Abstract
Purpose
Endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) generally takes longer to perform than conventional endoscopy and usually requires moderate/deep sedation with close surveillance for patient safety. The aim of this study was to compare the safety profiles and recovery scores propofol continuous infusion and intermittent midazolam (MDZ) injection as sedation for ESD.
Methods
Sixty EGC patients scheduled for ESDs between August and November 2008 were included in this prospective study and randomly divided into a propofol (P-group, 28 patients) and an MDZ (M-group, 32 patients) group using an odd–even system. The P-group received a 0.8 mg/kg induction dose and a 3 mg/kg/h maintenance dose of 1% propofol using an infusion pump. All patients received 15 mg pentazocine at the start of the ESD and at 60-min intervals thereafter. We recorded and analyzed blood pressure, oxygen saturation and heart rate during and following the procedure and evaluated post-anesthetic recovery scores (PARS) and subsequent alertness scores.
Results
The propofol maintenance and total dose amounts were (mean ± standard deviation) 3.7 ± 0.6 mg/kg/h and 395 ± 202 mg, respectively. The mean total dose of MDZ was 10.3 ± 4.5 mg. There were no cases of de-saturation <90% or hypotension <80 mmHg in either group. Alertness scores 15 and 60 min after the procedures were significantly higher in the P-group (4.9/4.9) than in the M-group (4.6/4.5; p < 0.05). The mean PARS 15 and 30 min after the ESDs were significantly higher in the P-group (9.6/9.9) than in the M-group (8.6/9.2; p < 0.01).
Conclusion
Based on our results, the ESDs for EGC performed under sedation using propofol continuous infusion were as safe as those performed using intermittent MDZ injection. Propofol-treated patients had a quicker recovery profile than those treated with MDZ. We therefore recommend the use of continuous propofol sedation for ESD, but sedation guidelines for the use of propofol are necessary.
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References
Oda I, Gotoda T, Hamanaka H, Eguchi T, Saito Y, Matsuda T, et al. Endoscopic submucosal dissection for early gastric cancer: technical feasibility, operation time and complications from a large consecutive series. Dig Endosc. 2005;17:54–8.
American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology. 2002;96:1004–17.
Diab FH, King PD, Barthel JS, Marshall JB. Efficacy and safety of combined meperidine and midazolam for EGD sedation compared with midazolam alone. Am J Gastroenterol. 1996;91:1120–5.
Patel S, Vargo JJ, Khandwala F, Lopez R, Trolli P, Dumot JA, et al. Deep sedation occurs frequently during elective endoscopy with meperidine and midazolam. Am J Gastroenterol. 2005;100:2689–95.
DeWitt J, McGreevy K, Sherman S, Imperiale TF. Nurse-administered propofol sedation compared with midazolam and meperidine for EUS: a prospective, randomized trial. Gastrointest Endosc. 2008;68:499–509.
Heuss LT, Schnieper P, Drewe J, Pflimlin E, Beglinger C. Safety of propofol for conscious sedation during endoscopic procedures in high-risk patients: a prospective, controlled study. Am J Gastroenterol. 2003;98:1751–7.
Tohda G, Higashi S, Wakahara S, Morikawa M, Sakumoto H, Kane T. Propofol sedation during endoscopic procedures: safe and effective administration by registered nurses supervised by endoscopists. Endoscopy. 2006;38:360–7.
Vargo JJ, Zuccaro GJ, Dumot JA, Shermock KM, Morrow JB, Conwell DL, et al. Gastroenterologist-administered propofol versus meperidine and midazolam for advanced upper endoscopy: a prospective, randomized trial. Gastroenterology. 2002;123:8–16.
McQuaid KR, Laine L. A systematic review and meta-analysis of randomized, controlled trials of moderate sedation for routine endoscopic procedures. Gastrointest Endosc. 2008;67:910–23.
Koshy G, Nair S, Norkus EP, Hertan HI, Pitchumoni CS. Propofol versus midazolam and meperidine for conscious sedation in GI endoscopy. Am J Gastroenterol. 2000;95:1476–9.
Sipe BW, Rex DK, Latinovich D, Overley C, Kinser K, Bratcher L, et al. Propofol versus midazolam/meperidine for outpatient colonoscopy: administration by nurses supervised by endoscopists. Gastrointest Endosc. 2002;55:815–25.
Ng JM, Kong CF, Nyam D. Patient-controlled sedation with propofol for colonoscopy. Gastrointest Endosc. 2001;54:8–13.
Carlsson U, Grattidge P. Sedation for upper gastrointestinal endoscopy: a comparative study of propofol and midazolam. Endoscopy. 1995;27:240–3.
Patterson KW, Casey PB, Murray JP, O’Boyle CA, Cunningham AJ. Propofol sedation for outpatient upper gastrointestinal endoscopy: comparison with midazolam. Br J Anaesth. 1991;67:108–11.
Gasparovic S, Rustemovic N, Opacic M, Premuzic M, Korusic A, Bozikov J, et al. Clinical analysis of propofol deep sedation for 1, 104 patients undergoing gastrointestinal endoscopic procedures: a three year prospective study. World J Gastroenterol. 2006;12:327–30.
Fantani L, Agostoni M, Casati A. Target-controlled propofol infusion during monitored anesthesia in patients undergoing ERCP. Gastrointest Endosc. 2004;60:361–6.
Wehrmann T, Kokabpick S, Lembcke B, Caspary WF, Seifert H. Efficacy and safety of intravenous propofol sedation during routine ERCP: a prospective, controlled study. Gastrointest Endosc. 1999;49:677–83.
Qadeer MA, Vargo JJ, Khandwala F, Lopez R, Zuccaro G. Propofol versus traditional sedative agents for gastrointestinal endoscopy: a meta-analysis. Clin Gastroenterol Hepatol. 2005;3:1049–456.
Training Committee. American Society for Gastrointestinal Endoscopy. Training guideline for use of propofol in gastrointestinal endoscopy. Gastrointest Endosc. 2004;60:167–72.
Aldrete JA, Kroulik D. A postanesthetic recovery score. Anesth Analg. 1970;49:924–34.
Aldrete JA. Modifications to the postanesthesia score for use in ambulatory surgery. J Perianesth Nurs. 1998;13:148–55.
Kongkam P, Pornphisarn B, Rerknimitr R. Non-anesthetist administered propofol for ERCP; efficacy, safety profile and side effect: a prospective randomized trial. Gastrointest Endosc. 2004;59:P127.
Kongkam P, Rerknimitr R, Punyathavorn S, Amorn CS, Ponauthai Y, Prempracha N, et al. Propofol infusion versus intermittent meperidine and midazolam injection for conscious sedation in ERCP. J Gastrointestin Liver Dis. 2008;17:291–7.
Krugliak P, Ziff B, Rusabrov Y, Rosenthal A, Fich A, Gurman GM. Propofol versus midazolam for conscious sedation guided by processed EEG during endoscopic retrograde cholangiopancreatography: a prospective, randomized, double-blind study. Endoscopy. 2000;32:677–82.
Riphaus A, Stergiou N, Wehrmann T. Sedation with propofol for routine ERCP in high-risk octogenarians: a randomized, controlled study. Am J Gastroenterol. 2005;100:1957–63.
Oei-Lim VL, Kalkman CJ, Bartelsman J, Res JC, van Wezel HB. Cardiovascular responses, arterial oxygen saturation and plasma catecholamine concentration during upper gastrointestinal endoscopy using conscious sedation with midazolam or propofol. Eur J Anaesthesiol. 1998;15:535–43.
Rex DK, Overley C, Kinser K, Coates M, Lee A, Goodwine BW, et al. Safety of propofol administered by registered nurses with gastroenterologist supervision in 2000 endoscopic cases. Am J Gastroenterol. 2002;97:1159–63.
Kulling D, Fantin AC, Biro P, Bauerfeind P, Fried M. Safer colonoscopy with patient-controlled analgesia and sedation with propofol and alfentanil. Gastrointest Endosc. 2001;54:1–7.
Jung M, Hofmann C, Kiesslich R, Brackertz A. Improved sedation in diagnostic and therapeutic ERCP: propofol is an alternative to midazolam. Endoscopy. 2000;32:233–8.
ASGE Standards of Practice Committee. Guidelines for the use of deep sedation and anesthesia for GI endoscopy. Gastrointest Endosc. 2002;56:613–7.
Wehrmann T, Grotkamp J, Stergiou N, Riphaus A, Kluge A, Lembcke B, et al. Electroencephalogram monitoring facilitates sedation with propofol for routine ERCP: a randomized, controlled trial. Gastrointest Endosc. 2002;56:817–24.
Nelson DB, Freeman ML, Silvis SE. A randomized, controlled trial of transcutaneous carbondioxide monitoring during ERCP. Gastrointest Endosc. 2000;51:288–95.
Prstojevich SJ, Sabol SR, Goldwasser MS, Jonson C. Utility of capnography in predicting venous carbondioxide partial pressure in sedated patients during outpatient oral surgery. J Oral Maxillofac Surg. 1987;45:3–10.
Gilger MA, Spearman RS, Dietrich CL. Safety and effectiveness of ketamine as a sedative agent for pediatric GI endoscopy. Gastrointest Endosc. 2004;59:659–63.
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Kiriyama, S., Gotoda, T., Sano, H. et al. Safe and effective sedation in endoscopic submucosal dissection for early gastric cancer: a randomized comparison between propofol continuous infusion and intermittent midazolam injection. J Gastroenterol 45, 831–837 (2010). https://doi.org/10.1007/s00535-010-0222-8
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DOI: https://doi.org/10.1007/s00535-010-0222-8