Stepwise sedation for elderly patients with mild/moderate COPD during upper gastrointestinal endoscopy

AIM: To investigate stepwise sedation for elderly patients with mild/moderate chronic obstructive pulmonary disease (COPD) during upper gastrointestinal (GI) endoscopy. METHODS: Eighty-six elderly patients with mild/moderate COPD and 82 elderly patients without COPD scheduled for upper GI endoscopy were randomly assigned to receive one of the following two sedation methods: stepwise sedation involving three-stage administration of propofol combined with midazolam [COPD with stepwise sedation (group Cs), and nonCOPD with stepwise sedation (group Ns)] or continuous sedation involving continuous administration of propofol combined with midazolam [COPD with continuous sedation (group Cc), and non-COPD with continuous sedation (group Nc)]. Saturation of peripheral oxygen (SpO 2 ), blood pressure, and pulse rate were monitored, and patient discomfort, adverse events, drugs dosage, and recovery time were recorded. RESULTS: All endoscopies were completed successfully. The occurrences of hypoxemia in groups Cs, Cc, Ns, and Nc were 4 (9.3%), 12 (27.9%), 3 (7.3%), and 5 (12.2%), respectively. The occurrence of hypoxemia in group Cs was significantly lower than that in group Cc (P < 0.05). The average decreases in value of SpO 2 , systolic blood pressure, and diastolic blood pressure in group Cs were significantly lower than those in group Cc. Additionally, propofol dosage and overall rate of adverse events in group Cs were lower than those in group Cc. Finally, the recovery time in group Cs was significantly shorter than that in group Cc, and that in group Ns was significantly shorter than that in group Nc (P < 0.001). CONCLUSION: The stepwise sedation method is effective and safer than the continuous sedation method for elderly patients with mild/moderate COPD during upper GI endoscopy.     

Ketamine and midazolam sedation for pediatric gastrointestinal endoscopy in the Arab world

AIM: To evaluate the safety and effectiveness of intravenous ketamine-midazolam sedation during pediatric endoscopy in the Arab world.METHODS: A retrospective cohort study of all pediatric endoscopic procedures performed between 2002-2008 at the shared endoscopy suite of King Abdullah University Hospital, Jordan University of Science & Technology, Jordan was conducted. All children were > 1 year old and weighed > 10 kg with American Society of Anesthesiologists class 1 or 2. Analysis was performed in terms of sedation-related complications (desaturation, respiratory distress, apnea, bradycardia, cardiac arrest, emergence reactions), adequacy of sedation, need for sedation reversal, or failure to complete the procedure.RESULTS: A total of 301 patients (including 160 males) with a mean age of 9.26 years (range, 1-18 years) were included. All were premedicated with atropine; and 79.4% (239/301) had effective and uneventful sedation. And 248 (82.4%) of the 301 patients received a mean dose of 0.16 mg/kg (range, 0.07-0.39) midazolam and 1.06 mg/kg (range, 0.31-2.67) ketamine, respectively within the recommended dosage guidelines. Recommended maximum midazolam dose was exceeded in 17.6% patients [34 female (F):19 male (M), P = 0.003] and ketamine in 2.7% (3 M:5 F). Maximum midazolam dose was more likely to be exceeded than ketamine (P < 0.001). Desaturation occurred in 37 (12.3%) patients, and was reversible by supplemental oxygen in all except 4 who continue to have desaturation despite supplemental oxygen. Four (1.3%) patients had respiratory distress and 6 (2%) were difficult to sedate and required a 3rd sedative; 12 (4%) required reversal and 7 (2.3%) failed to complete the procedure. None developed apnea, bradycardia, arrest, or emergence reactions.CONCLUSION: Ketamine-midazolam sedation appears safe and effective for diagnostic pediatric gastrointestinal endoscopy in the Arab world for children aged > 1 year and weighing > 10 kg without co-morbidities.     

Development and validation of a theoretical test in non-anaesthesiologist-administered propofol sedation for gastrointestinal endoscopy

Objective: Safety with non-anaesthesiologist-administered propofol sedation (NAAP) during gastrointestinal (GI) endoscopy is related to theoretical knowledge. A summative testing of knowledge before attempting supervised nurse-administered propofol sedation (NAPS) in the clinic is advised. The aims of this study were to develop a theoretical test about propofol sedation, to gather validity evidence for the test and to measure the effect of a NAPS-specific training course.

Material and methods: A three-phased psychometric study on multiple choice questionnaire (MCQ) test development, gathering of validity evidence and evaluation of the effect of a specific NAAP course on the test result. A MCQ containing 86 questions was developed and administered 113 times to 91 participants representing novices, intermediates and experienced.

Results: Question difficulty analyses revealed 50 level I and II questions. The 50 MCQs showed mean (SD) intergroup differences (p?=?0.001) between novices?=?28.6 (4.82), intermediates?=?36.8 (5.43) and experienced?=?41.8 (4.65) and provided a pass score of 35.2. The course with pre-course test had significant effect on the knowledge of nurses (18% increase) and physicians (19% increase; p?=?0.001 and 0.001, respectively).

Conclusions: Data supported the validity of the developed MCQ test. The NAPS-specific course with pre-course testing adds theoretical knowledge to already well-prepared participants.     

笑气清醒镇静镇痛与丙泊酚静脉麻醉用于胃镜检查的临床价值比较研究

目的研究笑气化状态的诱导过程并比较笑气清醒镇静镇痛与丙泊酚静脉麻醉用于胃镜检查的安全性及有效性。方法选择2013年4月至2013年10月行胃镜检查患者400例,随机分为笑气组200例和丙泊酚组200例,记录笑气组达到笑气化状态的时间及浓度,2组患者检查前、中、后的收缩压、舒张压、心率、血氧饱和度,及药物起效时间、胃镜操作时间、镇静效果、恢复时间、留院时间、不良反应。检查结束后医生与患者填写调查问卷。结果笑气组达到笑气化状态的平均时间为（3．16±0．65）min,男性与女性无明显差异[（3．16±0．71）比（3．16±0．58）min,t=0．006,P〉0．05）;达到笑气化状态的平均笑气浓度为（43．68±5．05）％,男性明显高于女性[（45．30±4．99）％比（41．46±4．30）％,t=3．042,P〈0．05]。与检查前比较,丙泊酚组检查中的收缩压、舒张压、心率、血氧饱和度均明显降低（P〈0．05）,而笑气组检查中的收缩压、舒张压、心率均明显升高（P〈0．05）。丙泊酚组的起效时间及操作时间比笑气组短（P〈0．05）,镇静效果比笑气组更深（P〈0．05）,但笑气组的恢复时间、留院时间均比丙泊酚组明显减少（P〈0．05）。检查中丙泊酚组部分患者出现低氧血症、低血压、心率过缓等不良反应,而笑气组主要不良反应为恶心、干呕等咽部刺激反应。调查问卷结果显示：笑气组的医师满意度、患者满意度、患者愿意再次接受检查的比例均低于丙泊酚组（86±3．7比96±2．6,87±2．8比98±1．2,87％比99％,P〈0．05）。结论笑气清醒镇静镇痛及丙泊酚静脉麻醉用于胃镜检查均是有效的,但前者对心肺功能影响更小更安全。准确识别笑气化状态是笑气清醒镇静镇痛成功实施的关键。重视影响笑气清醒镇静镇痛技术安全性及有效性的9个因素,对于优?     

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.     

丙泊酚联合芬太尼作为肝硬化患者无痛胃镜检查镇静剂的临床效果观察

目的 前瞻性探讨肝硬化患者无痛胃镜检查过程中应用丙泊酚联合芬太尼作为镇静剂的安全性和可行性.方法 肝硬化患者和非肝硬化患者各50例分别纳入肝硬化镇静组和非肝硬化镇静组,接受丙泊酚联合芬太尼镇静下的胃镜检查;另选择30例肝硬化患者进行传统胃镜检查.观察各组镇静前或检查前、检查开始后5min、检查开始后10 min和检查结束后1h患者的生命体征变化情况,分析镇静前或检查前、检查结束后4h数字连接试验A(NCT-A)及轨迹描绘试验(LTT)结果,汇总并发症发生情况.结果 肝硬化镇静组和非肝硬化镇静组镇静后血压、心率、呼吸频率和脉搏血氧饱和度均有不同程度的下降(P＞0.05或P＜0.05),至检查结束后1h各项监测指标可基本恢复(P＞0.05);肝硬化镇静组总的并发症发生率为36％ (18/50),与非肝硬化镇静组的14％ (7/50)比较差异有统计学意义(P＜0.05),但低血压、心动过缓和低氧血症各并发症的发生率比较差异无统计学意义(P＞0.05);肝硬化镇静组与肝硬化非镇静组无一例胃镜检查后出现临床型肝性脑病.肝硬化镇静组、肝硬化非镇静组前后两个观察时点NCT-A和LTT均较非肝硬化镇静组明显延长[镇静或检查前:(55.1 ±22.1)s、(58.6±23.1)s比(36.9 ±7.0)s,(98.6±33.1)s、(89.5±15.6)s比(81.4±13.6)s;检查结束后4h:(54.4±21.6)s、(58.3±22.4)s比(36.3 ±6.3)s,(88.4 ±30.6)s、(80.2±15.9)s比(71.8±12.0)s;P＜0.05],但肝硬化镇静组与肝硬化非镇静组比较差异均无统计学意义(P＞0.05);各组内前后两个观察时点比较,NCT-A均无明显变化(P＞0.05),但LTT均明显缩短(P＜0.05),考虑与“学习效应”有关;NCT-A和LTT前后两个观察时点变化差值三组间比较差异均无统计学意义(P＞0.05).结论 丙泊酚联合芬太尼用于肝硬化患者胃镜检查的深度镇静是相对安全的,不会诱发或加重轻微肝性脑病,不会导致不可逆转的并发症.     

异丙酚在肝硬化患者无痛胃镜中的应用

[目的]探讨肝硬化患者无痛胃镜检查过程中应用异丙酚作为镇静剂的安全性和可行性。[方法]肝硬化患者(肝硬化组)和非肝硬化患者(对照组)各20例接受异丙酚镇静下的胃镜检查,观察2组患者检查前后及过程中的生命体征,数字连接试验A(NCT-A)及并发症发生情况。[结果]肝硬化组与对照组无痛胃镜检查时间、异丙酚用量相比均差异无统计学意义(P0.05),2组患者检查过程中血压、心率、呼吸频率均有不同程度下降,至苏醒后均基本恢复,但2组检查后清醒时间比较差异有统计学意义(P0.05)。肝硬化组与对照组总并发症率以及低血压、低氧血症和心动过缓发生率比较均差异无统计学意义(P0.05)。肝硬化组操作前后2次NCT-A检查时间均较对照组明显延长(P0.05),但2组检查前后NCT-A完成时间差异无统计学意义(P0.05)。[结论]异丙酚用于肝硬化患者无痛胃镜检查安全,未诱发或加重肝性脑病。     

Fentanyl for sedation during upper gastrointestinal endoscopy

The effects of sedation by intravenous fentanyl on the rate-pressure product (pulse rate x systolic blood pressure/100), arterial oxygen saturation, electrocardiographic change, and serum cortisol concentration were studied during gastroduodenoscopy in 84 patients randomized to receive fentanyl or no intravenous sedative (controls). Fentanyl administration increased the tolerance of patients and attenuated the endoscopy-induced rise in rate-pressure product and serum cortisol concentration. Desaturation of arterial oxygen was minimal and there was no difference in arterial oxygen saturation between the fentanyl group and the control group. Therefore, fentanyl appears to be a favorable sedative for upper gastrointestinal endoscopy, since its administration increased the tolerance of patients and decreased cardiac oxygen consumption.     

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.     

Propofol versus midazolam and meperidine for conscious sedation in GI endoscopy

OBJECTIVE: Propofol (2,6-diisopropyl phenol) is a relatively new intravenous sedative hypnotic with an ideal pharmacokinetic profile for conscious sedation. In this study, we compared the safety and efficacy of propofol versus the conventional regimen of midazolam and meperidine for conscious sedation in GI endoscopy. METHODS: In this prospective study, 274 patients that included many elderly patients with multiple comorbid conditions underwent GI endoscopic procedures at our hospital. A total of 150 patients received propofol (20-120 mg) and fentanyl (0.25-1.5 mg). The control group of 124 patients was given midazolam (2-6 mg) and meperidine (25-75 mg). The dose of medication was titrated according to patient need and the duration of the procedure. A "comfort score" on a scale of 1-4 assessed the efficacy of the drugs based on pain or discomfort to the patient and ease of endoscopy. A "sedation score" was used to assess the degree of sedation on a scale of 1-5. The Aldrete score was used to measure recovery from anesthesia at 5 and 10 min after the procedure. RESULTS: After controlling for age, American Society of Anesthesiologists' Physical Status Classification (ASA grade), and type and duration of procedure, logistic regression analysis determined that propofol resulted in 2.04 times better patient comfort (p = 0.033, 95% CI = 1.058-3.923). Propofol was 1.84 times more likely to produce deeper sedation than the regimen of midazolam and meperidine (p = 0.027, 95% CI = 1.071-3.083). The recovery from sedation was faster in patients receiving propofol, although this did not reach statistical significance. The safety parameters between the two groups were comparable. CONCLUSION: Propofol was associated with a statistically significant improvement in comfort and sedation score when compared to midazolam and meperidine.     

The effect of age on the relative potency of midazolam and diazepam for sedation in upper gastrointestinal endoscopy

Diazepam and midazolam are considered safe and effective sedative agents for diagnostic procedures. However, there have been recent reports of deaths in older patients receiving midazolam for sedation. We examined the relative potency of diazepam compared with midazolam as a function of age in two large groups of patients receiving intravenous benzodiazepines for upper gastrointestinal endoscopy. While midazolam and diazepam are approximately equivalent before age 60, after age 60 the relative potency of midazolam compared with diazepam increases markedly. The rapid decline in dose necessary to sedate older patients with midazolam may explain deaths occurring in older patients who have received this drug. Until this problem receives definitive study, we advise that diazepam be preferred over midazolam for intravenous sedation in patients over 60.