Etomidate and midazolam for reduction of anterior shoulder dislocation: a randomized,controlled trial

STUDY OBJECTIVE: We determine whether patients with acute, anterior shoulder dislocation undergoing emergency department procedural sedation and analgesia (PSA) with intravenous etomidate would experience a reduced time of impaired consciousness when compared with a group of patients receiving intravenous midazolam. METHODS: This study was a prospective, double-blinded, randomized, institutional review board-approved trial of ED patients with anterior shoulder dislocation. Patients were randomized to receive intravenous boluses of etomidate (0.1 mg/kg) or midazolam (0.033 mg/kg) during PSA. The primary outcome for comparison was PSA duration. RESULTS: Forty-six patients with anterior shoulder dislocation were enrolled: 22 in the etomidate group and 24 in the midazolam group. Three patients sustained reduction without physician or sedative intervention. Two patients were excluded from protocol because of unavailable study drug or fracture dislocation. The median lowest modified postanesthetic recovery score observed during PSA was 5 (95% confidence interval [CI] 4 to 7) in the etomidate group and 6 (95% CI 6 to 7) in the midazolam group. The median time of PSA for patients receiving etomidate was 10 minutes (95% CI 8 to 15) compared with 23 minutes (95% CI 16 to 30) for patients receiving midazolam, with a difference between the group medians of 13 minutes (95% CI 5 to 22). Reduction success was achieved in 37 (90%) of 41 patients: 2 did not experience reduction with etomidate and 2 did not experience reduction with midazolam. There were 15 PSA complications reported. CONCLUSION: Etomidate provides effective PSA for reduction of ED patients with anterior shoulder dislocation. When compared with midazolam, etomidate use confers a significantly shorter period of PSA.     

Impact of flumazenil on recovery after outpatient endoscopy: a placebo-controlled trial

BACKGROUND: Flumazenil is an imidazobenzodiazepine that blocks the central effects of benzodiazepines by competitive interaction at the receptor level. In this study we assessed the impact of flumazenil use on postsedation observation time in outpatients undergoing endoscopy. METHODS: Sixty outpatients received midazolam for conscious sedation and were randomized after endoscopy to receive intravenous flumazenil (0.1 mg/mL) or placebo until awake or a total of 10 mL was given. All patients were assessed using various psychomotor and cognitive tests at baseline and at 5, 15, 30, 45 and 60 minutes after flumazenil or placebo was administered. RESULTS: The two groups were similar in age, gender, midazolam dose (mg/kg), vital signs, and baseline parameters. The average dose of flumazenil given was 0.41 mg. Sedation scores returned to presedation levels earlier in the flumazenil group, with significant differences compared to placebo at 5 minutes (84.6% vs. 24.2%), 15 minutes (88. 5% vs. 57.6%) and 30 minutes (96.2% vs. 66.7%). Other parameters tested were not significantly different for patients receiving placebo compared to those given flumazenil. Sedation scores returned to baseline earlier than other psychomotor and cognitive tests in both groups. Flumazenil reduced the mean observation time from 23.5 minutes to 8.3 minutes (p < 0.0005), a difference of 15.2 minutes (64.7%) based on sedation score. CONCLUSIONS: Flumazenil significantly reduces postsedation observation time. Actual cost savings will vary depending on staff and facility capacity, patient volume, flumazenil cost, and unit cost of observation time.     

Synergistic sedation with midazolam and propofol versus midazolam and pethidine in colonoscopies: a prospective,randomized study

OBJECTIVE: The aim of our study was to compare the safety and efficacy of the synergistic sedation with a low dose of midazolam combined with propofol versus the standard regimen of midazolam and pethidine for conscious sedation in colonoscopy in a group of patients that included a sufficient number of elderly patients with several comorbidities. METHODS: A total of 120 consecutive patients undergoing colonoscopy in a prospective study were randomly assigned to one of two medication regimens (55 patients were over 65 yr). Patients in group A (n = 64) received i.v. 2 mg (<70 kg b.w.) or 3 mg (>70 kg b.w.) of midazolam and a median dose of 80 mg of propofol (range 40-150). Patients in group B (n = 56) received i.v. a median dose of 5 mg of midazolam (range 3-7) and 75 mg of pethidine (range 50-125). The patient's comfort level was assessed by a 4-point scale 24 h after the procedure. The time to recover from sedation was assessed at 5, 10, and 30 min after the procedure by using the Aldrete score. RESULTS: Multivariate stepwise logistic regression analysis revealed that among sex, age, duration of the test, American Society of Anesthesiologists' Physical Status Classification grade, and the sort of sedation, the synergistic sedation with midazolam and propofol was the only factor associated with a higher level of patient comfort (chi2 = 5.5, p < 0.05). Additional multivariate stepwise logistic regression analysis revealed that among sex, age, duration of the test, American Society of Anesthesiologists' Physical Status Classification grade, and the sort of sedation, the synergistic sedation with midazolam and propofol was the only factor associated with a quicker patient recovery time (chi2 = 24.5, p < 0.01; chi2 = 51.7, p < 0.01; chi2 = 148.4, p < 0.01 for Aldrete in 10 min, 20 min, and 30 min, respectively). The endoscopist's evaluation of patient sedation and cardiorespiratory parameters were similar in both groups and in all age groups. CONCLUSIONS: Our data suggest that the synergistic sedation with a low dose of midazolam combined with propofol was superior to a standard combination of midazolam and the opioid pethidine for colonoscopies as far as the patient comfort and recovery times are concerned.     

内镜下食管黏膜切除术的麻醉方法比较

目的比较早期食管癌及癌前病变内镜下食管黏膜切除术中2种静脉麻醉的应用效果及安全性。方法140例早期食管癌及癌前病变行内镜下食管黏膜切除术的患者,随机分为2组,每组70例。I组为咪唑安定＋异丙酚,Ⅱ组为咪唑安定＋依托咪酯。观察比较2组患者手术过程中生命体征、麻醉效果、清醒时间及术中、术后不良反应。结果2种麻醉方式均能满足内镜治疗的需要。I组患者治疗过程中血压、心率较检查前有不同程度的下降;Ⅱ组患者治疗过程中血压、心率相对平稳,与检查前比较差异无统计学意义,与I组比较部分观察时点差异有统计学意义（P〈0．05）。2组患者血氧饱合度均在正常范围,苏醒时间差异无统计学意义。Ⅱ组患者肌震颤或阵挛发生率明显高于I组,心动过缓及低血压发生率低于I组,组间比较差异均有统计学意义（P均〈0．05）。少数患者术后有疼痛、恶心及头晕等不适,组间比较差异无统计学意义。结论异丙酚和依托咪酯麻醉均能满足消化内镜治疗的要求,使用依托咪酯麻醉的患者血流动力学更平稳。     

Premedication with orally administered midazolam in adults undergoing diagnostic upper endoscopy: a double-blind placebo-controlled randomized trial

BACKGROUND: A double-blind placebo-controlled randomized trial was conducted to investigate the safety and the efficacy of orally administered midazolam as premedication for patients undergoing elective EGD. METHODS: A total of 130 patients were randomized to receive either 7.5 mg of midazolam orally (n = 65) or a placebo (n = 65) as premedication. Outcomes measures included the anxiety score (visual analog scale) during EGD, overall tolerance, extent of amnesia, overall satisfaction, patient willingness to repeat the procedure, recovery time, and hemodynamic changes after medication. RESULTS: The median (interquartile range) anxiety score during the procedure in the midazolam group was significantly lower than that in the control group (2.0 [0-4.9] vs. 3.8 [2.1-7.95], p < 0.001). A significantly greater number of patients in the midazolam group graded overall tolerance as "excellent or good" (70.8% vs. 49.2%, p = 0.012) and reported a partial to complete amnesia response (52.3% vs. 32.3%, p = 0.02) when compared with the control group. Patients in the midazolam group were more willing to repeat the procedure if necessary (89.2% vs. 69.2%, p = 0.005). The median (interquartile range) recovery time was significantly longer in the midazolam group than in the control group (5 [5-15] minutes vs. 5 [5-10] minutes, p = 0.014). There were no statistically significant differences in satisfaction score and hemodynamic changes between groups. CONCLUSIONS: Premedication by oral administration of midazolam is a safe and an effective method of sedation that significantly reduces anxiety and improves overall tolerance for patients undergoing EGD.     

依托咪酯静脉不同速度输注对胸科手术患者麻醉诱导期肌阵挛的影响

目的:研究依托咪酯麻醉诱导期静脉不同速度输注,对胸科手术患者肌阵挛的影响。方法:选择全身麻醉下行胸科手术男性患者90例,随机分为3组,在麻醉诱导期首先以不同的速度静注0.3 mg/kg的依托咪酯。V200组30例,输注速度为200μg/s;V400组30例,输注速度为400μg/s;V800组30例,输注速度为800μg/s。3组患者均在入睡后静注肌松剂和芬太尼镇痛。记录各组在开始静注依托咪酯即刻(T0)、停止注药时(T1)及停止注药后2 min(T2)的平均动脉压(MAP)、心率(HR)和经皮脉搏氧饱和度(SpO2)等参数、输注时间以及T0至T2期间是否发生肌阵挛及其程度。结果:3组肌阵挛发生率分别为3.3%、33.3%及73.3%,各组间比较差异均有统计学意义(P<0.05)。3组患者间肌阵挛程度分级比较,V200组,低于V400组低于V800组,差异均有统计学意义(P<0.05)。且V200组和V400组程度以1级为主,而V800组程度以3级为主。HR和SpO2值在组间和组内各时点比较差异均无统计学意义。MAP值分别在T1、T2时点组间比较V800组均低于V200组,差异均有统计学意义(P<0.05),V400组和V800组MAP值分别在组内比较T1、T2时点均明显低于T0点,差异均有统计学意义(P<0.05)。结论:减慢依托咪酯的输注速度,可以明显降低肌阵挛的发生率及肌阵挛的程度,合理的输注速度还可以避免依托咪酯对平均动脉压的降低。     

Low-Dose Ketamine Pretreatment Reduces the Incidence and Severity of Myoclonus Induced by Etomidate: A Randomized,Double-Blinded,Controlled Clinical Trial

Myoclonic movement induced by etomidate is a common but undesirable problem during general anesthesia induction. To investigate the influence of pretreatment with low-dose ketamine on the incidence and severity of myoclonus induced by etomidate, 104 patients were randomized allocated to 1 of 2 equally sized groups (n = 52) to receive either intravenous low-dose ketamine 0.5 mg/kg (group K) or an equal volume of normal saline (group S) 1 minute before induction of anesthesia with 0.3-mg/kg etomidate. The incidence and severity of myoclonus were assessed for 2 minutes after administration of etomidate. Here, we found that the incidence and intensity of myoclonus were both significantly reduced in low-dose ketamine-treated group compared with saline-treated group. The incidence of adverse effects was low and similar between groups. These results demonstrate that intravenous infusion of low-dose ketamine 0.5 mg/kg 1 minute prior to etomidate administration is effective in relieving etomidate-induced myoclonic movements during general anesthesia induction.     

Technical performance of colonoscopy in patients sedated with nurse-administered propofol

OBJECTIVES: Nurse-administered propofol has gained attention as a safe and effective means of sedation for patients undergoing endoscopic procedures. However, little is known about the effect of propofol on the technical performance of colonoscopy. METHODS: Three separate studies were conducted. In the first study, we reviewed procedure notes from consecutive colonoscopies performed by a single experienced endoscopist at our hospital endoscopy unit on patients sedated with either nurse-administered propofol (n = 162) or midazolam/narcotic (n = 164). In the second study, 100 eligible colonoscopy outpatients were randomized to receive either nurse-administered propofol (n = 50) or midazolam/fentanyl (n = 50). In both studies, the measured parameters included visualization of the cecum, time required to reach the cecum, repositioning of the patient, and the application of abdominal counterpressure. In a third study, we reviewed the rate of cecal intubation and colonic perforation in the first 2357 patients in our unit receiving nurse-administered propofol. RESULTS: In the retrospective comparative study, there was no difference in the cecal intubation rate in those receiving propofol (99.4%) compared to those receiving midazolam/narcotic (97%; p= 0.1), and three of five failed cecal intubations in the latter group resulted from obstructing masses. Patients sedated with propofol were repositioned less frequently compared to those receiving midazolam/narcotic (3.7%vs 26.2%) (p < 0.0001). Abdominal pressure was employed in 9.9% of patients sedated with propofol compared to 19.5% (p= 0.01) of those given midazolam/narcotic. The mean time to reach the cecum was lower in the propofol group than in the midazolam/narcotic group (4.6 min vs 6.0 min, p= 0.002). In the prospective randomized study, the endoscopist intubated the cecum in all 100 patients. Patients in the propofol group were repositioned less frequently than those in the midazolam/fentanyl group (2%vs 24%, respectively, p= 0.001). The number of cases requiring abdominal counterpressure was not significantly different between the propofol and midazolam/fentanyl groups (12%vs 24%, respectively, p= 0.1). The mean time to reach the cecum in the propofol group (3.2 min) was similar to that in the midazolam/fentanyl group (3.8 min, p= 0.08). Among the first 2357 patients in our unit undergoing colonoscopy with nurse-administered propofol, the rate of complete colonoscopy was 99.2% and there were no perforations. CONCLUSION: Nurse-administered propofol sedation is safe and simplifies the technical performance of colonoscopy compared to midazolam/narcotic sedation.     

Cardioversion: What to choose? Etomidate or propofol

Context:

Electrical cardioversion is a short painful procedure to regain normal sinus rhythm requiring anaesthesia for haemodynamic stability, sedation, analgesia and early recovery.

Aims:

To compare propofol and etomidate as sedatives during cardioversion.

Settings and Design:

Single centred, prospective and randomized single blind study comprising 60 patients.

Subjects and Methods:

Patients more than 18 years, American Society of Anesthesiologists I/II/III grades undergoing elective cardioversion, randomly divided to receive propofol 1 mg/kg intravenous (IV) bolus followed by 0.5 mg/kg (Group P, n = 30) or etomidate (Group E, n = 30) 0.1 mg/kg followed by 0.05 mg/kg. All patients received IV fentanyl (1 μg/kg) before procedure. Heart rate, blood pressure (BP) (systolic BP [SBP], diastolic BP [DBP], mean arterial pressure), respiratory rate, Aldrete recovery score (ARS) and Ramsay sedation score (RSS) were assessed at 1, 2, 5, 10, 15, 20 and 30 min post cardioversion. Incidence of hypotension, respiratory depression and side effects were compared.

Statistical analysis used:

Student''s unpaired t-test, Chi-square test and Mann–Whitney test. P < 0.05 was taken as significant.

Results:

Group P showed significant fall in SBP, DBP, and mean BP at 2 min after cardioversion. Hypotension (33.3% Group P vs. 16.65% Group E) occurred more with propofol (P < 0.05). Group E showed better ARS at 1, 2, 5, 10, 15 and 20 min. Time required to attain RSS = 2 (659.1 s Group P and 435.7 s Group E) indicated longer recovery with propofol. Left atrial size (35.5-42.5 mm) did not affect success rate of cardioversion (80% Group P vs. 83.3% Group E). Incidence of myoclonus (Group E 26.67% vs. Group P 0%) showed significant difference.

Conclusions:

Etomidate/fentanyl is superior over propofol/fentanyl during cardioversion for quick recovery and haemodynamic stability.     

异丙芬分别复合芬太尼和米唑安定行无痛胃镜检查的研究

目的 比较异丙芬复合芬太尼或米唑安定用于无痛胃镜检查的有效性和安全性.方法 将180例需要无痛胃镜检查的患者分为A、B、C三组,每组各60例.A组单独静脉注射异丙芬1.5mg/kg,B组先注射芬太尼0.5mg后再注射异丙芬1.5mg/kg,C组先注射米唑安定0.02～0.03 mg/kg后再注射异丙芬1.5 mg/kg.至患者睫毛反射消失后开始插镜检查,如有呛咳、体动等表现时追加异丙芬30～40 mg.记录患者用药前、插镜前、检查结束后各时间点的呼吸、血氧饱和度、血压、心率以及不良反应.结果 B组和C组的异丙芬用量明显少于A组(P＜0.01).B组苏醒最快,没有注射部位疼痛,呛咳、体动等发生率明显低于A组(P＜0.05).结论 异丙芬联合芬太尼组具有麻醉镇痛效果好、副反应少、苏醒快等优点,更适合于无痛胃镜检查.     

Sedation with propofol for routine ERCP in high-risk octogenarians: a randomized, controlled study

OBJECTIVES: Adequate patient sedation is mandatory for diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP). In this respect it is known that the short-acting anesthetic propofol offers certain potential advantages for sedation during ERCP, but there are no controlled studies concerning the feasibility and safety of propofol sedation in elderly, high-risk patients. METHODS: One hundred and fifty consecutive patients aged >or=80 yr with high comorbidity (ASA score >or=III: 91 %), randomly received midazolam plus meperidine (n = 75) or propofol alone (n = 75) for sedation during ERCP. Vital signs were continuously monitored and procedure-related parameters, recovery time, and quality as well as patients' cooperation and tolerance of the procedure were assessed. RESULTS: Clinically relevant changes in vital signs were observed at comparable frequencies with a temporary oxygen desaturation (<90%) occurring in eight patients in the propofol-group and seven patients receiving midazolam/meperidine (n.s.). Hypotension was documented in two patients in the propofol group and one patient receiving midazolam/meperidine. Propofol provided a significantly better patient cooperation than midazolam/meperidine (p < 0.01), but the procedure tolerability was rated nearly the same by both groups. Mean recovery time was significantly shorter in the propofol group (22 +/- 7 min vs 31 +/- 8 min for midazolam/meperidine (p < 0.01)) while the recovery score was significantly higher under propofol (8.3 +/- 1.2 vs 6.1 +/- 1.1(p < 0.01)). During recovery a significant lower number of desaturation events (<90%) were observed in the propofol group (12%) than in the midazolam/meperidine group (26%, p < 0.01). CONCLUSION: Under careful monitoring the use of propofol for sedation during ERCP is superior to midazolam/meperidine even in high-risk octogenarians.     

Efficacy and safety of intravenous propofol sedation during routine ERCP: a prospective, controlled study

BACKGROUND: Adequate patient sedation is mandatory for diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP). The short-acting anesthetic propofol offers certain potential advantages for endoscopic procedures, but controlled studies proving its superiority over benzodiazepines for ERCP are lacking. METHODS: During a 6-month period 198 consecutive patients undergoing routine ERCP randomly received either midazolam (n = 98) or propofol (n = 99) for sedation. Vital signs (heart rate, blood pressure, oxygen saturation) were continuously monitored and procedure-related parameters, the recovery time and quality (recovery score) as well as the patient's cooperation and tolerance of the procedure (visual analog scales) were prospectively assessed. RESULTS: Patients receiving propofol or midazolam were well matched with respect to demographic and clinical data, ERCP findings, and the performance of associated procedures. Propofol caused a more rapid onset of sedation than midazolam (p < 0.01). Clinically relevant changes in vital signs were observed at comparable frequencies with temporary oxygen desaturation occurring (< 85 %) in 6 patients in the propofol group and 4 patients receiving midazolam (not significant). However, an episode of apnea had to be managed by mask ventilation via an ambu bag (lasting 8 minutes) in one of the patients receiving propofol sedation. Mean recovery times as well as the recovery scores were significantly shorter with propofol (p < 0. 01). Propofol provided significantly better patient cooperation than midazolam ( p < 0.01), but procedure tolerability was rated the same by both groups of patients (not significant). CONCLUSIONS: Intravenous sedation with propofol for ERCP is (1) more effective than sedation with midazolam, (2) safe under adequate patient monitoring, and (3) associated with a faster postprocedure recovery.     

Premedication with orally administered lorazepam in adults undergoing ERCP: a randomized double-blind study

BACKGROUND: Restlessness often complicates ERCP and may be a reason for premature termination of the procedure. OBJECTIVE: Our purpose was to evaluate whether a premedication with orally administered lorazepam could reduce the need for sedatives and improve sedation quality. DESIGN: Randomized double-blind trial. SETTING: Therapeutic ERCP with an intravenous sedation containing midazolam, propofol, and S(+)-ketamine. PATIENTS: 95 inpatients (aged 20-91 years). INTERVENTIONS: 1 mg of lorazepam (n=47) or placebo (n=48) given orally before ERCP. MAIN OUTCOME MEASUREMENT: Total amount of administered propofol. RESULTS: Heart rate, blood pressure, number of oxygen desaturations, and states of restlessness did not differ between the groups. The same amount of midazolam was administered in both groups. There was no significant difference in the total amount of propofol to achieve adequate sedation (lorazepam vs placebo: 71+/-5 vs 63+/-4 microg/kg/min, mean+/-SE). Paradoxically, patients pretreated with lorazepam even needed more propofol in the early phase of sedation (275+/-39 vs 159+/-37 microg/kg in minutes 5-10, P<.05) and the total amount of ketamine administered was higher in this group as well (15.8+/-1.4 vs 11.3+/-1.2 microg/kg/min, P<.05). In both groups there were high rates of satisfaction with the course of the procedure evaluated both by the endoscopists and the patients. CONCLUSION: The trial failed to show an advantage of an oral premedication with lorazepam. The amount of sedatives administered in the lorazepam group even tended to be higher. A premedication with lorazepam may be counterproductive when followed by sedation containing another benzodiazepine.     

Carbon dioxide accumulation during analgosedated colonoscopy: Comparison of propofol and midazolam

AIM: To characterize the profiles of alveolar hypoventilation during colonoscopies performed under sedoanalgesia with a combination of alfentanil and either midazolam or propofol. METHODS: Consecutive patients undergoing routine colonoscopy were randomly assigned to sedation with either propofol or midazolam in an open-labeled design using a titration scheme. All patients received 4 μg/kg per body weight alfentanil for analgesia and 3 L of supplemental oxygen. Oxygen saturation (SpO 2 ) was measured by pulse oximetry (POX), and capnography (PcCO 2 ) was continuously measured using a combined dedicated sensor at the ear lobe. Instances of apnea resulting in measures such as stimulation of the patient, a chin lift, a mask maneuver, or withholding of sedation were recorded. PcCO 2 values (as a parameter of sedation-induced hypoventilation) were compared between groups at the following distinct time points: baseline, maximal rise, termination of the procedure and 5 min after termination of the procedure. The number of patients in both study groups who regained baseline PcCO 2 values (± 1.5 mmHg) five minutes after the procedure was determined.RESULTS: A total of 97 patients entered this study. The data from 14 patients were subsequently excluded for clinical procedure-related reasons or for technical problems. Therefore, 83 patients (mean age 62 ± 13 years) were successfully randomized to receive propofol (n = 42) or midazolam (n = 41) for sedation. Most of the patients were classified as American Society of Anesthesiologists (ASA) Ⅱ [16 (38%) in the midazolam group and 15 (32%) in the propofol group] and ASA Ⅲ [14 (33%) and 13 (32%) in the midazolam and propofol groups, respectively]. A mean dose of 5 (4-7) mg of Ⅳ midazolam and 131 (70-260) mg of Ⅳ propofol was used during the procedure in the corresponding study arms. The mean SpO 2 at baseline (%) was 99 ± 1 for the midazolam group and 99 ± 1 for the propofol group. No cases of hypoxemia (SpO 2 85%) or apnea were recorded. However, an increase in PcCO 2 that indicated alveolar hypoventilation occurred in both groups after administration of the first drug and was not detected with pulse oximetry alone. The mean interval between the initiation of sedation and the time when the PcCO 2 value increased to more than 2 mmHg was 2.8 ± 1.3 min for midazolam and 2.8 ± 1.1 min for propofol. The mean maximal rise was similar for both drugs: 8.6 ± 3.7 mmHg for midazolam and 7.4 ± 3.2 mmHg for propofol. Five minutes after the end of the procedure, the mean difference from the baseline values was significantly lower for the propofol treatment compared with midazolam (0.9 ± 3.0 mmHg vs 4.3 ± 3.7 mmHg, P = 0.0000169), and significantly more patients in the propofol group had regained their baseline value ± 1.5 mmHg (32 of 41vs 12 of 42,P = 0.0004). CONCLUSION: A significantly higher number of patients sedated with propofol had normalized PcCO 2 values five minutes after sedation when compared with patients sedated with midazolam.     

Nurse-administered propofol versus midazolam and meperidine for upper endoscopy in cirrhotic patients

OBJECTIVES: Upper GI endoscopy is often performed in patients with chronic liver disease to screen for esophageal and gastric varices. Propofol is currently under evaluation as an alternative to the combination of midazolam and meperidine for sedation during endoscopic procedures. The purpose of this study was to compare nurse-administered propofol to midazolam and meperidine for sedation in patients with chronic liver disease undergoing diagnostic upper GI endoscopy. METHODS: Twenty outpatients who had known chronic liver disease (Child-Pugh class A or B) and were undergoing variceal screening were randomized to receive propofol or midazolam plus meperidine for sedation. Administration of sedation was performed by a registered nurse and supervised by the endoscopist. Outcome measures studied were induction and recovery times, efficacy and safety of sedation, patient satisfaction, and return to baseline function. RESULTS: The mean dose of propofol and meperidine/midazolam administered was 203 mg (SD 43.7, range 150-280) and 71.3 mg (SD 17.7, range 50-100)/5.3 mg (SD 0.9, range 3.0-6.0), respectively. The mean time to achieve adequate sedation was 3.6 min (SD 1.2) for the propofol group in comparison to 7.3 min (SD 2.8) for the meperidine/midazolam group (p<0.05). Procedure times between the groups were similar: propofol, 3.9 min (SD 1.9); midazolam/meperidine, 2.7 min (SD 0.8) (p=0.11). The level of sedation achieved by the propofol group was greater (p=0.0001). Time to full recovery was faster in the propofol group: 34.9 min (SD 10.3) versus 51.6 min (SD 18.4) (p<0.05). The mean time to reach a maximal level of alertness on the Observer's Assessment of Alertness and Sedation Scale for the propofol group was 15 min (SD 3.6) versus 29 min (SD 10.5) (p=0.001). Although both groups recorded a high level of satisfaction, patients receiving propofol expressed greater overall mean satisfaction with the quality of their sedation at the time of discharge (p<0.05), and reported a return to baseline function sooner in the majority of cases. Propofol achieved comparable levels of efficacy and safety to meperidine/midazolam in our study group. Both were well tolerated with minimal complications. CONCLUSIONS: Propofol sedation administered by registered nurses in the setting of adequate patient monitoring is efficacious and well tolerated in patients with liver disease who are undergoing variceal screening by upper endoscopy. Patients were more satisfied with the quality of sedation, and return to baseline function was usually sooner compared to results achieved with midazolam/meperidine. Propofol offers advantages over meperidine/midazolam in cirrhotic patients.     

依托咪酯联合丙泊酚镇静应用于超重患者无痛胃镜检查的效果观察

[目的]比较超重患者无痛胃镜检查中依托咪酯联合丙泊酚与单独使用丙泊酚的效果。[方法]将60例患者随机分为丙泊酚组(P组)和依托咪酯联合丙泊酚组(EP组)。P组在胃镜检查前首次给予1%丙泊酚(1 mg/kg),EP组给予1%丙泊酚(0.5 mg/kg)加依托咪酯(0.1 mg/kg)。后重复给予P组10~20 mg丙泊酚或EP组5~10 mg丙泊酚加1~2 mg依托咪酯,以维持足够的镇静水平。[结果]与T0比较,T1及T2时刻2组患者的收缩压、舒张压、平均动脉压、心率均明显降低,且与EP组相比,P组下降更为显著,差异有统计学意义(P<0.05),EP组麻醉后循环波动较小。与P组相比,EP组患者从静脉注入麻醉药物到患者意识消失的时间更长(P<0.05)。EP组低血压、呼吸抑制以及注射痛的发生例数低于P组,差异有统计学意义(均P<0.05)。[结论]依托咪酯联合丙泊酚对超重患者无痛胃镜检查中的呼吸和循环影响不大,患者苏醒质量高,不良反应少,比单用丙泊酚更安全有效。     

Patient-controlled sedation versus intravenous sedation for colonoscopy in elderly patients: a prospective randomized controlled trial

BACKGROUND: A prospective randomized trial was conducted to compare the safety, effectiveness, and patient acceptance of patient-controlled sedation and intravenous sedation for colonoscopy in a group of elderly patients undergoing outpatient colonoscopy. METHODS: One hundred patients over 65 years of age were recruited and randomized to patient-controlled sedation (n = 50) or intravenous sedation (n = 50) groups by means of computer-generated numbers. In the patient-controlled sedation group, a mixture of propofol and alfentanil was delivered by means of a patient-controlled pump; each bolus delivered 4.8 mg propofol and 12 microg alfentanil. No loading dose was used and the lockout time was set at zero. In the intravenous sedation group, fixed doses of diazemuls (0.1 mg/kg) and meperidine (0.5 mg/kg) were given with further increases in dosages administered at the discretion of the endoscopist. Outcome measures assessed included cardiopulmonary complications, recovery time, pain score, and satisfaction score. RESULTS: The mean (SD) age of patients in the patient-controlled sedation and intravenous sedation groups were, respectively, 72.4 years (5.3) and 73.5 years (6.1). The mean dose of propofol consumed in the patient-controlled sedation group was 0.79 (0.46) mg/kg. The mean doses of diazemuls and meperidine consumed in intravenous sedation group were, respectively, 5.8 (1.3) mg and 30.1 (6.8) mg. Hypotension occurred in 2 (4%) patients in the patient-controlled sedation group and 14 (28%) in the intravenous sedation group (p < 0.01). Oxygen desaturation was recorded for 4 patients (8%) in the intravenous sedation group. The median (interquartile range [IQR]) recovery time was significantly shorter in the patient-controlled sedation group compared with the intravenous sedation group (respectively, 0 minutes [IQR 0-5] vs. 5 minutes [IQR 5-10]; p < 0.01). There were no statistically significant differences between groups for pain and satisfaction scores. CONCLUSIONS: Patient-controlled sedation appears to be safer than intravenous sedation, with comparable effectiveness and acceptance, in elderly patients undergoing elective outpatient colonoscopy.     

Target-controlled infusion during monitored anesthesia care in patients undergoing EUS: Propofol alone versus midazolam plus propofol: A prospective double-blind randomised controlled trial

BACKGROUND: It has been speculated that midazolam may be effective in reducing the required dose of propofol during sedation. AIM: To evaluate the sparing effect of midazolam during target-controlled propofol infusion. METHODS: Two hundred-seventy patients undergoing upper endoscopic ultrasound were randomised to receive sedation with propofol plus placebo (group A) or plus midazolam (group B). Outcome parameters were the procedure duration, the discharge time and the satisfaction of patients, operator and nurse about the quality of sedation. RESULTS: The mean propofol dose administered was 364+/-207 mg in group A and 394+/-204 mg in group B. Mean procedure duration (group A: 32+/-17 min, group B: 35+/-22 min) and discharge time (group A: 39+/-30 min, group B: 38+/-24 min) were similar in both groups. No severe complications were observed. The quality of sedation was judged satisfactory for all patients by both the endoscopist and the nurse assistant without any difference between the two groups. No patient remembered the procedure or reported it as unpleasant. CONCLUSIONS: Target-controlled propofol infusion provides safe and effective sedation; premedication with low dose of midazolam does not reduce the total amount of propofol administered. Further studies are needed to compare propofol alone with propofol co-administered with opioid.     

Safety and Efficacy of Deep Sedation with Propofol Alone or Combined with Midazolam Administrated by Nonanesthesiologist for Gastric Endoscopic Submucosal Dissection

Background/Aims

Endoscopic submucosal dissection (ESD) is accepted as a treatment for gastric neoplasms and usually requires deep sedation. The aim of this study was to evaluate the safety and efficacy profiles of deep sedation induced by continuous propofol infusion with or without midazolam during ESD.

Methods

A total of 135 patients scheduled for ESDs between December 2008 and June 2010 were included in this prospective study and were randomly assigned to one of two groups: the propofol group or the combination group (propofol plus midazolam).

Results

The propofol group reported only one case of severe hypoxemia with no need of mask ventilation or intubation. Additionally, 18 cases of mild hypotension were observed in the propofol group, and 11 cases were observed in the combination group. The combination group had a lower mean total propofol dose (378 mg vs 466 mg, p<0.012), a longer mean recovery time (10.5 minutes vs 7.9 minutes, p=0.027), and a lower frequency of overall adverse events (32.8% vs 17.6%, p=0.042).

Conclusions

Deep sedation induced by continuous propofol infusion was shown to be safe during ESD. The combination of continuous propofol infusion and intermittent midazolam injection can decrease the total dose and infusion rate of propofol and the overall occurrence of adverse events.     

Pharmacoeconomic evaluation of flumazenil for routine outpatient EGD

BACKGROUND: Flumazenil is a benzodiazepine antagonist indicated for reversal of the sedative effects of benzodiazepines. Previous studies suggest that flumazenil may shorten recovery time after endoscopy, but there are few data on actual recovery room times and charges. METHODS: Fifty patients undergoing routine upper endoscopy were sedated with midazolam alone in the usual titrated manner. Patients were randomized in a double-blind fashion to receive either flumazenil or saline immediately after procedure. Assessments of responsiveness, speech, facial expression, and ptosis (Observer's Assessment of Alertness/Sedation [OAA/S] scale) were made before procedure, immediately after procedure and every 15 minutes thereafter. The patient was discharged from the recovery room when vital signs and OAA/S scale reached preprocedure levels. Recovery room times and charges were recorded. RESULTS: The flumazenil group demonstrated shorter recovery room times and recovery room charges than the placebo group (p < 0.001). The difference in recovery room charges was not statistically different when flumazenil charges were included (p = 0.09). CONCLUSIONS: The routine use of flumazenil after midazolam sedation for upper endoscopy significantly shortened recovery time and charges but did not statistically reduce overall charges.