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Wu H, Zhuang Y, Wu W, Huang J, Huang H, Wang L. Post-operative cognitive dysfunction in patients following gastrointestinal endoscopic treatment. APPLIED NEUROPSYCHOLOGY. ADULT 2025; 32:307-312. [PMID: 36657421 DOI: 10.1080/23279095.2023.2168543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
We aimed to explore the changes in post-operative cognitive dysfunction (POCD) after gastrointestinal endoscopic treatment using detailed neuropsychological assessments. Patients hospitalized for gastrointestinal endoscopic polypectomy were recruited for neuropsychological evaluations, which included the Chinese version of the Mini-Mental State Examination (MMSE), Auditory-Verbal Learning Test, Digit Span Test (DST), Trail Making Task (TMT), Verbal Fluency Test, Clock Drawing Test, and Stroop test. Cognitive assessments were performed twice: one day before and 24 h after treatment. Healthy control subjects participated in the neuropsychological assessment during the same intervals. Detailed cognitive assessments were performed for 40 patients and 60 control subjects. Based on the Z scores, the incidence of POCD 24 h after gastrointestinal endoscopic treatment was 20%. Patients with POCD had significant impairment in the post-operative MMSE, forward DST, TMT, and Stroop interference effect correct count tests (all p < 0.05). Our preliminary results showed that patients were not fully recovered, and 20% had impairment in multiple cognitive assessments 24 h after a gastrointestinal endoscopy. As attention was affected, safety while discharging those patients should be a concern.
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Affiliation(s)
- Haining Wu
- Department of Neurology, Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian, China
- Department of Neurology, Quanzhou First Hospital Affiliated to Fujian Medical University, Quanzhou, Fujian, China
| | - Yingying Zhuang
- Department of Gastroenterology, Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian, China
| | - Weiqi Wu
- Department of Neurology, Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian, China
| | - Junying Huang
- Department of Neurology, Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian, China
| | - Honghong Huang
- Department of Neurology, Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian, China
| | - Lingxing Wang
- Department of Neurology, Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian, China
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Xie G, Estevez M, Heybati K, Vogt M, Smith M, Moshe C, Chan J, Kumbhari V, Chadha R. Single-agent versus combination regimens containing propofol: a retrospective cohort study of recovery metrics and complication rates in a hospital-based endoscopy suite. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2025; 75:844602. [PMID: 40023496 PMCID: PMC11951190 DOI: 10.1016/j.bjane.2025.844602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2024] [Revised: 01/29/2025] [Accepted: 01/31/2025] [Indexed: 03/04/2025]
Abstract
BACKGROUND Anesthesiologists are often tasked with overseeing sedation in non-surgical settings. We aim to determine whether adding adjuvant sedatives to propofol affects the recovery times and complication rates after endoscopy. METHODS We conducted a retrospective cohort study of adults (≥18) who received propofol while undergoing esophagogastroduodenoscopy (EGD) and/or colonoscopy (COL) at a large academic institution over a four-year period. Patients receiving propofol alone were compared against patients receiving propofol in combination with midazolam, fentanyl, ketamine, or dexmedetomidine. The primary outcome was PACU length of stay, adjusted for age, sex, and ASA Score. Secondary outcomes included incidence of PACU postoperative nausea and vomiting, hypoxemia (SpO2 < 90%), bradycardia (HR < 60 bpm), and escalation of care (hospital admission), reported in adjusted odds ratios and their 95% confidence intervals. RESULTS Across the study period, 28,532 cases were included. Colonoscopies performed under propofol+fentanyl sedation were associated with significantly longer PACU LOS compared to propofol alone. Adjusted mean PACU LOS was significantly longer in patients receiving adjuvant fentanyl, compared to propofol alone (p < 0.01) and propofol + dexmedetomidine (p < 0.01). Patients receiving propofol alone exhibited a 9.4% incidence of bradycardia, 16.0% hypoxia, 0.89% PONV, and 0.40% hospitalization. Adjuvant fentanyl use was associated with higher odds of hypoxia across all procedure types (p < 0.05). Adjuvant dexmedetomidine was associated with higher rates of bradycardia, but lower rates of hypoxia, PONV, and hospitalization (p < 0.05). CONCLUSIONS With the exception of fentanyl, combining propofol with other sedatives was not associated with longer recovery times. The incidence of complications differed significantly with the use of adjuvant fentanyl or dexmedetomidine.
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Affiliation(s)
- Guozhen Xie
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, USA
| | - Maria Estevez
- Clinical Studies Unit, Mayo Clinic Jacksonville, FL, USA
| | - Kiyan Heybati
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, USA
| | - Matthew Vogt
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Michael Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Jacksonville, FL, USA
| | - Christine Moshe
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Jacksonville, FL, USA
| | - Johanna Chan
- Department of Gastroenterology and Hepatology, Mayo Clinic Jacksonville, FL, USA
| | - Vivek Kumbhari
- Department of Gastroenterology and Hepatology, Mayo Clinic Jacksonville, FL, USA
| | - Ryan Chadha
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Jacksonville, FL, USA.
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Xie G, Estevez M, Heybati K, Vogt M, Smith M, Moshe C, Chan J, Kumbhari V, Chadha R. Outcomes of anesthesia-supported versus endoscopist-driven sedation modalities: a retrospective cohort study. Gastrointest Endosc 2025:S0016-5107(25)00048-3. [PMID: 39880215 DOI: 10.1016/j.gie.2025.01.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2024] [Revised: 12/09/2024] [Accepted: 01/19/2025] [Indexed: 01/31/2025]
Abstract
BACKGROUND AND AIMS The use of anesthesia has become commonplace in many procedural settings. The goal of this study is to compare sedation modalities used by endoscopists and anesthesiologists in the endoscopy suite, particularly with respect to recovery time and adverse events. METHODS We conducted a retrospective cohort study including adults (≥18 years of age) undergoing outpatient EGD and/or colonoscopy at Mayo Clinic in Jacksonville, Florida between October 1st, 2018 and December 31st, 2022. Cases were classified as using propofol only, propofol ± adjuvants (PA; including dexmedetomidine, ketamine, fentanyl, and midazolam), general anesthesia (GA) with endotracheal tube, or fentanyl/midazolam (FM) only. The primary outcome was length of stay (LOS) in the postanesthesia care unit (PACU), and secondary outcomes included the incidence of postoperative nausea and vomiting (PONV), hypoxemia (Spo2 risk 90%), bradycardia (heart rate <60 bpm), and escalation of care (hospital admission). RESULTS The analysis included 56,361 cases. Among patients who received FM sedation, the mean PACU LOS was 52.01, 49.68, and 53.24 minutes for EGD, colonoscopy, and combined procedures, respectively. This was significantly higher than the mean PACU LOS for GA (44.65, 41.41, and 41.92 minutes, respectively), for PA (32.35, 35.75, and 33.42 minutes, respectively), and for propofol (31.63, 32.61, and 33.29 minutes, respectively; P < .0001). Of patients receiving FM, 8.39% experienced bradycardia, 6.12% experienced hypoxia, 0.24% experienced PONV, and 0.05% were hospitalized. These were substantially lower than the rates for other sedation groups, and odds ratios were significantly lower than 1.00 (P < .05) in 30 of 36 comparisons across procedural, sedative, and outcome categories. CONCLUSIONS Sedation achieved with FM correlated with a lower rate of adverse events but a significantly longer PACU LOS compared with propofol, PA, or GA.
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Affiliation(s)
- Guozhen Xie
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Maria Estevez
- Clinical Studies Unit, Mayo Clinic, Jacksonville, Florida, USA
| | - Kiyan Heybati
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthew Vogt
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Christine Moshe
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Johanna Chan
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Vivek Kumbhari
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Ryan Chadha
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida, USA.
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Bundil I, Baltruschat S, Zhang J. Characterising and differentiating cognitive and motor speed in older adults: structural equation modelling on a UK longitudinal birth cohort. BMJ Open 2024; 14:e083968. [PMID: 39160108 PMCID: PMC11337668 DOI: 10.1136/bmjopen-2024-083968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 07/29/2024] [Indexed: 08/21/2024] Open
Abstract
OBJECTIVES Information processing speed (IPS) has been proposed to be a key component in healthy ageing and cognitive functioning. Yet, current studies lack a consistent definition and specific influential characteristics. This study aimed to investigate IPS as a multifaceted concept by differentiating cognitive and motor IPS. DESIGN, SETTING AND PARTICIPANTS A retrospective data analysis using data from the Medical Research Council National Survey of Health and Development (a population-based cohort of UK adults born in 1946) at childhood (ages 8, 11 and 15) and adulthood (ages 60-64 and 68-70). Using structural equation modelling, we constructed two models of IPS with 2124 and 1776 participants, respectively. OUTCOME MEASURES Measures of interest included IPS (ie, letter cancellation, simple and choice reaction time), intelligence (ie, childhood intelligence and National Adult Reading Test), verbal memory, socioeconomic status (SES) and cognitive functions measured by the Addenbrooke's Cognitive Examination III, as well as a variety of health indexes. RESULTS We found distinct predictors for cognitive and motor IPS and how they relate to other cognitive functions in old age. In our first model, SES and antipsychotic medication usage emerged as significant predictors for cognitive IPS, intelligence and smoking as predictors for motor IPS while both share sex, memory and antiepileptic medication usage as common predictors. Notably, all differences between both IPS types ran in the same direction except for sex differences, with women performing better than men in cognitive IPS and vice versa in motor IPS. The second model showed that both IPS measures, as well as intelligence, memory, antipsychotic and sedative medication usage, explain cognitive functions later in life. CONCLUSION Taken together, these results shed further light on IPS as a whole by showing there are distinct types and that these measures directly relate to other cognitive functions.
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Affiliation(s)
- Indra Bundil
- School of Psychology, Cardiff University, Cardiff, UK
| | | | - Jiaxiang Zhang
- School of Psychology, Cardiff University, Cardiff, UK
- Department of Computer Science, Swansea University, Swansea, UK
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Zheng L, Ye M, Ma J, Jin C, Yang Y, Li H, Zheng R, Wang Y. Effects of adding adjuvants to propofol on the post-anesthesia cognitive function in patients undergoing gastroscopy/colonoscopy: a systematic review and meta-analysis. Expert Opin Drug Saf 2024; 23:995-1005. [PMID: 38217432 DOI: 10.1080/14740338.2024.2305705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 11/28/2023] [Indexed: 01/15/2024]
Abstract
OBJECTIVES This study aimed to elucidate the effects of propofol plus adjuvants on postoperative cognitive dysfunction (POCD) and patient satisfaction. METHODS Studies published up to September 2023 on the Chinese National Knowledge Infrastructure (CNKI), Wanfang Data, Sinomed, PubMed, Embase, Cochrane Library, Web of Science, and Clinictrials.gov websites were searched. Binary summary of results was used for meta-analyses. RESULTS We included 18 studies (2691 patients). The combined sedation did not affect the processing speed (ES = 0.02, 95%CI: -0.01, 0.04; I2 = 79.3%, p < 0.001), attention (ES = 0.02, 95%CI: -0.02, 0.05; I2 = 95.0%, p < 0.001), nor working memory (ES = 0.02, 95%CI: -0.03, 0.06; I2 = 94.4%, p < 0.001) in CogState brief battery tool. A significant effect of combined sedation was observed in the domain of visual learning in CogState tool (ES = -0.03, 95%CI: -0.04, -0.02; I2 = 15.8%, p = 0.306). The TDT (ES = 4.96, 95%CI: 2.92, 7.00) indicates that combined sedation would increase error rates in the tests of cognitive function. The DSST (ES = 0.16, 95% CI: -0.44, 0.75) shown that combined sedation does not affect cognitive function. In addition, an insignificant difference in patient satisfaction between combined sedation and propofol alone was observed (ES = -0.03, 95%CI: -0.09, 0.02). CONCLUSION The available evidence suggests that propofol combined with adjuvants may affect POCD but not patient satisfaction. REGISTRATION NUMBER INPLASY2023110092.
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Affiliation(s)
- Liupu Zheng
- Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Mengqian Ye
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Jun Ma
- Division of Epidemiology and Biostatistics, School of Public Health and Management, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Chen Jin
- Division of Epidemiology and Biostatistics, School of Public Health and Management, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Yan Yang
- Division of Epidemiology and Biostatistics, School of Public Health and Management, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Haoqi Li
- Division of Epidemiology and Biostatistics, School of Public Health and Management, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Rongyuan Zheng
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Yi Wang
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
- Division of Epidemiology and Biostatistics, School of Public Health and Management, Wenzhou Medical University, Wenzhou, Zhejiang, China
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Yahav-Shafir D, Orkin D, Zahavi G, Epstein I, Nadler M, Berkenstadt H. Patient-Reported Quality of Recovery after Sedation for Endoscopy in the Elderly. Gerontology 2024; 70:455-460. [PMID: 38316110 PMCID: PMC11078320 DOI: 10.1159/000536647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 01/27/2024] [Indexed: 02/07/2024] Open
Abstract
INTRODUCTION Although sedation is critical in minimizing discomforts in patients, conflicting data regarding the safety of sedation among the elderly population exist. This prospective study aimed to compare the quality of recovery (QoR) from gastrointestinal endoscopy performed under sedation between elderly and younger patients. METHODS We included 177 patients aged 40-64 (group 1, n = 66), 65-79 (group 2, n = 76), and ≥80 (group 3, n = 35) years. QoR was assessed 1 day after the procedure using the quality of recovery 15 (QoR-15) questionnaire, which is a 15-item questionnaire with scores ranging from 0 to 150. Patient demographic, procedural, and sedation data were collected, and neurocognitive function was assessed before and a day after sedation. RESULTS Groups 1 and 3 differed according to the Mini-Cog test and 3-word memory test performed before the procedure (p < 0.001). QoR-15 scores between groups were not different (139 ± 19 group 1, 141 ± 17 group 2, and 147 ± 26 group 3; p > 0.05). Patients in groups 3 and 2 were administered lower doses of propofol and midazolam than those in group 1. The incidence of oxygen desaturation (SaO2 <90% for >30 s) was lower in groups 1 and 2 than in group 3 (p = 0.01). CONCLUSIONS As indicated by the QoR-15 questionnaire, the QoR from sedation was not significantly different between the study groups.
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Affiliation(s)
- Dana Yahav-Shafir
- Department of Anesthesiology, Sheba Medical Center, Tel Hashomer, Israel
- Faculty of Medicine, Tel Aviv University Faculty of Medicine, Tel Aviv, Israel
| | - Dina Orkin
- Department of Anesthesiology, Sheba Medical Center, Tel Hashomer, Israel
- Faculty of Medicine, Tel Aviv University Faculty of Medicine, Tel Aviv, Israel
| | - Guy Zahavi
- Department of Anesthesiology, Sheba Medical Center, Tel Hashomer, Israel
- Faculty of Medicine, Tel Aviv University Faculty of Medicine, Tel Aviv, Israel
| | - Inna Epstein
- Department of Anesthesiology, Sheba Medical Center, Tel Hashomer, Israel
- Faculty of Medicine, Tel Aviv University Faculty of Medicine, Tel Aviv, Israel
| | - Moshe Nadler
- Institute of Gastroenterology, Sheba Medical Center, Tel Hashomer, Israel
| | - Haim Berkenstadt
- Department of Anesthesiology, Sheba Medical Center, Tel Hashomer, Israel
- Faculty of Medicine, Tel Aviv University Faculty of Medicine, Tel Aviv, Israel
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Mariotti AL, Pattee J, Edmundowicz SA, Hardesty TD, Sharma SM, Lemley MG, Rist SD, Weitzel N, Faruki AA. Operational outcomes of propofol sedation versus fentanyl, midazolam and diphenhydramine sedation for endoscopies and colonoscopies at an academic medical center. PLoS One 2023; 18:e0294418. [PMID: 38011117 PMCID: PMC10681235 DOI: 10.1371/journal.pone.0294418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 11/01/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND On July 1st, 2021, the University of Colorado Hospital (UCH) implemented new sedation protocols in the luminal gastrointestinal (GI) suite. GI proceduralist supervised, Nurse Administered Sedation with fentanyl, midazolam, and diphenhydramine (NAS) sedation was transitioned to Monitored Anesthesia Care with propofol under physician anesthesiologist supervision (MAC). OBJECTIVE To determine if there are statistically significant reductions in Sedation-Start to Scope-In time (SSSI) when using Monitored Anesthesia Care with propofol (MAC) versus Nurse Administered Sedation with fentanyl, midazolam, and diphenhydramine (NAS). Secondary objectives were to determine if statistically significant improvements to other operational times, quality measures, and satisfaction metrics were present. METHOD This study was a retrospective analysis of a natural experiment resultant of a change from NAS to MAC sedation protocols. Outcomes for NAS protocols from 1/1/21-6/30/21 were compared to outcomes of MAC protocols from the dates 8/1/21-10/31/21. Results were analyzed using Quasi-Poisson regression analysis and stratified based on upper GI, lower GI, and combined procedures. Patient demographic data including age, biological sex, comorbidities, and BMI, were adjusted for in the analysis. ASA matching was not performed as nursing sedation does not use ASA classifications. Pre-anesthesia co-morbidities were assessed via evaluation of a strict set of comorbidities abstracted from the electronic medical record. Perioperative operational outcomes include Sedation Start to Scope-In (SSSI), In-Room to Scope-In Time (IRSI), Scope Out to Out of Room (SOOR), Total Case Length (TCL), and Post Anesthesia Care Unit Length of Stay (PACU LOS). Quality outcomes include PACU Administered Medications (PAM), and Clinician Satisfaction Scores (CSS). RESULTS A total of 5,582 gastrointestinal (GI) endoscopic cases (upper, lower, and combined endoscopies) were observed. Statistically significant decreases in SSSI of 2.5, 2.1, and 2.2 minutes for upper, lower, and dual GI procedures were observed when using MAC protocols. A statistically significant increase in satisfaction scores of 47.0 and 19.6 points were observed for nurses and proceduralists, respectively, when using MAC. CONCLUSION MAC protocols for endoscopic GI procedures at UCH led to statistically significant decreases in the time required to complete procedures thus increasing operational efficiency.
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Affiliation(s)
- Andrew L. Mariotti
- School of Medicine, University of Colorado, Aurora, Colorado, United States of America
| | - Jack Pattee
- Colorado School of Public Health, University of Colorado, Aurora, Colorado, United States of America
| | - Steven A. Edmundowicz
- Department of Gastroenterology, University of Colorado School of Medicine, Aurora, Colorado, United States of America
| | | | - Savita M. Sharma
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, Colorado, United States of America
| | - M. G. Lemley
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, Colorado, United States of America
| | - Scott D. Rist
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, Colorado, United States of America
| | - Nathaen Weitzel
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, Colorado, United States of America
| | - Adeel A. Faruki
- Department of Anesthesiology, MD Anderson Cancer Center, Houston, Texas, United States of America
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Potestio CP, Dibato J, Bolkus K, Awad A, Thayasivam U, Patel A, Bright A, Mitrev LV. Post-Operative Cognitive Dysfunction in Elderly Patients Receiving Propofol Sedation for Gastrointestinal Endoscopies: An Observational Study Utilizing Processed Electroencephalography. Cureus 2023; 15:e46588. [PMID: 37933341 PMCID: PMC10625787 DOI: 10.7759/cureus.46588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2023] [Indexed: 11/08/2023] Open
Abstract
BACKGROUND Propofol sedation is commonly administered during gastrointestinal (GI) procedures. The Patient State Index (PSI) is a processed electroencephalography (EEG) parameter obtained with the SedLine® Sedation Monitoring system (Masimo Corporation, Irvine, CA). When used to objectively assess the patient's level of consciousness, PSI may provide a more effective, safer titration of sedation during GI procedures. We hypothesize that having more or longer episodes of deep sedation as assessed by PSI (i.e., PSI<26) would correlate with developing new-onset or worsening post-operative cognitive dysfunction (POCD). METHODS This was a pragmatic, double-blinded observational study of 400 patients aged ≥65 years undergoing upper GI endoscopy, lower GI endoscopy, or a combined procedure utilizing propofol sedation at a tertiary-care [A1] academic medical center. The patients were monitored with the SedLine® Brain Function Monitor, software version 2 (Masimo Corporation, Irvine, CA), throughout the case, starting at baseline (i.e., before administration of propofol) and stopping at case end. We assessed the subjects' cognitive function via an in-person interview at baseline (pre-procedure) and telephone interviews at 1, 7 (±1), and 90 days after study enrollment. Cognitive function was assessed by administering the short blessed test (SBT), which is a validated brief cognitive screening appropriate for in-person and telephone administration. RESULTS The correlations between the change in SBT score and the pre-defined parameters of PSI were not significant (all p-values >5%). There was a significant drop in SBT scores on day seven. Higher age was also significantly associated with a drop in SBT from baseline. Deep sedation, as evidenced by the number of times PSI was lower than 26, was not predictive of the change in SBT, nor was gender, total propofol dose, or vasoactive drug use during the procedure. CONCLUSIONS The observed incidence of POCD after GI procedures with propofol sedation was low (1.3% at seven days and 2.95% at 90 days) and lower than at the baseline. Age was associated with a greater average decline in SBT score, although the absolute change was small (-0.067 per year of age increase). Deeper sedation, as documented by the PSI score, was not associated with a change in POCD measured with the SBT.
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Affiliation(s)
| | - John Dibato
- Department of Clinical Biostatistics, Cooper Medical School of Rowan University, Camden, USA
| | - Kelly Bolkus
- Department of Anesthesiology, Cooper University Health Care, Camden, USA
| | - Ahmed Awad
- Department of Anesthesiology, Cooper University Hospital, Camden, USA
| | | | - Avish Patel
- Department of Anesthesiology, Cooper Medical School of Rowan University, Camden, USA
| | - Anshel Bright
- Department of Anesthesiology, Cooper Medical School of Rowan University, Camden, USA
| | - Ludmil V Mitrev
- Department of Anesthesiology, Cooper University Hospital, Camden, USA
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Hao XW, Zhan YL, Li P, Zhang ST, Yan XD, Li XM, Xiang W. Recovery of driving skills after endoscopy under propofol sedation: a prospective pilot study to assess the driving skills after endoscopic sedation using driving simulation. BMC Anesthesiol 2023; 23:223. [PMID: 37355565 PMCID: PMC10290334 DOI: 10.1186/s12871-023-02122-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 05/03/2023] [Indexed: 06/26/2023] Open
Abstract
BACKGROUND Patients are recommended not to drive for at least the first 24 h after endoscopy with propofol sedation. However, the evidence underlying these recommendations is scarce. We hypothesized that after endoscopic procedures performed under propofol sedation, the subject's driving ability was restored in less than 24 h. METHODS We prospectively enrolled thirty patients between 20 and 70 years possessing a legitimate driver's license scheduled for endoscopy at our hospital. The sample chosen was a convenience sample. Gastroscopy or colonoscopy was performed with propofol sedation. Before and after endoscopy, the investigator drove the subjects to the laboratory to assess their driving skills using a driving simulation system, which employs 3 driving scenarios designed by professional transportation researchers. The blood propofol concentration was estimated before endoscopy, and 2 and 4 h after endoscopy. The primary outcome was the time required for subjects to recover their driving ability after propofol sedation. The secondary outcome was the blood propofol concentration before and after endoscopic procedures under propofol anesthesia. RESULTS Thirty volunteers participated in the study and 18 of them completed all the interventions. In the low-risk S-curve scene, the mean acceleration, lane deviation, and number of deviations from the path at baseline (0.016 cm/s2, 42.50 cm, and 0.83, respectively) were significantly less than that at post-2 h (0.029 cm/s2, P = 0.001; 53.80 cm, P = 0.014; 2.06, P = 0.022). In the moderate-(overtaking) and high-risk (emergency collision avoidance) scenes, the tested parameters at baseline and post-2 h were statistically comparable. In the low-, moderate-, and high-risk scenes the tested parameters at baseline and post-4 h were statistically comparable. The total range of propofol was 120-280 mg.The mean blood concentration of propofol at post-2 h was 0.81 ± 0.40 µg/mL, and at post-4 h was below the limit of detection. CONCLUSION After endoscopy performed under propofol sedation, subjects' driving abilities were completely restored at 4 h when tested on a simulator.
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Affiliation(s)
- Xiao-Wen Hao
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Beijing, 100050, China
| | - Yuan-Lin Zhan
- Psychiatry Department, Beijing Hai-Dian Hospital, Beijing, 100080, China
| | - Peng Li
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Beijing, 100050, China.
| | - Shu-Tian Zhang
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Beijing, 100050, China
| | - Xue-Dong Yan
- MOT Key Laboratory of Transport Industry of Big Data Application Technologies for Comprehensive Transport, Beijing Jiaotong University, Beijing, 100044, China
| | - Xiao-Meng Li
- Centre for Accident Research and Road Safety-Queensland (CARRS-Q), Queensland University of Technology (QUT), Kelvin Grove, QLD, 4059, Australia
| | - Wang Xiang
- School of Traffic & Transportation Engineering, Changsha University of Science & Technology, Changsha, 410114, China
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Yamaguchi D, Morisaki T, Sakata Y, Mizuta Y, Nagatsuma G, Inoue S, Shimakura A, Jubashi A, Takeuchi Y, Ikeda K, Tanaka Y, Yoshioka W, Hino N, Ario K, Tsunada S, Esaki M. Usefulness of discharge standards in outpatients undergoing sedative endoscopy: a propensity score-matched study of the modified post-anesthetic discharge scoring system and the modified Aldrete score. BMC Gastroenterol 2022; 22:445. [PMCID: PMC9635164 DOI: 10.1186/s12876-022-02549-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 10/20/2022] [Indexed: 11/06/2022] Open
Abstract
Background This study aimed to evaluate the usefulness of discharge standards in outpatients undergoing sedative endoscopy by comparing the modified post-anesthetic discharge scoring system (MPADSS) and the modified Aldrete score. Methods We prospectively enrolled 376 outpatients who underwent gastrointestinal endoscopy under midazolam sedation; 181 outpatients were assessed regarding discharge after sedative endoscopy using the MPADSS (group M), and 195 patients were assessed by the modified Aldrete score (group A). The clinical characteristics, types of endoscopy, endoscopic outcomes, and anesthesia outcomes were evaluated between the two groups. We compared discharge score, recovery time, and adverse events using propensity-score matching. Results Propensity-score matching created 120 matched pairs. The proportion of patients who had a recovery time within 60 min after endoscopy was significantly higher in group A than that in group M (42.5% versus 25.0%, respectively; P < 0.01). The proportion of patients who required > 120 min of recovery time after endoscopy was significantly lower in group A than that in group M (0.0% versus 5.0%, respectively; P = 0.03). However, significantly more patients had drowsiness at discharge in group A compared with group M (19.1% versus 5.0%, respectively; P < 0.01). There was no significant difference in the adverse event rate within 24 h of discharge between the groups. Conclusions Patients assessed by the modified Aldrete score were allowed to discharge earlier than those assessed by the MPADSS. However, a patient’s level of consciousness should be assessed carefully, especially in patients who visit the hospital alone. Supplementary Information The online version contains supplementary material available at 10.1186/s12876-022-02549-7.
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Affiliation(s)
- Daisuke Yamaguchi
- grid.440125.6Department of Gastroenterology, National Hospital Organization Ureshino Medical Center, Ureshino, Japan ,grid.412339.e0000 0001 1172 4459Division of Gastroenterology, Department of Internal Medicine, Saga University, Saga, 849-8501 Japan
| | - Tomohito Morisaki
- grid.440125.6Department of Gastroenterology, National Hospital Organization Ureshino Medical Center, Ureshino, Japan ,Department of Gastroenterology, Japan Community Health care Organization Isahaya General Hospital, Nagasaki, Japan
| | - Yasuhisa Sakata
- grid.412339.e0000 0001 1172 4459Division of Gastroenterology, Department of Internal Medicine, Saga University, Saga, 849-8501 Japan
| | - Yumi Mizuta
- grid.440125.6Department of Gastroenterology, National Hospital Organization Ureshino Medical Center, Ureshino, Japan
| | - Goshi Nagatsuma
- grid.440125.6Department of Gastroenterology, National Hospital Organization Ureshino Medical Center, Ureshino, Japan
| | - Suma Inoue
- grid.440125.6Department of Gastroenterology, National Hospital Organization Ureshino Medical Center, Ureshino, Japan
| | - Akane Shimakura
- grid.440125.6Department of Gastroenterology, National Hospital Organization Ureshino Medical Center, Ureshino, Japan
| | - Amane Jubashi
- grid.440125.6Department of Gastroenterology, National Hospital Organization Ureshino Medical Center, Ureshino, Japan
| | - Yuki Takeuchi
- grid.440125.6Department of Gastroenterology, National Hospital Organization Ureshino Medical Center, Ureshino, Japan
| | - Kei Ikeda
- grid.440125.6Department of Gastroenterology, National Hospital Organization Ureshino Medical Center, Ureshino, Japan
| | - Yuichiro Tanaka
- grid.440125.6Department of Gastroenterology, National Hospital Organization Ureshino Medical Center, Ureshino, Japan
| | - Wataru Yoshioka
- grid.440125.6Department of Gastroenterology, National Hospital Organization Ureshino Medical Center, Ureshino, Japan
| | - Naoyuki Hino
- grid.440125.6Department of Gastroenterology, National Hospital Organization Ureshino Medical Center, Ureshino, Japan
| | - Keisuke Ario
- grid.440125.6Department of Gastroenterology, National Hospital Organization Ureshino Medical Center, Ureshino, Japan
| | - Seiji Tsunada
- grid.440125.6Department of Gastroenterology, National Hospital Organization Ureshino Medical Center, Ureshino, Japan
| | - Motohiro Esaki
- grid.412339.e0000 0001 1172 4459Division of Gastroenterology, Department of Internal Medicine, Saga University, Saga, 849-8501 Japan
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11
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Kang S, Chae YJ, Park SK, Kim TG, Joe HB. Prevention of Bradycardia during Spinal Anesthesia under Dexmedetomidine Sedation in Older Adults. J Clin Med 2022; 11:jcm11216349. [PMID: 36362576 PMCID: PMC9657617 DOI: 10.3390/jcm11216349] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 10/11/2022] [Accepted: 10/26/2022] [Indexed: 11/16/2022] Open
Abstract
Older adults exhibit reduced physiological responses to beta-adrenergic stimulation and parasympathetic inhibition. This study aimed to investigate the effect of reducing the incidence of bradycardia in the atropine and ephedrine pretreatment group compared to the control group in older adults who received spinal anesthesia with intravenous dexmedetomidine. Overall, 102 older adults aged over 65 years were randomly divided into three groups, and saline (control group), atropine at 0.5 mg (atropine group), and ephedrine at 8 mg (ephedrine group) were administered intravenously to each group as pretreatment. Immediately after spinal anesthesia, dexmedetomidine loading and study drug injections were commenced. The primary outcome was the incidence of bradycardia (<50 beats per min) within 60 min following dexmedetomidine loading. The incidence of bradycardia requiring atropine treatment was significantly higher in the control group than in the atropine and ephedrine groups (27.3% vs. 6.1% and 8.8%, respectively; p = 0.035), and no difference was noted between the atropine and ephedrine groups. Therefore, if ephedrine or atropine is selected and used according to the patient’s condition and clinical situation, it may be helpful in preventing bradycardia during spinal anesthesia using dexmedetomidine in older patients.
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Affiliation(s)
- Seyoon Kang
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon 16499, Korea
| | - Yun Jeong Chae
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon 16499, Korea
| | - Sun Kyung Park
- Department of Anesthesiology and Pain Medicine, Jeju National College of Medicine, Jeju 63241, Korea
| | - Taek Geun Kim
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon 16499, Korea
| | - Han Bum Joe
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon 16499, Korea
- Correspondence: ; Tel.: +82-31-219-4916
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12
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Sneyd JR, Absalom AR, Barends CRM, Jones JB. The appropriate way to measure blood pressure for sedated colonoscopy. Response to Br J Anaesth 2022. Br J Anaesth 2022; 129:e25-e27. [PMID: 35618536 DOI: 10.1016/j.bja.2022.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 04/21/2022] [Accepted: 04/21/2022] [Indexed: 11/30/2022] Open
Affiliation(s)
- J Robert Sneyd
- Faculty of Medicine and Dentistry, University of Plymouth, John Bull Building, Plymouth Science Park, Plymouth, UK.
| | - Anthony R Absalom
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Clemens R M Barends
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jordan B Jones
- College of Osteopathic Medicine, Rocky Vista University, Ivins, UT, USA
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13
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Tan Y, Ouyang W, Tang Y, Fang N, Fang C, Quan C. Effect of remimazolam tosilate on early cognitive function in elderly patients undergoing upper gastrointestinal endoscopy. J Gastroenterol Hepatol 2022; 37:576-583. [PMID: 34907594 PMCID: PMC9303590 DOI: 10.1111/jgh.15761] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 10/14/2021] [Accepted: 12/02/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND AND AIM Remimazolam tosilate (RT) is under evaluation as a sedative for endoscopic procedures. Herein, we aimed to evaluate safety including cognition recovery of RT administered in elderly patients undergoing upper gastrointestinal endoscopy and assess its safety dosage. METHODS Ninety-nine patients presenting for upper gastrointestinal endoscopy were randomized to receive 0.1 mg/kg RT (R1) or 0.2 mg/kg RT (R2), or propofol (P). Cognitive functions (memory, attention, and executive function) were measured via neuropsychological tests conducted before sedation and 5 min after recovery to full alertness. Adverse events were also assessed. RESULTS There were no statistical differences between postoperative and baseline results for R1 group and P group, whereas those for R2 group revealed worsened postoperative cognitive functions (immediate recall and short delay recall) than baseline (P < 0.05). Compared with P group, Scores demonstrated worse restoration of immediate recall in R1 group, immediate recall, short-delayed recall, and attention function in R2 group (P < 0.05). Patients in R2 group had a longer sedation time (12.09 vs 8.27 vs 8.21 min; P < 0.001) and recovery time (6.85 vs 3.82 vs 4.33 min; P < 0.001) than that in R1 group and P group. Moreover, the incidence of hypotension was 3.0% in R1 group, whereas it was 21.2% in R2 group and 48.5% in P group (P < 0.05). CONCLUSION The addition of 0.1 mg/kg RT as an adjunct to opiate sedation for upper gastrointestinal endoscopy not only achieves more stable perioperative hemodynamics but also achieves acceptable neuropsychiatric functions in elderly patients.
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Affiliation(s)
- Yingjie Tan
- Department of Anesthesiology, The Third Xiangya HospitalCentral South UniversityChangshaChina
| | - Wen Ouyang
- Department of Anesthesiology, The Third Xiangya HospitalCentral South UniversityChangshaChina
| | - Yongzhong Tang
- Department of Anesthesiology, The Third Xiangya HospitalCentral South UniversityChangshaChina
| | - Ning Fang
- Department of Gastroenterology, The Third Xiangya HospitalCentral South UniversityChangshaChina
| | - Chao Fang
- National Drug Clinical Trail CenterHunan Cancer HospitalChangshaChina
| | - Chengxuan Quan
- Department of Anesthesiology, The Third Xiangya HospitalCentral South UniversityChangshaChina
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14
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Buckley RA, Atkins KJ, Silbert B, Scott DA, Evered L. Digital clock drawing test metrics in older patients before and after endoscopy with sedation: An exploratory analysis. Acta Anaesthesiol Scand 2022; 66:207-214. [PMID: 34811719 DOI: 10.1111/aas.14003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 10/25/2021] [Accepted: 11/02/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND In the postoperative period, clinically feasible instruments to monitor elderly patients' neurocognitive recovery and discharge-readiness, especially after short-stay procedures, are limited. Cognitive monitoring may be improved by a novel digital clock drawing test (dCDT). We screened for cognitive impairment with the 4 A Test (4AT) and then administered the dCDT pre and post short-stay procedure (endoscopy). The primary aim was to investigate whether the dCDT was sensitive to a change in cognitive status postendoscopy. We also investigated if preoperative cognitive status impacted postendoscopy dCDT variables. METHODS We recruited 100 patients ≥65 years presenting for endoscopy day procedures at a single metropolitan hospital. Participants were assessed after admission and immediately before discharge from the hospital. We administered the 4AT, followed by both command and copy clock conditions of the dCDT. We analysed the total drawing time (dCDT time), as well as scored the drawn clock against the established Montreal Cognitive Assessment (MoCA) criteria both before and after endoscopy. RESULTS Linear regression showed higher 4AT test scores (poorer performance) were associated with longer postoperative dCDT time (β = 5.6, p = 0.012) for the command condition after adjusting for preoperative baseline dCDT metrics, sex, age, and years of education. CONCLUSION Postoperative dCDT time-based variables slowed in those with baseline cognitive impairment detected by the 4AT, but not for those without cognitive impairment. Our results suggest the dCDT, using the command mode, may help detect cognitive impairment in patients aged >65 years after elective endoscopy.
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Affiliation(s)
- Richard A. Buckley
- University of Melbourne Melbourne Victoria Australia
- Department of Anaesthesia and Acute Pain Medicine St Vincent's Hospital Melbourne Fitzroy Victoria Australia
| | - Kelly J. Atkins
- University of Melbourne Melbourne Victoria Australia
- Department of Anaesthesia and Acute Pain Medicine St Vincent's Hospital Melbourne Fitzroy Victoria Australia
| | - Brendan Silbert
- University of Melbourne Melbourne Victoria Australia
- Department of Anaesthesia and Acute Pain Medicine St Vincent's Hospital Melbourne Fitzroy Victoria Australia
| | - David A. Scott
- University of Melbourne Melbourne Victoria Australia
- Department of Anaesthesia and Acute Pain Medicine St Vincent's Hospital Melbourne Fitzroy Victoria Australia
| | - Lisbeth Evered
- University of Melbourne Melbourne Victoria Australia
- Department of Anaesthesia and Acute Pain Medicine St Vincent's Hospital Melbourne Fitzroy Victoria Australia
- Department of Anesthesiology Weill Cornell Medicine New York New York USA
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15
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Edalatkhah S, Hazrati E, Hashemi M, Golaghaei A, Kheradmand B, Rafiei M. Evaluation of anesthesia quality with three methods: "propofol + fentanyl" vs. "propofol + fentanyl + lidocaine" vs. "propofol + fentanyl + lidocaine + ketamine" in patients referred to the scoping ward. J Family Med Prim Care 2022; 11:672-676. [PMID: 35360792 PMCID: PMC8963641 DOI: 10.4103/jfmpc.jfmpc_1387_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 10/25/2021] [Accepted: 12/13/2021] [Indexed: 12/21/2022] Open
Abstract
Introduction: Toleration of the complexity and pain of interventions such as endoscopy and colonoscopy is highly difficult for patients. Considering the disagreement on the method of injection of propofol, this study was performed to evaluate the quality of anesthesia using the three methods of propofol + fentanyl, propofol + fentanyl + lidocaine, and propofol + fentanyl + lidocaine + ketamine. Methods: This one-way blind clinical trial study included 99 patients who were admitted in three groups by block randomization method. In a group of patients that were sedated with propofol + fentanyl + lidocaine + ketamine, the dose of all drugs is reduced by half the amount of the other groups. Variables included age, sex, frequency of cough, apnea, need for jaw thrust maneuver, O2 saturation, duration of recovery, and procedural satisfaction. Data were analyzed using SPSS version 20.0. P value of < 0.05 was considered to be significant. Results: The three groups were similar in terms of demographic characteristics. The effects of the three sedation protocols on the variables showed that patient’s apnea, cough, O2 saturation, and also proceduralist satisfaction in the group of the patient that sedated with four drugs was significantly higher (P < 0.05) than other groups. But there was no significant difference between the three groups when comparing the recovery time and need for jaw thrust during the procedure. Conclusion: The findings of the present study showed that the use of combination of “propofol + fentanyl + lidocaine + ketamine” with lower doses, significantly results in higher quality sedation compared with higher doses of “propofol + fentanyl + lidocaine” or “propofol + fentanyl” for scoping procedures.
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Affiliation(s)
- Sepehr Edalatkhah
- Research Center of Surgery and Trauma, AJA University of Medical Sciences, Tehran, Iran
| | - Ebrahim Hazrati
- Research Center of Surgery and Trauma, AJA University of Medical Sciences, Tehran, Iran
| | - Mahmoodreza Hashemi
- Research Center of Surgery and Trauma, AJA University of Medical Sciences, Tehran, Iran
| | - Alireza Golaghaei
- Research Center of Surgery and Trauma, AJA University of Medical Sciences, Tehran, Iran
| | - Behroz Kheradmand
- Research Center of Surgery and Trauma, AJA University of Medical Sciences, Tehran, Iran
| | - Mohamadreza Rafiei
- Research Center of Surgery and Trauma, AJA University of Medical Sciences, Tehran, Iran
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16
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Xiao X, Xiao N, Zeng F, Chen H, Zhang L, He X. Gastroscopy sedation: clinical trial comparing propofol and sufentanil with or without remimazolam. Minerva Anestesiol 2022; 88:223-229. [PMID: 35072431 DOI: 10.23736/s0375-9393.21.15917-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Propofol-sufentanil is often used in clinical anesthesia for patients undergoing sedative gastroscopy, but there are still adverse events such as longer recovery time, respiratory depression and higher doses of propofol etc. This study was to evaluate the sedative effect of remimazolam-propofol-sufentanil in sedative gastroscopy. METHODS Patients who were going to have gastroscopy examination were randomly divided into two groups: Group RM (remimazolam-propofol-sufentanil group) and group PR (propofol-sufentanil group). Patients of each group were anesthetized according to the corresponding anesthesia procedure, and all observation indices were recorded. RESULTS In the RM group, there were only small and unsignificant changes in the values of SBP, HR, RR and SpO2 after anesthesia(P>0.05), while the values of SBP, HR, RR and SpO2 in the PR group at each time point after anesthesia were significantly lower than those at T0, and the values of SBP and RR at T2, T3 and T4 were also significantly lower than those at T1（P<0.05). The dosage of propofol (38±9 mg) in the RM group was significantly less than that (115±15 mg) in the PR group, meanwhile the anesthesia time (8.4±1.6 min), awakening time (2.9±0.8 min), discharge time (6.7±3.1 min) of the RM group were also significantly shorter than those of the PR group (14.5±3.3, 8.7±1.9, 12.4±3.6 min)（P<0.05), but there was no statistical significance between the two groups in other indices（P>0.05). CONCLUSIONS In clinical practice, remimazolam-propofol-sufentanil sedative scheme has more advantages than propofol-sufentanil sedative scheme.
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Affiliation(s)
- Xingpeng Xiao
- Department of Anesthesiology, Renmin Hospital, Wuhan University, Wuhan, Hubei, China
| | - Nengke Xiao
- Muse college, The Chinese University of Hong Kong, Shenzhen, Guangdong, China
| | - Fenghua Zeng
- Department of Anaesthesiology, Renmin Hospital of Qinghai province, Xining, Qinghai, China
| | - Hexiang Chen
- Department of Anesthesiology, Renmin Hospital, Wuhan University, Wuhan, Hubei, China
| | - Lei Zhang
- Department of Anesthesiology, Renmin Hospital, Wuhan University, Wuhan, Hubei, China
| | - Xuan He
- Department of Anesthesiology, Renmin Hospital, Wuhan University, Wuhan, Hubei, China -
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17
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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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Sneyd JR, Absalom AR, Barends CRM, Jones JB. Hypotension during propofol sedation for colonoscopy: an exploratory analysis. Br J Anaesth 2021; 128:610-622. [PMID: 34916051 PMCID: PMC9008870 DOI: 10.1016/j.bja.2021.10.044] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 10/11/2021] [Accepted: 10/17/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Intraoperative and postoperative hypotension occur commonly and are associated with organ injury and poor outcomes. Changes in arterial blood pressure (BP) during procedural sedation are not well described. METHODS Individual patient data from five trials of propofol sedation for colonoscopy and a clinical database were pooled and explored with logistic and linear regression. A literature search and focused meta-analysis compared the incidence of hypotension with propofol and alternative forms of procedural sedation. Hypotensive episodes were characterised by the original authors' definitions (typically systolic BP <90 mm Hg). RESULTS In pooled individual patient data (n=939), 36% of procedures were associated with episodes of hypotension. Longer periods of propofol sedation and larger propofol doses were associated with longer-lasting and more-profound hypotension. Amongst 380 patients for whom individual BP measurements were available, 107 (28%) experienced systolic BP <90 mm Hg for >5 min, and in 89 (23%) the episodes exceeded 10 min. Meta-analysis of 18 RCTs identified an increased risk ratio for the development of hypotension in procedures where propofol was used compared with the use of etomidate (two studies; n=260; risk ratio [RR] 2.0 [95% confidence interval: 1.37-2.92]; P=0.0003), remimazolam (one study; n=384; RR 2.15 [1.61-2.87]; P=0.0001), midazolam (14 studies; n=2218; RR 1.46 [1.18-1.79]; P=0.0004), or all benzodiazepines (15 studies; n=2602; 1.67 [1.41-1.98]; P<0.00001). Hypotension was less likely with propofol than with dexmedetomidine (one study; n=60; RR 0.24 [0.09-0.62]; P=0.003). CONCLUSIONS Hypotension is common during propofol sedation for colonoscopy and of a magnitude and duration associated with harm in surgical patients.
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Affiliation(s)
- J Robert Sneyd
- Faculty of Medicine and Dentistry, University of Plymouth, Plymouth, UK.
| | - Anthony R Absalom
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Clemens R M Barends
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Jordan B Jones
- College of Osteopathic Medicine, Rocky Vista University, Ivins, UT, USA
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19
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Association between preoperative serum homocysteine and delayed neurocognitive recovery after non-cardiac surgery in elderly patients: a prospective observational study. Perioper Med (Lond) 2021; 10:37. [PMID: 34743734 PMCID: PMC8574052 DOI: 10.1186/s13741-021-00208-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 07/17/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Homocysteine, folate, and vitamin B12 involved in 1-carbon metabolism are associated with cognitive disorders. We sought to investigate the relationships between these factors and delayed neurocognitive recovery (dNCR) after non-cardiac surgery. METHODS This was a prospective observational study of patients (n = 175) who were ≥ 60 years of age undergoing non-cardiac surgery. Patients were evaluated preoperatively and for 1 week postoperatively by using neuropsychological tests and were divided into dNCR or non-dNCR groups according to a Z-score ≤ - 1.96 on at least two of the tests. The relationship between the occurrence of dNCR and preoperative levels of homocysteine, folate, and vitamin B12 was analyzed. Univariate and multivariable logistic regression analyses were conducted to identify factors associated with dNCR. RESULTS Delayed neurocognitive recovery was observed in 36 of 175 patients (20.6%; 95% confidence interval [CI], 14.5-26.6%) 1 week postoperatively. Patients who developed dNCR had significantly higher median [interquartile range (IQR)] homocysteine concentrations (12.8 [10.9,14.4] μmol/L vs 10.6 [8.6,14.7] μmol/L; P = 0.02) and lower folate concentrations (5.3 [4.2,7.3] ng/mL vs 6.9 [5.3,9.5] ng/mL; P = 0.01) than those without dNCR. Compared to the lowest tertile, the highest homocysteine tertile predicted dNCR onset (odds ratio [OR], 3.9; 95% CI, 1. 3 to 11.6; P = 0.02), even after adjusting for age, sex, education, and baseline Mini Mental State Examination. CONCLUSIONS Elderly patients with high homocysteine levels who underwent general anesthesia for non-cardiac surgery have an increased risk of dNCR. This knowledge could potentially assist in the development of preventative and/or therapeutic measures. TRIAL REGISTRATION NCT03084393 ( https://www.clinicaltrials.gov ).
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20
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Chua NJ, Dimopoulos G, Scott DA, Silbert BS, Evered LA. Impaired cognitive performance on MoCA testing at discharge in elderly patients following day endoscopy and its relationship to preoperative mild cognitive impairment. Anaesth Intensive Care 2021; 49:357-365. [PMID: 34378411 DOI: 10.1177/0310057x21997459] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In patients admitted to hospital, preoperative mild cognitive impairment predicts postoperative complications. The effect of mild cognitive impairment on discharge readiness among the day stay surgery population is unknown. Our aims were to determine the incidence of impaired cognitive performance at discharge after day stay endoscopy and whether pre-existing mild cognitive impairment was associated with its development. A single-centre cohort study of elective day stay endoscopy patients was undertaken. Over a three-month period, data were collected from 69 patients aged 65 years and over. Patients were cognitively assessed on admission and discharge using the Montreal cognitive assessment tool and the three-minute diagnostic confusion assessment method. At baseline, patients who scored 1.5 or more standard deviations below age-adjusted levels on the Montreal cognitive assessment tool in conjunction with a subjective memory complaint were classified as having mild cognitive impairment. At discharge, patients were classified as having impaired cognitive performance if there was a reduction in the Montreal cognitive assessment tool score by at least two points. We also assessed delirium and subsyndromal delirium at discharge using the three-minute diagnostic confusion assessment method. We identified mild cognitive impairment in 23 patients (33.3%) on admission, and impaired performance on the Montreal cognitive assessment tool test at discharge in 35 (50.7%) patients. There was no association between mild cognitive impairment on admission and impaired cognitive performance at discharge (50.0% versus 51.1%, P = 0.94). This study demonstrates that evidence of impaired cognitive performance on the Montreal cognitive assessment tool testing is present after day stay endoscopy in over 50% of elderly patients, but this is not associated with preoperative cognitive status.
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Affiliation(s)
- Nathan J Chua
- Melbourne Medical School, University of Melbourne, Melbourne, Australia.,Department of Acute Pain and Anaesthesia, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Georgia Dimopoulos
- Melbourne Medical School, University of Melbourne, Melbourne, Australia.,Department of Acute Pain and Anaesthesia, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - David A Scott
- Melbourne Medical School, University of Melbourne, Melbourne, Australia.,Department of Acute Pain and Anaesthesia, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Brendan S Silbert
- Melbourne Medical School, University of Melbourne, Melbourne, Australia.,Department of Acute Pain and Anaesthesia, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Lisbeth A Evered
- Melbourne Medical School, University of Melbourne, Melbourne, Australia.,Department of Acute Pain and Anaesthesia, St Vincent's Hospital Melbourne, Melbourne, Australia.,Department of Anesthesiology, Weill Cornell Medicine, New York, USA
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21
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Updates and controversies in anesthesia for advanced interventional pulmonology procedures. Curr Opin Anaesthesiol 2021; 34:455-463. [PMID: 34148971 DOI: 10.1097/aco.0000000000001029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Advanced bronchoscopic procedures continues to grow, and are now commonly used to diagnose and/or treat a variety of pulmonary conditions that required formal thoracic surgery in past decades. Pharmacologic developments have provided new therapeutic options, as have technical advances in both anesthesia and interventional pulmonology. This review discusses technical and clinical issues and advances in providing anesthesia for advanced bronchoscopic procedures. It also discusses some controversial issues that have yet to be fully resolved. RECENT FINDINGS We discuss anesthetic considerations for new procedures such as the new technology used in electromagnetic navigation bronchoscopy, and bronchoscopic cryotherapy. We also review new ventilation strategies as well as pharmacologic advances and recent trends in the utilization of anesthetic adjuvants, and the use of short-acting opioids like remifentanil, and alpha agonist sedatives such as dexmedetomidine. SUMMARY The anesthetic framework and the discussions presented here should help forge effective communication between the interventional pulmonologist and the anesthesiologist In the Bronchoscopy Suite nonoperating room anesthesia with the goal of enhancing patient safety.
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22
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Gurunathan U, Rahman T, Williams Z, Vandeleur A, Sriram S, Harch J, Boggett S, Hill C, Bowyer A, Royse C. Effect of Midazolam in Addition to Propofol and Opiate Sedation on the Quality of Recovery After Colonoscopy: A Randomized Clinical Trial. Anesth Analg 2020; 131:741-750. [PMID: 31922999 DOI: 10.1213/ane.0000000000004620] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND There is a concern that midazolam, when used as a component of sedation for colonoscopy, may impair cognition and prolong recovery. We aimed to identify whether midazolam produced short- and longer-term effects on multiple dimensions of recovery including cognition. METHODS A 2-center double-blinded, placebo-controlled, parallel-group, randomized, phase IV study with a 1:1 allocation ratio was conducted in adults ≥18 years of age undergoing elective outpatient colonoscopy, with sufficient English language proficiency to complete the Postoperative Quality of Recovery Scale (PostopQRS). Participants were administered either midazolam (0.04 mg·kg) or an equivalent volume of 0.9% saline before sedation with propofol with or without an opiate. The primary outcome was incidence of recovery in the cognitive domain of the PostopQRS on day 3 after colonoscopy, which was analyzed using a χ test. Secondary outcomes included recovery in other domains of the PostopQRS over time, time to eye-opening, and hospital stay, and patient and endoscopist satisfaction. All hypotheses were defined before recruitment. RESULTS During September 2015 to June 2018, 406 patients were allocated to either midazolam (n = 201) or placebo (n = 205), with one withdrawn before allocation. There was no significant difference in recovery in the cognitive domain of the PostopQRS on day 3 after colonoscopy (midazolam 86.8% vs placebo 88.7%, odds ratio, 0.838; 95% confidence interval [CI], 0.42-1.683; P= .625). Furthermore, there was no difference in recovery over time in the cognitive domain of the PostopQRS (P = .534). Overall recovery of the PostopQRS increased over time but was not different between groups. Furthermore, there were no differences between groups for nociceptive, emotive, activities-of-daily-living domains of the PostopQRS. Patient and endoscopist satisfaction were high and not different. There were no differences in time to eye-opening (midazolam 9.4 ± 12.8 minutes vs placebo 7.3 ± 0.7 minutes; P = .055), or time to hospital discharge (midazolam 103.4 ± 1.4 minutes vs placebo 98.4 ± 37.0 minutes; P = .516). CONCLUSIONS The addition of midazolam 0.04 mg·kg as adjunct to propofol and opiate sedation for elective colonoscopy did not show evidence of any significant differences in recovery in the cognitive domain of the PostopQRS, overall quality of recovery as measured by the PostopQRS, or emergence and hospital discharge times. The use of midazolam should be determined by the anesthesiologist.
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Affiliation(s)
- Usha Gurunathan
- From the The Prince Charles Hospital, Brisbane, Queensland, Australia.,University of Queensland, Brisbane, Queensland, Australia
| | - Tony Rahman
- From the The Prince Charles Hospital, Brisbane, Queensland, Australia.,Queensland University of Technology and University of Sunshine Coast, Queensland, Australia
| | - Zelda Williams
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
| | - Ann Vandeleur
- From the The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Sweta Sriram
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
| | - Jennifer Harch
- From the The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Stuart Boggett
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
| | - Cindy Hill
- From the The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Andrea Bowyer
- Department of Anesthesia and Pain Management, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Colin Royse
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia.,Outcomes Research Consortium, Cleveland Clinic, Cleveland, Ohio
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Alexander JC, Joshi GP. Think Before You Administer: Is Routine Benzodiazepine Premedication Before Endoscopy in Adults Necessary? Anesth Analg 2020; 131:738-740. [PMID: 32940443 DOI: 10.1213/ane.0000000000004784] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- John C Alexander
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern, Dallas, Texas
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24
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Tian L, Luan H, Zhu P, Zhang Z, Bao H. A randomized controlled trial for measuring effects on cognitive functions of adding ketamine to propofol during sedation for colonoscopy. Medicine (Baltimore) 2020; 99:e21859. [PMID: 32899015 PMCID: PMC7478513 DOI: 10.1097/md.0000000000021859] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 07/19/2020] [Accepted: 07/23/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The purpose of this study was to evaluate the effects of adding ketamine to propofol on cognitive functions in patients undergoing sedation for colonoscopy. METHODS In this randomized, double-blinded, and controlled study, 200 patients were randomly allocated to ketamine/propofol admixture group (Group KP, n = 100), and propofol group (Group P, n = 100). Patients in Group KP received 0.25 mg/kg of ketamine and 0.5 mg/kg of propofol. Patients in Group P received 0.5 mg/kg propofol. Cognitive functions were measured using CogState battery before and after the colonoscopy procedure. Ninety five patients in Group KP and 92 patients in Group P had completed the CogStates tests and were included in the data analysis. RESULTS Compared with before procedure baseline, the performance on detection and identification tasks were significantly impaired after the procedure in both Group KP (P = .004, P = .001) and Group P patients (P = .005, P < .001). However, one-card learning accuracy and One-back memory was only impaired in Group KP patients (P = .006, P = .040) after the endoscopy but left intact in Group P patients. Group KP patients showed more severe impairment in one-card learning accuracy compared with Group P patients (P = .044). Group KP patients have better 5 minutes MAP (P = .005) and were also less likely to suffer from complications such as respiratory depression (P = .023) and hypotension (P = .015). OAA/S scores, BIS, MAP, complications, recovery times, and endoscopist and patient satisfaction were similar between the 2 groups. CONCLUSION Although adding ketamine to propofol for sedation in colonoscopy provided fewer complications such as respiratory depression and hypotension, it also causes more impairment in cognitive functions.
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Affiliation(s)
- Liang Tian
- Department of Anesthesiology, Lianyungang Clinical College of Nanjing Medical University, The First People's Hospital of Lianyungang, Lianyungang
| | - Hengfei Luan
- Department of Anesthesiology, Lianyungang Clinical College of Nanjing Medical University, The First People's Hospital of Lianyungang, Lianyungang
| | - Pin Zhu
- Department of Anesthesiology, Lianyungang Clinical College of Nanjing Medical University, The First People's Hospital of Lianyungang, Lianyungang
| | - Zhiyuan Zhang
- Department of Pathology, Basic Medical Sciences of Nanjing Medical University
| | - Hongguang Bao
- Department of Anesthesiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
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Comparison of the Effects of Midazolam/Fentanyl, Midazolam/Propofol, and Midazolam/Fentanyl/Propofol on Cognitive Function After Gastrointestinal Endoscopy. Surg Laparosc Endosc Percutan Tech 2020; 29:441-446. [PMID: 31135712 DOI: 10.1097/sle.0000000000000679] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Drugs used for sedation/analgesia during gastrointestinal (GI) endoscopy, including midazolam, fentanyl, and propofol, result in short-term, reversible decline in cognitive function. This prospective cohort trial aimed to identify the sedative/analgesic regimen associated with the least impairment of cognition at the time of discharge. METHODS Patients undergoing elective GI endoscopy were included. Patients investigated at the Prince of Wales Hospital, Sydney, received midazolam/fentanyl (M/F), whereas patients investigated at the Prince of Wales Private Hospital, Sydney, received midazolam/fentanyl/propofol (M/F/P) or midazolam/propofol (M/P). Patients underwent a computerized neurocognitive test, the CogState Brief Battery, before sedation and at discharge. RESULTS Patients in the M/F group who received gastroscopy (n=22) were administered midazolam 3.36 mg (±0.79 mg) and fentanyl 61.36 μg (±16.77 μg), those who received colonoscopy (n=50) were administered midazolam 3.98 mg (±1.06 mg) and fentanyl 74.50 μg (±24.48 μg), and those who received gastroscopy/colonoscopy (n=28) were administered midazolam 4.82 mg (±1.41 mg) and fentanyl 94.64 μg (±24.35 μg). Patients in the M/F/P group who received colonoscopy (n=45) were administered midazolam 2.77 mg (±0.55 mg), fentanyl 45.11 μg (±25.78 μg), and propofol 148.64 mg (±57.65 mg), and those who received gastroscopy/colonoscopy (n=36) were administered midazolam 2.64 mg (±0.472 mg), fentanyl 35.28 μg (±19.16 μg), and propofol 168.06 mg (±60.75 mg). Nineteen patients in the M/P group who received gastroscopy (n=19) were administered midazolam 2.37 mg (±0.04 mg) and propofol 13.68 mg (±37.74 mg). Neurocognitive scores were significantly lower in the postprocedure test compared with baseline scores for detection, identification, and one card learning (P<0.001). Postprocedure detection test scores were significantly impaired in the M/F group compared with the M/F/P and M/P groups. Predictors of poorer neurocognitive function were midazolam dosage >3 mg (P<0.006) and fentanyl dosage >50 μg (P<0.009). CONCLUSION The use of propofol in GI endoscopy allows for less exposure to midazolam and fentanyl and is associated with improved cognition at the time of discharge.
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Beck S, Zins L, Holthusen C, Rademacher C, von Breunig F, Tennstedt P, Haese A, Graefen M, Zöllner C, Fischer M. Comparison of Cognitive Function After Robot-Assisted Prostatectomy and Open Retropubic Radical Prostatectomy: A Prospective Observational Single-Center Study. Urology 2020; 139:110-117. [PMID: 32084412 DOI: 10.1016/j.urology.2019.12.045] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 11/27/2019] [Accepted: 12/20/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To assess the effects of robot-assisted radical prostatectomy in the Trendelenburg position on postoperative neurocognitive outcomes this study compared cognitive function between patients who underwent robot-assisted radical prostatectomy and those who underwent open retropubic radical prostatectomy. METHODS Objective evaluations of pre- and postoperative cognitive function were performed upon admission and before hospital discharge, by using a neuropsychological test battery. We collected self-reported data on cognitive failures at 3 months postoperatively. Binary logistic regression analysis was used to assess the effects of surgical technique on postoperative cognitive performance. RESULTS The pre- and postoperative neuropsychological assessments were completed by 367 patients with a median age of 64 years (range 44-76). The incidence of postoperative cognitive dysfunction was 23.9% after robot-assisted (39/165) and 22.3% after open radical prostatectomy (45/202). There was no significant difference in postoperative cognitive function during the early postoperative period (P = 0.758) and self-reported cognitive failures at 3 months (P = 0.303) between robot-assisted and open surgery. Surgical technique was not associated with early postoperative cognitive dysfunction in multivariable analysis (OR 1.012, 95%CI: 0.608-1.685, P = 0.962). CONCLUSION Compared with open surgery in supine position postoperative neurocognitive disorders do not occur more frequently after robot-assisted radical prostatectomy in the extreme Trendelenburg position. Based on these findings potential adverse effects on cognitive function do not have to be considered in the choice of surgical approach for radical prostatectomy.
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Affiliation(s)
- Stefanie Beck
- Department of Anesthesiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Linnea Zins
- Department of Anesthesiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Clara Holthusen
- Department of Anesthesiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Cornelius Rademacher
- Department of Anesthesiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Franziska von Breunig
- Department of Anesthesiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Pierre Tennstedt
- Martini-Klinik, Prostate Cancer Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alexander Haese
- Martini-Klinik, Prostate Cancer Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Markus Graefen
- Martini-Klinik, Prostate Cancer Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Zöllner
- Department of Anesthesiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marlene Fischer
- Department of Anesthesiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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27
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Delgado AADA, de Moura DTH, Ribeiro IB, Bazarbashi AN, dos Santos MEL, Bernardo WM, de Moura EGH. Propofol vs traditional sedatives for sedation in endoscopy: A systematic review and meta-analysis. World J Gastrointest Endosc 2019; 11:573-588. [PMID: 31839876 PMCID: PMC6885729 DOI: 10.4253/wjge.v11.i12.573] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 08/17/2019] [Accepted: 09/11/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Propofol is commonly used for sedation during endoscopic procedures. Data suggests its superiority to traditional sedatives used in endoscopy including benzodiazepines and opioids with more rapid onset of action and improved post-procedure recovery times for patients. However, Propofol requires administration by trained healthcare providers, has a narrow therapeutic index, lacks an antidote and increases risks of cardio-pulmonary complications. AIM To compare, through a systematic review of the literature and meta-analysis, sedation with propofol to traditional sedatives with or without propofol during endoscopic procedures. METHODS A literature search was performed using MEDLINE, Scopus, EMBASE, the Cochrane Library, Scopus, LILACS, BVS, Cochrane Central Register of Controlled Trials, and The Cumulative Index to Nursing and Allied Health Literature databases. The last search in the literature was performed on March, 2019 with no restriction regarding the idiom or the year of publication. Only randomized clinical trials with full texts published were included. We divided sedation therapies to the following groups: (1) Propofol versus benzodiazepines and/or opiate sedatives; (2) Propofol versus Propofol with benzodiazepine and/or opioids; and (3) Propofol with adjunctive benzodiazepine and opioid versus benzodiazepine and opioid. The following outcomes were addressed: Adverse events, patient satisfaction with type of sedation, endoscopists satisfaction with sedation administered, dose of propofol administered and time to recovery post procedure. Meta-analysis was performed using RevMan5 software version 5.39. RESULTS A total of 23 clinical trials were included (n = 3854) from the initial search of 6410 articles. For Group I (Propofol vs benzodiazepine and/or opioids): The incidence of bradycardia was not statistically different between both sedation arms (RD: -0.01, 95%CI: -0.03-+0.01, I 2: 22%). In 10 studies, the incidence of hypotension was not statistically difference between sedation arms (RD: 0.01, 95%CI: -0.02-+0.04, I 2: 0%). Oxygen desaturation was higher in the propofol group but not statistically different between groups (RD: -0.03, 95%CI: -0.06-+0.00, I 2: 25%). Patients were more satisfied with their sedation in the benzodiazepine + opioid group compared to those with monotherapy propofol sedation (MD: +0.89, 95%CI: +0.62-+1.17, I 2: 39%). The recovery time after the procedure showed high heterogeneity even after outlier withdrawal, there was no statistical difference between both arms (MD: -15.15, 95%CI: -31.85-+1.56, I 2: 99%). For Group II (Propofol vs propofol with benzodiazepine and/or opioids): Bradycardia had a tendency to occur in the Propofol group with benzodiazepine and/or opioid-associated (RD: -0.08, 95%CI: -0.13--0.02, I 2: 59%). There was no statistical difference in the incidence of bradycardia (RD: -0.00, 95%CI: -0.08-+0.08, I 2: 85%), desaturation (RD: -0.00, 95%CI: -0.03-+0.02, I 2: 44%) or recovery time (MD: -2.04, 95%CI: -6.96-+2.88, I 2: 97%) between sedation arms. The total dose of propofol was higher in the propofol group with benzodiazepine and/or opiates but with high heterogeneity. (MD: 70.36, 95%CI: +53.11-+87.60, I 2: 61%). For Group III (Propofol with benzodiazepine and opioid vs benzodiazepine and opioid): Bradycardia and hypotension was not statistically significant between groups (RD: -0.00, 95%CI: -0.002-+0.02, I 2: 3%; RD: 0.04, 95%CI: -0.05-+0.13, I 2: 77%). Desaturation was evaluated in two articles and was higher in the propofol + benzodiazepine + opioid group, but with high heterogeneity (RD: 0.15, 95%CI: 0.08-+0.22, I 2: 95%). CONCLUSION This meta-analysis suggests that the use of propofol alone or in combination with traditional adjunctive sedatives is safe and does not result in an increase in negative outcomes in patients undergoing endoscopic procedures.
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Affiliation(s)
- Aureo Augusto de Almeida Delgado
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403000, Brazil
| | - Diogo Turiani Hourneaux de Moura
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403000, Brazil
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Igor Braga Ribeiro
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403000, Brazil
| | - Ahmad Najdat Bazarbashi
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Marcos Eduardo Lera dos Santos
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403000, Brazil
| | - Wanderley Marques Bernardo
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403000, Brazil
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Gu Z, Xin L, Wang H, Hu C, Wang Z, Lu S, Xu J, Qian Y, Wang J. Doxapram alleviates low SpO 2 induced by the combination of propofol and fentanyl during painless gastrointestinal endoscopy. BMC Anesthesiol 2019; 19:216. [PMID: 31757206 PMCID: PMC6873474 DOI: 10.1186/s12871-019-0860-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 09/30/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Painless gastrointestinal endoscopy under intravenous propofol anesthesia is widely applied in the clinical scenario. Despite the good sedation and elimination of anxiety that propofol provides, low SpO2 may also result. Doxapram is a respiratory stimulant with a short half-life. The primary aim of this study was to investigate the effects of doxapram on alleviating low SpO2 induced by the combination of propofol and fentanyl during painless gastrointestinal endoscopy. METHODS In this prospective study, patients scheduled for painless gastrointestinal endoscopy were randomly assigned to group D or S with 55 patients per group. Initially, both groups received a combination of propofol and fentanyl. Patients in group D received 50 mg doxapram after propofol injection, while patients in group S received an equal volume of saline. Vital signs of the patients, propofol dose, examination duration, and incidences of low SpO2 were recorded. RESULTS There were no statistical differences in propofol consumption and examination duration between the two groups. Twenty-six patients in group S experienced low SpO2 versus 10 in group D (P = 0.001). Nineteen patients in group S underwent oxygenation with a face mask in contrast to 8 in group D (P = 0.015). Eighteen patients in group S were treated with jaw lifting compared to 5 in group D (P = 0.002). Four patients in group S underwent assisted respiration compared to 2 in group D (without statistical difference). The average oxygen saturation in group S was significantly lower than that in group D at 1, 2 and 3 min after propofol injection (P < 0.001, P = 0.001 and P = 0.020, respectively). There were no statistical differences in oxygen saturation at other time points. There were no statistical differences in MAP and HR (except for the time point of 1 min after the induction) between the two groups. CONCLUSIONS Low dose of doxapram can effectively alleviate low SpO2 in painless gastrointestinal endoscopy with intravenous propofol, without affecting propofol consumption, examination duration, MAP, or HR. TRAIL REGISTRATION The study was approved by the Institutional Ethics Committee of Clinical and New Technology of Wuxi People's Hospital on 20th July, 2018 (KYLLH2018029) and registered in the Chinese Clinical Trial Register on 16th August, 2018 (ChiCTR1800017832).
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Affiliation(s)
- Zhengfeng Gu
- Department of Anesthesiology, Wuxi People’s Hospital Affiliated to Nanjing Medical University, 299 Qingyang Road, Wuxi, 214023 Jiangsu China
| | - Lian Xin
- Department of Anesthesiology, Wuxi People’s Hospital Affiliated to Nanjing Medical University, 299 Qingyang Road, Wuxi, 214023 Jiangsu China
| | - Haoxing Wang
- Department of Anesthesiology, Wuxi People’s Hospital Affiliated to Nanjing Medical University, 299 Qingyang Road, Wuxi, 214023 Jiangsu China
| | - Chunxiao Hu
- Department of Anesthesiology, Wuxi People’s Hospital Affiliated to Nanjing Medical University, 299 Qingyang Road, Wuxi, 214023 Jiangsu China
| | - Zhiping Wang
- Department of Anesthesiology, Wuxi People’s Hospital Affiliated to Nanjing Medical University, 299 Qingyang Road, Wuxi, 214023 Jiangsu China
| | - Shunmei Lu
- Department of Anesthesiology, Wuxi People’s Hospital Affiliated to Nanjing Medical University, 299 Qingyang Road, Wuxi, 214023 Jiangsu China
| | - Jingjing Xu
- Department of Anesthesiology, Wuxi People’s Hospital Affiliated to Nanjing Medical University, 299 Qingyang Road, Wuxi, 214023 Jiangsu China
| | - Yiling Qian
- Department of Anesthesiology, Wuxi People’s Hospital Affiliated to Nanjing Medical University, 299 Qingyang Road, Wuxi, 214023 Jiangsu China
| | - Jun Wang
- Department of Anesthesiology, Wuxi People’s Hospital Affiliated to Nanjing Medical University, 299 Qingyang Road, Wuxi, 214023 Jiangsu China
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Allampati S, Wen S, Liu F, Kupec JT. Recovery of cognitive function after sedation with propofol for outpatient gastrointestinal endoscopy. Saudi J Gastroenterol 2019; 25:188-193. [PMID: 30618439 PMCID: PMC6526733 DOI: 10.4103/sjg.sjg_369_18] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND/AIM Most endoscopies performed in the United States utilize sedation. Anesthesia provides patient comfort and improved procedural quality but adds to the complexity of scheduling routine outpatient procedures. We aimed to assess the return of cognitive function after propofol administration in patients undergoing outpatient endoscopies. PATIENTS AND METHODS Cognitive recovery for patients undergoing endoscopy under monitored anesthesia care was evaluated using EncephalApp. Patients were tested before and after procedure and healthy controls were tested twice, 30 min apart. Results were tabulated in on state (on time) and off state (off time) and total time (on time + off time). The time difference between pre- and post-tests, "delta," was calculated for on, off, and total times. Wilcoxon rank test was used to check the difference in mean delta of all three test times between cases and controls and to check for statistical significance. RESULTS The difference in mean time between cases and controls was significant for off (P < 0.0001) and total (P = 0.0002) times. No statistically significant difference was noted in mean time for on time (P = 0.013) between cases and controls. Cognitive flexibility, a measure of on time, returned to baseline after procedural sedation even though psychomotor speed, a measure of off time and total time, had not. CONCLUSION Cognitive flexibility returns to baseline within 30-45 min after propofol sedation despite delayed return of psychomotor speed and reaction time.
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Affiliation(s)
- Sanath Allampati
- Department of Medicine, West Virginia University, WV, USA,Address for correspondence: Dr. Sanath Allampati, 1, Stadium Drive, Morgantown, WV - 26506, USA. E-mail:
| | - Sijin Wen
- Department of Biostatistics, West Virginia University, WV, USA
| | - Feiyu Liu
- Department of Biostatistics, West Virginia University, WV, USA
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Sargin M, Uluer MS, Şimşek B. The effect of bispectral index monitoring on cognitive performance following sedation for outpatient colonoscopy: a randomized controlled trial. SAO PAULO MED J 2019; 137:305-311. [PMID: 31508796 PMCID: PMC9744010 DOI: 10.1590/1516-3180.2018.0383210519] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 05/21/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Bispectral index (BIS) monitoring can positively affect cognitive performance through decreasing the use of sedative agents. We aimed to evaluate the effect of BIS monitoring on early cognitive performance among patients undergoing sedation for colonoscopy. DESIGN AND SETTING Randomized, controlled trial in a university hospital. METHODS 100 patients were randomized into two groups. In the monitored group (n = 50), the depth of anesthesia was monitored using the BIS, and BIS scores were maintained between 60 and 80. In the usual care group (n = 50), BIS monitoring was not performed. To determine the patients' baseline cognitive performance levels, the mini-mental state examination (MMSE), Trieger dot test (TDT) and clock drawing test (CDT) were used. The patients' post-procedure cognitive performance levels were determined when they were classified as ready for discharge. RESULTS The total volume (mg) of propofol used [median (range) IQR] in the sedation procedure was lower in the monitored group [100 (50-200) 100-140] than in the usual care group [150 (75-200) 100-200] (P < 0.001). The discharge scores [mean (SD)] using MMSE and CDT were higher in the monitored group [26 (3) and 3 (1), respectively] than in the usual care group [23 (3) and 2 (1), respectively] (P = 0.002 and P = 0.002, respectively). The discharge scores using TDT [mean (SD)] were lower in the monitored group [11 (7)] than in the usual care group [15 (11)] (P = 0.033). CONCLUSION BIS monitoring among sedated patients was associated with lower propofol use and smaller decline in cognitive performance. CLINICAL TRIAL REGISTRATION This trial was registered in the Australian New Zealand Clinical Trial Registry (ACTRN12617000134325).
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Affiliation(s)
- Mehmet Sargin
- MD, Assistant Professor, Anesthesiology and Reanimation Department, Selçuk Üniversitesi Tıp Fakültesi, Konya, Turkey.
| | - Mehmet Selçuk Uluer
- MD. Physician, Anesthesiology and Reanimation Department, Health Sciences University, Konya Eğitim ve Araştırma Hastanesi, Konya, Turkey.
| | - Barış Şimşek
- MD. Physician, Anesthesiology and Reanimation Department, Health Sciences University, Konya Eğitim ve Araştırma Hastanesi, Konya, Turkey.
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Comparison of Maternal Stress Response to Midazolam/Fentanyl and Propofol During Cesarean Delivery Under Spinal Anesthesia: A Double-Blinded Randomized Controlled Trial. WOMEN’S HEALTH BULLETIN 2018. [DOI: 10.5812/whb.82741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Martin DP, Warner ME, Johnson RL, Judd MA, Walsh MT, Hanson AC, Schroeder DR, Burkle CM. Outpatient Dismissal With a Responsible Adult Compared With Structured Solo Dismissal: A Retrospective Case-Control Comparison of Safety Outcomes. Mayo Clin Proc Innov Qual Outcomes 2018; 2:234-240. [PMID: 30225456 PMCID: PMC6132205 DOI: 10.1016/j.mayocpiqo.2018.06.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 06/02/2018] [Accepted: 06/08/2018] [Indexed: 12/02/2022] Open
Abstract
Objective To test the hypothesis that patients dismissed alone in a sedation dismissal process (SDP) have no greater risk of adverse outcome compared with those who were dismissed with a responsible adult. Patients and Methods We compared 2441 SDP patients undergoing 2703 procedures with 4923 unique control patients who underwent 5133 procedures between June 1, 2012, and March 31, 2017. Results The rate of unplanned readmission related to the procedure was 0.11% (n=9), and there was no difference between SDP (0.07%) and controls (0.14%). Similarly, there was no difference in complication rates between SDP patients and controls when restricting to “all causes” unplanned readmissions within 24 hours and unplanned readmissions related to procedure. Conclusion With proper preparation, short-acting anesthetic/sedation medications, and sound clinical judgment, the presence of a responsible adult escort is not associated with reduced risk following discharge after ambulatory anesthesia. This practice may lessen the hardships reported by patients in needing to obtain an escort and the inconveniences and delays experienced by ambulatory procedural facilities when patients arrive without a designated escort.
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Affiliation(s)
- David P. Martin
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
- Correspondence: Address to David P. Martin, MD, PhD, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905.
| | - Mary E. Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Rebecca L. Johnson
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Marlea A. Judd
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Michael T. Walsh
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Andrew C. Hanson
- Department of Health Sciences Research, Division of Biostatistics, Mayo Clinic, Rochester, MN
| | - Darrell R. Schroeder
- Department of Health Sciences Research, Division of Biostatistics, Mayo Clinic, Rochester, MN
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Yoon SW, Choi GJ, Lee OH, Yoon IJ, Kang H, Baek CW, Jung YH, Woo YC. Comparison of propofol monotherapy and propofol combination therapy for sedation during gastrointestinal endoscopy: A systematic review and meta-analysis. Dig Endosc 2018; 30:580-591. [PMID: 29526045 DOI: 10.1111/den.13050] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 03/05/2018] [Indexed: 01/22/2023]
Abstract
BACKGROUND AND AIM Previous randomized controlled trials have reported conflicting findings comparing propofol combination therapy (PCT) with propofol monotherapy (PMT) for sedation of patients undergoing gastrointestinal endoscopy. Therefore, a systematic review was carried out to compare the efficacy and safety of PCT and PMT in such patients. METHODS We searched MEDLINE, EMBASE and CENTRAL databases to identify all randomized controlled trials that compared the efficacy and safety of PCT and PMT for sedation of patients undergoing gastrointestinal endoscopy. Primary endpoints were incidence of respiratory complications, hypotension and arrhythmia, dose of propofol used, and recovery time. Procedure duration and the satisfaction of patients and doctors were also evaluated. RESULTS A total of 2250 patients from 22 studies were included in the final analysis. The combined analysis did not show any difference between PCT and PMT in the incidence of respiratory complications (risk ratio [RR], 0.80; 95% CI, 0.52 to 1.23; I2 = 58.34%), hypotension (RR, 1.06; 95% CI, 0.63 to 1.78; I2 = 72.13%), arrhythmia (RR,1.40; 95% CI, 0.74 to 2.64; I2 = 43.71%), recovery time (standardized mean difference [SMD], 0.16; 95% CI, -0.49 to 0.81; I2 = 95.9%), procedure duration (SMD, 0.04; 95% CI, -0.05 to 0.14; I2 = 0.0%), patient satisfaction (SMD, 0.13; 95% CI, -0.26 to 0.52; I2 = 89.63%) or doctor satisfaction (SMD, 0.01; 95% CI, -0.15 to 0.17; I2 = 0.00%). However, the dose of propofol used was significantly lower in PCT than in PMT (SMD, -1.38; 95% CI, -1.99 to -0.77; I2 = 97.70%). CONCLUSION PCT showed comparable efficacy and safety to PMT with respect to respiratory complications, hypotension and arrhythmia, recovery time, procedure duration, patient satisfaction, and doctor satisfaction. However, the average dose of propofol used was higher in PMT.
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Affiliation(s)
- Sang Won Yoon
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Geun Joo Choi
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Oh Haeng Lee
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Il Jae Yoon
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Hyun Kang
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Chong Wha Baek
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Yong Hun Jung
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Young Cheol Woo
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Korea
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Mason KP, Burkle CM. Do patients require "escorts" or "carers" for discharge following day surgery and office-based anesthesia? Both sides of the debate explored. Minerva Anestesiol 2018; 84:980-986. [DOI: 10.23736/s0375-9393.17.12450-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
Cognition is essential to all aspects of our everyday life. Although we take our cognitive function for granted, the perioperative period is prone to several aggressions that might impair it. Postoperative cognitive dysfunction, has been the aim of many studies recently, and was shown to be very common with an incidence that can reach 40%, yielding not only impairment in cognition, but also longer hospital stays, higher costs and greater mortality. While several studies have revealed some of the mechanisms contributing to postoperative cognitive dysfunction, the search for the perfect instrument to screen and measure cognitive (dys)function has proven more elusive. The present paper aims to review several cognitive evaluation methods, discussing their advantages and disadvantages as well as their potential clinical applications in evaluating the dynamics of the recovery of cognitive function after anesthesia and surgery. The current availability of easy to use computerized tests might provide the tools necessary to identify patients at risk, and promptly provide them with the adequate course of action.
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Affiliation(s)
- Sérgio Vide
- Hospital CLINIC de Barcelona, Anesthesiology Department, Systems Pharmacology Effect Control & Modeling (SPEC-M) Research Group, Barcelona, Spain; Hospital Pedro Hispano, Department of Anesthesia, Matosinhos, Portugal; Centro Hospitalar Universitário do Porto, Department of Anesthesiology, Center for Clinical Research in Anesthesia, Porto, Portugal
| | - Pedro L Gambús
- Hospital CLINIC de Barcelona, Anesthesiology Department, Systems Pharmacology Effect Control & Modeling (SPEC-M) Research Group, Barcelona, Spain; University of California San Francisco (UCSF), Department of Anesthesia and Perioperative Care, San Francisco, California, USA; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), NeuroImmunology Research Group, Barcelona, Spain.
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Computerized tests to evaluate recovery of cognitive function after deep sedation with propofol and remifentanil for colonoscopy. J Clin Monit Comput 2018; 33:107-113. [PMID: 29589170 DOI: 10.1007/s10877-018-0134-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 03/21/2018] [Indexed: 12/21/2022]
Abstract
The use of sedation for diagnostic procedures including gastrointestinal endoscopy is rapidly growing. Recovery of cognitive function after sedation is important because it would be important for most patients to resume safe, normal life soon after the procedure. Computerized tests have shown being accurate descriptors of cognitive function. The purpose of the present study was to evaluate the time course of cognitive function recovery after sedation with propofol and remifentanil. A prospective observational double blind clinical study conducted in 34 young healthy adults undergoing elective outpatient colonoscopy under sedation with the combination of propofol and remifentanil using a target controlled infusion system. Cognitive function was measured using a validated battery of computerized cognitive tests (Cogstate™, Melbourne, Australia) at different predefined times: prior to starting sedation (Tbaseline), and then 10 min (T10), 40 min (T40) and 120 min (T120) after the end of colonoscopy. Tests included the assessment of psychomotor function, attention, visual memory and working memory. All colonoscopies were completed (median time: 26 min) without significant adverse events. Patients received a median total dose of propofol and remifentanil of 149 mg and 98 µg, respectively. Psychomotor function and attention declined at T10 but were back to baseline values at T40 for all patients. The magnitude of psychomotor task reduction was large (d = 0.81) however 100% of patients were recovered at T40. Memory related tasks were not affected 10 min after ending sedation. Cognitive impairment in attention and psychomotor function after propofol and remifentanil sedation was significant and large and could be easily detected by computerized cognitive tests. Even though, patients were fully recovered 40 min after ending the procedure. From a cognitive recovery point of view, larger studies should be undertaken to propose adequate criteria for discharge after sedation.
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Singh SA, Prakash K, Sharma S, Dhakate G, Bhatia V. Comparison of propofol alone and in combination with ketamine or fentanyl for sedation in endoscopic ultrasonography. Korean J Anesthesiol 2018; 71:43-47. [PMID: 29441174 PMCID: PMC5809707 DOI: 10.4097/kjae.2018.71.1.43] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 04/03/2017] [Accepted: 04/16/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND We evaluated whether the addition of a small dose of ketamine or fentanyl would lead to a reduction in the total dose of propofol consumed without compromising the safety and recovery of patients having endoscopic ultrasonography (EUS). METHODS A total of 210 adult patients undergoing elective EUS under sedation were included in the study. Patients were randomized into three groups. Patients were premedicated intravenously with normal saline in group 1, 50 µg fentanyl in group 2, and 0.5 mg/kg ketamine in group 3. All patients received intravenous propofol for sedation. Propofol consumption in mg/kg/h was noted. The incidence of hypotension, bradycardia, desaturation, and coughing was noted. The time to achieve a Post Anesthesia Discharge Score (PADS) of 10 was also noted. RESULTS There were 68 patients in group 1, 70 in group 2, and 72 in group 3. The amount of propofol consumed was significantly higher in group 1 (9.25 [7.3-13.2]) than in group 2 (8.8 [6.8-12.2]) and group 3 (7.6 [5.7-9.8]). Patient hemodynamics and oxygenation were well maintained and comparable in all groups. The time to achieve a PADS of 10 was significantly higher in group 3 compared to the other two groups. CONCLUSIONS The use of 50 µg fentanyl or 0.5 mg/kg ketamine in a single dose during EUS reduces the dose of propofol required for sedation. However, unlike the addition of fentanyl, the addition of ketamine increased the time to recovery. Thus, 50 µg fentanyl is a good additive to propofol infusion for sedation during EUS to reduce the requirement for propofol without affecting the time to recovery.
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Affiliation(s)
- Shweta A Singh
- Department of Anaesthesiology and Critical Care, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Kelika Prakash
- Department of Anaesthesiology and Critical Care, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Sandeep Sharma
- Department of Anaesthesiology and Critical Care, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Gaurav Dhakate
- Department of Anaesthesiology and Critical Care, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Vikram Bhatia
- Department of Hepatology, Institute of Liver & Biliary Sciences, New Delhi, India
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Anesthesia for Colonoscopy. Anesthesiology 2018. [DOI: 10.1007/978-3-319-74766-8_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Ekmekçi P, Erkan G, Yilmaz H, K Kazbek B, C Köksoy U, Doganay G, Filiz Tüzüner D. Effect of Different Sedation Regimes on Cognitive Functions in Colonoscopy. Euroasian J Hepatogastroenterol 2017; 7:158-162. [PMID: 29201800 PMCID: PMC5670261 DOI: 10.5005/jp-journals-10018-1239] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 06/04/2017] [Indexed: 01/14/2023] Open
Abstract
Aim: To compare the effects of propofol/remifentanil and meperidine/midazolam on postprocedure cognitive function. Materials and methods: A total of 100 American Society of Anesthesiologists (ASA) score I to III patients undergoing elective colonoscopy were taken into the study and divided into two groups. Exclusion criteria were patient refusal, mini mental test (MMT) <26, The Amsterdam Preoperative Anxiety and Information Scale (APAIS) >10, advanced cardiopulmonary or psychiatric disease, chronic alcohol abuse, morbid obesity, and known allergy to study drugs. In group MM, 2 mg midazolam and 20 mg meperidine was given intravenously and additional 1 to 2 mg midazolam and 20 mg meperidine (with a maximum total of 5 mg midazolam and 50 mg meperidine) was given when bispectral index (BIS) was >80. In group RP, 100 μg/kg/minute propofol infusion and 1 μg/kg remifentanil bolus was administered and additional 0.5 μg/kg remifentanil bolus was given when BIS was >80. Observer’s Assessment of Alertness/Sedation scale (OAA/S) and Facial Pain Score (FPS) values were recorded. Cognitive function was measured by Trieger Dot Test (TDT) and Digit Symbol Substitution Test (DSST). Results: The study was concluded with 100 patients. Heart rate was slower and BIS values were lower in group RP throughout the procedure. Blood pressure was lower in group RP without clinical significance. There was no difference concerning recovery time and visual analog scores (VASs). In group MM, TDT scores were higher and DSST scores were lower. Satisfaction was higher in group RP. Conclusion: Propofol/remifentanil combination is better than meperidine/midazolam combination concerning cognitive function in sedation for colonoscopy. Clinical significance: The addition of BIS monitorization to evaluate the depth of sedation and the negative effects of midazolam meperidine combination on postprocedural cognitive function. How to cite this article: Ekmekci P, Erkan G, Yilmaz H, Kazbek BK, Koksoy UC, Doganay G, Tüzüner F. Effect of Different Sedation Regimes on Cognitive Functions in Colonoscopy. Euroasian J Hepato-Gastroenterol 2017;7(2):158-162.
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Affiliation(s)
- Perihan Ekmekçi
- Department of Anesthesiology and Reanimation, Ufuk University, Ankara, Turkey
| | - Gulbanu Erkan
- Department of Gastroenterology, Anesthesiology and Reanimation, Ufuk University, Ankara, Turkey
| | - Hakan Yilmaz
- Department of Anesthesiology and Reanimation, Ufuk University, Ankara, Turkey
| | - Baturay K Kazbek
- Department of Anesthesiology and Reanimation, Ufuk University, Ankara, Turkey
| | - Ulku C Köksoy
- Department of Anesthesiology and Reanimation, Ufuk University, Ankara, Turkey
| | - Güler Doganay
- Department of Anesthesiology and Reanimation, Ufuk University, Ankara, Turkey
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Karamnov S, Sarkisian N, Grammer R, Gross WL, Urman RD. Analysis of Adverse Events Associated With Adult Moderate Procedural Sedation Outside the Operating Room. J Patient Saf 2017; 13:111-121. [DOI: 10.1097/pts.0000000000000135] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Sathananthan D, Young E, Nind G, George B, Ashby A, Drummond S, Redel K, Green N, Singh R. Assessing the safety of physician-directed nurse-administered propofol sedation in low-risk patients undergoing endoscopy and colonoscopy. Endosc Int Open 2017; 5:E110-E115. [PMID: 28210707 PMCID: PMC5305421 DOI: 10.1055/s-0042-121667] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background and study aims Physician-directed nurse-administered balanced propofol sedation (PhD NAPS) in patients undergoing endoscopy and/or colonoscopy is being increasingly utilized worldwide. However, this method of sedation is not universally employed in Australian hospitals due to concerns surrounding its safety. The aim of this study was to assess the safety of PhD NAPS in low-risk patients undergoing endoscopy and/or colonoscopy. Patients and methods This study was conducted at a single tertiary teaching hospital in Adelaide, Australia. It was a prospective study involving 1000 patients with an ASA score of 1 - 3 presenting with any indication for endoscopy, colonoscopy or both. A total of 981 patients (451 male) with a mean age of 53 years (range: 16 - 87) were recruited from January 2010 to October 2012. 440 endoscopies, 420 colonoscopies, and 121 combined procedures were performed. The intra-procedural adverse events (AEs) were recorded. Results There were no major intra-procedural adverse events. Minor AEs occurred in 6.42 % of patients, and resolved spontaneously or with intravenous fluid boluses in all cases. Conclusion PhD NAPS is safe when the proceduralist and nursing staff are adequately trained and strict patient selection criteria are used.
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Affiliation(s)
| | - Edward Young
- University of Adelaide Medical School, Adelaide, South Australia
| | - Garry Nind
- Lyell McEwin Hospital – Gastroenterology, Adelaide, South Australia
| | - Biju George
- Lyell McEwin Hospital – Gastroenterology, Adelaide, South Australia
| | - Angelie Ashby
- University of Adelaide/Lyell McEwin Hospital, Endoscopy Unit, Elizabeth Vale, South Australia
| | - Sharon Drummond
- University of Adelaide/Lyell McEwin Hospital, Endoscopy Unit, Elizabeth Vale, South Australia
| | - Kasia Redel
- University of Adelaide/Lyell McEwin Hospital, Endoscopy Unit, Elizabeth Vale, South Australia
| | - Neville Green
- Lyell McEwin Hospital – Anaesthetics, Elizabeth Vale, South Australia
| | - Rajvinder Singh
- Lyell McEwin Hospital – Gastroenterology, Adelaide, South Australia
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Carvalho Ferreira FP, Barbosa Lima AP, de Paula EDCM, Ferreira Conti ACDC, Valarelli DP, de Almeida-Pedrin RR. Orthodontic Protocol Using Mini-Implant for Class II Treatment in Patient with Special Needs. Case Rep Dent 2016; 2016:1057263. [PMID: 27847652 PMCID: PMC5101373 DOI: 10.1155/2016/1057263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Accepted: 09/20/2016] [Indexed: 11/24/2022] Open
Abstract
Improving facial and dental appearance and social interaction are the main factors for special needs (SN) patients to seek orthodontic treatment. The cooperation of SN patients and their parents is crucial for treatment success. Objective. To show through a case report the satisfactory results, both functional and esthetic, in patients with intellectual disability, congenital nystagmus, and severe scoliosis. Materials Used. Pendulum device with mini-implants as anchorage unit. Results. Improvement of facial and dental esthetics, correction of Class II malocclusion, and no root resorption shown in the radiographic follow-up. Conclusion. Knowing the limitations of SN patients, having a trained team, motivating and counting on the cooperation of parents and patients, and employing quick and low-cost orthodontic therapy have been shown to be the essential factors for treatment success.
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Messina AG, Wang M, Ward MJ, Wilker CC, Smith BB, Vezina DP, Pace NL. Anaesthetic interventions for prevention of awareness during surgery. Cochrane Database Syst Rev 2016; 10:CD007272. [PMID: 27755648 PMCID: PMC6461159 DOI: 10.1002/14651858.cd007272.pub2] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND General anaesthesia is usually associated with unconsciousness. 'Awareness' is when patients have postoperative recall of events or experiences during surgery. 'Wakefulness' is when patients become conscious during surgery, but have no postoperative recollection of the period of consciousness. OBJECTIVES To evaluate the efficacy of two types of anaesthetic interventions in reducing clinically significant awareness:- anaesthetic drug regimens; and- intraoperative anaesthetic depth monitors. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL, ISSUE 4 2016); PubMed from 1950 to April 2016; MEDLINE from 1950 to April 2016; and Embase from 1980 to April 2016. We contacted experts to identify additional studies. We performed a handsearch of the citations in the review. We did not search trial registries. SELECTION CRITERIA We included randomized controlled trials (RCTs) of either anaesthetic regimens or anaesthetic depth monitors. We excluded volunteer studies, studies of patients prior to skin incision, intensive care unit studies, and studies that only randomized different word presentations for memory tests (not anaesthetic interventions).Anaesthetic drug regimens included studies of induction or maintenance, or both. Anaesthetic depth monitors included the Bispectral Index monitor, M-Entropy, Narcotrend monitor, cerebral function monitor, cerebral state monitor, patient state index, and lower oesophageal contractility monitor. The use of anaesthetic depth monitors allows the titration of anaesthetic drugs to maintain unconsciousness. DATA COLLECTION AND ANALYSIS At least two authors independently scanned abstracts, extracted data from the studies, and evaluated studies for risk of bias. We made attempts to contact all authors for additional clarification. We performed meta-analysis statistics in packages of the R language. MAIN RESULTS We included 160 studies with 54,109 enrolled participants; 53,713 participants started the studies and 50,034 completed the studies or data analysis (or both). We could not use 115 RCTs in meta-analytic comparisons because they had zero awareness events. We did not merge 27 of the remaining 45 studies because they had excessive clinical and methodological heterogeneity. We pooled the remaining 18 eligible RCTs in meta-analysis. There are 10 studies awaiting classification which we will process when we update the review.The meta-analyses included 18 trials with 36,034 participants. In the analysis of anaesthetic depth monitoring (either Bispectral Index or M-entropy) versus standard clinical and electronic monitoring, there were nine trials with 34,744 participants. The overall event rate was 0.5%. The effect favoured neither anaesthetic depth monitoring nor standard clinical and electronic monitoring, with little precision in the odds ratio (OR) estimate (OR 0.98, 95% confidence interval (CI) 0.59 to 1.62).In a five-study subset of Bispectral Index monitoring versus standard clinical and electronic monitoring, with 34,181 participants, 503 participants gave awareness reports to a blinded, expert panel who adjudicated or judged the outcome for each patient after reviewing the questionnaires: no awareness, possible awareness, or definite awareness. Experts judged 351 patient awareness reports to have no awareness, 87 to have possible awareness, and 65 to have definite awareness. The effect size favoured neither Bispectral Index monitoring nor standard clinical and electronic monitoring, with little precision in the OR estimate for the combination of definite and possible awareness (OR 0.96, 95% CI 0.35 to 2.65). The effect size favoured Bispectral Index monitoring for definite awareness, but with little precision in the OR estimate (OR 0.60, 95% CI 0.13 to 2.75).We performed three smaller meta-analyses of anaesthetic drugs. There were nine studies with 1290 participants. Wakefulness was reduced by ketamine and etomidate compared to thiopental. Wakefulness was more frequent than awareness. Benzodiazepines reduces awareness compared to thiopental, ketamine, and placebo., Also, higher doses of inhaled anaesthetics versus lower doses reduced the risk of awareness.We graded the quality of the evidence as low or very low in the 'Summary of findings' tables for the five comparisons.Most of the secondary outcomes in this review were not reported in the included RCTs. AUTHORS' CONCLUSIONS Anaesthetic depth monitors may have similar effects to standard clinical and electrical monitoring on the risk of awareness during surgery. In older studies comparing anaesthetics in a smaller portion of the patient sample, wakefulness occurred more frequently than awareness. Use of etomidate and ketamine lowered the risk of wakefulness compared to thiopental. Benzodiazepines compared to thiopental and ketamine, or higher doses of inhaled anaesthetics versus lower doses, reduced the risk of awareness.
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Affiliation(s)
- Anthony G Messina
- School of Management, University of Texas at DallasThe Alliance for Medical Management EducationBox 2331920 N. Coit RoadRichardsonTXUSA75080
| | - Michael Wang
- University of LeicesterClinical Psychology UnitLancaster RoadLeicesterUKLE1 7HA
| | - Marshall J Ward
- Dartmouth‐Hitchcock Medical Center1 Medical Center DrLebanonNHUSA03766
| | - Chase C Wilker
- ARUP LaboratoriesClinical Toxicology IIISalt Lake CityUTUSA
| | - Brett B Smith
- University of UtahUniversity of Utah School of MedicineSalt Lake CityUTUSA84112
| | - Daniel P Vezina
- University of UtahDepartment of Anesthesiology, Department of Internal Medicine, Division of CardiologySalt Lake CityUTUSA
- Veteran's AdministrationEchocardiography LaboratorySalt Lake CityUTUSA
| | - Nathan Leon Pace
- University of UtahDepartment of Anesthesiology3C444 SOM30 North 1900 EastSalt Lake CityUTUSA84132‐2304
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Yatabe T, Tamura T, Yamashita K, Yokoyama M. Influence of dexmedetomidine on cognitive function in volunteers. J Clin Anesth 2016; 33:92-6. [DOI: 10.1016/j.jclinane.2016.03.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 07/27/2015] [Accepted: 03/05/2016] [Indexed: 10/21/2022]
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Becerra L, Aasted CM, Boas DA, George E, Yücel MA, Kussman BD, Kelsey P, Borsook D. Brain measures of nociception using near-infrared spectroscopy in patients undergoing routine screening colonoscopy. Pain 2016; 157:840-848. [PMID: 26645550 PMCID: PMC4794375 DOI: 10.1097/j.pain.0000000000000446] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Colonoscopy is an invaluable tool for the screening and diagnosis of many colonic diseases. For most colonoscopies, moderate sedation is used during the procedure. However, insufflation of the colon produces a nociceptive stimulus that is usually accompanied by facial grimacing/groaning while under sedation. The objective of this study was to evaluate whether a nociceptive signal elicited by colonic insufflation could be measured from the brain. Seventeen otherwise healthy patients (age 54.8 ± 9.1; 6 female) undergoing routine colonoscopy (ie, no history of significant medical conditions) were monitored using near-infrared spectroscopy (NIRS). Moderate sedation was produced using standard clinical protocols for midazolam and meperidine, titrated to effect. Near-infrared spectroscopy data captured during the procedure was analyzed offline to evaluate the brains' responses to nociceptive stimuli evoked by the insufflation events (defined by physician or observing patients' facial responses). Analysis of NIRS data revealed a specific, reproducible prefrontal cortex activity corresponding to times when patients grimaced. The pattern of the activation is similar to that previously observed during nociceptive stimuli in awake healthy individuals, suggesting that this approach may be used to evaluate brain activity evoked by nociceptive stimuli under sedation, when there is incomplete analgesia. Although some patients report recollection of procedural pain after the procedure, the effects of repeated nociceptive stimuli in surgical patients may contribute to postoperative changes including chronic pain. The results from this study indicate that NIRS may be a suitable technology for continuous nociceptive afferent monitoring in patients undergoing sedation and could have applications under sedation or anesthesia.
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Affiliation(s)
- Lino Becerra
- P.A.I.N. Group, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA, USA Center for Pain and the Brain, Harvard Medical School, Boston, MA, USA Departments of Radiology Anesthesia and Critical Care, and Medicine, Massachusetts General Hospital, Boston, MA, USA
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das Neves JFNP, das Neves Araújo MMP, de Paiva Araújo F, Ferreira CM, Duarte FBN, Pace FH, Ornellas LC, Baron TH, Ferreira LEVVDC. Colonoscopy sedation: clinical trial comparing propofol and fentanyl with or without midazolam. Braz J Anesthesiol 2016; 66:231-6. [PMID: 27108817 DOI: 10.1016/j.bjane.2014.09.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Accepted: 09/17/2014] [Indexed: 01/31/2023] Open
Abstract
Colonoscopy is one of the most common procedures. Sedation and analgesia decrease anxiety and discomfort and minimize risks. Therefore, patients prefer to be sedated when undergoing examination, although the best combination of drugs has not been determined. The combination of opioids and benzodiazepines is used to relieve the patient's pain and discomfort. More recently, propofol has assumed a prominent position. This randomized prospective study is unique in medical literature that specifically compared the use of propofol and fentanyl with or without midazolam for colonoscopy sedation performed by anesthesiologists. The aim of this study was to evaluate the side effects of sedation, discharge conditions, quality of sedation, and propofol consumption during colonoscopy, with or without midazolam as preanesthetic. The study involved 140 patients who underwent colonoscopy at the University Hospital of the Federal University of Juiz de Fora. Patients were divided into two groups: Group I received intravenous midazolam as preanesthetic 5min before sedation, followed by fentanyl and propofol; Group II received intravenous anesthesia with fentanyl and propofol. Patients in Group II had a higher incidence of reaction (motor or verbal) to the colonoscope introduction, bradycardia, hypotension, and increased propofol consumption. Patient satisfaction was higher in Group I. According to the methodology used, the combination of midazolam, fentanyl, and propofol for colonoscopy sedation reduces propofol consumption and provides greater patient satisfaction.
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Affiliation(s)
| | | | | | | | | | - Fabio Heleno Pace
- Universidade Federal de Juiz de Fora (UFJF), Juiz de Fora, MG, Brazil
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Allen M, Leslie K, Hebbard G, Jones I, Mettho T, Maruff P. A randomized controlled trial of light versus deep propofol sedation for elective outpatient colonoscopy: recall, procedural conditions, and recovery. Can J Anaesth 2015; 62:1169-78. [PMID: 26335904 DOI: 10.1007/s12630-015-0463-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 08/13/2015] [Indexed: 12/13/2022] Open
Abstract
PURPOSE This study aimed to determine if the incidence of recall was equivalent between light and deep sedation for colonoscopy. Secondary analysis included complications, patient clinical recovery, and post-procedure cognitive impairment. METHODS Two hundred patients undergoing elective outpatient colonoscopy were randomized to light (bispectral index [BIS] 70-80) or deep (BIS < 60) sedation with propofol and fentanyl. Recall was assessed by the modified Brice questionnaire, and cognition at baseline and discharge was assessed using a Cogstate test battery. RESULTS The median (interquartile range [IQR]) BIS values were different in the two groups (69 [65-74] light sedation vs 53 [46-59] deep sedation; P < 0.0001). The incidence of recall was 12% in the light sedation group and 1% in the deep sedation group. The risk difference for recall was 0.11 (90% confidence interval, 0.05 to 0.17) in the intention-to-treat analysis, thus refuting equivalence in recall between light and deep sedation (0.05 significance level; 10% equivalence margin). Overall sedation-related complications were more frequent with deep sedation than with light sedation (66% vs 47%, respectively; P = 0.008). Recovery was more rapid with light sedation than with deep sedation as determined by the mean (SD) time to reach a score of 5 on the Modified Observer's Assessment of Alertness/Sedation Scale [3 (4) min vs 7 (4) min, respectively; P < 0.001] and by the median [IQR] time to readiness for hospital discharge (65 [57-80] min vs 74 [63-86] min, respectively; P = 0.001). The incidence of post-procedural cognitive impairment was similar in those randomized to light (19%) vs deep (16%) sedation (P = 0.554). CONCLUSION Light sedation was not equivalent to deep sedation for procedural recall, the spectrum of complications, or recovery times. This study provides evidence to inform discussions with patients about sedation for colonoscopy. This trial was registered at the Australian and New Zealand Clinical Trials Registry, number 12611000320954.
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Affiliation(s)
- Megan Allen
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Australia. .,Anaesthesia, Perioperative and Pain Medicine Unit, University of Melbourne, Melbourne, Australia.
| | - Kate Leslie
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Australia.,Anaesthesia, Perioperative and Pain Medicine Unit, University of Melbourne, Melbourne, Australia.,Department of Pharmacology, University of Melbourne, Melbourne, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Geoffrey Hebbard
- Department of Gastroenterology, Royal Melbourne Hospital, Melbourne, Australia.,Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Ian Jones
- Colorectal Surgery Unit, Royal Melbourne Hospital, Melbourne, Australia.,Department of Surgery, University of Melbourne, Melbourne, Australia
| | - Tejinder Mettho
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Australia.,Anaesthesia, Perioperative and Pain Medicine Unit, University of Melbourne, Melbourne, Australia
| | - Paul Maruff
- Cogstate Ltd, Melbourne, Australia.,Centre for Neuroscience, University of Melbourne, Melbourne, Australia
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Fanti L, Gemma M, Agostoni M, Rossi G, Ruggeri L, Azzolini ML, Dabizzi E, Beretta L, Testoni PA. Target Controlled Infusion for non-anaesthesiologist propofol sedation during gastrointestinal endoscopy: The first double blind randomized controlled trial. Dig Liver Dis 2015; 47:566-71. [PMID: 25840875 DOI: 10.1016/j.dld.2015.03.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 03/02/2015] [Accepted: 03/06/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Target Controlled Infusion is a sophisticated tool for providing optimal sedation regimen avoiding under or oversedation in gastrointestinal endoscopy. AIMS To compare standard moderate sedation vs. non-anaesthesiologist-administered propofol sedation during gastrointestinal endoscopy. METHODS Randomized controlled trial of 70 consecutive colonoscopies and 70 consecutive esophagogastroduodenoscopies (EGD). Standard group (n=70), received fentanyl (1 μg/kg)+midazolam (0.03-0.04 mg/kg) or midazolam only; propofol group (n=70), received fentanyl (1 μg/kg)+propofol Target Controlled Infusion (1.2-1.6 μg/ml) or propofol Target Controlled Infusion only. Discharge time, endoscopist satisfaction and patient satisfaction were recorded in all endoscopies. RESULTS Colonoscopy: discharge time was significantly shorter in the propofol than the standard group (1.1 ± 0.3 vs. 5 ± 10.2 min, respectively; P=0.03). Endoscopist satisfaction was significantly higher (98.3 ± 11.4/100 vs. 87.2±12/100; P=0.001); patient satisfaction was significantly higher (95 ± 9.3/100 vs. 85.5 ± 14.4/100; P=0.002) in the propofol compared to the standard group. EGD: discharge time was not significantly different in the propofol and standard groups (1.1 ± 0.7 vs. 3.9 ± 9.2 min, respectively; P=0.146). Endoscopist satisfaction was significantly higher (92.7 ± 14.3/100 vs. 82.8 ± 21.2/100; P=0.03); patient satisfaction was significantly higher (93.8 ± 18.2/100 vs. 76.5 ± 25.2/100; P=0.003). In the propofol group 94.3% of patients vs. 71.4% of patients in standard group asked to receive the same sedation in the future (P=0.021). CONCLUSION Target Controlled Infusion is a promising method for non-anaesthesiologist-administered propofol sedation.
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Affiliation(s)
- Lorella Fanti
- Division of Gastroenterology and Gastrointestinal Endoscopy, Vita-Salute San Raffaele University - Scientific Institute San Raffaele, Milan, Italy.
| | - Marco Gemma
- Department of Anesthesiology, Vita-Salute San Raffaele University - Scientific Institute San Raffaele, Milan, Italy
| | - Massimo Agostoni
- Department of Anesthesiology, Vita-Salute San Raffaele University - Scientific Institute San Raffaele, Milan, Italy
| | - Gemma Rossi
- Division of Gastroenterology and Gastrointestinal Endoscopy, Vita-Salute San Raffaele University - Scientific Institute San Raffaele, Milan, Italy
| | - Laura Ruggeri
- Department of Anesthesiology, Vita-Salute San Raffaele University - Scientific Institute San Raffaele, Milan, Italy
| | - Maria Luisa Azzolini
- Department of Anesthesiology, Vita-Salute San Raffaele University - Scientific Institute San Raffaele, Milan, Italy
| | - Emanuele Dabizzi
- Division of Gastroenterology and Gastrointestinal Endoscopy, Vita-Salute San Raffaele University - Scientific Institute San Raffaele, Milan, Italy
| | - Luigi Beretta
- Department of Anesthesiology, Vita-Salute San Raffaele University - Scientific Institute San Raffaele, Milan, Italy
| | - Pier Alberto Testoni
- Division of Gastroenterology and Gastrointestinal Endoscopy, Vita-Salute San Raffaele University - Scientific Institute San Raffaele, Milan, Italy
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Maeda S, Tomayasu Y, Higuchi H, Ishii-Maruhama M, Yamane A, Yabuki A, Honda Y, Egusa M, Miyawaki T. Independent factors affecting recovery time after sedation in patients with intellectual disabilities. Open Dent J 2015; 9:146-9. [PMID: 25926898 PMCID: PMC4407006 DOI: 10.2174/1874210601509010146] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Revised: 03/18/2015] [Accepted: 03/20/2015] [Indexed: 11/27/2022] Open
Abstract
Purpose : The purpose of this study was to identify independent factors associated with prolonged recovery time after intravenous sedation for dental treatment in patients with intellectual disabilities. Methods : This study was designed as a prospective cohort study. Participants were patients with intellectual disabilities, for whom sedation for dental treatment was planned in Okayama University Hospital. The outcome variable was recovery time. The predictor variables were patient background, antiepileptic and psychotropic drugs, and anesthesia-related variables. Factors affecting the outcome were examined with multiple regression analysis. Results : We enrolled 260 cases in this study. Oral midazolam was a strong independent determinant in prolonged recovery time. Teeth extraction, short treatment time and lower body mass index were significant independent predictors of prolonged recovery time. Conclusion : Oral midazolam is a clear independent determinant of prolonged recovery time after sedation, while psychotropic drugs and antiepileptic drugs were not independent determinants in this study.
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Affiliation(s)
- Shigeru Maeda
- Department of Dental Anesthesiology, Okayama University Hospital. Okayama, Japan
| | - Yumiko Tomayasu
- Department of Dental Anesthesiology and Special Care Dentistry, Okayama University, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hitoshi Higuchi
- Department of Dental Anesthesiology, Okayama University Hospital. Okayama, Japan
| | | | - Ayaka Yamane
- Department of Dental Anesthesiology, Okayama University Hospital. Okayama, Japan
| | - Akiko Yabuki
- Department of Dental Anesthesiology, Okayama University Hospital. Okayama, Japan
| | - Yuka Honda
- Department of Dental Anesthesiology and Special Care Dentistry, Okayama University, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Masahiko Egusa
- Special Needs Dentistry, Okayama University Hospital, Okayama, Japan
| | - Takuya Miyawaki
- Department of Dental Anesthesiology and Special Care Dentistry, Okayama University, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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