Moderate level sedation during endoscopy: a prospective study using low-dose propofol, meperidine/fentanyl, and midazolam

BACKGROUND: Propofol provides several benefits over benzodiazepine and narcotic agents as a sedative medication for endoscopic procedures, including faster recovery and improved patient satisfaction. However, its use generally has been limited to anesthesiologists because of the risks associated with deep sedation. METHODS: One hundred patients undergoing colonoscopy or EGD were sedated with low-dose propofol, midazolam, and fentanyl (or meperidine). Depth of sedation was assessed at 2-minute intervals by an independent observer by using the American Society of Anesthesiologists criteria. Recovery time was determined by using paired neuropsychometric tests. A post-procedure satisfaction survey and 24-hour follow-up questionnaires were administered. RESULTS: For colonoscopy and EGD, respectively, the mean propofol dose was 98 mg and 79 mg, the mean midazolam dose was 0.9 mg and 0.8 mg, the mean fentanyl dose was 69 mcg and 63 mcg, and the mean meperidine dose was 42 mg (for both procedures). There were 628 assessments of the level of sedation performed during 74 colonoscopies and 101 assessments during 26 EGDs. The level of sedation was minimal in 77%, moderate in 21%, and deep in 2% of assessments. Nine of the 13 episodes of deep sedation were recorded during colonoscopy and 4 during EGD. In no instance was more than a single assessment of deep sedation recorded during one procedure. Ninety-eight percent of patients were satisfied with the sedation, and 71% returned to their usual activities within 2 hours of discharge. There was no serious adverse event. CONCLUSIONS: Endoscopic sedation with low-dose propofol, a narcotic agent, and midazolam produces a moderate level of sedation. The quality of sedation and measures of recovery are comparable with the results reported with standard-dose propofol.     

Safety and effectiveness of ketamine as a sedative agent for pediatric GI endoscopy

BACKGROUND: The ideal sedation for children undergoing GI endoscopy remains elusive. After ketamine was introduced as a sedative agent in our GI procedure suite, improved sedation and reduced complications were observed. The aim of this study was to assess the safety and effectiveness of ketamine as a sedative agent for GI endoscopy in pediatric patients. METHODS: A retrospective cohort study of 402 procedures (EGD, colonoscopy) was performed. Sedation-related complications were defined as hypoxia (oxygen saturation <95% by pulse oximetry), agitation, emergence reactions, stridor, laryngospasm, nausea, vomiting, aspiration, and muscle twitching, or any combination thereof. Sedation groups were defined as the following: Group I, midazolam and meperidine (n=192); Group II, midazolam, meperidine, and ketamine (n=82); and Group III, midazolam and ketamine (n=128). RESULTS: Group 1 (midazolam and meperidine) had the highest frequency of complications, most commonly hypoxia. Group 3 (midazolam and ketamine) had the lowest rate of complications (p=0.001) and the highest rate of adequate sedation, although the difference was not significant (p=0.07). CONCLUSIONS: The combination of midazolam and ketamine appears to provide safe and effective sedation for pediatric patients undergoing endoscopy.     

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

BACKGROUND & AIMS: Even though propofol has better recovery profile than traditional agents, its use is limited because of the perception of increased complication rates. Because an adequately powered trial comparing risk of propofol with traditional agents is lacking, we performed a meta-analysis of the current literature. METHODS: We searched Medline (1966-October 2004), EMBASE (1980-October 2004), and Cochrane controlled trials registry. The following 4 cardiopulmonary complications were assessed: hypoxia, hypotension, arrhythmias, and apnea. Procedures were divided into 3 groups: esophagogastroduodenoscopy group, colonoscopy group, and endoscopic retrograde cholangiopancreatography/endoscopic ultrasonography group. Pooled odds ratios for complications were calculated for all the procedures combined and then separately for the 3 groups. Random effects models were used for 2-proportion comparisons. RESULTS: Of the 90 citations identified, 12 original studies qualified for this meta-analysis and included 1161 patients. Of these, 634 received propofol, and 527 received midazolam, meperidine, and/or fentanyl. Most of the included studies were randomized trials of moderate quality and nonsignificant heterogeneity (Cochran Q = 4.81, P = .90). Compared with traditional sedative agents, the pooled odds ratio with the use of propofol for developing hypoxia or hypotension for all the procedures combined was 0.74 (95% confidence interval [CI], 0.44-1.24); for EGD, 0.85 (95% CI, 0.33-2.17); for colonoscopy, 0.4 (95% CI, 0.2-0.79); and for ERCP/EUS, 1.07 (95% CI, 0.38-3.01). CONCLUSIONS: Propofol sedation during colonoscopy appears to have lower odds of cardiopulmonary complications compared with traditional agents, but for other procedures, the risk of complications is similar.     

The changing landscape of practice patterns regarding unsedated endoscopy and propofol use: a national Web survey

BACKGROUND: Lower reimbursements for endoscopic procedures and increasing demand for screening endoscopy over the past decade have spurred efforts to increase efficiency in the performance of endoscopic procedures. Two dichotomous approaches have emerged: (1) unsedated endoscopy and (2) propofol sedation. The aim was to determine national practice patterns of unsedated endoscopy and propofol sedation, and to assess endoscopists' attitudes toward unsedated screening with an electronic survey. METHODS: A short survey was developed and then was converted to a Web-based format. All national members of the American Society for Gastrointestinal Endoscopy (ASGE) were invited via electronic mail (e-mail) to participate. Survey data were collected electronically. RESULTS: Two e-mails elicited responses to the Web survey from 18% (724) of national ASGE members contacted, within 2 weeks. Of the respondents, 45% do not routinely offer unsedated EGD and colonoscopy, and only 15% of those respondents plan to incorporate unsedated endoscopy into their practice in the next year. Of the 55% who currently perform unsedated endoscopy, 85% do no more than 25 unsedated procedures per year. Lack of patient acceptance was the most common reason cited for not offering unsedated endoscopy. Most endoscopists felt that the availability of unsedated esophagoscopy or colonoscopy would not significantly increase screening for Barrett's esophagus or colonic polyps/colorectal cancer, respectively. Routine use of propofol sedation for EGD, colonoscopy, and ERCP/EUS was reported by 19%, 22%, and 19%, respectively. Community practitioners were more likely to use propofol than those at academic centers (p < 0.0002 for all). Of those not currently using propofol, 43% plan to incorporate it into their practice within the next year. Over 70% of respondents would themselves choose to be sedated for routine endoscopic procedures. CONCLUSIONS: Electronic surveys allow for rapid distribution and data collection but suffer from a limited response rate. The survey suggests that unsedated endoscopy has limited acceptance in the United States, and, without a major intervention that affects endoscopists' attitudes, its use is not likely to increase significantly. Unsedated endoscopy will not have a great impact on endoscopic screening. In contrast, propofol sedation has already gained acceptance in the community, and the routine use of propofol in endoscopy units will likely increase in the future.     

Propofol for endoscopic sedation: A protocol for safe and effective administration by the gastroenterologist

BACKGROUND: There is increasing interest in the use of propofol, an ultrashort-acting hypnotic agent, for sedation during endoscopic examinations. A protocol was developed for administration of propofol, combined with small doses of midazolam and meperidine, for endoscopic sedation under the direction of a gastroenterologist. Initial experience with using this protocol is described. METHODS: A total of 819 consecutive endoscopic examinations under sedation with propofol, midazolam, and meperidine (or fentanyl), in adherence with the sedation protocol, were reviewed retrospectively. RESULTS: There were 638 colonoscopies and 181 EGDs; 89% of patients were classified as American Society of Anesthesiologists (ASA) class I or II. Mean dosages of medications were: propofol 63 (33.5) mg, meperidine 48 (7.2) mg, and midazolam 1 (0.12) mg. The dose of propofol was inversely correlated with age and ASA class, and positively correlated with patient weight and duration of examination. Hypotension (>20 mm Hg decline in either systolic or diastolic blood pressure) developed in 218 (27%) patients, and hypoxemia (oxygen saturation <90%) developed in 75 (9%). All episodes of hypotension and hypoxemia were transient, and no patient required administration of a pharmacologic antagonist or assisted ventilation. The average time for recovery after colonoscopy and after EGD was, respectively, 25 minutes and 28 minutes. All EGDs and 98% of colonoscopies were completed successfully. CONCLUSIONS: On the basis of this initial experience, it is believed that propofol, potentiated by small doses of midazolam and meperidine, can be safely and effectively administered under the direction of a gastroenterologist. Additional research will be necessary to determine whether propofol is superior to the current methods of sedation.     

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.     

Conscious sedation during endoscopic retrograde cholangiopancreatography: midazolam or midazolam plus meperidine?

BACKGROUND AND OBJECTIVE: No consensus exists for the safest and most effective agent and for optimal drug doses for sedation during endoscopic retrograde cholangiopancreatography (ERCP). We aimed to compare the efficacy of midazolam with that of midazolam+meperidine, which provided comfort for the patient during ERCP. MATERIALS AND METHODS: The patients were randomized to sedation with midazolam only (2.87+/-0.67 mg) (n=48, median age 55.54+/-14.66, 21 women, 27 men) or midazolam (1.82+/-0.71 mg) with meperidine (42.81+/-14.61 mg) (n= 48, median age 55.48+/-2.57, 20 women, 28 men). Procedure-related parameters and the efficacy of sedation as assessed by the endoscopist and the patients were compared. RESULTS: Prior endoscopic history, preprocedure anxiety scores, age, sex, baseline vital signs and type of interventions were similar in both groups. Sedation level, duration of procedure and recovery time were comparable in both groups. Sedation quality assessment scale was significantly higher in the midazolam with meperidine group. Degree of pain sensed during the procedure was significantly lower in the midazolam with meperidine group. Midazolam with meperidine group had better patient satisfaction. Twenty-four hours after the procedure, the degree of amnesia between both sedation groups was similar. The number of patients unwilling to repeat the procedure was distinctly higher in midazolam group. Development of hypoxia and arrythmia in the midazolam and midazolam with meperidine groups were comparable. Two patients in the midazolam group developed paradoxical agitation. CONCLUSIONS: Conscious sedation for ERCP can be successfully and safely achieved by using either only midazolam or a low dose of midazolam with meperidine. Adding of meperidine to midazolam resulted in better patient and endoscopist comfort.     

Sedation-associated hiccups in adults undergoing gastrointestinal endoscopy and colonoscopy

AIM: To investigate whether the incidence of hiccups in patients undergoing esophagogastroduodenoscopy (EGD) or same-day bidirectional endoscopy (EGD and colonoscopy; BDE) with sedation is different from those without sedation in terms of quantity, duration and typical onset time.METHODS: Consecutive patients scheduled for elective EGD or same-day BDE at the gastrointestinal endoscopy unit or the health examination center were allocated to two groups: EGD without sedation (Group A) and BDE with sedation (Group B). The use of sedation was based on the patients’ request. Anesthesiologists participated in this study by administrating sedative drugs as usual. A single experienced gastroenterologist performed both the EGD and the colonoscopic examinations for all the patients. The incidence, duration and onset time of hiccups were measured in both groups. In addition, the association between clinical variables and hiccups were analyzed.RESULTS: A total of 435 patients were enrolled in the study. The incidences of hiccups in the patients with and without sedation were significantly different (20.5% and 5.1%, respectively). The use of sedation for patients undergoing endoscopy was still significantly associated with an increased risk of hiccups (adjusted odds ratio: 8.79, P < 0.001) after adjustment. The incidence of hiccups in males under sedation was high (67.4%). The sedated patients who received 2 mg midazolam developed hiccups more frequently compared to those receiving 1 mg midazolam (P = 0.0028). The patients with the diagnosis of gastroesophageal reflux disease (GERD) were prone to develop hiccups (P = 0.018).CONCLUSION: Male patients undergoing EGD or BDE with sedation are significantly more likely to suffer from hiccups compared to those without sedation. Midazolam was significantly associated with an increased risk of hiccups. Furthermore, patients with GERD are prone to develop hiccups.     

A national study of cardiopulmonary unplanned events after GI endoscopy

BACKGROUND: Cardiopulmonary unplanned events (CUE) related to conscious sedation constitute a major proportion of GI endoscopy-associated complications. OBJECTIVES: Our purpose was to study the incidence of CUE during GI endoscopy and to determine factors that may predict CUE. DESIGN: Retrospective CORI (Clinical Outcomes Research Initiative) database review. PATIENTS: Undergoing GI endoscopy under conscious sedation. MAIN OUTCOME MEASUREMENT: CUE associated with GI endoscopy. RESULTS: Data on 324,737 unique procedures (EGD, 140,692; colonoscopy, 174,255; ERCP, 6092; and EUS, 3698) performed with the patient under conscious sedation were analyzed. Unplanned events were reported in 1.4% of procedures; 0.9% were associated with CUE. Rates of CUE with EGD, colonoscopy, ERCP, and EUS were 0.6%, 1.1%, 2.1%, and 0.9%, respectively. Multiple logistic regression revealed patient age (odds ratio [OR] 1.02, 95% CI 1.01-1.02) and ASA class were significant predictors of CUE (OR compared with ASA I: ASA II 1.05, 95% CI 0.95-1.16; ASA III 1.8, 95% CI 1.6-2.0, ASA IV 3.2, 95% CI 2.5-4.1, ASA V 7.5; 95% CI 3.2-17.6). Inpatient procedures were associated with higher CUE (OR 1.5, 95% CI 1.3-1.7). Compared with universities, nonuniversity sites (OR 1.2, 95% CI 1.1-1.4) and Veterans Administration Medical Centers (OR 1.4, 95% CI 1.2-1.5) had significantly higher CUE. Use of supplemental oxygen during a procedure was associated with significantly more CUE (OR 1.2, 95% CI 1.1-1.3). Involvement of a trainee with a procedure was also associated with higher CUE (OR 1.3, 95% CI 1.1-1.4). LIMITATIONS: Retrospective review of data entered voluntarily by endoscopists not trained on CORI data entry. CONCLUSIONS: During GI endoscopy with conscious sedation, patient's age, higher ASA grade, inpatient status, trainee participation, and routine use of oxygen are associated with a higher incidence of CUE.     

A systematic review and meta-analysis of randomized, controlled trials of moderate sedation for routine endoscopic procedures

BACKGROUND: Numerous agents are available for moderate sedation in endoscopy. OBJECTIVE: Our purpose was to compare efficacy, safety, and efficiency of agents used for moderate sedation in EGD or colonoscopy. DESIGN: Systematic review of computerized bibliographic databases for randomized trials of moderate sedation that compared 2 active regimens or 1 active regimen with placebo or no sedation. PATIENTS: Unselected adults undergoing EGD or colonoscopy with a goal of moderate sedation. MAIN OUTCOME MEASUREMENTS: Sedation-related complications, patient assessments (satisfaction, pain, memory, willingness to repeat examination), physician assessments (satisfaction, level of sedation, patient cooperation, examination quality), and procedure-related efficiency outcomes (sedation, procedure, or recovery time). RESULTS: Thirty-six studies (N = 3918 patients) were included. Sedation improved patient satisfaction (relative risk [RR] = 2.29, range 1.16-4.53) and willingness to repeat EGD (RR = 1.25, range 1.13-1.38) versus no sedation. Midazolam provided superior patient satisfaction to diazepam (RR = 1.18, range 1.07-1.29) and less frequent memory of EGD (RR = 0.57, range 0.50-0.60) versus diazepam. Adverse events and patient/physician assessments were not significantly different for midazolam (with or without narcotics) versus propofol except for slightly less patient satisfaction (RR = 0.90, range 0.83-0.97) and more frequent memory (RR = 3.00, range 1.25-7.21) with midazolam plus narcotics. Procedure times were similar, but sedation and recovery times were shorter with propofol than midazolam-based regimens. LIMITATIONS: Marked variability in design, regimens tested, and outcomes assessed; relatively poor methodologic quality (Jadad score 相似文献   

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

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

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.     

Endoscopist administered sedation during ERCP: impact of chronic narcotic/benzodiazepine use and predictive risk of reversal agent utilization

OBJECTIVES: When administered by endoscopists conventional sedation regimens for endoscopic retrograde cholangipancreatography (ERCP) consist of intravenous (IV) benzodiazepines and opiates. As yet, standardized dosing regimens for individual patients do not exist. The aims of this study were to (a) determine sedative doses in patients with and without a history of narcotic or benzodiazepine use, (b) assess the frequency of reversal agent utilization, and (c) assess potential predictive factors for reversal agent utilization. METHODS: Clinical data from January 1, 2004, to December 31, 2005, were abstracted from a computerized endoscopy database to determine: demographics, median sedation dosages, risk of reversal agent use, and clinical outcome related to sedation. Univariate and logistic regression analysis were performed to assess independent predictive factors for reversal agent utilization. RESULTS: Of 3,179 patients undergoing ERCP, 3,058 received sedation directed by the endoscopists. Meperidine and midazolam IV were given at a median dose of 125 mg and 7 mg, respectively, during a mean procedure time of 42 min. One hundred eighty-six patients reported routine use of narcotics or benzodiazepines (6%). These patients were younger, predominantly female, required higher doses of meperidine and midazolam, and received IV promethazine during procedural sedation more frequently than patients not using narcotics or benzodiazepines. One hundred twenty-four patients required reversal agents (4%). They were relatively older, required significantly higher doses of meperidine and received promethazine more frequently than the nonreversed group. CONCLUSIONS: In a single, high volume ERCP center, endoscopist administered sedation was provided in 96% of cases. Patient age >or=80 yr, dose of meperidine, and the use of promethazine were independent risk factors for the need of reversal agents.     

Comparison of Fentanyl Versus Meperidine for Analgesia in Pediatric Gastrointestinal Endoscopy

This study compared the safety and efficacy of fentanyl and meperidine for analgesia in pediatric gastrointestinal endoscopy. In a double-blind, randomized trial, 24 patients (11 males) received either fentanyl (1 microg/kg) or meperidine (1 mg/kg). These analgesics were administered in unmarked syringes by an investigator who did not participate in the procedure or in the evaluation of the patient's sedation. There were 17 Caucasians and 7 African-Americans whose mean age was 10.4 +/- 4.4 years. Thirteen patients received meperidine and 11 received fentanyl. Midazolam was given to all patients as needed to provide sufficient sedation for the procedure. Study subjects underwent EGD (n = 17) or colonoscopy (n = 7). There were no differences as assessed by patient, endoscopist, or assistant for tolerance, discomfort, procedure ease, recovery time, complications, heart rate, blood pressure, or oxygen saturation. We conclude that meperidine and fentanyl are equally effective in providing analgesia for pediatric gastrointestinal endoscopy.     

Diphenhydramine as an adjunct to sedation for colonoscopy: a double-blind randomized, placebo-controlled study

BACKGROUND: Intravenous benzodiazepines in combination with opiates are used to achieve moderate sedation for colonoscopy. Although effective, these agents have potential adverse effects, such as respiratory depression and hypotension. Diphenhydramine hydrochloride possesses central nervous system depressant effects that theoretically could provide a synergistic effect for sedating patients. OBJECTIVE: The objective was to assess the efficacy of adding diphenhydramine hydrochloride as an adjunct to improve sedation and to reduce the amount of standard sedatives used during colonoscopy. DESIGN: We conducted a prospective, randomized, double-blind, placebo-controlled study. SETTING: The study was conducted in a university hospital with an active GI fellowship training program. PATIENTS: The study group comprised 270 patients undergoing screening/diagnostic/therapeutic colonoscopy were enrolled. INTERVENTIONS: Patients were randomized to receive either 50 mg of diphenhydramine or placebo, given intravenously 3 minutes before starting conscious sedation with intravenous midazolam and meperidine. MAIN OUTCOME MEASUREMENTS: The main outcome measure was anesthetic effect as assessed by the endoscopy team and by the patient; quantity of adjunctive sedatives to achieve adequate sedation. RESULTS: Of 270 patients, data were analyzed for 258 patients, with 130 patients in the diphenhydramine group and 128 patients in the placebo group. There was a 10.1% reduction in meperidine usage and 13.7% reduction in midazolam usage in favor of the diphenhydramine group. The mean evaluation scores as judged by the faculty, the fellows, and the nurses were statistically significant in favor of the diphenhydramine group. In addition, patient scores for overall sedation and pain level favored the group that received diphenhydramine. CONCLUSIONS: Intravenous diphenhydramine given before initiation of standard sedation offers a significant benefit to conscious sedation for patients undergoing colonoscopy.     

Midazolam versus diazepam for combined esophogastroduodenoscopy and colonoscopy

This study compares the effects of two different benzodiazepines used for conscious sedation during combined upper gastrointestinal endoscopy (EGD) and colonoscopy. Subjects were assessed for their degree of analgesia and amnesia for the procedure, prior experience with endoscopy, and willingness to undergo another similar procedure should such be necessary. The patients were randomized single blind to receive either midazolam or diazepam for their preprocedure sedation. The amount of preprocedure sedation utilized was determined by titration of the dose to achieve slurring of speech. Prior to receiving either agent, the subjects were shown a standard card containing pictures of 10 common objects, were asked to name and remember them, and were told they would be quizzed (at 30 min and 24 hr) after being sedated for their recollection as to the objects pictured on the card. Each subject filled out a questionnaire addressing their perceived discomfort during the endoscopic procedure and their memory of the procedure 24 hr after the procedure. Sixty-three percent of the midazolam-sedated subjects reported total amnesia for their colonoscopy vs 20% of diazepam-sedated patients (P<0.001). Fifty-three percent of midazolam-sedated patients reported total amnesia of their upper gastrointestinal endoscopy vs only 23% of diazepam-sedated subjects (P<0.05). The midazolam-sedated subjects reported experiencing less pain with both upper gastrointestinal endoscopy (P<0.05) and colonoscopy (P<0.001) than did the diazepam-sedated group. Most importantly, the midazolam group was more willing to undergo another similar endoscopic procedure should they be asked to do so by their physician (P<0.05). Subjects greater than 60 years of age required significantly less midazolam for sedation than did the younger subjects (P<0.001). This difference in dosing based upon age was not observed in the diazepam-sedated group. Based upon these data we conclude that midazolam is superior to diazepam in producing conscious sedation for combined upper gastrointestinal endoscopy and colonoscopy with regard to: (1) amnesia for the procedures, (2) discomfort experienced at the time of the procedure, and (3) better patient acceptance of future gastrointestinal endoscopic procedures.This work was supported in part by a grant from the Gastroenterology Medical Research Foundation of Southwestern Pennsylvania.     

Propofol use in endoscopic retrograde cholangiopancreatography and endoscopic ultrasound

Compared to standard endoscopy,endoscopic retrograde cholangiopancreatography(ERCP)and endoscopic ultrasound(EUS)are often lengthier and more complex,thus requiring higher doses of sedatives for patient comfort and compliance.The aim of this review is to provide the reader with information regarding the use,safety profile,and merits of propofol for sedation in advanced endoscopic procedures like ERCP and EUS,based on the current literature.     

Sedation for gastrointestinal endoscopy. Analysis of tolerance and complications.

OBJECTIVE: To analyse tolerance and complications in patients undergoing a gastrointestinal endoscopy. PATIENTS AND METHODS: One hundred forty three patients were prospectively studied: 44.8% underwent a diagnostic upper endoscopy; 13.3%, a therapeutic upper endoscopy; 37%, a diagnostic colonoscopy and 4.9%, a therapeutic colonoscopy. Midazolam or midazolam combined with meperidine were used. Tolerance, level of sedation and complications were studied. Chis quare and ratio comparison tests were used for the statistical analysis. P-values less than 0.05 were considered as statistically significant. RESULTS: In the diagnostic upper endoscopy group, tolerance was better with midazolam plus meperidine vs midazolam only (83.8% and 59.3% respectively); p < 0.05. In the therapeutic upper endoscopy group, tolerance was also better when both drugs were combined; p < 0.05. In the diagnostic and therapeutic colonoscopy groups, tolerance was good in 63.5% and 85.7% of patients, respectively. Men had better tolerance for upper endoscopy; p < 0.05. Tolerance was worse in patients under 40 years of age for upper endoscopy; p < 0.05. Mild desaturation occur in 27.3% of patients, being more severe in therapeutic procedures; p < 0.05. CONCLUSIONS: Tolerance was good in a high percentage of patients, and better in men and in patients older than 40 years of age. The main problem is desaturation, that increases in therapeutic procedures.     

Sedation and Analgesia for Gastrointestinal Endoscopy

We compared analgesia and sedation provided by one of four different opioids in combination with midazolam during gastrointestinal endoscopy. Patients were given 1–3 mg midazolam and meperidine 50–100 mg, fentanyl 50–100 μg, sufentanil 5–10 μg, or alfentanil 150–300 μg, plus additional opioid and/or midazolam if needed. No untoward effects ( i.e. , O₂ saturation <85%, nausea, vomiting, severe bradycardia) occurred. Sedation and analgesia were comparable in the upper gastrointestinal groups. The number of patients with amnesia for the exahmination was highest in the meperidine group. Recovery time generally was shorter with alfentanil and sufentanil. Recovery time of the lower gastrointestinal patients was significantly longer in the meperidine group than in the other groups; analgesia scores for sufentanil were significantly lower than for meperiodin. sedation scores of these patients were highest in the meperiding group. The number of patients given meperidine who wee amnesic was significantly greater than for the other opioids. Meperidine was better than the other opioids with regard to patients comfort and amnesia during colonoscopy.     

Which should go first during same‐day bidirectional endosocopy with propofol sedation?

Background and Aim: Same‐day bidirectional endoscopy, including esophagogastroduodenoscopy (EGD) and colonoscopy, is frequently performed to screen for cancer and gastrointestinal bleeding. However, the optimal sequence for the procedures is unclear thus far. The aim of this study was to evaluate the optimal sequence for same‐day bidirectional endoscopy. Methods: Consecutive patients undergoing same‐day bidirectional endoscopy under propofol sedation were randomized to either the colonoscopy‐first group (colonoscopy followed by EGD, n = 87) or the EGD‐first group (EGD followed by colonoscopy, n = 89). We evaluated the propofol dose, procedure duration, patient tolerance and recovery, adverse events, and endoscopic findings. The patient tolerance was assessed with a 0–10 visual analog scale. Results: Total procedure times, patients' tolerance and recovery, adverse events, and endoscopic findings were similar between the two groups. The total propofol dose was significantly higher for the colonoscopy‐first group than for the EGD‐first group (mean 95% credibility limit: 135.7 [70–201.4] mg vs 124.7 [64.1–185.3] mg, respectively, P = 0.024). Patients in the colonoscopy‐first group moved significantly more during colonoscopy than those in the EGD‐first group: 1.1 (0–3.8) versus 0.6 (0–2.9) scores, respectively (P = 0.024). Conclusion: The optimal sequence for same‐day bidirectional endoscopy is EGD followed by colonoscopy. In this order, the procedure is better tolerated, and patients require a lower overall dose of propofol.