Abstract
Purpose
To compare anesthesiologist-controlled sedation (ACS) with patient-controlled sedation (PCS), with respect to propofol requirements, sedation, and recovery, in patients undergoing extracorporeal shockwave lithotripsy for urinary calculi.
Methods
Sixty-four patients were randomized, in this doubleblind study, to receive propofol sedation according to one of two regimens: infusion of 200 μg·kg-1·min-1 for ten minutes reduced thereafter to 50-150 μg·kg-1·min-1 titrated by an anesthesiologist, according to patient response (group ACS), or propofol administered by patient-controlled analgesia (bolus dose 300 μg·kg-1, lockout interval three minutes, no basal infusion), (group PCS). All patients received midazolam 10 μg·kg-1 iv and fentanyl 1 μg·kg-1 iv preoperatively, followed by fentanyl infused at a rate of 0.5 μg·kg-1·hr-1 throughout the procedure. Sedation and analgesia were assessed using the A-line ARX index and visual analogue scale, respectively. Psychomotor recovery and readiness for recovery room discharge were assessed using the Trieger dot test and postanesthesia discharge score, respectively. Patient satisfaction was assessed on a sevenpoint scale (1-7).
Results
In comparison to group PCS, patients in group ACS received more propofol (398 ± 162 mg vs 199 ± 68 mg, P < 0.001), were more sedated (A-line ARX index: 35 ± 16 vs 73 ± 16,P < 0.001), experienced less pain (visual analogue scale: 0 ± 0 vs 3 ± 1, P < 0.001), and were more satisfied (median [Q1, Q3]: 7 [7, 7] vs 6 [6, 7],P < 0.001). In contrast, patients in group PCS had faster psychomotor recovery (Trieger dot test median [Q1, Q3]: 8 [4, 16] vs 16 [12, 26] dots missed, P = 0.002) and achieved postanesthesia discharge score ≥ 9 earlier (median [Q1, Q3]: 40 [35, 60] vs 88 [75, 100] min,P < 0.001) compared with group ACS.
Conclusion
In comparison to PCS for patients undergoing extracorporeal shockwave lithotripsy, propofol/fentanyl ACS is associated with increased propofol administration, deeper sedation levels, and greater patient comfort. However, ACS is associated with slower recovery and a longer time to meet discharge criteria, when compared to PCS.
Résumé
Objectif
Comparer la sédation contrôlée par ľanesthésiologiste (SCA) á la sédation contrôlée par le patient (SCP) quant aux demandes de propofol, á la sédation et á la récupération chez des patients devant subir une lithotripsie á ondes de choc électrohydraulique pour urolithiase.
Méthode
Soixante-quatre patients, répartis au hasard pour une étude á double insu, ont reçu : soit une sédation par une perfusion de propofol de 200 μg·kg-1·min-1 pendant dix minutes, réduite ensuite á 50 -150 μg·kg-1·min-1 ajustée par un anesthésiologiste en fonction de la réaction du patient (groupe SCA), soit du propofol en analgésie autocontrôlée (bolus de 300 μg·kg-1, période réfractaire de trois minutes, sans perfusion initiale), (groupe SCP). Avant ľopération, tous les patients ont reçu 10μg·kg-1 de midazolam iv et 1 μg·kg-1 de fentanyl iv, puis une perfusion de fentanyl á 0,5 μg·kg-1·h-1 tout au long de ľintervention. La sédation et ľanalgésie ont été évaluées par ľindex A-line ARX et ľéchelle visuelle analogique (EVA), respectivement. La récupération psychomotrice et ľétat permettant de quitter la salle de réveil ont été évalués par le Trieger Dot Test et les critères de sortie de la salle de réveil, respectivement. La satisfaction du patient a été évaluée sur une échelle de sept points 1-7).
Résultats
Comparés aux patients du groupe SCP, ceux du groupe SCA ont reçu plus de propofol (398 ± 162 mg vs 199 ± 68 mg, P < 0,001), et plus de sédatifs (index A-line ARX : 35 ± 16 vs 73 ± 16, P < 0,001), éprouvé moins de douleur (EVA : 0 ± 0 vs 3 ± 1, P < 0,001) et ont été plus satisfaits (médiane [Q1, Q3] : 7 [7, 7] vs 6 [6, 7], P < 0,001). Par ailleurs, les patients du groupe SCP ont connu une récupération psychomotrice plus rapide (mé diane du Trieger dot test [Q1, Q3] : 8 [4, 16] vs 16 [12, 26] points manqués, P = 0,002) et ont atteint les critères de sortie de la salle de réveil ≥ 9 plus tôt (médiane [Q1, Q3] : 40 [35, 60] vs 88 [75, 100] min, P < 0,001).
Conclusion
Comparée á la SCP pour une lithotripsie á ondes de choc électrohydraulique, la SCA au propofol/fentanyl est associée á une plus grande consommation de propofol, á des niveaux de sédation plus profonds et á un plus grand confort du patient. Mais la SCA, comparée á la SCP, retarde la récupération et prolonge le temps en salle de réveil.
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Alhashemi, J.A., Kaki, A.M. Anesthesiologist-controlled versus patient-controlled propofol sedation for shockwave lithotripsy. Can J Anesth 53, 449–455 (2006). https://doi.org/10.1007/BF03022616
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DOI: https://doi.org/10.1007/BF03022616