Deep sedation for endoscopic retrograde cholangiopancreatography: intravenous propofol alone versus intravenous propofol with oral midazolam premedication
G. A. Paspatis1
, M. M. Manolaraki2
, E. Vardas1
, A. Theodoropoulou1
, G. Chlouverakis3
1Department of Gastroenterology, Benizelion General Hospital, Heraklion-Crete, Greece
2Department of Anesthesiology, Benizelion General Hospital, Heraklion-Crete, Greece
3Department of Social Medicine, University of Crete, Heraklion-Crete, Greece
Background and study aims: The primary objective of the present study was to compare the dosage of intravenous propofol required in patients being sedated with propofol alone (group P) with the dosage of propofol required in patients who also received an oral dose of midazolam (group M + P) for endoscopic retrograde cholangiopancreatography (ERCP) procedures. The secondary objectives were to compare the two groups with regard to patient anxiety levels before the procedure, patient satisfaction, the recovery time, and the adverse events related to sedation.
Patients and methods: A total of 91 consecutive patients undergoing ERCP were randomly assigned to one of the two medication regimens. Patients in group P (n = 45) received only intravenous propofol, titrated to achieve deep sedation. Patients in group M + P (n = 46) received 7.5 mg of midazolam orally 30 minutes before being given intravenous propofol, which was similarly titrated to achieve deep sedation.
Results: Patients receiving propofol alone required higher doses of propofol compared with those receiving synergistic sedation (512 ± 238 mg vs. 330 ± 223 mg respectively, P < 0.001). The patients’ anxiety levels before the procedure were lower in group M + P patients than in group P patients (P < 0.001). The mean percentage decline in oxygen saturation during the procedure was significantly greater in group P patients than it was in group M + P patients. A significant drop in the oxygen saturation (to < 90 %) occurred in 11 group P patients and in three group M + P patients (P = 0.02).
Conclusions: Our data suggest that synergistic sedation with an oral dose of midazolam combined with intravenous propofol can provide a significant benefit, with a reduction in the dosage of propofol required and in patient anxiety levels before ERCP.
References
1
Cohen L B, Wecsler J S, Gaetano J N. et al .
Endoscopic sedation in the United States: results from a nationwide survey.
Am J Gastroenterol.
2006;
101
967-974
3
Cohen L B, Dubovsky A N, Aisenberg J. et al .
Propofol for endoscopic sedation: a protocol for safe and effective administration by the gastroenterologist.
Gastrointest Endosc.
2003;
58
725-732
4
Paspatis G A, Charoniti I, Manolaraki M. et al .
Synergistic sedation with oral midazolam as a premedication and intravenous propofol versus intravenous propofol alone in upper gastrointestinal endoscopies in children: a prospective, randomized study.
J Pediatr Gastroenterol Nutr.
2006;
43
195-199
5
Faulx A L, Vela S, Das A. et al .
The changing landscape of practice patterns regarding unsedated endoscopy and propofol use: a national web survey.
Gastrointest Endosc.
2005;
62
9-15
7
Vargo J J, Zuccaro Jr G, Dumot J A. et al .
Gastroenterologist-administered propofol versus meperidine and midazolam for advanced upper endoscopy: a prospective, randomized trial.
Gastroenterology.
2002;
123
8-16
8
Fanti L, Agostoni M, Casati A. et al .
Target-controlled propofol infusion during monitored anesthesia in patients undergoing ERCP.
Gastrointest Endosc.
2004;
60
361-366
9
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
10
Jung M, Hofmann C, Kiesslich R. et al .
Improved sedation in diagnostic and therapeutic ERCP: propofol is an alternative to midazolam.
Endoscopy.
2000;
32
233-238
11
Seifert H, Schmitt T H, Gultekin T. et al .
Sedation with propofol plus midazolam versus propofol alone for interventional endoscopic procedures: a prospective, randomized study.
Aliment Pharmacol Ther.
2000;
14
1207-1214
12
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
1957-1963
13
Krugliak P, Ziff B, Rusabrov Y. et al .
Propofol versus midazolam for conscious sedation guided by processed EEG during endoscopic retrograde cholangiopancreatography: a prospective, randomized, double-blind study.
Endoscopy.
2000;
32
677-682
14
Koch M E, Gevirtz C.
Propofol may be safely administered by trained nonanesthesiologists. Con: propofol: far from harmless.
Am J Gastroenterol.
2004;
99
1208-1211
17
Qadeer M A, Vargo J J, Khandwala F. et al .
Propofol versus traditional sedative agents for gastrointestinal endoscopy: a meta-analysis.
Clin Gastroenterol Hepatol.
2005;
3
1049-1056
18
Wysowski D K, Pollock M L.
Reports of death with use of propofol (Diprivan) for nonprocedural (long-term) sedation and literature review.
Anesthesiology.
2006;
105
1047-1051
19
VanNatta M E, Rex D K.
Propofol alone titrated to deep sedation versus propofol in combination with opioids and/or benzodiazepines and titrated to moderate sedation for colonoscopy.
Am J Gastroenterol.
2006;
101
2209-2217
21
Cohen L B, Hightower C D, Wood D A. et al .
Moderate level sedation during endoscopy: a prospective study using low-dose propofol, meperidine/fentanyl, and midazolam.
Gastrointest Endosc.
2004;
59
795-803
22
Paspatis G A, Manolaraki M, Xirouchakis G. et al .
Synergistic sedation with midazolam and propofol versus midazolam and pethidine in colonoscopies: a prospective, randomized study.
Am J Gastroenterol.
2002;
97
1963-1967
28
Rex D K, Heuss L T, Walker J A. et al .
Trained registered nurses/endoscopy teams can administer propofol safely for endoscopy.
Gastroenterology.
2005;
129
1384-1391
29
Vargo J J.
Propofol may be safely administered by trained nonanesthesiologists. Pro: propofol demystified: it is time to change the sedation paradigm.
Am J Gastroenterol.
2004;
99
1207-1208
30
Aisenberg J, Cohen L B, Piorkowski Jr J D.
Propofol use under the direction of trained gastroenterologists: an analysis of the medicolegal implications.
Am J Gastroenterol.
2007;
101
707-713
31
Heuss L T, Froehlich F, Beglinger C.
Changing patterns of sedation and monitoring practice during endoscopy: results of a nationwide survey in Switzerland.
Endoscopy.
2005;
37
161-166
32
Mui L M, Teoh A Y, Ng E K. et al .
Premedication with orally administered midazolam in adults undergoing diagnostic upper endoscopy: a double-blind placebo-controlled randomized trial.
Gastrointest Endosc.
2005;
61
195-200
34
Kuganeswaran E, Clarkston W K, Cuddy P G. et al .
A double-blind placebo-controlled trial of oral midazolam as premedication before flexible sigmoidoscopy.
Am J Gastroenterol.
1999;
94
3215-3219
35
Liacouras C A, Mascarenhas M, Poon C. et al .
Placebo-controlled trial assessing the use of oral midazolam as a premedication to conscious sedation for pediatric endoscopy.
Gastrointest Endosc.
1998;
47
455-460
36
Martinez J L, Sutters K A, Waite S. et al .
A comparison of oral diazepam versus midazolam, administered with intravenous meperidine, as premedication to sedation for pediatric endoscopy.
J Pediatr Gastroentrol Nutr.
2002;
35
51-58
38
Vargo J J, Holub J L, Faigel D O. et al .
Risk factors for cardiopulmonary events during propofol-mediated upper endoscopy and colonoscopy.
Aliment Pharmacol Ther.
2006;
24
955-963
41
Christe C, Janssens J P, Armenian B. et al .
Midazolam sedation for upper gastrointestinal endoscopy in older persons: a randomized, double-blind, placebo-controlled study.
J Am Geriatr Soc.
2000;
48
1398-1403
42
Vargo J J, Zuccaro Jr G, Dumot J A. et al .
Automated graphic assessment of respiratory activity is superior to pulse oximetry and visual assessment for the detection of early respiratory depression during therapeutic upper endoscopy.
Gastrointest Endosc.
2002;
55
826-831
