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Propofol-remifentanil patient-controlled sedation for endoscopic procedures: a prospective service audit

Sédation au propofol-rémifentanil contrôlée par le/la patient·e pour les interventions endoscopiques : un audit prospectif de service

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Abstract

Purpose

Following demand, we established a patient-controlled propofol-remifentanil sedation service for endoscopy overseen by an anesthesiologist. To assess the effectiveness of the intervention of this service and any complications, we prospectively audited the service. Our primary outcomes of interest were adequacy of sedation and patient satisfaction. Secondary outcomes included any adverse events associated with the sedation.

Methods

Patients were referred for failure of procedure under endoscopist-administered sedation, refusal of procedure without general anesthesia (GA), or planned complex procedure. We included all 670 procedures performed between 2017 and 2021. We used a mixture of 8.9 mg·mL−1 propofol and 5.4 µg·mL−1 remifentanil with a 1-mL bolus and 20-sec lockout. We assessed the adequacy of sedation using the Modified Gloucester Scale and categorized adverse events according to the Tracking and Reporting Outcomes of Procedural Sedation.

Results

All 670 procedures were accomplished with adequate sedation without the need for ventilation or GA, and all patients were satisfied with the sedation. The complication rate was low, with no sentinel airway or respiratory events. Nineteen out of 670 patients (2.8%) had an incidence of airway obstruction (requiring a simple airway maneuver). The body mass index (BMI) was documented in 18/19 of these patients and the average BMI in this group was 35 kg·m−2. Seven of the 670 patients (1%) had self-terminating apnea, 3/670 patients (0.4%) vomited, no patients aspirated, and 17/665 patients (2.6%) required a vasopressor to maintain blood pressure within 20% of preprocedure values.

Conclusion

The results from our prospective service audit indicate that propofol-remifentanil patient-controlled sedation is a safe and reliable technique in patients undergoing endoscopic procedures.

Résumé

Objectif

Pour répondre à la demande, nous avons mis en place un service de sédation au propofol-rémifentanil contrôlée par le/la patient·e pour l’endoscopie supervisé par l’anesthésiologiste. Pour évaluer l’efficacité de l’intervention de ce service et ses complications, nous avons audité le service de manière prospective. Les principaux critères d’évaluation d’intérêt étaient l’adéquation de la sédation et la satisfaction des patient·es. Les critères d’évaluation secondaires incluaient tous les événements indésirables associés à la sédation.

Méthode

Les patient·es ont été référé·es pour échec d’une intervention sous sédation administrée par l’endoscopiste, refus d’une intervention sans anesthésie générale (AG) ou intervention complexe planifiée. Nous avons inclus les 670 interventions réalisées entre 2017 et 2021. Nous avons utilisé un mélange de 8,9 mg·mL−1 de propofol et 5,4 μg·mL−1 de rémifentanil avec un bolus de 1 mL et une période de verrouillage de 20 secondes. Nous avons évalué l’adéquation de la sédation à l’aide de l’échelle de Gloucester modifiée et classé les événements indésirables en fonction de l’outil de suivi et de déclaration des issues de la sédation procédurale (Tracking and Reporting Outcomes of Procedural Sedation).

Résultats

Les 670 interventions ont été réalisées avec une sédation adéquate sans avoir besoin de ventilation ou d’AG, et tou·tes les patient·es étaient satisfait·es de la sédation. Le taux de complications était faible, sans événements sentinelles respiratoires ou des voies aériennes. Dix-neuf patient·es sur 670 (2,8 %) ont présenté une incidence d’obstruction des voies aériennes (nécessitant une simple manœuvre des voies aériennes). L’indice de masse corporelle (IMC) a été documenté chez 18/19 de ces patient·es et l’IMC moyen dans ce groupe était de 35 kg·m−2. Sept des 670 patient·es (1 %) ont eu une apnée qui s’est terminée spontanément, 3/670 (0,4 %) ont vomi, il n’y a pas eu d’aspiration et 17/665 patient·es (2,6 %) ont eu besoin d’un vasopresseur pour maintenir la pression artérielle dans la plage de 20 % entourant leurs valeurs préopératoires.

Conclusion

Les résultats de notre audit prospectif du service indiquent que la sédation au propofol-rémifentanil contrôlée par le/la patient·e est une technique sécuritaire et fiable chez les personnes bénéficiant d’interventions endoscopiques.

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Author contributions

Hannah J. Blanshard contributed to all aspects of this manuscript, including conception and design; acquisition, analysis, and interpretation of data; and drafting the article. Paula J. Joy contributed to the analysis and interpretation of the data and drafting the article.

Disclosures

None.

Funding statement

None.

Prior conference presentation

Preliminary data were presented at the Society of Anaesthetists of the South Western Region Autumn Scientific Meeting 2021 (18–19 November, Bristol, UK).

Editorial responsibility

This submission was handled by Dr. Vishal Uppal, Associate Editor, Canadian Journal of Anesthesia/Journal canadien d’anesthésie.

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This article is accompanied by an Editorial. Please see Can J Anesth 2023; https://doi.org/10.1007/s12630-023-02592-2.

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Joy, P.J., Blanshard, H.J. Propofol-remifentanil patient-controlled sedation for endoscopic procedures: a prospective service audit. Can J Anesth/J Can Anesth 70, 1735–1743 (2023). https://doi.org/10.1007/s12630-023-02593-1

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