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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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Wehrmann T, Riphaus A, Eckardt AJ, Klare P, Kopp I, von Delius S, Rosien U, Tonner PH. Updated S3 Guideline "Sedation for Gastrointestinal Endoscopy" of the German Society of Gastroenterology, Digestive and Metabolic Diseases (DGVS) - June 2023 - AWMF-Register-No. 021/014. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:e654-e705. [PMID: 37813354 DOI: 10.1055/a-2165-6388] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Affiliation(s)
- Till Wehrmann
- Clinic for Gastroenterology, DKD Helios Clinic Wiesbaden, Wiesbaden, Germany
| | - Andrea Riphaus
- Internal Medicine, St. Elisabethen Hospital Frankfurt Artemed SE, Frankfurt, Germany
| | - Alexander J Eckardt
- Clinic for Gastroenterology, DKD Helios Clinic Wiesbaden, Wiesbaden, Germany
| | - Peter Klare
- Department Internal Medicine - Gastroenterology, Diabetology, and Hematology/Oncology, Hospital Agatharied, Hausham, Germany
| | - Ina Kopp
- Association of the Scientific Medical Societies in Germany e.V. (AWMF), Berlin, Germany
| | - Stefan von Delius
- Medical Clinic II - Internal Medicine - Gastroenterology, Hepatology, Endocrinology, Hematology, and Oncology, RoMed Clinic Rosenheim, Rosenheim, Germany
| | - Ulrich Rosien
- Medical Clinic, Israelite Hospital, Hamburg, Germany
| | - Peter H Tonner
- Anesthesia and Intensive Care, Clinic Leer, Leer, Germany
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Wehrmann T, Riphaus A, Eckardt AJ, Klare P, Kopp I, von Delius S, Rosien U, Tonner PH. Aktualisierte S3-Leitlinie „Sedierung in der gastrointestinalen Endoskopie“ der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS). ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:1246-1301. [PMID: 37678315 DOI: 10.1055/a-2124-5333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Affiliation(s)
- Till Wehrmann
- Klinik für Gastroenterologie, DKD Helios Klinik Wiesbaden, Wiesbaden, Deutschland
| | - Andrea Riphaus
- Innere Medizin, St. Elisabethen Krankenhaus Frankfurt Artemed SE, Frankfurt, Deutschland
| | - Alexander J Eckardt
- Klinik für Gastroenterologie, DKD Helios Klinik Wiesbaden, Wiesbaden, Deutschland
| | - Peter Klare
- Abteilung Innere Medizin - Gastroenterologie, Diabetologie und Hämato-/Onkologie, Krankenhaus Agatharied, Hausham, Deutschland
| | - Ina Kopp
- Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V. (AWMF), Berlin, Deutschland
| | - Stefan von Delius
- Medizinische Klinik II - Innere Medizin - Gastroenterologie, Hepatologie, Endokrinologie, Hämatologie und Onkologie, RoMed Klinikum Rosenheim, Rosenheim, Deutschland
| | - Ulrich Rosien
- Medizinische Klinik, Israelitisches Krankenhaus, Hamburg, Deutschland
| | - Peter H Tonner
- Anästhesie- und Intensivmedizin, Klinikum Leer, Leer, Deutschland
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Ang TL, Seet E, Goh YC, Ng WK, Koh CJ, Lui HF, Li JW, Oo AM, Lim KBL, Ho KS, Chew MH, Quan WL, Tan DMY, Ng KH, Goh HS, Cheong WK, Tseng P, Ling KL. Academy of Medicine, Singapore clinical guideline on the use of sedation by non-anaesthesiologists during gastrointestinal endoscopy in the hospital setting. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2022; 51:24-39. [PMID: 35091728 DOI: 10.47102/annals-acadmedsg.2021306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
INTRODUCTION In Singapore, non-anaesthesiologists generally administer sedation during gastrointestinal endoscopy. The drugs used for sedation in hospital endoscopy centres now include propofol in addition to benzodiazepines and opiates. The requirements for peri-procedural monitoring and discharge protocols have also evolved. There is a need to develop an evidence-based clinical guideline on the safe and effective use of sedation by non-anaesthesiologists during gastrointestinal endoscopy in the hospital setting. METHODS The Academy of Medicine, Singapore appointed an expert workgroup comprising 18 gastroenterologists, general surgeons and anaesthesiologists to develop guidelines on the use of sedation during gastrointestinal endoscopy. The workgroup formulated clinical questions related to different aspects of endoscopic sedation, conducted a relevant literature search, adopted Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology and developed recommendations by consensus using a modified Delphi process. RESULTS The workgroup made 16 recommendations encompassing 7 areas: (1) purpose of sedation, benefits and disadvantages of sedation during gastrointestinal endoscopy; (2) pre-procedural assessment, preparation and consent taking for sedation; (3) Efficacy and safety of drugs used in sedation; (4) the role of anaesthesiologist administered sedation during gastrointestinal endoscopy; (5) performance of sedation; (6) post-sedation care and discharge after sedation; and (7) training in sedation for gastrointestinal endoscopy for non-anaesthesiologists. CONCLUSION These recommendations serve to guide clinical practice during sedation for gastrointestinal endoscopy by non-anaesthesiologists in the hospital setting.
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Affiliation(s)
- Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
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Jin EH, Song JH, Lee J, Bae JH, Chung SJ. Midazolam dose is associated with recurrence of paradoxical reactions during endoscopy. World J Clin Cases 2021; 9:8763-8772. [PMID: 34734054 PMCID: PMC8546803 DOI: 10.12998/wjcc.v9.i29.8763] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 07/06/2021] [Accepted: 08/31/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Midazolam is commonly used for sedation during gastrointestinal procedures. However, some patients experience paradoxical reactions characterized by excessive movement or excitement.
AIM To investigate the rate of recurrence of paradoxical reactions to midazolam during an upper endoscopy.
METHODS We retrospectively reviewed 122152 sedative endoscopies among a total of 58553 patients at the Seoul National University Hospital, Healthcare System Gangnam Center, from July 2013 to December 2018. Among them, 361 patients with a history of paradoxical reaction during sedative upper endoscopy were enrolled. The characteristics of patients in the recurrent and non-recurrent groups were compared via multivariable analysis using logistic regression.
RESULTS Paradoxical reactions occurred in 0.86% (1054/122152) of endoscopies, and in 1.51% (888/58553) of patients. Among the 361 subjects with previous paradoxical reactions in sedative endoscopies, 111 (30.7%) experienced further paradoxical reactions. Univariable analysis revealed that the total midazolam dose used was higher in the recurrent group (6.74 ± 2.58 mg) than in the non-recurrent group (5.49 ± 2.04 mg; P < 0.0001). Patients were administered a lower dose of midazolam than previous doses: 1 mg less in the recurrent group and 2 mg less in the non-recurrent group. Multivariable analysis showed that the midazolam dose difference was an independent risk factor for recurrent paradoxical reaction (odds ratio: 1.213, 95%CI: 1.099-1.338, P = 0.0001).
CONCLUSION The rate of recurrence of paradoxical reactions is significantly associated with midazolam dosage. The dose of midazolam administered to patients with previous paradoxical reactions should be less than that previously used.
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Affiliation(s)
- Eun Hyo Jin
- Department of Internal Medicine, Healthcare Research Institute, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul 06236, South Korea
| | - Ji Hyun Song
- Department of Internal Medicine, Healthcare Research Institute, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul 06236, South Korea
| | - Jooyoung Lee
- Department of Internal Medicine, Healthcare Research Institute, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul 06236, South Korea
| | - Jung Ho Bae
- Department of Internal Medicine, Healthcare Research Institute, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul 06236, South Korea
| | - Su Jin Chung
- Department of Internal Medicine, Healthcare Research Institute, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul 06236, South Korea
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Patient-Controlled Sedation Versus Clinician-Administered Sedation for Endoscopic Retrograde Cholangiopancreatography: A Systematic Review. Anesth Analg 2021; 134:765-772. [PMID: 34543253 DOI: 10.1213/ane.0000000000005766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Patient-controlled sedation (PCS) has been explored as a sedation method in endoscopic retrograde cholangiopancreatography (ERCP), yet a comprehensive review article on this topic is lacking. We performed a systematic review to compare PCS against clinician-administered sedation. The primary objectives are to compare the sedative dosage used and the sedation depth, while secondary objectives are to compare sedation failure rates, clinician intervention rates, and patient satisfaction. A systematic literature search was conducted on MEDLINE, EMBASE, and the Cochrane Library Database using the terms "ERCP," "Sedation," "Patient-controlled," and related terms. Randomized controlled trials comparing PCS against clinician-administered sedation in adults undergoing ERCP were included. Articles without English full texts were excluded. Studies were reviewed by 2 independent reviewers. The Cochrane Risk of Bias tool was used for quality assessment of individual included trials. This systematic review is registered in the International Prospective Register of Systematic Reviews (CRD42020198647). A total of 2619 articles were identified from the literature search. A total of 2615 articles were excluded based on the exclusion criteria. Four articles (comprised of 4 independent trials involving 425 patients) were included in analysis. When compared with clinician-administered sedation, PCS in ERCP may lead to lower propofol dosage used and lower sedation depth. The sedation failure rates appear to be higher in PCS, whereas lower rates of airway maneuvers are required. No significant difference was observable for patient satisfaction rates between PCS and clinician-administered sedation. The included studies demonstrated unclear to high risk of bias, particularly in randomization, incomplete outcome data, and outcome measurement. PCS appears to be a feasible option for sedation in ERCP. Nonetheless, large-scale, high-quality trials will be required before PCS can be regularly implemented in ERCP.
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Patient-controlled Anesthesia With Propofol During Bronchoscopy. J Bronchology Interv Pulmonol 2021; 27:73-74. [PMID: 32209917 DOI: 10.1097/lbr.0000000000000649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Lightdale JR. Sedation for Pediatric Gastrointestinal Procedures. PEDIATRIC SEDATION OUTSIDE OF THE OPERATING ROOM 2021:397-412. [DOI: 10.1007/978-3-030-58406-1_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
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Patient-controlled Sedation During Flexible Bronchoscopy: A Randomized Controlled Trial. J Bronchology Interv Pulmonol 2020; 27:77-85. [PMID: 31478938 DOI: 10.1097/lbr.0000000000000610] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Patient-controlled sedation (PCS) is a documented method for endoscopic procedures considered to facilitate early recovery. Limited data have been reported, however, on its use during flexible bronchoscopy (FB). METHODS This study hypothesized that PCS with propofol during FB would facilitate early recovery, with similar bronchoscopist and patient satisfaction compared with nurse-controlled sedation (NCS) with midazolam. A total of 150 patients were randomized 1:1:1 into a control group (premedication with morphine-scopolamine and NCS with midazolam), PCS-MS group (premedication with morphine-scopolamine and PCS with propofol), and PCS-G group (premedication with glycopyrronium and PCS with propofol). RESULTS The procedures included transbronchial biopsy, transbronchial needle aspiration, cryotherapy/biopsy, and/or multistation endobronchial ultrasound. FB duration values in median (range) were 40 (10 to 80), 39 (12 to 68), and 44 (10 to 82) minutes for the groups NCS, PCS-MS, and PCS-G, respectively. An overall 81% of the patients in the combined PCS groups were ready for discharge (modified Post Anaesthetic Discharge Scoring System, score 10) 2 hours after bronchoscopy compared with 40% in the control group (P<0.0001). Between PCS groups, 96% of the PCS-G group patients were ready for discharge compared with 65% in the PCS-MS group (P=0.0002) at 2 hours. Bronchoscopists' and patients' satisfaction scores were high in all groups. Postdischarge quality scores showed no differences among the groups. CONCLUSION PCS with propofol during FB is feasible, as it shortened recovery time without compromising procedure conditions for bronchoscopists or patients. A rapid postsedation stabilization of vital signs facilitates surveillance before the patient leaves the hospital.
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Dossa F, Medeiros B, Keng C, Acuna SA, Baxter NN. Propofol versus midazolam with or without short-acting opioids for sedation in colonoscopy: a systematic review and meta-analysis of safety, satisfaction, and efficiency outcomes. Gastrointest Endosc 2020; 91:1015-1026.e7. [PMID: 31926966 DOI: 10.1016/j.gie.2019.12.047] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Accepted: 12/30/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Propofol is increasingly being used for sedation in colonoscopy; however, its benefits over midazolam (± short-acting opioids) are not well quantified. The objective of this study was to compare safety, satisfaction, and efficiency outcomes of propofol versus midazolam (± short-acting opioids) in patients undergoing colonoscopy. METHODS We systematically searched Medline, Embase, and the Cochrane library (to July 30, 2018) for randomized controlled trials of colonoscopies performed with propofol versus midazolam (± short-acting opioids). We pooled odds ratios for cardiorespiratory outcomes using mixed-effects conditional logistic models. We pooled standardized mean differences (SMDs) for patient and endoscopist satisfaction and efficiency outcomes using random-effects models. RESULTS Nine studies of 1427 patients met the inclusion criteria. There were no significant differences in cardiorespiratory outcomes (hypotension, hypoxia, bradycardia) between sedative groups. Patient satisfaction was high in both groups, with most patients reporting willingness to undergo a future colonoscopy with the same sedative regimen. In the meta-analysis, patients sedated with propofol had greater satisfaction than those sedated with midazolam (± short-acting opioids) (SMD, .54; 95% confidence interval [CI], .30-.79); however, there was considerable heterogeneity. Procedure time was similar between groups (SMD, .15; 95% CI, .04-.27), but recovery time was shorter in the propofol group (SMD, .41; 95% CI, .08-.74). The median difference in recovery time was 3 minutes, 6 seconds shorter in patients sedated with propofol. CONCLUSIONS Both propofol and midazolam (± short-acting opioids) result in high patient satisfaction and appear to be safe for use in colonoscopy. The marginal benefits to propofol are small improvements in satisfaction and recovery time.
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Affiliation(s)
- Fahima Dossa
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada; Department of Surgery, St Michael's Hospital, Toronto, Ontario, Canada
| | - Braeden Medeiros
- Department of Biology, Western University, London, Ontario, Canada
| | - Christine Keng
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Sergio A Acuna
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Nancy N Baxter
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada; Department of Surgery, St Michael's Hospital, Toronto, Ontario, Canada
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Medical, Political, and Economic Considerations for the Use of MAC for Endoscopic Sedation: Big Price, Little Justification? Dig Dis Sci 2020; 65:2466-2472. [PMID: 32671589 PMCID: PMC7363687 DOI: 10.1007/s10620-020-06464-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The last few decades of gastrointestinal (GI) endoscopy have seen phenomenal growth. In many aspects, GI endoscopy has led the field of nonsurgical interventional medicine. In many aspects, this growth is facilitated by advancements in sedation-both drugs and techniques. Unfortunately, the topic of GI endoscopy sedation is also mired in many controversies, mainly emanating from the cost of anesthesia providers. While no one debates their role in the majority of advanced endoscopic procedures, the practice of universal propofol sedation in the USA, delivered by anesthesia providers, needs a closer look. In this review, medical, political, and economic considerations of this important topic are discussed in a very frank and honest way. While such ubiquitous propofol use has increased satisfaction of both patients and gastroenterologists, there is little justification. More importantly, going by the evidence, there is even less justification for the mandated anesthesia providers use for such delivery. Unfortunately, the FDA could not be convinced otherwise. The new drug fospropofol met the same fate. Approval of SEDASYS®, the first computer-assisted personalized sedation system, was a step in the right direction, nevertheless an insufficient step that failed to takeoff. As a result, in spite of years of research and efforts of many august societies, the logjam of balancing cost and justification of propofol sedation has continued. We hope that recent approval of remimazolam, a novel benzodiazepine, and potential approval of oliceridine, a novel short-acting opioid, might be able to contain the cost without compromising the quality of sedation.
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Schraag S. TIVA Drugs for Sedation. TAKING ON TIVA 2019:154-161. [DOI: 10.1017/9781316659069.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Alteration of coupling between brain and heart induced by sedation with propofol and midazolam. PLoS One 2019; 14:e0219238. [PMID: 31314775 PMCID: PMC6636731 DOI: 10.1371/journal.pone.0219238] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 06/20/2019] [Indexed: 11/19/2022] Open
Abstract
For a comprehensive understanding of the nervous system, several previous studies have examined the network connections between the brain and the heart in diverse conditions. In this study, we identified coupling between the brain and the heart along the continuum of sedation levels, but not in discrete sedation levels (e. g., wakefulness, conscious sedation, and deep sedation). To identify coupling between the brain and the heart during sedation, we induced several depths of sedation using patient-controlled sedation with propofol and midazolam. We performed electroencephalogram (EEG) spectral analysis and extracted the instantaneous heart rate (HR) from the electrocardiogram (ECG). EEG spectral power dynamics and mean HR were compared along the continuum of sedation levels. We found that EEG sigma power was the parameter most sensitive to changes in the sedation level and was correlated with the mean HR under the effect of sedative agents. Moreover, we calculated the Granger causality (GC) value to quantify brain-heart coupling at each sedation level. Additionally, the GC analysis revealed noticeably different strengths and directions of causality among different sedation levels. In all the sedation levels, GC values from the brain to the heart (GCb→h) were higher than GC values from the heart to the brain (GCh→b). Moreover, the mean GCb→h increased as the sedation became deeper, resulting in higher GCb→h values in deep sedation (1.97 ± 0.18 in propofol, 2.02 ± 0.15 in midazolam) than in pre-sedation (1.71 ± 0.13 in propofol, 1.75 ± 0.11 in midazolam; p < 0.001). These results show that coupling between brain and heart activities becomes stronger as sedation becomes deeper, and that this coupling is more attributable to the brain-heart direction than to the heart-brain direction. These findings provide a better understanding of the relationship between the brain and the heart under specific conditions, namely, different sedation states.
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Patel J, Fang J, Taylor LJ, Adler DG, Gawron AJ. Safety and efficacy of non-anesthesiologist administration of propofol sedation during esophagogastroduodenoscopy in the intensive care unit. Endosc Int Open 2019; 7:E625-E629. [PMID: 30993168 PMCID: PMC6461546 DOI: 10.1055/a-0829-6284] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 11/15/2018] [Indexed: 12/17/2022] Open
Abstract
Background and study aims Propofol sedation is an increasingly popular method of sedation for gastrointestinal endoscopic procedures. The safety and efficacy of the non-anesthesiologist administration of propofol (NAAP) sedation has been demonstrated in the ambulatory setting. However, NAAP sedation in intensive care unit (ICU) patients has not been reported. The purpose of this study is to determine safety and efficacy of NAAP sedation in an ICU population. Methods We retrospectively reviewed esophagogastroduodenoscopies (EGD) performed with NAAP sedation in our intensive care units from June 2014 to September 2016. All EGDs were performed for evaluation of gastrointestinal bleeding. The primary end point of this study was to analyze the incidence of sedation-related adverse events (AEs). The secondary end points included successful completion of procedure and any endoscopic interventions performed. Results Two of 161 procedures (1.2 %) had sedation-related AEs requiring procedure termination. One hundred forty-six of 161 procedures (90.7 %) were successfully completed. Incomplete procedures were due to excess heme, retained food or obstructive lesions (13/161, 8.1 %). Endoscopic intervention was performed successfully in 17/24 cases (70.8 %) that had endoscopically treated lesions identified. One hundred six of 161 patients (66 %) were American Society of Anesthesiologists (ASA) classification III or IV. Conclusion Our retrospective analysis demonstrated that EGDs can be successfully completed in ICU patients using NAAP sedation. When procedures cannot be completed, it is rarely due to sedation-related AEs. NAAP sedation further allows adequate examination and successful treatment of high-risk lesions. NAAP sedation appears safe and effective for endoscopic procedures in the ICU setting.
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Affiliation(s)
- Janaki Patel
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - John Fang
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - Linda J. Taylor
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - Douglas G. Adler
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - Andrew J. Gawron
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, United States,Corresponding author Andrew J. Gawron 30 N 1900 E, SOM 4R118Salt Lake City, UT 84132+1-801-581-7476
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Zhang W, Zhu Z, Zheng Y. Effect and safety of propofol for sedation during colonoscopy: A meta-analysis. J Clin Anesth 2018; 51:10-18. [PMID: 30059837 DOI: 10.1016/j.jclinane.2018.07.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 07/23/2018] [Accepted: 07/23/2018] [Indexed: 02/08/2023]
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Xue M, Tian J, Zhang J, Zhu H, Bai J, Zhang S, Wang Q, Wang S, Song X, Ma D, Li J, Zhang Y, Li W, Wang D. No increased risk of perforation during colonoscopy in patients undergoing propofol versus traditional sedation: A meta-analysis. Indian J Gastroenterol 2018. [PMID: 29520582 DOI: 10.1007/s12664-017-0814-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS The safety of propofol sedation during colonoscopy remains unclear, and we performed a meta-analysis to assess the risk of perforation in patients undergoing propofol vs. traditional sedation. METHODS MEDLINE, CBM, VIP, CNKI, and Wanfang databases were searched up to December 2016. Two reviewers independently assessed abstract of those searched articles. Data about perforation condition in propofol and traditional sedation groups were extracted and combined using the random effects model. RESULTS A total of 19 studies were included in the current meta-analysis. Compared to traditional sedation, propofol sedation did not increase the risk of perforation (RD = - 0.00, 95% CI - 0.00~0.00, p = 0.98; subgroup analysis: OR = 1.30, 95% CI 0.83~2.05, p = 0.25). CONCLUSION This meta-analysis suggested that propofol sedation did not increase the risk of perforation compared to traditional sedation during colonoscopy.
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Affiliation(s)
- Minmin Xue
- Department of Gastroenterology, Chinese People's Liberation Army 254 Hospital, Tianjin, 300070, People's Republic of China
| | - Jian Tian
- Department of Gastroenterology, Chinese People's Liberation Army 254 Hospital, Tianjin, 300070, People's Republic of China
| | - Jing Zhang
- Department of Gastroenterology, Chinese People's Liberation Army 254 Hospital, Tianjin, 300070, People's Republic of China
| | - Hongbin Zhu
- Department of Gastroenterology, Chinese People's Liberation Army 254 Hospital, Tianjin, 300070, People's Republic of China
| | - Jun Bai
- Department of Gastroenterology, Chinese People's Liberation Army 254 Hospital, Tianjin, 300070, People's Republic of China
| | - Sujuan Zhang
- Department of Gastroenterology, Chinese People's Liberation Army 254 Hospital, Tianjin, 300070, People's Republic of China
| | - Qili Wang
- Department of Gastroenterology, Chinese People's Liberation Army 254 Hospital, Tianjin, 300070, People's Republic of China
| | - Shuge Wang
- Department of Gastroenterology, Chinese People's Liberation Army 254 Hospital, Tianjin, 300070, People's Republic of China
| | - Xuzheng Song
- Department of Gastroenterology, Chinese People's Liberation Army 254 Hospital, Tianjin, 300070, People's Republic of China
| | - Donghong Ma
- Department of Gastroenterology, Chinese People's Liberation Army 254 Hospital, Tianjin, 300070, People's Republic of China
| | - Jia Li
- Department of Gastroenterology, Chinese People's Liberation Army 254 Hospital, Tianjin, 300070, People's Republic of China
| | - Yongmin Zhang
- Department of Gastroenterology, Chinese People's Liberation Army 254 Hospital, Tianjin, 300070, People's Republic of China
| | - Wei Li
- Department of Gastroenterology, Chinese People's Liberation Army 254 Hospital, Tianjin, 300070, People's Republic of China
| | - Dongxu Wang
- Department of Gastroenterology, Chinese People's Liberation Army 254 Hospital, Tianjin, 300070, People's Republic of China.
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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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Spatio-temporal dynamics of multimodal EEG-fNIRS signals in the loss and recovery of consciousness under sedation using midazolam and propofol. PLoS One 2017; 12:e0187743. [PMID: 29121108 PMCID: PMC5679575 DOI: 10.1371/journal.pone.0187743] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 10/25/2017] [Indexed: 12/29/2022] Open
Abstract
On sedation motivated by the clinical needs for safety and reliability, recent studies have attempted to identify brain-specific signatures for tracking patient transition into and out of consciousness, but the differences in neurophysiological effects between 1) the sedative types and 2) the presence/absence of surgical stimulations still remain unclear. Here we used multimodal electroencephalography–functional near-infrared spectroscopy (EEG–fNIRS) measurements to observe electrical and hemodynamic responses during sedation simultaneously. Forty healthy volunteers were instructed to push the button to administer sedatives in response to auditory stimuli every 9–11 s. To generally illustrate brain activity at repetitive transition points at the loss of consciousness (LOC) and the recovery of consciousness (ROC), patient-controlled sedation was performed using two different sedatives (midazolam (MDZ) and propofol (PPF)) under two surgical conditions. Once consciousness was lost via sedatives, we observed gradually increasing EEG power at lower frequencies (<15 Hz) and decreasing power at higher frequencies (>15 Hz), as well as spatially increased EEG powers in the delta and lower alpha bands, and particularly also in the upper alpha rhythm, at the frontal and parieto-occipital areas over time. During ROC from unconsciousness, these spatio-temporal changes were reversed. Interestingly, the level of consciousness was switched on/off at significantly higher effect-site concentrations of sedatives in the brain according to the use of surgical stimuli, but the spatio-temporal EEG patterns were similar, regardless of the sedative used. We also observed sudden phase shifts in fronto-parietal connectivity at the LOC and the ROC as critical points. fNIRS measurement also revealed mild hemodynamic fluctuations. Compared with general anesthesia, our results provide insights into critical hallmarks of sedative-induced (un)consciousness, which have similar spatio-temporal EEG-fNIRS patterns regardless of the stage and the sedative used.
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Wadhwa V, Issa D, Garg S, Lopez R, Sanaka MR, Vargo JJ. Similar Risk of Cardiopulmonary Adverse Events Between Propofol and Traditional Anesthesia for Gastrointestinal Endoscopy: A Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2017; 15:194-206. [PMID: 27451091 DOI: 10.1016/j.cgh.2016.07.013] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Revised: 07/02/2016] [Accepted: 07/06/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Even though propofol use for gastrointestinal endoscopic procedures has increased over the past decade, there is a perception that it causes a higher rate of cardiopulmonary adverse events. The aim of this study was to compare the sedation-related adverse events associated with use of propofol vs nonpropofol agents for endoscopic procedures. We also wanted to determine the influence of duration or complexity of the procedures and endoscopist-directed (gastroenterologist) vs non-gastroenterologist-directed sedation on the outcomes. METHODS A search was conducted using Medline, EMBASE, and the Cochrane controlled trials registry. The following cardiopulmonary adverse events were assessed: hypoxia, hypotension, and arrhythmias. The procedures were divided into 2 groups based on the procedure length: a nonadvanced endoscopic procedure group consisting of esophagogastroduodenoscopy, colonoscopy, and sigmoidoscopy, and an advanced endoscopic procedures group including endoscopic retrograde cholangiopancreatography, endoscopic ultrasonography, balloon enteroscopy, and endoscopic submucosal dissection. Pooled odds ratios for complications were calculated for all the procedures combined and then separately for the 2 groups. Random-effects models were used for 2-proportion comparisons. RESULTS Of the 2117 citations identified, 27 original studies qualified for this meta-analysis and included 2518 patients. Of these, 1324 received propofol, and 1194 received midazolam, meperidine, pethidine, remifentanil, and/or fentanyl. Most of the included studies were randomized trials of moderate quality and nonsignificant heterogeneity (Cochran Q, 26.07; P = .13). Compared with traditional sedative agents, the pooled odds ratio with the use of propofol for developing hypoxia for all the procedures combined was 0.82 (95% confidence interval [CI], 0.63-1.07), and for developing hypotension was 0.92 (95% CI, 0.64-1.32). In the nonadvanced endoscopic procedure group, those who received propofol were 39% less likely to develop complications than those receiving traditional sedative agents (odds ratio, 0.61; 95% CI, 0.38-0.99). There was no difference in the complication rate for the advanced endoscopic procedure group (odds ratio, 0.86; 95% CI, 0.56-1.34). A subgroup analysis did not show any difference in adverse events when propofol was administered by gastroenterologists or nongastroenterologists. CONCLUSIONS Propofol sedation has a similar risk of cardiopulmonary adverse events compared with traditional agents for gastrointestinal endoscopic procedures. Propofol use in simple endoscopic procedures was associated with a decreased number of complications. When used for gastrointestinal endoscopic procedures of a complex nature and longer duration, propofol was not associated with increased rates of hypoxemia, hypotension, or arrhythmias. Administration of propofol by gastroenterologists does not appear to increase the complication rates.
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Affiliation(s)
- Vaibhav Wadhwa
- Department of Internal Medicine, Fairview Hospital, Cleveland Clinic, Cleveland, Ohio
| | - Danny Issa
- Department of Gastroenterology and Hepatology, Virginia Commonwealth University, Richmond, Virginia
| | - Sushil Garg
- Department of Internal Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Rocio Lopez
- Department of Biostatistics, Cleveland Clinic, Cleveland, Ohio
| | - Madhusudhan R Sanaka
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio
| | - John J Vargo
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio.
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Pambianco D, Niklewski P. Computer-Assisted and Patient-Controlled Sedation Platforms. Gastrointest Endosc Clin N Am 2016; 26:563-76. [PMID: 27372778 DOI: 10.1016/j.giec.2016.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
As the number and complexity of endoscopic procedures increase, the role of sedation has been integral in patient and physician satisfaction. This article discusses the advances of computer-assisted and patient-controlled platforms. These computer-assisted and patient-controlled platforms use different anesthetics and analgesics, all with the intent of achieving improved consistency in the level of sedation, appropriate to the needs of patients, while also improving patient safety. These systems have been around for decades; however, few are approved for use in the United States, and several still require further study before broad clinical application.
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Affiliation(s)
- Daniel Pambianco
- Charlottesville Medical Research, 325 Winding River Lane, Suite 102, Charlottesville, VA 22911, USA.
| | - Paul Niklewski
- Department of Pharmacology and Cell Biophysics, University of Cincinnati College of Medicine, 231 Albert Sabin Way, University of Cincinnati, Cincinnati, OH 45267-0575, USA; Xavier University, 3800 Victory Pkwy, Cincinnati, OH 45207, USA; Sedasys, a Division of Ethicon Endo-Surgery, Inc, Ethicon Endo-Surgery Inc, 4545 Creek Road, Cincinnati, OH 45242, USA
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21
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Ekin A, Donmez F, Taspinar V, Dikmen B. Patient-controlled sedation in orthopedic surgery under regional anesthesia: a new approach in procedural sedation. Rev Bras Anestesiol 2015; 63:410-4. [PMID: 24263045 DOI: 10.1016/j.bjan.2012.07.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2012] [Accepted: 07/16/2012] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Regional anesthesia is a commonly used technique in orthopedic procedures. Sedation should reduce the patient's anxiety and fear while increasing regional anesthesia quality. This study evaluated the hemodynamic changes, level of sedation, both patients' and surgeons' levels of satisfaction and potential side effects in patient-controlled sedation using propofol. METHODS This randomized clinical trial studied sixty ASA physical class I-III patients scheduled for total knee replacement surgery under combined spinal-epidural anesthesia. Patients in Group P (n = 30) received propofol via a patient-controlled analgesia device with the following settings: intravenous propofol bolus dose 400 μg.kg(-1), 5-minute lockout interval and no basal infusion. In Group S, we infused saline 150 using the same settings. To determine the level of sedation, we used BIS and Observer's Assessment of Alertness/ Sedation Scale. For all patients, we recorded the number of requests. As the fi nal evaluation, we scored surgeons' and patients' satisfaction on 4-point scales. RESULTS Both BIS values and OAA/S scores were lower in Group P than in Group S. Patients' satisfaction was higher in Group P, although there was no significant difference with respect to surgeons' satisfaction between the groups. The number of requests for sedation was significantly higher in Group S. However, most requests were considered unsuccessful. CONCLUSION This study suggests that patient-controlled sedation with propofol can be used efficiently in orthopedic procedures.
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Affiliation(s)
- Abdulselam Ekin
- Departamento de Anestesiologia, Special Genesis Hospital, Diyarbakir, Turquia
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22
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Lightdale JR. Sedation for Pediatric Gastrointestinal Procedures. PEDIATRIC SEDATION OUTSIDE OF THE OPERATING ROOM 2015:351-366. [DOI: 10.1007/978-1-4939-1390-9_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
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Sultan SS. Patient-controlled sedation with propofol/remifentanil versus propofol/alfentanil for patients undergoing outpatient colonoscopy, a randomized, controlled double-blind study. Saudi J Anaesth 2014; 8:S36-40. [PMID: 25538518 PMCID: PMC4268525 DOI: 10.4103/1658-354x.144068] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
CONTEXT Many techniques are used for sedation of colonoscopies. Patient-controlled sedation (PCS) is utilizing many drugs or drug combinations. AIMS The aim of this study is to compare the safety and feasibility of propofol/remifentanil versus propofol/alfentanil given to sedate patients undergoing outpatient colonoscopies through a patient-controlled technique. SETTINGS AND DESIGN Controlled randomized and double-blind study. MATERIALS AND METHODS A total of 80 patients were randomly divided into two groups; PA group received a combination of propofol/alfentanil and PR group received propofol/remifentanil combination. Patients were monitored for heart rate (HR), blood pressure (BP), oxygen saturation, and Ramsay sedation scale (RSS). Times of the following events were recorded; initiation of sedation, insertion and removal of the colonoscope, recovery and discharge. Five intervals were calculated; time to sedation, procedure time, postprocedure time, procedure room time, and postanesthesia care unit (PACU) time. Endoscopist and patient satisfaction scores were obtained. STATISTICAL ANALYSIS USED Unpaired Student's t-test was used to compare between the two groups. Paired Student's t-test was used to compare baseline readings with readings after 30 min of sedation in the same group when needed. RESULTS Both groups showed slowing of the HR and decrease in mean arterial BP. HR and mean arterial BP were significantly lower 5 and 10 min after initiation of sedation in PR group when compared with PA group. Both HR and mean arterial BP returned to presedation readings 30 min after initiation of sedation in PR group but not in PA group. No differences between the two groups concerning oxygen saturation, RSS, endoscopist and patient satisfaction scores. Postprocedure and PACU times were significantly prolonged in PA group. CONCLUSION PCS with either remifentanil/propofol or alfentanil/propofol for patients undergoing outpatient colonoscopy is safe and feasible. Remifentanil/proofol has more beneficial advantages in this setting secondary to its more rapid clearance.
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Affiliation(s)
- Sherif S. Sultan
- Department of Anesthesia and Intensive Care, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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25
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Sethi S, Wadhwa V, Thaker A, Chuttani R, Pleskow DK, Barnett SR, Leffler DA, Berzin TM, Sethi N, Sawhney MS. Propofol versus traditional sedative agents for advanced endoscopic procedures: a meta-analysis. Dig Endosc 2014; 26:515-24. [PMID: 24354404 DOI: 10.1111/den.12219] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Accepted: 11/11/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM The optimum method for sedation for advanced endoscopic procedures is not known. Propofol deep sedation has a faster recovery time than traditional sedative agents, but may be associated with increased complication rates. The aim of the present study was to pool data from all available studies to systematically compare the efficacy and safety of propofol with traditional sedative agents for advanced endoscopic procedures. METHODS Databases including PubMed, Embase, Web of Science and the Cochrane Central Register of Controlled Trials updated as of January 2013 were searched. Main outcome measures were procedure duration, recovery time, incidence of complications (hypotension, hypoxia), sedation level, patient cooperation and amnesia during advanced endoscopic procedures such as endoscopic retrograde cholangiopancreatography, endoscopic ultrasonography, and deep small bowel enteroscopy. RESULTS Nine prospective randomized trials with a total of 969 patients (485 propofol, 484 conscious sedation) were included in the meta-analysis. Pooled mean difference in procedure duration between propofol and traditional sedative agents was -2.3 min [95% CI: -6.36 to 1.76, P = 0.27], showing no significant difference in procedure duration between the two groups. Pooled mean difference in recovery time was -30.26 min [95% CI: -46.72 to -13.80, P < 0.01], showing significantly decreased recovery time with propofol. There was also no significant difference between the two groups with regard to hypoxia and hypotension. CONCLUSIONS Propofol for advanced endoscopic procedures is associated with shorter recovery time, better sedation and amnesia level without an increased risk of cardiopulmonary complications. Overall patient cooperation was also improved with propofol sedation.
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Affiliation(s)
- Saurabh Sethi
- Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, USA
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Tschirdewahn S, Rübben H, Schenck M. [Urological surgery with analogosedation and local anesthesia. What makes sense?]. Urologe A 2013; 52:1302-11. [PMID: 23959458 DOI: 10.1007/s00120-013-3316-0] [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: 11/30/2022]
Abstract
OBJECTIVE Analogosedation and local anesthesia, including regional nerve blocks are used for endoscopic diagnostic or radiological and ultrasound-guided procedures in which the patient should not move or has to be free of pain. We retrospectively analyzed patient satisfaction, complications and the risk of urological interventions with analgosedation and/or local anesthesia between 2008 and 2012. MATERIAL AND METHODS In total 21,690 urological patients underwent surgical treatment at the Department of Urology of the University Hospital of Essen between 2008 and 2012 and 3,327 of these cases were performed by urologists with the patient under analogosedation (n=1484) and local anesthesia (n=1843). In total 13 surgical and endoscopic procedures were separately analyzed and evaluated for safety and practicability. RESULTS In five cases (0.15%) the procedures with analgosedation or local anesthesia were interrupted because of agitation (n=3) and in one case the transurethal resection was stopped due to a large bladder tumor. One patient suffered anaphylactic shock after preoperative intravenous application of cefuroxim 1.5 g. After cardiopulmonary resuscitation and a short stay on the intensive care unit the patient was discharged after 2 days.Conclusions. Local anesthesia and analgosedation should be performed by urologists for minor surgery, endoscopic procedures and radiological or ultrasound-guided treatment. For safety reasons there should always be a second medical doctor present for assistance. Analgesia with deep sedation or loss of defensive reflexes should be administered by anesthesiologists.
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27
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Bastaki M, Douzinas EE, Fotis TG, Bakos DS, Mitsos AP, Argyra E, Konstantinou MI, Soultati AS, Kapritsou M, Katostaras T, Konstantinou EA. A randomized double-blind trial of anesthesia provided for colonoscopy by university-degreed anesthesia nurses in Greece: safety and efficacy. Gastroenterol Nurs 2013; 36:223-230. [PMID: 23732788 DOI: 10.1097/sga.0b013e318295e473] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
There are numerous studies in the literature of anesthesia administered during colonoscopy including various methods, drugs, and monitoring systems; however, none of them has studied whether a university-degreed nurse anesthesia provider (known as a certified registered nurse anesthetist in the United States) is skillful enough to provide safe anesthesia in patients undergoing endoscopic procedures. The aim of our study was to determine whether anesthesia provided by a university-degreed nurse anesthesia provider during an endoscopic procedure is comparable in terms of safety and efficacy with routine sedation practice. This randomized, double-blind study included 100 adult patients who underwent colonoscopy conducted in the Evgenidion University Hospital during a single year. Subjects were divided into 2 groups: the first group received the usual scheme of intravenous sedation with midazolam and fentanyl administered by a member of the endoscopic team that was blind to Bispectral Index (BIS) values recordings (Group 0). The second group received intravenous bolus injection of propofol bolus by a university-degreed anesthesia registered nurse based on the BIS values (Group 1). The average of the mean BIS values of Group 0 was 85.07 (SD = 8.01) and for Group 1 was 76.1 (SD = 10.88; p = .04). The parameters of "patient memory during procedure" and the satisfaction scores (as self-assessed by the patients as well as 2 gastroenterologists) were also significantly different between the patients of the 2 groups (p = .000). Comparison between the 2 groups showed that the sedation offered by a university-degreed nurse anesthesia provider was absolutely safe and effective, offering particular comfort to the patient during the intervention and contributing significantly to its successful results.
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Affiliation(s)
- Maria Bastaki
- Faculty of Nursing, National and Kapodistrian University of Athens, Athens, Greece
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USSUI VM, SILVA ALWD, BORGES LV, SILVA JGND, ZEITUNE JMR, HASHIMOTO CL. WHAT ARE THE MOST IMPORTANT FACTORS REGARDING ACCEPTANCE TO THE COLONOSCOPY? ARQUIVOS DE GASTROENTEROLOGIA 2013; 50:23-30. [DOI: 10.1590/s0004-28032013000100006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2012] [Accepted: 10/18/2012] [Indexed: 02/06/2023]
Abstract
ContextColonoscopy plays an indubitable role in the setting of clinical practice, however, it is an invasive exam; complex, lengthy, embarrassing, not devoid of risks and discomfort that yields fear and anxiety in the majority of patients. In a new era of rising competition between health institutions, where the quality of health care and client satisfaction are praised, studies regarding tolerance-related colonoscopy issues yield great potential to be explored. In the present study, tolerance is defined as willingness to repeat the exam.ObjectivesEvaluate information associated to bowel preparation, the exam itself and post-examination period that might interfere with the tolerance to the colonoscopy.MethodsAnalysis of the tolerance to the colonoscopy at three stages (pre, post, and during) through a checklist: patient's questionnaire and a medical assessment form were used.ResultsIn this present study, 91.2% of 373 patients exhibited positive tolerance to the colonoscopy. Aspects related to a negative level of tolerance were patient gender (12.9% of women versus 3.2% of men would not repeat the exam), age extremes (less than 20 years and greater than 80 years of age), and abdominal pain, both during the bowel preparation and after the procedure.ConclusionsGender, age, patient cooperation and abdominal pain were the decisive components regarding tolerance to the colonoscopy. Notably, in two phases of the exam, the abdominal pain was the most important feature associated to a lessened tolerance.
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Amornyotin S. Sedation and monitoring for gastrointestinal endoscopy. World J Gastrointest Endosc 2013; 5:47-55. [PMID: 23424050 PMCID: PMC3574612 DOI: 10.4253/wjge.v5.i2.47] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Revised: 07/11/2012] [Accepted: 12/01/2012] [Indexed: 02/05/2023] Open
Abstract
The safe sedation of patients for diagnostic or therapeutic procedures requires a combination of properly trained physicians and suitable facilities. Additionally, appropriate selection and preparation of patients, suitable sedative technique, application of drugs, adequate monitoring, and proper recovery of patients is essential. The goal of procedural sedation is the safe and effective control of pain and anxiety as well as to provide an appropriate degree of memory loss or decreased awareness. Sedation practices for gastrointestinal endoscopy (GIE) vary widely. The majority of GIE patients are ambulatory cases. Most of this procedure requires a short time. So, short acting, rapid onset drugs with little adverse effects and improved safety profiles are commonly used. The present review focuses on commonly used regimens and monitoring practices in GIE sedation. This article is to discuss the decision making process used to determine appropriate pre-sedation assessment, monitoring, drug selection, dose of sedative agents, sedation endpoint and post-sedation care. It also reviews the current status of sedation and monitoring for GIE procedures in Thailand.
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Affiliation(s)
- Somchai Amornyotin
- Somchai Amornyotin, Department of Anesthesiology and Siriraj Gastrointestinal Endoscopy Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
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Wang D, Chen C, Chen J, Xu Y, Wang L, Zhu Z, Deng D, Chen J, Long A, Tang D, Liu J. The use of propofol as a sedative agent in gastrointestinal endoscopy: a meta-analysis. PLoS One 2013; 8:e53311. [PMID: 23308191 PMCID: PMC3540096 DOI: 10.1371/journal.pone.0053311] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Accepted: 11/27/2012] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES To assess the efficacy and safety of propofol sedation for gastrointestinal endoscopy, we conducted a meta-analysis of randomized controlled trials (RCTs) comparing propofol with traditional sedative agents. METHODS RCTs comparing the effects of propofol and traditional sedative agents during gastrointestinal endoscopy were found on MEDLINE, the Cochrane Central Register of Controlled Trials, and EMBASE. Cardiopulmonary complications (i.e., hypoxia, hypotension, arrhythmia, and apnea) and sedation profiles were assessed. RESULTS Twenty-two original RCTs investigating a total of 1,798 patients, of whom 912 received propofol only and 886 received traditional sedative agents only, met the inclusion criteria. Propofol use was associated with shorter recovery (13 studies, 1,165 patients; WMD -19.75; 95% CI -27.65, 11.86) and discharge times (seven studies, 471 patients; WMD -29.48; 95% CI -44.13, -14.83), higher post-anesthesia recovery scores (four studies, 503 patients; WMD 2.03; 95% CI 1.59, 2.46), better sedation (nine studies, 592 patients; OR 4.78; 95% CI 2.56, 8.93), and greater patient cooperation (six studies, 709 patients; WMD 1.27; 95% CI 0.53, 2.02), as well as more local pain on injection (six studies, 547 patients; OR 10.19; 95% CI 3.93, 26.39). Effects of propofol on cardiopulmonary complications, procedure duration, amnesia, pain during endoscopy, and patient satisfaction were not found to be significantly different from those of traditional sedative agents. CONCLUSIONS Propofol is safe and effective for gastrointestinal endoscopy procedures and is associated with shorter recovery and discharge periods, higher post-anesthesia recovery scores, better sedation, and greater patient cooperation than traditional sedation, without an increase in cardiopulmonary complications. Care should be taken when extrapolating our results to specific practice settings and high-risk patient subgroups.
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Affiliation(s)
- Daorong Wang
- Department of Gastrointestinal Surgery, Subei People’s Hospital of Jiangsu Province (Clinical Medical College of Yangzhou University), Yangzhou, Jiangsu Province, People’s Republic of China
| | - Chaowu Chen
- Department of Gastroenterology, Subei People’s Hospital of Jiangsu Province (Clinical Medical College of Yangzhou University), Yangzhou, Jiangsu Province, People’s Republic of China
| | - Jie Chen
- Department of Gastrointestinal Surgery, Subei People’s Hospital of Jiangsu Province (Clinical Medical College of Yangzhou University), Yangzhou, Jiangsu Province, People’s Republic of China
| | - Yaxiang Xu
- Department of Gastrointestinal Surgery, Subei People’s Hospital of Jiangsu Province (Clinical Medical College of Yangzhou University), Yangzhou, Jiangsu Province, People’s Republic of China
| | - Lu Wang
- Department of Gastroenterology, Subei People’s Hospital of Jiangsu Province (Clinical Medical College of Yangzhou University), Yangzhou, Jiangsu Province, People’s Republic of China
| | - Zhen Zhu
- Department of Gastroenterology, Subei People’s Hospital of Jiangsu Province (Clinical Medical College of Yangzhou University), Yangzhou, Jiangsu Province, People’s Republic of China
| | - Denghao Deng
- Department of Gastroenterology, Subei People’s Hospital of Jiangsu Province (Clinical Medical College of Yangzhou University), Yangzhou, Jiangsu Province, People’s Republic of China
| | - Juan Chen
- Department of Gastroenterology, Subei People’s Hospital of Jiangsu Province (Clinical Medical College of Yangzhou University), Yangzhou, Jiangsu Province, People’s Republic of China
| | - Aihua Long
- Department of Gastroenterology, Subei People’s Hospital of Jiangsu Province (Clinical Medical College of Yangzhou University), Yangzhou, Jiangsu Province, People’s Republic of China
| | - Dong Tang
- Department of Gastrointestinal Surgery, Subei People’s Hospital of Jiangsu Province (Clinical Medical College of Yangzhou University), Yangzhou, Jiangsu Province, People’s Republic of China
| | - Jun Liu
- Department of Gastroenterology, Subei People’s Hospital of Jiangsu Province (Clinical Medical College of Yangzhou University), Yangzhou, Jiangsu Province, People’s Republic of China
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Cardin F, Minicuci N, Campigotto F, Andreotti A, Granziaera E, Donà B, Martella B, Terranova C, Militello C. Difficult colonoscopies in the propofol era. BMC Surg 2012; 12 Suppl 1:S9. [PMID: 23173918 PMCID: PMC3499204 DOI: 10.1186/1471-2482-12-s1-s9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND To study the relationship between endoscopic practice and adverse events during colonoscopy under standard deep sedation induced and monitored by an anesthetist. METHODS We investigated the routine activity of an endoscopy center at the Padova University teaching hospital. We considered not only endoscopic and cardiorespiratory complications, but also the need to use high-dose propofol to complete the procedure, and the inability to complete the procedure. Variables relating to the patient's clinical conditions, bowel preparation, the endoscopist's and the anesthetist's experience, and the duration of the procedure were input in the model. RESULTS 617 procedures under deep sedation were performed with a 5% rate of adverse events. The average dose of propofol used was 2.6 ± 1.2 mg/kg. In all, 14 endoscopists and 42 anesthetists were involved in the procedures. The logistic regression analysis identified female gender (OR=2.3), having the colonoscopy performed by a less experienced endoscopist (OR=1.9), inadequate bowel preparation (OR=3.2) and a procedure lasting longer than 17.5 minutes (OR=1.6) as the main risk factors for complications. An ASA score of 2 carried a 50% risk reduction (OR=0.5). DISCUSSION AND CONCLUSIONS Our model showed that none of the variables relating to anesthesiological issues influenced which procedures would prove difficult.
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Affiliation(s)
- Fabrizio Cardin
- Department of Surgical and Gastroenterological Sciences, Padova University Hospital, Italy, Via Giustiniani n2, 35126 Padova, Italy.
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El Chafic AH, Eckert G, Rex DK. Prospective description of coughing, hemodynamic changes, and oxygen desaturation during endoscopic sedation. Dig Dis Sci 2012; 57:1899-907. [PMID: 22271416 DOI: 10.1007/s10620-012-2057-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2011] [Accepted: 01/05/2012] [Indexed: 12/28/2022]
Abstract
BACKGROUND Deep sedation is increasingly used for endoscopy. The impact of sedation level on hemodynamic status, oxygenation, and aspiration risk is incompletely described. AIMS To describe the incidence of intraprocedural cough, hemodynamic changes, oxygen desaturation, and their relationship to clinical factors and sedation level. METHODS Detailed prospective recordings of hemodynamic changes, oxygen desaturation, and cough during 757 nonemergent endoscopic procedures done under sedation using propofol, midazolam, and/or fentanyl. RESULTS Thirteen percent of patients had at least one cough and 3% had prolonged cough. Cough was more common in nonsmokers (P = 0.05), upper endoscopy (P < 0.0001), with propofol (P = 0.0008), longer procedures (P = 0.0001), and hiccups (P = 0.01). The association between supine positioning during colonoscopy and cough approached significance (P = 0.06). Oxygen desaturation was rare (4%) and associated only with deep sedation (P = 0.02). Mean systolic and diastolic blood pressure (BP) dropped by 7.3 and 5.6% respectively. Decreases in systolic BP were more common in whites (P = 0.03), males (P = 0.004), nonsmokers (P = 0.04), during colonoscopy (P < 0.0001), and in patients receiving midazolam and fentanyl (P = 0.01). Heart rate (HR) dropped >20% from baseline in 15% of patients and was more common during colonoscopy (P = 0.002). HR increased >20% in 20% of patients and was more common with coughing (P < 0.0001) and in younger patients (P = 0.0002). No patient required pharmacologic treatment of BP or HR. CONCLUSIONS We have described procedural predictors of cough that may help clinicians reduce the risk of aspiration during endoscopy. Hemodynamic changes during endoscopy are common but largely clinically insignificant.
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Affiliation(s)
- Abdul Hamid El Chafic
- Division of Gastroenterology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
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Zuo XL, Li Z, Liu XP, Li CQ, Ji R, Wang P, Zhou CJ, Liu H, Li YQ. Propofol vs midazolam plus fentanyl for upper gastrointestinal endomicroscopy: A randomized trial. World J Gastroenterol 2012; 18:1814-21. [PMID: 22553407 PMCID: PMC3332296 DOI: 10.3748/wjg.v18.i15.1814] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2011] [Revised: 12/06/2011] [Accepted: 03/10/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the endomicroscopic image quality of integrated confocal laser endomicroscopy (iCLE) and sedation efficacy of propofol vs midazolam plus fentanyl (M/F).
METHODS: Consecutive outpatients undergoing iCLE were prospectively recruited and randomized to the propofol group (P group) or M/F group. The patient, performing endoscopist and endoscopic assistant were blinded to the randomization. The quality of endomicroscopic images and anesthetic efficacy outcomes were blindly evaluated after iCLE examination.
RESULTS: There were significantly more good quality endomicroscopic images in the propofol group than in the M/F group (72.75% vs 52.89%, P < 0.001). The diagnostic accuracy for upper gastrointestinal mucosal lesions using confocal laser endomicroscopy favors the P group, although this did not reach statistical significance. Adverse events and patient assessment were not significantly different for M/F vs propofol except for more frequent intraprocedural recall with M/F. Procedure duration and sedation times were significantly longer in the M/F group, while the scores of endoscopist, anesthetist and assistant assessment were all significantly better in the P group.
CONCLUSION: Sedation with propofol might increase the proportion of good quality endomicroscopic images, and may result in improved procedural efficacy and diagnostic accuracy during iCLE examination.
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Pambianco DJ, Vargo JJ, Pruitt RE, Hardi R, Martin JF. Computer-assisted personalized sedation for upper endoscopy and colonoscopy: a comparative, multicenter randomized study. Gastrointest Endosc 2011; 73:765-72. [PMID: 21168841 DOI: 10.1016/j.gie.2010.10.031] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2009] [Accepted: 10/19/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND The SEDASYS System is an investigational computer-assisted personalized sedation system integrating propofol delivery with patient monitoring to enable endoscopist/nurse teams to safely administer propofol. OBJECTIVE To compare the safety and effectiveness of the SEDASYS System to the current standard of care for sedation during routine endoscopic procedures. DESIGN Nonblinded multicenter randomized comparative study. SETTING Four ambulatory surgery centers, 3 endoscopy centers, and 1 academic center in the United States. PATIENTS One thousand American Society of Anesthesiologists physical status class I to III adults undergoing routine colonoscopy or EGD. INTERVENTIONS Sedation with the SEDASYS System (SED) and sedation with each site's current standard of care (CSC; benzodiazepine/opioid combination). MAIN OUTCOME MEASUREMENTS Area under the curve of oxygen desaturation was the primary endpoint. Secondary endpoints included patient satisfaction, clinician satisfaction, level of sedation, and patient recovery time. RESULTS Four hundred ninety-six patients were randomized to SED and 504 to CSC. Area under the curve of oxygen desaturation was significantly lower for SED (23.6 s·%) than for CSC (88.0 s·%; P = .028). Patients were predominately minimally to moderately sedated in both groups. SED patients were significantly more satisfied than CSC patients (P = .007). Clinician satisfaction was greater with SED than with CSC (P < .001). SED patients recovered faster than CSC patients (P < .001). The incidence of adverse events was 5.8% in the SED group and 8.7% in the CSC group. LIMITATIONS Nonblinded. CONCLUSIONS The SEDASYS System could provide endoscopist/nurse teams a safe and effective on-label means to administer propofol to effect minimal to moderate sedation during routine colonoscopy and EGD.
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Affiliation(s)
- Daniel J Pambianco
- Charlottesville Medical Research and Charlottesville Gastroenterology Associates, 325 Winding River Lane, Suite 102, Charlottesville, VA 22911, USA
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Banerjee S, Desilets D, Diehl DL, Farraye FA, Kaul V, Kethu SR, Kwon RS, Mamula P, Pedrosa MC, Rodriguez SA, Song LMWK, Tierney WM. Computer-assisted personalized sedation. Gastrointest Endosc 2011; 73:423-7. [PMID: 21237458 DOI: 10.1016/j.gie.2010.10.035] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2010] [Accepted: 10/20/2010] [Indexed: 02/08/2023]
Abstract
The American Society for Gastrointestinal Endoscopy (ASGE) Technology Committee provides reviews of new or emerging endoscopic technologies that have the potential to have an impact on the practice of GI endoscopy. Evidence-based methodology is used, with a MEDLINE literature search to identify pertinent preclinical and clinical studies on the topic, and a MAUDE (Manufacturer and User Facility Device Experience; U.S. Food and Drug Administration Center for Devices and Radiological Health) database search to identify the reported complications of a given technology. Both are supplemented by accessing the "related articles" feature of PubMed and by scrutinizing pertinent references cited by the identified studies. Controlled clinical trials are emphasized but, in many cases, data from randomized, controlled trials are lacking. In such cases, large case series, preliminary clinical studies, and expert opinions are used. Technical data are gathered from traditional and Web-based publications, proprietary publications, and informal communications with pertinent vendors. For this review, the MEDLINE database was searched through January 2010 using the keywords "computer," "computerized," "computer-assisted," "sedation," "propofol." Reports on Emerging Technology are drafted by 1 or 2 members of the ASGE Technology Committee, reviewed and edited by the committee as a whole, and approved by the Governing Board of the ASGE. These reports are scientific reviews provided solely for educational and informational purposes. Reports on Emerging Technology are not rules and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment or payment for such treatment.
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Leung J, Mann S, Siao-Salera R, Ransibrahmanakul K, Lim B, Canete W, Samson L, Gutierrez R, Leung FW. A randomized, controlled trial to confirm the beneficial effects of the water method on U.S. veterans undergoing colonoscopy with the option of on-demand sedation. Gastrointest Endosc 2011; 73:103-10. [PMID: 21184876 DOI: 10.1016/j.gie.2010.09.020] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2010] [Accepted: 09/08/2010] [Indexed: 02/06/2023]
Abstract
BACKGROUND Sedation for colonoscopy discomfort imposes a recovery-time burden on patients. The water method permitted 52% of patients accepting on-demand sedation to complete colonoscopy without sedation. On-site and at-home recovery times were not reported. OBJECTIVE To confirm the beneficial effect of the water method and document the patient recovery-time burden. DESIGN Randomized, controlled trial, with single-blinded, intent-to-treat analysis. SETTING Veterans Affairs outpatient endoscopy unit. PATIENTS This study involved veterans accepting on-demand sedation for screening and surveillance colonoscopy. INTERVENTION Air versus water method for colonoscope insertion. MAIN OUTCOME MEASUREMENTS Proportion of patients completing colonoscopy without sedation, cecal intubation rate, medication requirement, maximum discomfort (0 = none, 10 = severe), procedure-related and patient-related outcomes. RESULTS One hundred veterans were randomized to the air (n = 50) or water (n = 50) method. The proportions of patients who could complete colonoscopy without sedation in the water group (78%) and the air group (54%) were significantly different (P = .011, Fisher exact test), but the cecal intubation rate was similar (100% in both groups). Secondary analysis (data as Mean [SD]) shows that the water method produced a reduction in medication requirement: fentanyl, 12.5 (26.8) μg versus 24.0 (30.7) μg; midazolam, 0.5 (1.1) mg versus 0.94 (1.20) mg; maximum discomfort, 2.3 (1.7) versus 4.9 (2.0); recovery time on site, 8.4 (6.8) versus 12.3 (9.4) minutes; and recovery time at home, 4.5 (9.2) versus 10.9 (14.0) hours (P = .049; P = .06; P = .0012; P = .0199; and P = .0048, respectively, t test). LIMITATIONS Single Veterans Affairs site, predominantly male population, unblinded examiners. CONCLUSION This randomized, controlled trial confirms the reported beneficial effects of the water method. The combination of the water method with on-demand sedation minimizes the patient recovery-time burden. ( CLINICAL TRIAL REGISTRATION NUMBER NCT00920751.).
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Affiliation(s)
- Joseph Leung
- Gastroenterology, University of California Davis Medical Center, Sacramento, USA
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Kiriyama S, Gotoda T, Sano H, Oda I, Nishimoto F, Hirashima T, Kusano C, Kuwano H. Safe and effective sedation in endoscopic submucosal dissection for early gastric cancer: a randomized comparison between propofol continuous infusion and intermittent midazolam injection. J Gastroenterol 2010; 45:831-7. [PMID: 20228999 DOI: 10.1007/s00535-010-0222-8] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2009] [Accepted: 02/14/2010] [Indexed: 02/04/2023]
Abstract
PURPOSE Endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) generally takes longer to perform than conventional endoscopy and usually requires moderate/deep sedation with close surveillance for patient safety. The aim of this study was to compare the safety profiles and recovery scores propofol continuous infusion and intermittent midazolam (MDZ) injection as sedation for ESD. METHODS Sixty EGC patients scheduled for ESDs between August and November 2008 were included in this prospective study and randomly divided into a propofol (P-group, 28 patients) and an MDZ (M-group, 32 patients) group using an odd-even system. The P-group received a 0.8 mg/kg induction dose and a 3 mg/kg/h maintenance dose of 1% propofol using an infusion pump. All patients received 15 mg pentazocine at the start of the ESD and at 60-min intervals thereafter. We recorded and analyzed blood pressure, oxygen saturation and heart rate during and following the procedure and evaluated post-anesthetic recovery scores (PARS) and subsequent alertness scores. RESULTS The propofol maintenance and total dose amounts were (mean +/- standard deviation) 3.7 +/- 0.6 mg/kg/h and 395 +/- 202 mg, respectively. The mean total dose of MDZ was 10.3 +/- 4.5 mg. There were no cases of de-saturation <90% or hypotension <80 mmHg in either group. Alertness scores 15 and 60 min after the procedures were significantly higher in the P-group (4.9/4.9) than in the M-group (4.6/4.5; p < 0.05). The mean PARS 15 and 30 min after the ESDs were significantly higher in the P-group (9.6/9.9) than in the M-group (8.6/9.2; p < 0.01). CONCLUSION Based on our results, the ESDs for EGC performed under sedation using propofol continuous infusion were as safe as those performed using intermittent MDZ injection. Propofol-treated patients had a quicker recovery profile than those treated with MDZ. We therefore recommend the use of continuous propofol sedation for ESD, but sedation guidelines for the use of propofol are necessary.
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Affiliation(s)
- Shinsuke Kiriyama
- Department of Endoscopy, National Cancer Center Hospital, Tokyo, Japan.
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Chlan LL, Weinert CR, Skaar DJ, Tracy MF. Patient-controlled sedation: a novel approach to sedation management for mechanically ventilated patients. Chest 2010; 138:1045-53. [PMID: 20299632 DOI: 10.1378/chest.09-2615] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Patient self-administration of medications for analgesia and procedural sedation is common. However, it is not known whether mechanically ventilated ICU patients can self-administer their own sedation to manage symptoms. METHODS This descriptive pilot study examined the safety, adequacy, and satisfaction of patient-controlled sedation (PCS) with a convenience sample of critically ill, mechanically ventilated patients (N = 17) in the ICUs at University of Minnesota Medical Center, Fairview, Minneapolis, Minnesota. Dexmedetomidine was administered via a patient-demand infusion pump system for a maximum of 24 h. Pumps were programmed with basal infusion plus patient-triggered boluses; nurses adjusted the basal infusion based on a dosing algorithm. Data were collected on sedation adequacy, additional dosing of analgesics and sedatives, hemodynamic parameters, safety of PCS, patient satisfaction with PCS, and nurse satisfaction with PCS. RESULTS Although a majority of the hemodynamic values were within the established safety parameters for the study, 25% of patients experienced mild adverse physiologic effects. Furthermore, despite patients' perception of sedation adequacy with PCS, 70% received supplemental opiates or benzodiazepine medications while participating in the study. Patients rated dexmedetomidine PCS favorably for self-management of anxiety, level of relaxation obtained, and comfort in self-administering sedation. Nurses also were generally satisfied with PCS as a method of sedation, dexmedetomidine as the sedative, and patient response to the sedation. CONCLUSIONS PCS warrants further investigation as a means to promote comfort in mechanically ventilated critically ill patients.
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Affiliation(s)
- Linda L Chlan
- School of Nursing, University of Minnesota, 5-160 Weaver-Densford Hall, 308 Harvard St SE, Minneapolis, MN 55455, USA.
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Ivano FH, Romeiro PCM, Matias JEF, Baretta GAP, Kay AK, Sasaki CA, Nakamoto R, Tambara EM. Estudo comparativo de eficácia e segurança entre propofol e midazolam durante sedação para colonoscopia. Rev Col Bras Cir 2010; 37:10-6. [DOI: 10.1590/s0100-69912010000100004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2008] [Accepted: 02/23/2009] [Indexed: 12/22/2022] Open
Abstract
OBJETIVO: Comparar a segurança e a eficácia do propofol com a do midazolam na sedação profunda durante colonoscopias. MÉTODOS: Sessenta e seis pacientes foram submetidos à colonoscopias e estudados prospectivamente. Um total de 50 pacientes recebeu 3,25 mg.kg-1 de peso de propofol. No grupo controle de 16 pacientes foi administrado 2,05 mg.kg-1 de peso de midazolam. A dose de manutenção foi titulada de acordo com a necessidade. Os parâmetros cardiovasculares e respiratórios observados foram a saturação de oxigênio, pressão arterial sistólica e diastólica e frequência cardíaca. Após o procedimento foi realizado um questionário sobre intercorrências como dor, desconforto e satisfação após a colonoscopia, utilizando uma escala visual de zero a dez. Foi aplicado o teste t de Student para a análise estatística. RESULTADOS: A amostra foi similar com relação às variáveis idade, peso, sexo e condição física. Houve diferença estatística significativa para os parâmetros saturação de oxigênio do sangue e pressão arterial sistólica entre os dois grupos. Não houve diferença estatística significativa para os parâmetros pressão arterial diastólica e pulso. Apesar das diferenças nos parâmetros cardiovasculares e respiratórios, não houve repercussões hemodinâmicas significativas. Não houve diferença estatística no parâmetro dor e satisfação. Os pacientes que apresentaram agitação (25%) no grupo midazolam, relataram mais desconforto (p=0,038). CONCLUSÃO: As variações nos parâmetros cardiovasculares e respiratórios, mesmo com diferenças significativas entre os grupos, não causaram repercussões clínicas significativas nos dois grupos, caracterizando a segurança na sedação profunda. A sedação com midazolam ou propofol não está associada a níveis de dor e satisfação diferentes entre os dois grupos. O grupo midazolan referiu significativamente mais desconforto que o grupo propofol.
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Abstract
BACKGROUND Despite the increasing popularity of propofol for sedation in colonoscopy, the optimal regimen is still controversial. Both propofol alone and propofol in combination with meperidine are frequently used during colonoscopy, but the impact of adding meperidine has not been evaluated. This study aimed to investigate if adding meperidine to propofol offers any advantage in terms of patient tolerance, recovery time, and postcolonoscopy discomforts. METHOD Consecutive patients admitted to the physical checkup department of our hospital were randomized to receive either meperidine plus propofol (combination group, n=100) or propofol alone (propofol group, n=100) for sedated colonoscopy. The patients' tolerance and postcolonoscopy discomforts (pain, bloating, dizziness, and nausea/vomiting) were assessed with a 0-10 visual analog scale. The recovery times were assessed with 5-minute and 10-minute Aldrete scores. RESULTS The dose of propofol was less in the combination group than the propofol group (129.80+/-37.93 mg vs. 147.90+/-47.85, mean+/-SD, P=0.003). The endoscopists, anesthetists, and nurses all rated patients' tolerance in favor of the combination group than the propofol group (mean+/-SD, endoscopists, 9.17+/-1.23 vs. 8.49+/-1.60, P=0.001; anesthetists, 9.21+/-1.08 vs. 8.63+/-1.37, P=0.001; nurses, 9.18+/-1.34 vs. 8.71+/-1.47, P=0.019, respectively). Patients in the combination group recovered earlier than the placebo group (5-min Aldrete scores: 9.48+/-1.09 vs. 9.05+/-1.32, mean+/-SD, P=0.013; short intervals to speak: 4.29+/-4.05 min vs. 6.30+/-5.22 min, P=0.003; and departure: 18.62+/-5.28 min vs. 20.28+/-5.68 min, P=0.034). There was also less abdominal bloating in the combination group after colonoscopy (1.23+/-1.79 vs. 2.19+/-2.12, mean+/-SD, P=0.004). Incidences of hypoxemia, hypotension, and overall satisfaction scores were comparable between the 2 groups. CONCLUSIONS For sedated colonoscopy, propofol in combination with meperidine is better than propofol alone in improving patients' tolerance and recovery.
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Lichtenstein DR, Jagannath S, Baron TH, Anderson MA, Banerjee S, Dominitz JA, Fanelli RD, Gan SI, Harrison ME, Ikenberry SO, Shen B, Stewart L, Khan K, Vargo JJ. Sedation and anesthesia in GI endoscopy. Gastrointest Endosc 2008; 68:815-26. [PMID: 18984096 DOI: 10.1016/j.gie.2008.09.029] [Citation(s) in RCA: 278] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2008] [Accepted: 09/19/2008] [Indexed: 02/08/2023]
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Propofol use for sedation during endoscopy in adults: a Canadian Association of Gastroenterology position statement. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2008; 22:457-9. [PMID: 18478130 DOI: 10.1155/2008/268320] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Over the past decade, multiple clinical reports have demonstrated that the use of propofol sedation for gastrointestinal endoscopy by gastroenterologists and trained endoscopy nurses is safe and effective in appropriately selected patients. Proposed benefits of propofol sedation include rapid onset of action, improved patient comfort and rapid clearance, as well as prompt recovery and discharge from the endoscopy unit. As a result of medical evidence, a number of international professional societies have endorsed the use of propofol in gastrointestinal endoscopy. In Canada, no formal guidelines currently exist. In the present article, the Clinical Affairs Committee of the Canadian Association of Gastroenterology presents a position statement, incorporating updated information on the use of propofol sedation for endoscopy in adult patients.
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Singh H, Poluha W, Cheung M, Choptain N, Baron KI, Taback SP. Propofol for sedation during colonoscopy. Cochrane Database Syst Rev 2008; 2008:CD006268. [PMID: 18843709 PMCID: PMC8988486 DOI: 10.1002/14651858.cd006268.pub2] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Propofol is increasingly used for sedation during colonoscopy, with many recent reports of randomized controlled trials (RCTs) and large non-randomized case series. OBJECTIVES The primary objective was to identify, analyze and summarize RCTs comparing the relative effectiveness, patient acceptance and safety of propofol for colonoscopy, to traditional sedatives (narcotics and/or benzodiazepines).The secondary objective was to synthesize the studies comparing propofol administration by anesthesiologists to that by non-anesthesiologists for sedation during colonoscopy. SEARCH STRATEGY We searched Medline, Cancerlit, EMBASE, CINAHL, LILACS, Biological Abstracts, Web of Science and the Cochrane Controlled Trials Registry database between January 1980 and June 2007; and conference proceeding abstracts for DDW, EUGW and ACG between 1990 and June 2007. There were no language restrictions. SELECTION CRITERIA Randomized controlled trials comparing use of propofol and traditional agents or administration of propofol by anesthesiologists to that by non-anesthesiologists for sedation during colonoscopy. DATA COLLECTION AND ANALYSIS Two reviewers independently extracted the data. The data were pooled using the Cochrane Collaborations' methodology and statistical software RevMan 4.2.10. MAIN RESULTS Twenty studies met the inclusion criteria for the primary objective. Most studies included only healthy out-patients. Recovery and discharge times were shorter with use of propofol. There was higher patient satisfaction with use of propofol (OR for dissatisfaction 0.35, 95% CI 0.23, 0.53). There was no difference in procedure time, cecal intubation rate or complications. There was no difference in pain control with non- patient controlled sedation (PCS) use of propofol as compared to the traditional agents (OR 0.90; 95% CI 0.58, 1.39). Although there was higher patient satisfaction (OR for dissatisfaction 0.42, 95% CI 0.20, 0.89), the pain control was inferior with use of PCS use of propofol as compared to the use of traditional agents (OR 3.09; 95% CI 2.15, 4.46).There was only one study comparing administration of propofol by anesthesiologists to that by non-anesthesiologists for sedation during colonoscopy, with no difference in procedure time or patient satisfaction. AUTHORS' CONCLUSIONS Propofol for sedation during colonoscopy for generally healthy individuals can lead to faster recovery and discharge times, increased patient satisfaction without an increase in side-effects. More studies with standardized end-points are needed to compare propofol administration by anesthesiologists to that by non-anesthesiologists.
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Affiliation(s)
- Harminder Singh
- Internal Medicine, University of Manitoba, John Buhler Research Centre, 805F-715 McDermot Avenue, Winnipeg, Manitoba, Canada, R3E 3P4.
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Singh H, Poluha W, Cheung M, Choptain N, Baron KI, Taback SP. Propofol for sedation during colonoscopy. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2008. [PMID: 18843709 DOI: 10.1002/14651858.cd006268] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Propofol is increasingly used for sedation during colonoscopy, with many recent reports of randomized controlled trials (RCTs) and large non-randomized case series. OBJECTIVES The primary objective was to identify, analyze and summarize RCTs comparing the relative effectiveness, patient acceptance and safety of propofol for colonoscopy, to traditional sedatives (narcotics and/or benzodiazepines).The secondary objective was to synthesize the studies comparing propofol administration by anesthesiologists to that by non-anesthesiologists for sedation during colonoscopy. SEARCH STRATEGY We searched Medline, Cancerlit, EMBASE, CINAHL, LILACS, Biological Abstracts, Web of Science and the Cochrane Controlled Trials Registry database between January 1980 and June 2007; and conference proceeding abstracts for DDW, EUGW and ACG between 1990 and June 2007. There were no language restrictions. SELECTION CRITERIA Randomized controlled trials comparing use of propofol and traditional agents or administration of propofol by anesthesiologists to that by non-anesthesiologists for sedation during colonoscopy. DATA COLLECTION AND ANALYSIS Two reviewers independently extracted the data. The data were pooled using the Cochrane Collaborations' methodology and statistical software RevMan 4.2.10. MAIN RESULTS Twenty studies met the inclusion criteria for the primary objective. Most studies included only healthy out-patients. Recovery and discharge times were shorter with use of propofol. There was higher patient satisfaction with use of propofol (OR for dissatisfaction 0.35, 95% CI 0.23, 0.53). There was no difference in procedure time, cecal intubation rate or complications. There was no difference in pain control with non- patient controlled sedation (PCS) use of propofol as compared to the traditional agents (OR 0.90; 95% CI 0.58, 1.39). Although there was higher patient satisfaction (OR for dissatisfaction 0.42, 95% CI 0.20, 0.89), the pain control was inferior with use of PCS use of propofol as compared to the use of traditional agents (OR 3.09; 95% CI 2.15, 4.46).There was only one study comparing administration of propofol by anesthesiologists to that by non-anesthesiologists for sedation during colonoscopy, with no difference in procedure time or patient satisfaction. AUTHORS' CONCLUSIONS Propofol for sedation during colonoscopy for generally healthy individuals can lead to faster recovery and discharge times, increased patient satisfaction without an increase in side-effects. More studies with standardized end-points are needed to compare propofol administration by anesthesiologists to that by non-anesthesiologists.
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Affiliation(s)
- Harminder Singh
- Internal Medicine, University of Manitoba, John Buhler Research Centre, 805F-715 McDermot Avenue, Winnipeg, Manitoba, Canada, R3E 3P4.
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An assessment of computer-assisted personalized sedation: a sedation delivery system to administer propofol for gastrointestinal endoscopy. Gastrointest Endosc 2008; 68:542-7. [PMID: 18511048 DOI: 10.1016/j.gie.2008.02.011] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2007] [Accepted: 02/04/2008] [Indexed: 12/12/2022]
Abstract
BACKGROUND Demand for colonoscopy and EGD procedures is increasing. Impediments to performing these examinations persist. Patients perceive these procedures as unpleasant and painful. The use of suboptimal sedatives results in inefficiency in endoscopy practices. Improving sedation methods utilizing precise control of preferred sedatives may increase patient satisfaction and practice efficiency. OBJECTIVE Our purpose was to demonstrate the feasibility of computer-assisted personalized sedation (CAPS) for facilitating the precise administration of propofol by endoscopist/nurse teams, achieving minimal to moderate sedation in subjects undergoing routine endoscopies. DESIGN Open label, single-center studies. SETTING Endoscopy clinics in Charlottesville, Virginia, and Gent, Belgium. SUBJECTS Twenty-four adults per center; 12 colonoscopies, 12 EGDs. INTERVENTIONS Propofol sedation with CAPS by endoscopist/registered nurse care teams. MAIN OUTCOME MEASUREMENTS Sedation level measured by modified observer's assessment of alertness/sedation (MOAA/S), recovery time measured from endoscope removal until Aldrete >/= 12, dosage of propofol, oxygen saturation, and safety assessments. RESULTS Subjects responded to mild tactile and verbal stimuli MOAA/S = 5, 4, 3, or 2) 99% of the time. Mean propofol doses in the United States and Belgium were 65.4 and 72.1 mg, respectively. Mean recovery times were 29 and 10 seconds, respectively. Oxygen desaturation occurred in only 6% of subjects. No device-related adverse events occurred. LIMITATION Open-label design. CONCLUSIONS Using CAPS, the endoscopist/nurse teams precisely controlled the administration of propofol achieving minimal to moderate sedation in subjects undergoing colonoscopy and EGD procedures. Mean propofol dosage was low and post-procedure recovery times were rapid. The device performed well when operated by the endoscopist/nurse team, with no device-related adverse events.
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Poon CM, Leung TL, Wong CW, Chan YL, Leung TC, Leong HT. Safety of nurse-administered propofol sedation using PCA pump for outpatient colonoscopy in Chinese patients: a pilot study. Asian J Surg 2008; 30:239-43. [PMID: 17962125 DOI: 10.1016/s1015-9584(08)60032-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND To determine the safety and effectiveness of nurse-administered propofol sedation using patient-controlled analgesia (PCA) pump in outpatient colonoscopy in a Chinese population. METHODS From April to June 2005, 50 consecutive ASA class I or II patients aged 18-65 undergoing outpatient colonoscopy in an endoscopy centre of a regional hospital were prospectively recruited in this study. After a loading dose of 40-60 mg intravenous propofol, a mixture containing 14.3 mg propofol and 35 microg alfentanil were delivered via a patient-controlled syringe pump as bolus dose by an endoscopy nurse under the supervision of an endoscopist during the procedure. Lockout time was set to be zero. We aimed to achieve conscious sedation, with an Observers Scale for Sedation and Alertness (OSSA) score of 3. The primary outcome measure was complications from sedation, which included hypotension, bradycardia and desaturation. Other outcome measures included onset time, patients pain score, endoscopists and nurses satisfaction on the level of sedation, patients satisfaction regarding the procedure (measured by 10 cm visual analogue scale), and their willingness to repeat the procedure. RESULTS The mean lowest systolic blood pressure and mean arterial pressure (MAP) were 103.2 +/- 12.4 mmHg and 78.3 +/- 11.0 mmHg, respectively. The mean percentage drop in MAP was 15.7 +/- 11.9%. Six patients (12.2%) developed transient hypotension. Three patients (6.1%) had bradycardia. There was no episode of desaturation. The median onset time to reach OSSA score of 3 was 1 minute (range, 0.5-20.5). The OSSA score of 3 could be maintained throughout the procedure. The mean loading dose of propofol was 48.9 +/- 6.7 mg. The mean total dosages of propofol and alfentanil given were 124.2 +/- 38.1 mg and 184.3 +/- 93.7 mug, respectively. Endoscopists, endoscopy nurses and patients were highly satisfied with the sedation. The median pain score was 1 (range, 0-10; 0 = no pain, 10 = very painful), and the mean recovery time was 2.8 +/- 2.8 minutes. Most patients (93.9%) were willing to repeat the procedure. CONCLUSION Nurse-administered propofol sedation using PCA pump is safe and effective in sedation and pain control in outpatient colonoscopy in a healthy Chinese population.
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Affiliation(s)
- Chi-Ming Poon
- Department of Surgery, North District Hospital, Sheung Shui, Hong Kong SAR
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Lubarsky DA, Candiotti K, Harris E. Understanding modes of moderate sedation during gastrointestinal procedures: a current review of the literature. J Clin Anesth 2007; 19:397-404. [PMID: 17869995 DOI: 10.1016/j.jclinane.2006.11.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2006] [Revised: 11/08/2006] [Accepted: 11/09/2006] [Indexed: 12/26/2022]
Abstract
Recommendations for routine screening for colorectal cancer with colonoscopy are likely to substantially increase the demand for provision of sedation for these procedures. Because of this burgeoning caseload and associated economic constraints, it is unlikely that anesthesiologists will be available for all such procedures, particularly those involving average-risk patients. Thus, sedative agents that can be safely administered by nonanesthesiologists, appropriately trained in monitoring and managing the patient's airway, are desperately needed. New concepts in sedation for colonoscopy include enhanced mechanisms for drug delivery such as patient-controlled sedation/analgesia and target-controlled infusion, along with the development of new drugs such as a modified cyclodextrin-based formulation of propofol and fospropofol disodium (Aquavan Injection), a water-soluble prodrug of propofol.
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Affiliation(s)
- David A Lubarsky
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL 33136, USA.
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Vargo JJ, Bramley T, Meyer K, Nightengale B. Practice efficiency and economics: the case for rapid recovery sedation agents for colonoscopy in a screening population. J Clin Gastroenterol 2007; 41:591-8. [PMID: 17577116 DOI: 10.1097/01.mcg.0000225634.52780.0e] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
GOAL To determine rapidly acting agents' impact on practice efficiency and cost for outpatient colonoscopy in a screening population. BACKGROUND Propofol-mediated endoscopic sedation is popular due to rapid sedation onset and superior recovery profile compared with sedation with an opioid and benzodiazepine. There are few data on the impact of this type of sedation on the economics and efficiency of an endoscopy unit. STUDY A provider-perspective economic model assessed the ability of propofol and fospropofol disodium (Aquavan, GPI 15715, MGI Pharma) to increase practice efficiency and determined break-even costs based on current colonoscopy reimbursement levels. Reimbursement inputs by practice setting, costs, and recovery profiles-taken from published literature examining time to discharge-were used to populate the model. To measure robustness of model results to changes in base case inputs, sensitivity analyses were performed. Using a Monte Carlo simulation, inputs were varied simultaneously and randomly for 1000 iterations to determine 95% confidence intervals (CI) for break-even costs. RESULTS In the time to complete 1 colonoscopy with midazolam/meperidine, 1.76 colonoscopies can be completed with propofol and 1.91 colonoscopies can be completed with fospropofol disodium. This efficiency benefit produced a break-even cost for rapid recovery agents of $71.53 (95% CI: $38.39, $105.67) in a hospital outpatient clinic and $61.48 (95% CI: $41.33, $108.99) in an ambulatory surgical center. One-way sensitivity analyses indicated the break-even cost of these agents was most sensitive to operating costs and time to discharge ratio. CONCLUSIONS Rapid recovery agents for colonoscopy can improve practice efficiency and offer economic advantages over traditional sedation.
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Affiliation(s)
- John J Vargo
- Department of Gastroenterology and Hepatology, The Cleveland Clinic Foundation, Cleveland, OH, USA
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Martínez J, Casellas JA, Aparicio JR, Garmendia M, Amorós A. [Safety of propofol administration by the staff of a gastrointestinal endoscopy unit]. GASTROENTEROLOGIA Y HEPATOLOGIA 2007; 30:105-9. [PMID: 17374321 DOI: 10.1157/13100070] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Deep sedation controlled by the staff of gastrointestinal endoscopy units is currently controversial. In the last few years, numerous studies have provided data supporting the safety of propofol use in these techniques. We present a large series of patients who underwent gastroscopy or colonoscopy under endoscopist-controlled deep sedation. A total of 875 procedures (297 gastroscopies and 578 colonoscopies) were included. In all procedures intravenous propofol with or without intravenous midazolam was administered. In gastroscopies, complications attributable to the sedation were found in only 6.7% of the patients, mostly due to desaturation, which was resolved without the need for intubation. In colonoscopies, complications were found in 11.2%, the most frequent being bradycardia and desaturation, none of which were serious. No association was found between the presence of complications and the propofol dose administered. In the group of patients undergoing colonoscopy, simultaneous midazolam administration allowed reduction of the propofol dose required to achieve deep sedation. In conclusion, propofol shows a good safety profile and excellent tolerance in patients undergoing gastroscopy and colonoscopy and can be administrated by the endoscopy team. At least in the case of colonoscopy, the associated use of midazolam allows the propofol dose to be decreased, thus, theoretically, reducing the drug's adverse effects.
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Affiliation(s)
- Juan Martínez
- Unidad de Endoscopia Digestiva, Hospital General Universitario de Alicante, España.
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Harrington L. Nurse-administered propofol sedation: a review of current evidence. Gastroenterol Nurs 2006; 29:371-83; quiz 384-5. [PMID: 17038838 DOI: 10.1097/00001610-200609000-00004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
This article highlights a highly controversial practice issue referred to as nurse-administered propofol sedation, which affects registered nurses as well as advanced practice nurses in many different practice settings across the United States. Amid varied advice from professional organizations and state licensing boards, a thorough and systematic review of the current evidence provides insight into the question of safety associated with the practice. The evidence examined includes position statements from professional organizations and state boards, information from the United States Food and Drug Administration and the Joint Commission on Accreditation of Healthcare Organizations, and published research since 1999. The body of evidence demonstrates diverse positions; however, the empirical evidence in the author's opinion unanimously supports nurse-administered propofol sedation as a safe practice in nonintubated adult patients. Under research conditions, participants had a low incidence of untoward events and were adequately rescued with no intubations required and no deaths reported.
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Affiliation(s)
- Linda Harrington
- Texas Christian University, Presbyterian Hospital of Plano, Texas 75287-5144, USA.
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