Endoscopy 2000; 32(3): 233-238
DOI: 10.1055/s-2000-96
Original Article
Georg Thieme Verlag Stuttgart ·New York

Improved Sedation in Diagnostic and Therapeutic ERCP: Propofol is an Alternative to Midazolam

M. Jung 1 , C. Hofmann 1 , R. Kiesslich 1 , A. Brackertz 2
  • 1 Department of Internal Medicine, St. Hildegardis Hospital, Academic Teaching Hospital of the Johannes-Gutenberg University, Mainz, Germany
  • 2 Department of Anesthesiology, St. Hildegardis Hospital, Academic Teaching Hospital of the Johannes-Gutenberg University, Mainz, Germany
Further Information

Publication History

Publication Date:
31 December 2000 (online)

Background and Study Aims: Adequate sedation of the patient is required for diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP). The anesthetic propofol, with its shorter half-life, affording better control, offers an alternative to the benzodiazepine midazolam. The aim of this randomized, controlled, unblinded study was to compare prospectively the quality of sedation under propofol and midazolam in patients undergoing ERCP.

Patients and Methods: A total of 80 patients were randomized to sedation with propofol alone (n = 40) or midazolam alone (n = 40). Blood pressure, pulse, and oxygen saturation were measured. Midazolam was given by the endoscopist and titrated to the patients' response during ERCP, to a maximum dose of 15 mg per patient. In the propofol group an anesthetist was present to administer the propofol and to observe the patient. Standardized testing procedures (Steward score, Trieger test) were used to determine the length of postendoscopy recovery time. Efficacy of sedation was assessed by investigators and patients, using scoring systems.

Results: Complete ERCP and adequate sedation was possible in 80 % of patients (32 out of 40) with midazolam, and in 97.5 % of patients (39 out of 40) with propofol (P < 0.01). The average propofol induction dose was 1.24 mg/kg body weight, with maintenance requiring a mean dose of 9 mg/kg body weight per hour, or the equivalent of 354 mg in total. The average dose of midazolam administered was 0.12 mg/kg body weight; the total dose averaged 8 mg. Recovery time in the propofol patients was significantly shorter (P < 0.01). The investigators (P < 0.01) and the patients (P < 0.05) both judged the quality of sedation to be better in the propofol group. There were no differences in blood pressure, pulse, or oxygen saturation between the two groups. One patient in the propofol group (79 years old) suffered a protracted apneic phase accompanied by hypotension that was managed by manual ventilation and drug therapy, and led to no complications.

Conclusions: Propofol proves to be an excellent sedative for ERCP and shows a shorter recovery time than midazolam. Because of the narrow therapeutic window, we recommend close patient monitoring.

References

  • 1 Jowell P S, Eisen G, Onken J, et al. Patient-controlled analgesia for conscious sedation during retrograde cholangiopancreatography: a randomized controlled trial.  Gastrointest Endosc. 1996;  43 490-494
  • 2 Reves J G, Fragen R J, Vinik H R, et al. Midazolam: pharmacology and uses.  Anesthesiology. 1985;  12 310-324
  • 3 Langley M S, Heel R C. Propofol: a review of its pharmacodynamic and pharmacokinetic properties and use as an intravenous anaesthetic.  Drugs. 1988;  35 334-372
  • 4 Bryson H M, Fulton B R, Faulds D. Propofol: an update of its use in anaesthesia and conscious sedation.  Drugs. 1995;  50 513-559
  • 5 Roseveare C, Seavell C, Patel P, et al. Patient-controlled sedation propofol and alfentanil during colonoscopy: a pilot study.  Endoscopy. 1998;  30 482-483
  • 6 Carlsson U, Grattidge P. Sedation for upper gastrointestinal endoscopy: a comparative study of propofol and midazolam.  Endoscopy. 1995;  27 240-243
  • 7 Patterson K W, Casey P B, Murray J P, et al. Propofol sedation for outpatient upper gastrointestinal endoscopy: comparison with midazolam.  Br J Anaesth. 1991;  67 108-111
  • 8 Wehrmann T, Kokabpick S, Lembcke B, et al. Efficacy and safety of intravenous propofol sedation during routine ERCP: a prospective, controlled study.  Gastrointest Endosc. 1999;  49 677-683
  • 9 Steward D J. A simplified scoring system for the post-operative recovery room.  Can Anaesthet Soc J. 1975;  22 111-113
  • 10 Trieger N, Newman M G, Miller J C. Measuring recovery from anesthesia - a simple test.  Anesth Analg. 1969;  48 136-140
  • 11 Keffee E, O'Connor K W. ASGE survey of endoscopic sedation and monitoring practice.  Gastrointest Endosc. 1990;  36 13-18
  • 12 Quine M A, Bell G D, McCloy R F, et al. Prospective audit of upper gastrointestinal endoscopy in two regions of England: safety, staffing, and sedation methods.  Gut. 1995;  36 462-467
  • 13 Arrowsmith J B, Gerstmann B B, Fleischer D E, et al. Results from the American Society for Gastrointestinal Endoscopy/U.S. Food and Drug Administration collaborative study on complication rate and drug use during gastrointestinal endoscopy.  Gastrointest Endosc. 1991;  37 421-427
  • 14 Gepts E, Van de Velde A, Devis G, et al. Continuous Diprivan infusions as sedative for endoscopy in gastroenterology.  Acta Endosc. 1983;  13 83-100
  • 15 Raymond J M, Capdenat E, Beyssac R, et al. Qualité de la récupération psychomotrice après une coloscopie sous anesthésie générale par propofol.  Gastroenterol Clin Biol. 1995;  19 373-377
  • 16 Goff J S. Effect of propofol on human sphincter of oddi.  Dig Dis Sci. 1995;  40 2364-2367
  • 17 Kim L S, Cammarano W B, Querimit L A, et al. Randomized controlled trial of propofol for patient sedation during endoscopic retrograde cholangiopancreatography (ERCP).  Gastrointest Endosc. 1998;  47 114
  • 18 Froehlich F, Thores J, Schwizer W, et al. Sedation and analgesia for colonoscopy: patient tolerance, pain and cardiorespiratory parameters.  Gastrointest Endosc. 1997;  45 1-9
  • 19 Mackay P. Fatal cardiovascular collapse following propofol induction in high-risk patients.  Anaesth Intensive Care. 1996;  24 125-126
  • 20 Robinson F P, Dundee J W, Halliday N J. Age affects the induction dose of propofol (“Diprivan”).  Postgrad Med J. 1993;  61 157-159

M.D. M. Jung

Innere Abteilung, St. Hildegardis-Krankenhaus

Hildegardstrasse 2

55131 Mainz, Germany

Phone: +49-6131-147753