Massimo Agostoni

Target-controlled propofol infusion during monitored anesthesia in patients undergoing ERCP

BACKGROUND A target-controlled infusion system automatically adjusts the rate of infusion of propofol to maintain a desired (target) concentration. The aim of this study was to determine whether administration of propofol with a target-controlled infusion system could improve the sedation of patients undergoing ERCP. METHODS A total of 205 consecutive patients undergoing ERCP were sedated by using a propofol target-controlled infusion system by an anesthesiologist. The target plasma concentration of propofol ranged from 2 to 5 microg/mL. A bolus dose of fentanyl (50-100 mcg) was administered if signs of insufficient analgesia were observed at the maximum target concentration of propofol allowed. The technical difficulty of ERCP was graded on a scale from 1 (least difficult) to 5 (most difficult). RESULTS The mean dosages of propofol and fentanyl administered were 465 (245) mg and 59 (23) mcg, respectively. The total dose of propofol administered and the mean duration of ERCP were related to the degree of difficulty of the procedure. No severe complication was observed; mean time to discharge was 31 (12) minutes. Time to discharge was not influenced by the difficulty of ERCP or by the total dose of propofol administered. CONCLUSIONS A target-controlled infusion system for administration of propofol provides safe and effective sedation during ERCP. Further studies are needed to determine the cost-effectiveness and the safety profile for infusion of propofol with a target-controlled infusion system by a nonanesthesiologist during ERCP.

Sedation and monitoring for gastrointestinal endoscopy: A nationwide web survey in Italy

BACKGROUND Best strategy of sedation/analgesia in gastrointestinal (GI) endoscopy is still debated. AIMS OF THE STUDY To evaluate sedation and monitoring practice among Italian gastroenterologists and to assess their opinion about non-anaesthesiologist propofol administration. METHODS A 19-item survey was mailed to all 1192 members of the Italian Society of Digestive Endoscopy (SIED). For each respondent were recorded demographic data, medical specialty, years of practise and practise setting. RESULTS A total of 494 SIED members returned questionnaires, representing a response rate of 41.4%. The most employed sedation pattern was benzodiazepines for oesophagogastroduodenoscopies (EGDS) in 50.8% of procedures, benzodiazepines plus opioids for colonoscopy and enteroscopy in 39.5% and 35.3% of procedures, respectively, propofol for endoscopic retrograde colangiopancreatography (ERCP) and endoscopic ultrasound (EUS) in 42.3% and 35.6% of procedures, respectively. With regard to propofol use, 66% respondents stated that propofol was exclusively administered by anaesthesiologists. However, 76.9% respondents would consider non-anaesthesiologist propofol administration after appropriate training. Pulse oximetry is the most employed system for procedural monitoring. Supplemental O(2) is routinely administered by 39.3% respondents. CONCLUSIONS Use of sedation has become a standard practise during GI endoscopy in Italy. Pattern varies for each type of procedure. Pulse oximetry is the most employed system of monitoring. Administration of propofol is still directed by anaesthesiologists.

Target Controlled Infusion for non-anaesthesiologist propofol sedation during gastrointestinal endoscopy: The first double blind randomized controlled trial

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.

Two dosages of remifentanil for patient-controlled analgesia vs. meperidine during colonoscopy: A prospective randomized controlled trial

UNLABELLED BACKGROUND AND STUDY: Combined use of opiates and benzodiazepines often results in delayed discharge after colonoscopy. AIMS To compare sedation quality of two dosages of patient controlled analgesia remifentanil with one another and with that of a midazolam-meperidine association during colonoscopy. METHODS Ninety patients undergoing colonoscopy were randomly assigned to three groups. Group M received a meperidine bolus (0.7 mg/kg) and sham patient controlled analgesia. Group R1 received remifentanil 0.5 μg/kg and group R2 remifentanil 0.8 μg/kg together with a patient-controlled analgesia pump injecting further boluses (2-min lock-out). Technical difficulties of the examination, gastroenterologists and patients satisfaction with sedoanalgesia were evaluated after colonoscopy on a 100 mm Visual Analogue Scale. Patients satisfaction was assessed 24 h later. RESULTS Group M had more adverse events (p = 0.044), required more rescue boluses (p = 0.0010), had lower Observers Assessment of Alertness and Sedation Scale score at the end of the procedure (p = 0.0016) and longer discharge time (p = 0.0001). Groups R1 and R2 did not differ with respect to these variables. Patients degree of pain and satisfaction with sedo-analgesia, endoscopists technical difficulty and satisfaction were not different among groups. CONCLUSIONS Remifentanil patient controlled analgesia is a safe approach to sedation for colonoscopy.

Swallowing Impairment during Propofol Target-Controlled Infusion

BACKGROUND:Sedatives can impair the swallowing process. We assessed the incidence and severity of swallowing impairment in patients sedated with propofol at clinically relevant doses. We also identified factors that were predictive of swallowing impairment. METHODS:In 80 patients scheduled to undergo elective gastrointestinal endoscopy under target-controlled infusion (TCI) propofol sedation, swallowing was evaluated by glottis videoendoscopy, using the Dysphagia Severity Score (DSS) and the Penetration and Aspiration Scale (PAS). The level of sedation was assessed with the Observer’s Assessment of Alertness/Sedation (OAAS) scale. Evaluations were obtained within each patient at 3 target effect-site propofol concentrations of 2, 3, and 4 &mgr;g/mL (Marsh model). RESULTS:At 2 &mgr;g/mL TCI, the OAAS score was 2 in 21 (26.25%) patients and 1 in 59 (73.75%). The OAAS score was 1 in all patients at 3 and 4 &mgr;g/mL TCI target. At 3 &mgr;g/mL TCI target, 19 (24.36%) patients had a DSS = 3 and 18 patients (23.08%) had a PAS = 7–8 (severe swallowing impairment). DSS was associated with increasing age (5-year odds ratio [OR] 1.53 [1.22–1.93]; P < 0.001), body mass index (BMI; OR 1.24 [1.08–1.42]; P = 0.002), and TCI target (OR 15.80 [7.76–32.20]; P < 0.001). In an alternative model incorporating OAAS instead of TCI target, DSS was associated with increasing age (5-year OR 1.13 [1.02–1.24]; P = 0.014) and BMI (OR 1.08 [1.02–1.15]; P = 0.006) and decreasing OAAS (OR 0.05 [0.006–0.36]; P = 0.003). PAS was associated with increasing age (5-year OR 1.09 [1.04–1.15]; P < 0.001), BMI (OR 1.23 [1.07–1.41]; P = 0.003), and TCI target (OR 15.23 [7.45–31.16]; P < 0.001). In an alternative model incorporating OAAS instead of TCI target, PAS was associated with increasing age (5-year OR 1.14 [1.04–1.26]; P = 0.007) and BMI (OR 1.09 [1.02–1.15]; P = 0.006) and decreasing OAAS (OR 0.05 [0.006–0.41]; P = 0.005). CONCLUSIONS:Aspiration due to swallowing impairment may occur during deep sedation produced by propofol at commonly used TCI targets. TCI targets are predictors of swallowing impairment; increased age and high BMI are concomitant risk factors.

A Much Sought-After Drug—Propofol Sedation for GI Endoscopy: Always Better but Who Cares?

Several hypnotic and analgesic strategies have beendevised for patients undergoing gastrointestinal (GI)endoscopy, ranging in a continuum from mild conscioussedation to general anesthesia.Endoscopic retrograde cholangiopancretography (ERCP)and endoscopic ultrasound (EUS) are particularly unpleas-ant diagnostic procedures for patients and more time con-suming than any other endoscopic procedure. Moreover,ERCP can be technically difficult and requires completepatient cooperation in order to be safely and successfullycompleted. Patients frequently are sedated for ERCP orEUS with intravenous bolus doses of benzodiazepines incombination with opioids, which are meant to improve thequality of sedation by providing analgesia. Deep sedation issometimes required.The introduction of propofol into clinical practice sig-nificantly changed the attitudes of both physicians andpatients towards sedation, with the result that propofolsedation for GI endoscopy has become common practiceworldwide. In recent years, propofol has been safely andeffectively used in advanced interventional endoscopicprocedures, such as ERCP and EUS, even for high-riskpatients [1]. Propofol is a hypnotic drug with rapid onsetand offset of action. Used as a single agent, it is commonlytitrated to attain deep sedation, whereas balanced propofolsedation (BPS), in which propofol use is associated withsmall doses of benzodiazepines and/or opioids, can besuccessfully titrated to attain moderate sedation.Several studies have shown that, when compared withconventional sedation, BPS with propofol, midazolam,and/or meperidine, yields higher physician and patientsatisfaction, better patient cooperation, and similar com-plication rates in patients undergoing therapeutic endo-scopic procedures. The total propofol dose may beexpected to be reduced by 50 % with BPS in comparisonwith propofol alone sedation.A critical advantage in dealing with BPS for moderatesedation is that it can be partially reverted, since antagonistsare available against both opioids and benzodiazepines.In the current issue of Digestive Diseases and Sciences,Tae Hoon Lee et al. [2] present the results of a randomizedprospective study comparing BPS (propofol, midazolam,and fentanyl) with propofol alone during moderate sedationfor ERCP and EUS. The authors demonstrate that propofolalone provides a shorter recovery time than BPS and iscomparably effective and safe. This paper is the naturalevolution of a previous study of the same authors in whichthey demonstrated a higher safety and efficacy of BPS incomparison with conventional sedation [3]. In this respect,Tae Hoon Lee et al. positively contribute to the knowledgeof sedation strategies for endoscopy.However, in another respect, they quietly and almostinadvertently hit a raw nerve in the ongoing debate aboutwho can/should provide propofol sedation. In both of theirstudies, sedation was provided by non-anesthesiologists,further adding to the body of literature indicating that theadministration of propofol by non-anesthesiologists may besafe and effective for selected patients undergoingadvanced endoscopic procedures.The subject of non-anesthesiologist administrationof propofol (NAAP), particularly for endoscopy, has