during gastroscopy has many side effects. A systematic review and meta-analysis were conducted to evaluate the safety and efficacy of the combined use of propofol and etomidate for sedation during gastroscopy. METHODS PubMed, Embase, Medline (via Ovid SP), Cochrane library databases, CINAHL (via EBSCO), China Biology Medicine disc (CBMdisc), Wanfang, VIP, and China National Knowledge Infrastructure (CNKI) databases were systematically searched. We included randomized controlled trials (RCTs) comparing the combined use of propofol and etomidate vs etomidate or propofol alone for sedation during gastroscopy. Data were pooled using the random-effects models or fixed-effect model based on heterogeneity. RESULTS Fifteen studies with 2973 participants were included in the analysis. Compared to propofol alone, the combined use of propofol and etomidate possibly increased recovery time (SMD = 0.14, 95% CI = 0.04-0.24; P = .005), and the risk for myoclonus (OR = 3.07, 95% CI = 1.73-5.44; P < .001), injection pain, and nausea and vomiting. Furthermore, compared to propofol alone, the combination of propofol and etomidate produced an apparent beneficial effect for mean arterial pressure (MAP) after anesthesia (SMD = 1.32, 95% CI = 0.38-2.26; P = .006), SPO2 after anesthesia (SMD = 0.99, 95% CI = 0.43-1.55; P < .001), apnea or hypoxemia (OR = 0.16, 95% CI = 0.08-0.33; P < .001), injection pain, and body movement. Further, compared to etomidate alone, the combination of propofol and etomidate reduced the risk for myoclonus (OR = 0.15, 95% CI = 0.11-0.22; P < .001), body movement, and nausea and vomiting. CONCLUSION The combination of propofol and etomidate might increase recovery time vs that associated with propofol, but it had fewer side effects on circulation and respiration in patients undergoing gastroscopy. The combined use of propofol and etomidate can improve and produce an apparent beneficial effect on the adverse effects of propofol or etomidate alone, and it was safer and more effective than propofol or etomidate alone.
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Affiliation(s)
| | | | | | | | - Junsong Jiang
- Department of Reproductive Medicine, The People's Hospital of Hechi, Hechi, PR China
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21
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The Comparison of Midazolam and Propofol in Gastrointestinal Endoscopy: A Systematic Review and Meta-analysis. Surg Laparosc Endosc Percutan Tech 2018; 28:153-158. [PMID: 29738382 DOI: 10.1097/sle.0000000000000532] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Midazolam and propofol are both used for sedation in gastrointestinal endoscopy. We conducted a systematic review and meta-analysis to compare the efficacy and safety of midazolam and propofol in gastrointestinal endoscopy. MATERIALS AND METHODS PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases were systematically searched. Randomized controlled trials assessing the effect of midazolam versus propofol on sedation in gastrointestinal endoscopy are included. Two investigators have independently searched for articles, extracted data, and assessed the quality of included studies. This meta-analysis was performed using the random-effect model. RESULTS Five randomized controlled trials involving 552 patients were included in the meta-analysis. Overall, compared with midazolam sedation during gastrointestinal endoscopy, propofol sedation results in higher endoscopist satisfaction scores during gastrointestinal endoscopy than midazolam [standard mean difference (Std. MD)=-0.71; 95% confidence interval (CI)=-1.05 to -0.37; P<0.0001), but the comparison shows no remarkable influence on patient satisfaction scores between midazolam and propofol (Std. MD=-0.34; 95% CI=-0.88 to 0.20; P=0.21), procedure time (Std. MD=0.14; 95% CI=-0.13 to 0.42; P=0.31), hypoxia [risk ratio (RR)=0.86; 95% CI=0.53-1.38; P=0.53), and bradycardia (RR=1.05; 95% CI=0.54-2.06; P=0.89). In addition, propofol shows higher incidence of hypotension than midazolam (RR=0.58; 95% CI=0.34-0.99; P=0.04). CONCLUSIONS When compared with midazolam sedation for gastrointestinal endoscopy, propofol sedation results in higher endoscopist satisfaction scores, but may increase the incidence of hypotension.
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Abstract
Supplemental Digital Content is available in the text.
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Early DS, Lightdale JR, Vargo JJ, Acosta RD, Chandrasekhara V, Chathadi KV, Evans JA, Fisher DA, Fonkalsrud L, Hwang JH, Khashab MA, Muthusamy VR, Pasha SF, Saltzman JR, Shergill AK, Cash BD, DeWitt JM. Guidelines for sedation and anesthesia in GI endoscopy. Gastrointest Endosc 2018; 87:327-337. [PMID: 29306520 DOI: 10.1016/j.gie.2017.07.018] [Citation(s) in RCA: 348] [Impact Index Per Article: 49.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 07/13/2017] [Indexed: 02/08/2023]
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Abstract
This article aims to detail the breadth and depth of advanced upper gastrointestinal endoscopic procedures. It will focus on sedation and airway management concerns pertaining to this emerged and emerging class of minimally invasive interventions. The article will also cover endoscopic hemostasis, endoscopic resection, stenting and Barrett eradication therapy plus endoscopic ultrasound. It additionally will address the nuances of endoscopic retrograde cholangiopancreatography and new natural orifice transluminal endoscopic surgery procedures including endoscopic cystgastrostomy and the per-oral endoscopic myotomy procedure.
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Shin DW, Cho JY, Han YS, Sim HY, Kim HS, Jung DU, Lee H. Risk factor analysis of additional administration of sedative agent and patient dissatisfaction in intravenous conscious sedation using midazolam for third molar extraction. J Korean Assoc Oral Maxillofac Surg 2017; 43:229-238. [PMID: 28875137 PMCID: PMC5583197 DOI: 10.5125/jkaoms.2017.43.4.229] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 05/10/2017] [Accepted: 05/26/2017] [Indexed: 11/07/2022] Open
Abstract
Objectives The primary purpose of this study was to investigate the factors related with additional administration of sedative agent during intravenous conscious sedation (IVS) using midazolam (MDZ). The secondary purpose was to analyze the factors affecting patient satisfaction. Materials and Methods Clinical data for 124 patients who had undergone surgical extraction of mandibular third molar under IVS using MDZ were retrospectively investigated in this case-control study. The initial dose of MDZ was determined by body mass index (BMI) and weight. In the case of insufficient sedation at the beginning of surgery, additional doses were injected. During surgery, peripheral oxygen saturation, bispectral index score (BIS), heart rate, and blood pressure were monitored and recorded. The predictor variables were sex, age, BMI, sleeping time ratio, dental anxiety, Pederson scale, and initial dose of MDZ. The outcome variables were additional administration of MDZ, observer's assessment of alertness/sedation, intraoperative amnesia, and patient satisfaction. Descriptive statistics were computed, and the P-value was set at 0.05. Results Most patients had an adequate level of sedation with only the initial dose of MDZ and were satisfied with the treatment under sedation; however, 19 patients needed additional administration, and 13 patients were unsatisfied. In multivariable logistic analysis, lower age (odds ratio [OR], 0.825; P=0.005) and higher dental anxiety (OR, 5.744; P=0.003) were related to additional administration; lower intraoperative amnesia (OR, 0.228; P=0.002) and higher BIS right before MDZ administration (OR, 1.379; P=0.029) had relevance to patient dissatisfaction. Conclusion The preoperative consideration of age and dental anxiety is necessary for appropriate dose determination of MDZ in the minor oral surgery under IVS. The amnesia about the procedure affects patient satisfaction positively.
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Affiliation(s)
- Dong-Whan Shin
- Department of Oral and Maxillofacial Surgery, Dankook University Jukjeon Dental Hospital, Yongin, Korea
| | - Jin-Yong Cho
- Department of Oral and Maxillofacial Surgery, Gachon University Gil Medical Center, Incheon, Korea
| | - Yoon-Sic Han
- Department of Oral and Maxillofacial Surgery, Section of Dentistry, SMG-SNU Boramae Medical Center, Seoul, Korea
| | - Hye-Young Sim
- Section of Dentistry, SMG-SNU Boramae Medical Center, Seoul, Korea
| | - Hee-Sun Kim
- Section of Dentistry, SMG-SNU Boramae Medical Center, Seoul, Korea
| | - Da-Un Jung
- Section of Dentistry, SMG-SNU Boramae Medical Center, Seoul, Korea
| | - Ho Lee
- Department of Oral and Maxillofacial Surgery, Section of Dentistry, SMG-SNU Boramae Medical Center, Seoul, Korea
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Williams MR, Ward DS, Carlson D, Cravero J, Dexter F, Lightdale JR, Mason KP, Miner J, Vargo JJ, Berkenbosch JW, Clark RM, Constant I, Dionne R, Dworkin RH, Gozal D, Grayzel D, Irwin MG, Lerman J, O'Connor RE, Pandharipande P, Rappaport BA, Riker RR, Tobin JR, Turk DC, Twersky RS, Sessler DI. Evaluating Patient-Centered Outcomes in Clinical Trials of Procedural Sedation, Part 1 Efficacy: Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research Recommendations. Anesth Analg 2017; 124:821-830. [PMID: 27622720 DOI: 10.1213/ane.0000000000001566] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research, established by the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks public-private partnership with the US Food and Drug Administration, convened a meeting of sedation experts from a variety of clinical specialties and research backgrounds with the objective of developing recommendations for procedural sedation research. Four core outcome domains were recommended for consideration in sedation clinical trials: (1) safety, (2) efficacy, (3) patient-centered and/or family-centered outcomes, and (4) efficiency. This meeting identified core outcome measures within the efficacy and patient-centered and/or family-centered domains. Safety will be addressed in a subsequent meeting, and efficiency will not be addressed at this time. These measures encompass depth and levels of sedation, proceduralist and patient satisfaction, patient recall, and degree of pain experienced. Consistent use of the recommended outcome measures will facilitate the comprehensive reporting across sedation trials, along with meaningful comparisons among studies and interventions in systematic reviews and meta-analyses.
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Affiliation(s)
- Mark R Williams
- From the *Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, New York; †Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, New York; ‡Department of Anesthesiology, Tufts School of Medicine, Boston, Massachusetts; §Department of Pediatrics, Southern Illinois University School of Medicine, Springfield, Illinois; ‖Department of Pediatrics, St John's Children's Hospital, Springfield, Illinois; ¶Department of Anesthesia, Harvard Medical School, Boston, Massachusetts; #Department of Anesthesiology, Boston Children's Hospital, Boston, Massachusetts; **Department of Anesthesia, University of Iowa, Iowa City; ††Pediatric Gastroenterology, University of Massachusetts Medical Center, University of Massachusetts Medical School, Worcester, Massachusetts; ‡‡Department of Anesthesiology, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts; §§Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, Minnesota; ‖‖Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota; ¶¶Department of Gastroenterology and Hepatology, Cleveland Clinic Lerner College of Medicine of Case Western University, Cleveland, Ohio; ##Pediatric Critical Care, Kosair Children's Hospital, University of Louisville School of Medicine, Louisville, Kentucky; ***Section for Professional Standards, American Society of Anesthesiologists Children's Hospital Colorado, University of Colorado School of Medicine, Denver, Colorado; †††Department of Anesthesiology, Hôpital Armand Trousseau, Paris, France; ‡‡‡Department of Pharmacology and Foundational Sciences, East Carolina University, Greenville, North Carolina; §§§Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, New York; ‖‖‖Division of Anesthesiology and CCM, Hadassah University Hospital, The Hebrew University of Jerusalem School of Medicine, Jerusalem, Israel; ¶¶¶Annovation BioPharma, Cambridge, Massachusetts; ###Department of Anesthesiology, University of Hong Kong, Hong Kong, China; ****Department of Anesthesiology, Women and Children's Hospital of Buffalo, SUNY at Buffalo, Buffalo, New York; ††††Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, Virginia; ‡‡‡‡Department of Anesthesiology, Vanderbilt University, Nashville, Tennessee; §§§§Analgesic Concepts LLC, Arlington, Virginia; ‖‖‖‖Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts; ¶¶¶¶Department of Critical Care Medicine and Neuroscience Institute, Maine Medical Center, Portland, Maine; ####Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina; *****Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington; †††††Department of Anesthesiology & Critical Care Medicine, Josie Robertson Surgery Center, Memorial Sloan Kettering Cancer Center, New York, New York; and ‡‡‡‡‡Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
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Abstract
OBJECTIVE Myoclonus, a common complication during intravenous induction with etomidate, is bothersome to both anesthesiologists and patients. This study explored the preventive effect of pretreatment with propofol on etomidate-related myoclonus. METHODS This was a prospective, double-blind, clinical, randomized controlled study. Totally, 363 patients who were scheduled for a short-duration, painless gastrointestinal endoscopy were divided into 5 groups. Four groups received 0 mg/kg (E group), 0.25 mg/kg (LPE group), 0.50 mg/kg (MPE group), or 0.75 mg/kg (HPE group) propofol pretreatment before etomidate anesthesia. Another group only received 1 to 2 mg/kg of propofol (P group) as anesthesia. The incidence and severity of myoclonus, patient circulation and respiratory status, and intraoperative and postoperative complications were recorded. RESULTS The incidence of myoclonus in the LPE group (26.8%), MPE group (16.4%), HPE group (14.9%), and P group (0) was lower than the E group (48.6%, P < .05). The incidence of grade 1, 2, and 3 of myoclonus in the LPE group, MPE group, HPE group, and P group was significantly lower than the E group, and that in the P group was lower than the LPE group (P < .05). The incidence of hypoxemia in the P group was higher than the E group, and the incidence of adverse events in the HPE group and P group was lower than the E group (P < .05). DISCUSSION Pretreatment with propofol was feasible for preventing etomidate-related myoclonus. Furthermore, as propofol dosage increased, its effect on reducing the incidence and severity of myoclonic movements induced by etomidate increased.
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Affiliation(s)
- Jinfeng Liu
- Department of Anesthesiology, The Second Affiliated Hospital, Harbin Medical University, and the Hei Long Jiang Province Key Lab of Research on Anesthesiology and Critical Care Medicine, Harbin
| | - Rongfang Liu
- Department of Anesthesiology, The Second Affiliated Hospital, Harbin Medical University, and the Hei Long Jiang Province Key Lab of Research on Anesthesiology and Critical Care Medicine, Harbin
- Affiliate Hospital of HeBei University Department of Anesthesiology, Affiliate Hospital of HeBei University, No.212 of Yuhua East Road, Baoding
| | - Chao Meng
- Department of Anesthesiology, The Second Affiliated Hospital, Harbin Medical University, and the Hei Long Jiang Province Key Lab of Research on Anesthesiology and Critical Care Medicine, Harbin
| | - Zhenhua Cai
- Department of Anesthesiology, The Second Affiliated Hospital, Harbin Medical University, and the Hei Long Jiang Province Key Lab of Research on Anesthesiology and Critical Care Medicine, Harbin
| | - Xiaoqi Dai
- Department of Anesthesiology, The Second Affiliated Hospital, Harbin Medical University, and the Hei Long Jiang Province Key Lab of Research on Anesthesiology and Critical Care Medicine, Harbin
| | - Chao Deng
- Department of Anesthesiology, The Second Affiliated Hospital, Harbin Medical University, and the Hei Long Jiang Province Key Lab of Research on Anesthesiology and Critical Care Medicine, Harbin
| | - Jiahang Zhang
- Department of Anesthesiology, The Second Affiliated Hospital, Harbin Medical University, and the Hei Long Jiang Province Key Lab of Research on Anesthesiology and Critical Care Medicine, Harbin
| | - Huacheng Zhou
- Department of Anesthesiology, The Fourth Affiliated Hospital, Harbin Medical University, Harbin, China
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Hsu WC, Orr J, Lin SP, Yu L, Tsou MY, Westenskow DR, Ting CK. Efficiency of oxygen delivery through different oxygen entrainment devices during sedation under low oxygen flow rate: a bench study. J Clin Monit Comput 2017; 32:519-525. [DOI: 10.1007/s10877-017-0023-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 04/24/2017] [Indexed: 10/19/2022]
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Da B, Buxbaum J. Training and Competency in Sedation Practice in Gastrointestinal Endoscopy. Gastrointest Endosc Clin N Am 2016; 26:443-62. [PMID: 27372769 DOI: 10.1016/j.giec.2016.02.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The practice of endoscopic sedation requires a thorough understanding of preprocedural assessment, sedation pharmacology, intraprocedure monitoring, adverse event management, and postprocedural care. The training process has become increasingly standardized and entails knowledge and practice-based components. The use of propofol in particular requires a higher level of structured training owing to its narrow therapeutic window. Simulation has increased opportunities for practice-based training in a controlled environment. After completion of training, the endoscopist must demonstrate competence in theoretical understanding and technical ability to administer sedation. Although individual institutions have certification processes, there is a lack of validated, standardized methods to confirm competence.
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Affiliation(s)
- Ben Da
- Division of Gastroenterology and Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - James Buxbaum
- Division of Gastroenterology and Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
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Liou JY, Ting CK, Hou MC, Tsou MY. A Response Surface Model Exploration of Dosing Strategies in Gastrointestinal Endoscopies Using Midazolam and Opioids. Medicine (Baltimore) 2016; 95:e3520. [PMID: 27281065 PMCID: PMC4907643 DOI: 10.1097/md.0000000000003520] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Classical midazolam-opioid combination for gastrointestinal endoscopy sedation has been adopted for decades. Dosing regimens have been studied but most require fixed dosing intervals. We intend to use a sophisticated pharmacodynamic tool, response surface model (RSM), to simulate sedation using different regimens. RSM can predict patient's response during different phases of the examination and predict patient's wake-up time with precision and without the need for fixed dosing intervals. We believe it will aid physicians in guiding their dosing strategy and timing.The study is divided into 2 parts. The first part is the full Greco RSMs development for 3 distinct phases: esophagogastroduodenoscopy (EGD), colonoscopy, and intersession (the time lapse between procedures). Observer's Assessment of Alertness Score (OAA/S) is used to assess patient response. The second part simulates 6 regimens with different characteristics using the RSMs: midazolam only, balanced midazolam and opioids, high-dose opioids and midazolam, low-dose midazolam with high-dose opioids, high-dose midazolam and low-dose opioids, and finally midazolam with continuous opioid infusion. Loss of response at 95% probability for adequate anesthesia during examination and return of consciousness at 50% probability during intersession was selected for simulation purposes.The average age of the patient population is 49.3 years. Mean BMI is 21.9 ± 2.3 kg/m. About 56.7% were females and none received prior abdominal surgery. The cecal intubation rate was 100%. Only 1 patient (3%) developed temporary hypoxemia, which was promptly managed with simple measures. The RSMs for each phase showed significant synergy between midazolam and alfentanil. The balanced midazolam and alfentanil combination provided adequate anesthesia and most rapid return of consciousness. The awakening time from the final drug bolus was 7.4 minutes during EGD and colonoscopy stimulation, and 9.1 minutes during EGD simulation.Simulation of regimens with different characteristics gives insights on dosing strategies. A balanced midazolam-alfentanil regimen is adequate in providing good anesthetic depth and most rapid return of consciousness. We believe with the aid of our RSM, clinicians can perform sedation with more flexibility and precision.
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Affiliation(s)
- Jing-Yang Liou
- From the Department of Anesthesiology, Taipei Veterans General Hospital (J-YL, C-KT, M-YT), National Yang-Ming University and School of Medicine (C-KT, M-CH, M-YT), and Center for Diagnostic and Treatment Endoscopy, Taipei Veterans General Hospital, Taipei, Taiwan, ROC (M-CH)
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Nilsson A, Grossmann B, Kullman E, Uustal E, Sjöberg F, Nilsson L. Sedation during endoscopic retrograde cholangiopancreatography: a randomized controlled study of patient-controlled propofol sedation and that given by a nurse anesthetist. Scand J Gastroenterol 2016; 50:1285-92. [PMID: 25898782 DOI: 10.3109/00365521.2015.1038848] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Different regimens are used for sedation during endoscopic retrograde cholangiopancreatography (ERCP). Our objectives were to compare safety, ease of treatment, recovery, and patients' experiences using patient-controlled sedation (PCS) with propofol, nurse anesthetist-controlled sedation (ACS), or the department's standard of care, midazolam given by the procedure team (control group). MATERIAL AND METHODS The study included 281 adults in 301 procedures. The PCS group (n = 101) delivered bolus doses of 5 mg of propofol according to their need for sedation. The ACS group (n = 100) had 2-8 mg/kg/h of propofol infused, with the target for sedation being level 3 of the Observer's Assessment of Alertness/Sedation (OAA/S) scale. The control group was given 2-3 mg of midazolam for induction and additional 1 mg if required. RESULTS PCS and ACS increased the ease of the procedure and reduced the number of sedation failures compared to midazolam sedation (ACS n = 0; PCS n = 4; midazolam n = 20). The ACS group had more deeply sedated patients (OAA/S level 2), desaturation, and obstructed airways than the PCS and midazolam groups. Time to full recovery (Aldrete score ≥9) was shortest following PCS. PCS resulted in the least fatigue and pain after the procedure. Patients' preference for PCS and ACS was the same. CONCLUSION PCS with propofol is superior to midazolam and comparable to ACS. PCS resulted in a rapid recovery, fewer respiratory events, and was almost as effective as ACS in ensuring a successful examination.
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Affiliation(s)
- Andreas Nilsson
- Department of Medical and Health Sciences, Linköping University , County Council of Östergötland, S-581 85 Linköping , Sweden
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Abstract
OPINION STATEMENT Sedation practices in the endoscopy suite have changed dramatically in the decades since the introduction of routine colonoscopy and esophagogastroduodenoscopy (EGD). Patients initially received moderate sedation (or even no sedation), but now frequently receive monitored anesthesia care (MAC). This significant shift has introduced anesthesiologists to the endoscopy suite along with new sedative medications and safety concerns. Appreciating the ramifications of this change requires an understanding of sedation depth, patient selection, drug use, sedation delivery, patient monitoring, recovery from sedation, and patient outcomes. Furthermore, the changing landscape of healthcare quality and reimbursement challenges us to provide the best possible care for our patients in the most economical way possible. The endoscopy suite is a unique sedation environment, and it is the purpose of this article to review those elements that contribute to a uniquely demanding work environment.
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Zhou X, Li BX, Chen LM, Tao J, Zhang S, Ji M, Wu MC, Chen M, Zhang YH, Gan GS, Song XY. Etomidate plus propofol versus propofol alone for sedation during gastroscopy: a randomized prospective clinical trial. Surg Endosc 2016; 30:5108-5116. [DOI: 10.1007/s00464-016-4861-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 03/05/2016] [Indexed: 01/26/2023]
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Development and Validation of a Prediction Model for Admission After Endoscopic Retrograde Cholangiopancreatography. Clin Gastroenterol Hepatol 2015; 13:2323-32.e1-9. [PMID: 26122761 PMCID: PMC4655134 DOI: 10.1016/j.cgh.2015.06.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 06/12/2015] [Accepted: 06/12/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS In outpatients undergoing endoscopic retrograde cholangiopancreatography (ERCP) with anesthesia, rates of and risk factors for admission are unclear. We aimed to develop a model that would allow physicians to predict hospitalization of patients during postanesthesia recovery. METHODS We conducted a retrospective study of data from ERCPs performed on outpatients from May 2012 through October 2013 at the Indiana University School of Medicine. Medical records were abstracted for preanesthesia, intra-anesthesia, and early (within the first hour) postanesthesia characteristics potentially associated with admission. Significant factors associated with admission were incorporated into a logistic regression model to identify subgroups with low, moderate, or high probabilities for admission. The population was divided into training (first 12 months) and validation (last 6 months) sets to develop and test the model. RESULTS We identified 3424 ERCPs during the study period; 10.7% of patients were admitted to the hospital, and 3.7% developed post-ERCP pancreatitis. Postanesthesia recovery times were significantly longer for patients requiring admission (362.6 ± 213.0 minutes vs 218.4 ± 71.8 minutes for patients not admitted; P < .0001). A higher proportion of admitted patients had high-risk indications. Admitted patients also had more severe comorbidities, higher baseline levels of pain, longer procedure times, performance of sphincter of Oddi manometry, higher pain during the first hour after anesthesia, and greater use of opiates or anxiolytics. A multivariate regression model identified patients who were admitted with a high level of accuracy in the training set (area under the curve, 0.83) and fair accuracy in the validation set (area under the curve, 0.78). On the basis of this model, nearly 50% of patients could be classified as low risk for admission. CONCLUSION By using factors that can be assessed through the first hour after ERCP, we developed a model that accurately predicts which patients are likely to be admitted to the hospital. Rates of admission after outpatient ERCP are low, so a policy of prolonged observation might be unnecessary.
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Bolat E, Çelikbilek M, Sarıkaya S, Yılmaz YK, Doğan S, Özbakır Ö. Effects of balanced propofol sedation on QT, corrected QT, and P-wave dispersion on upper endoscopy. Anatol J Cardiol 2015; 16:328-32. [PMID: 26488380 PMCID: PMC5336780 DOI: 10.5152/anatoljcardiol.2015.6264] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Objective: Combined sedation with propofol and benzodiazepines, known as balanced propofol sedation (BPS), was developed to increase patient comfort during endoscopy. However, the effects of BPS on P-wave dispersion (Pwd), QT interval, and corrected QT (QTc) interval after endoscopy have not been investigated. Methods: The study population consisted of 40 patients with BPS and 42 without sedation who were scheduled to undergo upper endoscopy in this cross-sectional prospective study. Patients with hypertension, diabetes mellitus, renal failure, chronic obstructive pulmonary disease, coronary artery disease, or valvular heart disease and those on medications that interfere with cardiac conduction times were excluded. Electrocardiograms (ECGs) was recorded in all patients pre-endoscopy and 10 min post-endoscopy. QT, QT dispersion (QTd), and Pwd were defined from 12-lead ECG. The QTc interval was calculated using Bazett’s formula. All analyses were performed using SPSS 15.0. Results: Post-endoscopy P max duration and Pwd were prolonged compared with baseline values (86±13 ms vs. 92±10 ms and 29±12 ms vs. 33±12 ms, respectively; p<0.05). Post-endoscopy QTc and QTd were decreased compared with baseline values, but these decreases were not statistically significant (431±25 ms vs. 416±30 ms and 62±28 ms vs. 43±22 ms, respectively; p>0.05). Conclusion: The present study showed that P-wave duration and Pwd values increased after endoscopy with a combination of midazolam and propofol sedation. Physicians should be made aware of the potential effects of BPS in terms on P-wave duration and Pwd values.
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Affiliation(s)
- Esef Bolat
- Department of Anesthesiology, Faculty of Medicine, Bozok University; Yozgat-Turkey.
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Fanti L, Gemma M, Agostoni M, Rossi G, Ruggeri L, Azzolini ML, Dabizzi E, Beretta L, Testoni PA. Target Controlled Infusion for non-anaesthesiologist propofol sedation during gastrointestinal endoscopy: The first double blind randomized controlled trial. Dig Liver Dis 2015; 47:566-71. [PMID: 25840875 DOI: 10.1016/j.dld.2015.03.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 03/02/2015] [Accepted: 03/06/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Target Controlled Infusion is a sophisticated tool for providing optimal sedation regimen avoiding under or oversedation in gastrointestinal endoscopy. AIMS To compare standard moderate sedation vs. non-anaesthesiologist-administered propofol sedation during gastrointestinal endoscopy. METHODS Randomized controlled trial of 70 consecutive colonoscopies and 70 consecutive esophagogastroduodenoscopies (EGD). Standard group (n=70), received fentanyl (1 μg/kg)+midazolam (0.03-0.04 mg/kg) or midazolam only; propofol group (n=70), received fentanyl (1 μg/kg)+propofol Target Controlled Infusion (1.2-1.6 μg/ml) or propofol Target Controlled Infusion only. Discharge time, endoscopist satisfaction and patient satisfaction were recorded in all endoscopies. RESULTS Colonoscopy: discharge time was significantly shorter in the propofol than the standard group (1.1 ± 0.3 vs. 5 ± 10.2 min, respectively; P=0.03). Endoscopist satisfaction was significantly higher (98.3 ± 11.4/100 vs. 87.2±12/100; P=0.001); patient satisfaction was significantly higher (95 ± 9.3/100 vs. 85.5 ± 14.4/100; P=0.002) in the propofol compared to the standard group. EGD: discharge time was not significantly different in the propofol and standard groups (1.1 ± 0.7 vs. 3.9 ± 9.2 min, respectively; P=0.146). Endoscopist satisfaction was significantly higher (92.7 ± 14.3/100 vs. 82.8 ± 21.2/100; P=0.03); patient satisfaction was significantly higher (93.8 ± 18.2/100 vs. 76.5 ± 25.2/100; P=0.003). In the propofol group 94.3% of patients vs. 71.4% of patients in standard group asked to receive the same sedation in the future (P=0.021). CONCLUSION Target Controlled Infusion is a promising method for non-anaesthesiologist-administered propofol sedation.
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Affiliation(s)
- Lorella Fanti
- Division of Gastroenterology and Gastrointestinal Endoscopy, Vita-Salute San Raffaele University - Scientific Institute San Raffaele, Milan, Italy.
| | - Marco Gemma
- Department of Anesthesiology, Vita-Salute San Raffaele University - Scientific Institute San Raffaele, Milan, Italy
| | - Massimo Agostoni
- Department of Anesthesiology, Vita-Salute San Raffaele University - Scientific Institute San Raffaele, Milan, Italy
| | - Gemma Rossi
- Division of Gastroenterology and Gastrointestinal Endoscopy, Vita-Salute San Raffaele University - Scientific Institute San Raffaele, Milan, Italy
| | - Laura Ruggeri
- Department of Anesthesiology, Vita-Salute San Raffaele University - Scientific Institute San Raffaele, Milan, Italy
| | - Maria Luisa Azzolini
- Department of Anesthesiology, Vita-Salute San Raffaele University - Scientific Institute San Raffaele, Milan, Italy
| | - Emanuele Dabizzi
- Division of Gastroenterology and Gastrointestinal Endoscopy, Vita-Salute San Raffaele University - Scientific Institute San Raffaele, Milan, Italy
| | - Luigi Beretta
- Department of Anesthesiology, Vita-Salute San Raffaele University - Scientific Institute San Raffaele, Milan, Italy
| | - Pier Alberto Testoni
- Division of Gastroenterology and Gastrointestinal Endoscopy, Vita-Salute San Raffaele University - Scientific Institute San Raffaele, Milan, Italy
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Studying and Incorporating Efficiency into Gastrointestinal Endoscopy Centers. Gastroenterol Res Pract 2015; 2015:764153. [PMID: 26101525 PMCID: PMC4458534 DOI: 10.1155/2015/764153] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2015] [Accepted: 04/26/2015] [Indexed: 02/07/2023] Open
Abstract
Efficiency is defined as the use of resources in such a way as to maximize the production of goods and services. Improving efficiency has been the focus of management in many industries; however, it has not been until recently that incorporating efficiency models into healthcare has occurred. In particular, the study and development of improvement projects aimed at enhancing efficiency in GI have been growing rapidly in recent years. This focus on improving efficiency in GI has been spurred by the dramatic rise in the demand for endoscopic procedures as well as the rising number of insured patients requiring GI care coupled at the same time with limited resources in terms of staffing and space in endoscopy centers. This paper will critically review the history of efficiency in endoscopy centers, first by looking at other healthcare industries that have extensively studied and improved efficiency in their fields, examine a number of proposed efficiency metrics and benchmarks in endoscopy centers, and finally discuss opportunities where endoscopy centers could improve their efficiency.
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Accuracy of CO₂ monitoring via nasal cannulas and oral bite blocks during sedation for esophagogastroduodenoscopy. J Clin Monit Comput 2015; 30:169-73. [PMID: 25895481 DOI: 10.1007/s10877-015-9696-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 04/17/2015] [Indexed: 01/01/2023]
Abstract
Esophagogastroduodenoscopy procedures are typically performed under conscious sedation. Drug-induced respiratory depression is a major cause of serious adverse effects during sedation. Capnographic monitoring of respiratory activity improves patient safety during procedural sedation. This bench study compares the performance of the nasal cannulas and oral bite blocks used to monitor exhaled CO2 during sedation. We used a spontaneously breathing mechanical lung to evaluated four CO2 sampling nasal cannulas and three CO2 sampling bite blocks. We placed pneumatic resistors in the mouth of the manikin to simulate different levels of mouth opening. We compared CO2 measurements taken from the sampling device to CO2 measurements taken directly from the trachea. The end tidal CO2 concentration (PETCO2) measured through the bite blocks and nasal cannulas was always lower than the corresponding PETCO2 measured at the trachea. The difference became larger as the amount of oxygen delivered through the devices increased. The difference was larger during normal ventilation than during hypoventilation. The difference became larger as the amount of oral breathing increased. The two nasal cannulas without oral cups failed to provide sufficient CO2 for breath detection when the mouth was fully open and oxygen was delivered at 10 L/min. Our simulation found that respiratory rate can be accurately monitored during the procedure using a CO2 sampling bite block or a nasal cannula with oral cup. The accuracy of PETCO2 measurements depends on the device used, the amount of supplement oxygen, the amount of oral breathing and the patient's minute ventilation.
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Cheriyan DG, Byrne MF. Propofol use in endoscopic retrograde cholangiopancreatography and endoscopic ultrasound. World J Gastroenterol 2014; 20:5171-5176. [PMID: 24833847 PMCID: PMC4017032 DOI: 10.3748/wjg.v20.i18.5171] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Revised: 01/12/2014] [Accepted: 03/13/2014] [Indexed: 02/07/2023] Open
Abstract
Compared to standard endoscopy, endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) are often lengthier and more complex, thus requiring higher doses of sedatives for patient comfort and compliance. The aim of this review is to provide the reader with information regarding the use, safety profile, and merits of propofol for sedation in advanced endoscopic procedures like ERCP and EUS, based on the current literature.
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Miyoshi H, Shimatani M, Kato K, Sumimoto K, Kurishima A, Kusuda T, Fukata N, Ikeura T, Takaoka M, Okazaki K. Transcutaneous monitoring of partial pressure of carbon dioxide during endoscopic retrograde cholangiopancreatography using a double-balloon endoscope with carbon dioxide insufflation under conscious sedation. Dig Endosc 2014; 26:436-41. [PMID: 23941285 DOI: 10.1111/den.12155] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Accepted: 07/05/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIM A double-balloon (DB) endoscope can be selectively inserted into the afferent loop to carry out endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy, allowing various types of endoscopic treatments for pancreaticobiliary diseases to be successfully carried out. In order to make such a lengthy procedure more comfortable and safe, sedatives and carbon dioxide (CO2 ) insufflation are widely used for gastrointestinal endoscopy. However, these techniques can increase the risk of CO2 retention. Recently, a new sensor for transcutaneous measurement of partial pressure of carbon dioxide (PCO2 ) has been introduced. The aim of the present study was to evaluate the changes in transcutaneous PCO2 (PtcCO2 ) during DB-ERCP with CO2 insufflation under conscious sedation and assess any complications related to sedation and CO2 insufflation. METHODS A total of 312 patients underwent DB-ERCP with CO2 insufflation at our hospital between March 2009 and December 2012. The patients were moderately sedated using midazolam with or without pentazocine. PtcCO2 was measured by a non-invasive sensor throughout DB-ERCP in all patients. RESULTS The mean peak PtcCO2 during the procedure was significantly higher than the mean PtcCO2 value before and after DB-ERCP. Body mass index, procedure time and dose of pentazocine were significantly higher in the CO2 retention group (peak PtcCO2 ≥ 50 mmHg). CO2 narcosis was observed in one case. CONCLUSIONS DB-ERCP with CO2 insufflation under conscious sedation might have the potential to increase the risk of CO2 retention. Hence, non-invasive and continuous PtcCO2 measurement is useful for early detection of hypercapnia.
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Affiliation(s)
- Hideaki Miyoshi
- Division of Gastroenterology and Hepatology, Kansai Medical University, Osaka, Japan
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Lee TH, Lee CK. Endoscopic sedation: from training to performance. Clin Endosc 2014; 47:141-50. [PMID: 24765596 PMCID: PMC3994256 DOI: 10.5946/ce.2014.47.2.141] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2014] [Revised: 02/25/2014] [Accepted: 02/26/2014] [Indexed: 12/24/2022] Open
Abstract
Adequate sedation and analgesia are considered essential requirements to relieve patient discomfort and pain and ultimately to improve the outcomes of modern gastrointestinal endoscopic procedures. The willingness of patients to undergo sedation during endoscopy has increased steadily in recent years and standard sedation practices are needed for both patient safety and successful procedural outcomes. Therefore, regular training and education of healthcare providers is warranted. However, training curricula and guidelines for endoscopic sedation may have conflicts according to varying legal frameworks and/or social security systems of each country, and well-recognized endoscopic sedation training systems are not currently available in all endoscopy units. Although European and American curricula for endoscopic sedation have been extensively developed, general curricula and guidelines for each country and institution are also needed. In this review, an overview of recent curricula and guidelines for training and basic performance of endoscopic sedation is presented based on the current literature.
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Affiliation(s)
- Tae Hoon Lee
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Chang Kyun Lee
- Division of Gastroenterology, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul, Korea
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Sieg A, Beck S, Scholl SG, Heil FJ, Gotthardt DN, Stremmel W, Rex DK, Friedrich K. Safety analysis of endoscopist-directed propofol sedation: a prospective, national multicenter study of 24 441 patients in German outpatient practices. J Gastroenterol Hepatol 2014; 29:517-23. [PMID: 24716213 DOI: 10.1111/jgh.12458] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND AIM Since 2008, there exists a German S3-guideline allowing non-anesthesiological administration of propofol for gastrointestinal endoscopy. In this prospective, national, multicenter study, we evaluated the safety of endoscopist-administered propofol sedation (EDP) in German outpatient practices of Gastroenterology. METHODS In this multicenter survey of 53 ambulatory practices of Gastroenterology, we prospectively evaluated 24 441 patients that had received EDP. We recorded adverse events during the endoscopic procedure and additionally retrieved questionnaires investigating subjective parameters 24 h after the endoscopic procedure. RESULTS In 24 441 patients 13 793 colonoscopies, 6467 esophagogastroduodenoscopies, and 4181 double examinations were performed. In this study, 52.1% of the patients received propofol mono-sedation, and 47.9% received a combination of midazolam and propofol. Major adverse events occurred in four patients (0.016%) enrolled to this study (three mask ventilations and one laryngospasm). Minor adverse events were observed in 112 patients (0.46%) with hypoxemia being the most common minor event. All patients with adverse events recovered without persistent impairment. Minor adverse events occurred more frequently in patients sedated with propofol mono compared to propofol and midazolam (P < 0.0001) and correlated with increasing propofol dosages (P < 0.001; Pearson correlation coefficient r = 0.044). Twenty-four hours after the endoscopy, patients sedated with propofol plus midazolam stated a significantly reduced sensation of pain (P < 0.01) and improved symptoms of dizziness, nausea and vomiting (P < 0.001) compared to patients having received propofol mono-sedation. CONCLUSION Four years after the implementation of a German S3-Guideline for endoscopic sedation, we demonstrated that EDP is a safe procedure.
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Xu CX, Chen X, Jia Y, Xiao DH, Zou HF, Guo Q, Wang F, Wang XY, Shen SR, Tong LL, Cao K, Liu XM. Stepwise sedation for elderly patients with mild/moderate COPD during upper gastrointestinal endoscopy. World J Gastroenterol 2013; 19:4791-8. [PMID: 23922479 PMCID: PMC3732854 DOI: 10.3748/wjg.v19.i29.4791] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Revised: 07/02/2013] [Accepted: 07/09/2013] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate stepwise sedation for elderly patients with mild/moderate chronic obstructive pulmonary disease (COPD) during upper gastrointestinal (GI) endoscopy. METHODS Eighty-six elderly patients with mild/moderate COPD and 82 elderly patients without COPD scheduled for upper GI endoscopy were randomly assigned to receive one of the following two sedation methods: stepwise sedation involving three-stage administration of propofol combined with midazolam [COPD with stepwise sedation (group Cs), and non-COPD with stepwise sedation (group Ns)] or continuous sedation involving continuous administration of propofol combined with midazolam [COPD with continuous sedation (group Cc), and non-COPD with continuous sedation (group Nc)]. Saturation of peripheral oxygen (SpO2), blood pressure, and pulse rate were monitored, and patient discomfort, adverse events, drugs dosage, and recovery time were recorded. RESULTS All endoscopies were completed successfully. The occurrences of hypoxemia in groups Cs, Cc, Ns, and Nc were 4 (9.3%), 12 (27.9%), 3 (7.3%), and 5 (12.2%), respectively. The occurrence of hypoxemia in group Cs was significantly lower than that in group Cc (P < 0.05). The average decreases in value of SpO2, systolic blood pressure, and diastolic blood pressure in group Cs were significantly lower than those in group Cc. Additionally, propofol dosage and overall rate of adverse events in group Cs were lower than those in group Cc. Finally, the recovery time in group Cs was significantly shorter than that in group Cc, and that in group Ns was significantly shorter than that in group Nc (P < 0.001). CONCLUSION The stepwise sedation method is effective and safer than the continuous sedation method for elderly patients with mild/moderate COPD during upper GI endoscopy.
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Boellaard TN, van der Paardt MP, Hollmann MW, Eberl S, Peringa J, Schouten LJ, Kavaliauskiene G, Runge JH, Tielbeek JAW, Stoker J. A multi-centre randomised double-blind placebo-controlled trial to evaluate the value of a single bolus intravenous alfentanil in CT colonography. BMC Gastroenterol 2013; 13:94. [PMID: 23706123 PMCID: PMC3671205 DOI: 10.1186/1471-230x-13-94] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Accepted: 05/21/2013] [Indexed: 01/23/2023] Open
Abstract
Background Pain is common during colonic insufflation required for CT colonography. We therefore evaluate whether a single intravenous alfentanil bolus has a clinically relevant analgesic effect compared with placebo in patients undergoing CT colonography. Methods A prospective multi-centre randomised double-blind placebo-controlled trial was performed in patients scheduled for elective CT colonography. Patients were randomised to receive either a bolus of 7.5 μg/kg alfentanil (n = 45) or placebo (n = 45). The primary outcome was the difference in maximum pain during colonic insufflation on an 11-point numeric rating scale. We defined a clinically relevant effect as a maximum pain reduction of at least 1.3 points. Secondary outcomes included total pain and burden of CT colonography (5-point scale), the most burdensome aspect and side effects. Our primary outcome was tested using a one-sided independent samples t-test. Results Maximum pain scores during insufflation were lower with alfentanil as compared with placebo, 5.3 versus 3.0 (P < 0.001). Total CT colonography pain and burden were also lower with alfentanil (2.0 vs. 1.6; P = 0.014 and 2.1 vs. 1.7; P = 0.007, respectively). With alfentanil fewer patients rated the insufflation as most burdensome aspect (56.1% vs. 18.6%; P = 0.001). Episodes with desaturations < 90% SpO2 were more common with alfentanil (8.1% vs. 44.4%; P < 0.001, but no clinically relevant desaturations occurred. Conclusions A low-dose intravenous alfentanil bolus provides a clinically relevant reduction of maximum pain during CT colonography and may improve the CT colonography acceptance, especially for patients with a low pain threshold. Trial registration Dutch Trial Register:
NTR2902
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Triantafillidis JK, Merikas E, Nikolakis D, Papalois AE. Sedation in gastrointestinal endoscopy: current issues. World J Gastroenterol 2013; 19:463-481. [PMID: 23382625 PMCID: PMC3558570 DOI: 10.3748/wjg.v19.i4.463] [Citation(s) in RCA: 167] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Revised: 11/11/2012] [Accepted: 12/25/2012] [Indexed: 02/06/2023] Open
Abstract
Diagnostic and therapeutic endoscopy can successfully be performed by applying moderate (conscious) sedation. Moderate sedation, using midazolam and an opioid, is the standard method of sedation, although propofol is increasingly being used in many countries because the satisfaction of endoscopists with propofol sedation is greater compared with their satisfaction with conventional sedation. Moreover, the use of propofol is currently preferred for the endoscopic sedation of patients with advanced liver disease due to its short biologic half-life and, consequently, its low risk of inducing hepatic encephalopathy. In the future, propofol could become the preferred sedation agent, especially for routine colonoscopy. Midazolam is the benzodiazepine of choice because of its shorter duration of action and better pharmacokinetic profile compared with diazepam. Among opioids, pethidine and fentanyl are the most popular. A number of other substances have been tested in several clinical trials with promising results. Among them, newer opioids, such as remifentanil, enable a faster recovery. The controversy regarding the administration of sedation by an endoscopist or an experienced nurse, as well as the optimal staffing of endoscopy units, continues to be a matter of discussion. Safe sedation in special clinical circumstances, such as in the cases of obese, pregnant, and elderly individuals, as well as patients with chronic lung, renal or liver disease, requires modification of the dose of the drugs used for sedation. In the great majority of patients, sedation under the supervision of a properly trained endoscopist remains the standard practice worldwide. In this review, an overview of the current knowledge concerning sedation during digestive endoscopy will be provided based on the data in the current literature.
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