Propofol sedation in routine endoscopy:A case series comparing target controlled infusion vs manually controlled bolus concept

BACKGROUND Many studies have addressed safety and effectiveness of non-anaesthesiologist propofol sedation(NAPS)for gastrointestinal(GI)endoscopy Target controlled infusion(TCI)is claimed to provide an optimal sedation regimen by avoiding under-or oversedation.AIM To assess safety and performance of propofol TCI sedation in comparison with nurse-administered bolus-sedation.METHODS Fouty-five patients undergoing endoscopy under TCI propofol sedation were prospectively included from November 2016 to May 2017 and compared to 87 patients retrospectively included that underwent endoscopy with NAPS.Patients were matched for age and endoscopic procedure.We recorded time of sedation and endoscopy,dosage of medication and adverse events.RESULTS There was a significant reduction in dose per time of propofol administered in the TCI group,compared to the NAPS group(8.2±2.7 mg/min vs 9.3±3.4 mg/min;P=0.046).The time needed to provide adequate sedation levels was slightly but significantly lower in the control group(5.3±2.7 min vs 7.7±3.3 min;P<0.001),nonetheless the total endoscopy time was similar in both groups.No differences between TCI and bolus-sedation was observed for mean total-dosage of propofol rate as well as adverse events.CONCLUSION This study indicates that sedation using TCI for GI endoscopy reduces the dose of propofol necessary per minute of endoscopy.This may translate into less adverse events.However,further and randomized trials need to confirm this trend.

Efficacy and safety of remimazolam in bronchoscopic sedation:A meta-analysis

BACKGROUND Remimazolam is a new benzodiazepine used for procedural sedation and general anesthesia.Several studies have used remimazolam for bendable bronchoscopy.AIM To assess the safety and efficacy of remimazolam for sedation in patients undergoing bendable bronchoscopy by performing a meta-analysis of randomized controlled trials(RCTs).METHODS We searched the EMBASE,PubMed,Cochrane Library,and Web of Science databases for RCTs on bendable bronchoscopic procedural sedation with remimazolam vs conventional sedatives(CS).RESULTS Five studies with 1080 cases were included.Remimazolam had the same sedation success rate compared with CS[relative risk(RR):1.35,95%CI:0.60-3.05,P=0.474,I2=99.6%].However,remimazolam was associated with a lower incidence of hypotension(RR:0.61;95%CI:0.40-0.95,P=0.027;I2=65.1%)and a lower incidence of respiratory depression(RR:0.50,95%CI:0.33-0.77,P=0.002,I2=42.3%).A subgroup analysis showed a higher success rate of sedation with remimazolam than midazolam(RR:2.45,95%CI:1.76-3.42,P<0.001).Compared with propofol,the incidence of hypotension(RR:0.45,95%CI:0.32-0.64,P<0.001,I2=0.0%),respiratory depression(RR:0.48,95%CI:0.30-0.76,P=0.002,I2=78.4%),hypoxemia(RR:0.36,95%CI:0.15-0.87,P=0.023),and injection pain(RR:0.04,95%CI:0.01-0.28,P=0.001)were lower.CONCLUSION Remimazolam is safe and effective during bronchoscopy.The sedation success rate was similar to that in the CS group.However,remimazolam has a higher safety profile,with fewer inhibitory effects on respiration and circulation.

Brain protective effect of dexmedetomidine vs propofol for sedation during prolonged mechanical ventilation in non-brain injured patients

BACKGROUND Dexmedetomidine and propofol are two sedatives used for long-term sedation.It remains unclear whether dexmedetomidine provides superior cerebral protection for patients undergoing long-term mechanical ventilation.AIM To compare the neuroprotective effects of dexmedetomidine and propofol for sedation during prolonged mechanical ventilation in patients without brain injury.METHODS Patients who underwent mechanical ventilation for>72 h were randomly assigned to receive sedation with dexmedetomidine or propofol.The Richmond Agitation and Sedation Scale(RASS)was used to evaluate sedation effects,with a target range of-3 to 0.The primary outcomes were serum levels of S100-βand neuron-specific enolase(NSE)every 24 h.The secondary outcomes were remifentanil dosage,the proportion of patients requiring rescue sedation,and the time and frequency of RASS scores within the target range.RESULTS A total of 52 and 63 patients were allocated to the dexmedetomidine group and propofol group,respectively.Baseline data were comparable between groups.No significant differences were identified between groups within the median duration of study drug infusion[52.0(IQR:36.0-73.5)h vs 53.0(IQR:37.0-72.0)h,P=0.958],the median dose of remifentanil[4.5(IQR:4.0-5.0)μg/kg/h vs 4.6(IQR:4.0-5.0)μg/kg/h,P=0.395],the median percentage of time in the target RASS range without rescue sedation[85.6%(IQR:65.8%-96.6%)vs 86.7%(IQR:72.3%-95.3),P=0.592],and the median frequency within the target RASS range without rescue sedation[72.2%(60.8%-91.7%)vs 73.3%(60.0%-100.0%),P=0.880].The proportion of patients in the dexmedetomidine group who required rescue sedation was higher than in the propofol group with statistical significance(69.2%vs 50.8%,P=0.045).Serum S100-βand NSE levels in the propofol group were higher than in the dexmedetomidine group with statistical significance during the first six and five days of mechanical ventilation,respectively(all P<0.05).CONCLUSION Dexmedetomidine demonstrated stronger protective effects on the brain compared to propofol for long-term mechanical ventilation in patients without brain injury.

Remimazolam for sedation in gastrointestinal endoscopy:A comprehensive review

Worldwide,a majority of routine endoscopic procedures are performed under some form of sedation to maximize patient comfort.Propofol,benzodiazepines and opioids continue to be widely used.However,in recent years,Remimazolam is gaining immense popularity for procedural sedation in gastrointestinal(GI)endoscopy.It is an ultra-short-acting benzodiazepine sedative which was approved by the Food and Drug Administration in July 2020 for use in procedural sedation.Remimazolam has shown a favorable pharmacokinetic and pharmacodynamic profile in terms of its non-specific metabolism by tissue esterase,volume of distribution,total body clearance,and negligible drug-drug interactions.It also has satisfactory efficacy and has achieved high rates of successful sedation in GI endoscopy.Furthermore,studies have demonstrated that the efficacy of Remimazolam is non-inferior to Propofol,which is currently a gold standard for procedural sedation in most parts of the world.However,the use of Propofol is associated with hemodynamic instability and respiratory depression.In contrast,Remimazolam has lower incidence of these adverse effects intra-procedurally and hence,may provide a safer alternative to Propofol in procedural sedation.In this comprehensive narrative review,highlight the pharmacologic characteristics,efficacy,and safety of Remimazolam for procedural sedation.We also discuss the potential of Remimazolam as a suitable alternative and how it can shape the future of procedural sedation in gastroenterology.

Sedation reversal trends at outpatient ambulatory endoscopic center vs in-hospital ambulatory procedure center using a triage protocol

BACKGROUND Routine outpatient endoscopy is performed across a variety of outpatient settings.A known risk of performing endoscopy under moderate sedation is the potential for over-sedation,requiring the use of reversal agents.More needs to be reported on rates of reversal across different outpatient settings.Our academic tertiary care center utilizes a triage tool that directs higher-risk patients to the in-hospital ambulatory procedure center(APC)for their procedure.Here,we report data on outpatient sedation reversal rates for endoscopy performed at an inhospital APC vs at a free-standing ambulatory endoscopy digestive health center(AEC-DHC)following risk stratification with a triage tool.AIM To observe the effect of risk stratification using a triage tool on patient outcomes,primarily sedation reversal events.METHODS We observed all outpatient endoscopy procedures performed at AEC-DHC and APC from April 2013 to September 2019.Procedures were stratified to their respective sites using a triage tool.We evaluated each procedure for which sedation reversal with flumazenil and naloxone was recorded.Demographics and characteristics recorded include patient age,gender,body mass index(BMI),American Society of Anesthesiologists(ASA)classification,procedure type,and reason for sedation reversal.RESULTS There were 97366 endoscopic procedures performed at AEC-DHC and 22494 at the APC during the study period.Of these,17 patients at AEC-DHC and 9 at the APC underwent sedation reversals(0.017%vs 0.04%;P=0.06).Demographics recorded for those requiring reversal at AEC-DHC vs APC included mean age(53.5±21 vs 60.4±17.42 years;P=0.23),ASA class(1.66±0.48 vs 2.22±0.83;P=0.20),BMI(27.7±6.7 kg/m^(2) vs 23.7±4.03 kg/m^(2);P=0.06),and female gender(64.7%vs 22%;P=0.04).The mean doses of sedative agents and reversal drugs used at AEC-DHC vs APC were midazolam(5.9±1.7 mg vs 8.9±3.5 mg;P=0.01),fentanyl(147.1±49.9μg vs 188.9±74.1μg;P=0.10),flumazenil(0.3±0.18μg vs 0.17±0.17μg;P=0.13)and naloxone(0.32±0.10 mg vs 0.28±0.12 mg;P=0.35).Procedures at AEC-DHC requiring sedation reversal included colonoscopies(n=6),esophagogastroduodenoscopy(EGD)(n=9)and EGD/colonoscopies(n=2),whereas APC procedures included EGDs(n=2),EGD with gastrostomy tube placement(n=1),endoscopic retrograde cholangiopancreatography(n=2)and endoscopic ultrasound's(n=4).The indications for sedation reversal at AEC-DHC included hypoxia(n=13;76%),excessive somnolence(n=3;18%),and hypotension(n=1;6%),whereas,at APC,these included hypoxia(n=7;78%)and hypotension(n=2;22%).No sedation-related deaths or long-term post-sedation reversal adverse outcomes occurred at either site.CONCLUSION Our study highlights the effectiveness of a triage tool used at our tertiary care hospital for risk stratification in minimizing sedation reversal events during outpatient endoscopy procedures.Using a triage tool for risk stratification,low rates of sedation reversal can be achieved in the ambulatory settings for EGD and colonoscopy.

Between Euthanasia and Dysthanasia: The Ethical Issue of Sedation in the Terminal Phase of Illness

Background: Deep sedation, euthanasia and therapeutic relentlessness lead us today to rethink the paradigm of life and the contingency of human existence. Between therapeutic relentlessness, the unreasonable care which uses heavy therapeutic means which are often disproportionate to the expected benefit, namely keeping alive a patient whose condition is considered medically hopeless;and euthanasia which would precipitate the process of death would be sedation in the terminal phase of the illness. Should doctors and families of comatose patients decide the “life” and “death” of their patients? For anti-euthanasia associations, doctors, relatives of terminally ill patients and the State itself, if they accept the principle of euthanasia, they are “murderers”, while for pro-euthanasists, the dignity of the human being would recommend that the days of patients in situations considered critical be shortened, to avoid unnecessary suffering and humiliation. Methods: A systematic review of the literature was carried out to identify relevant articles relating to euthanasia, dysthanasia and sedation in the terminal phase of illness. The search was conducted in French or English in three databases: PubMed, Google Scholar and Science Direct. Objectives: The objectives of this article are: 1) define the terminologies and concepts of palliative sedation, deep sedation, deep and continuous sedation until death, euthanasia and dysthanasia;2) present aspects of the meaning of life and the human person in African cultures;and 3) propose an ethical reflection on the value of life. Results: After precisely defining the concepts of euthanasia, dysthanasia and sedation, this research presented the African anthropological and ethical approach to the mysteries of life and death. Conclusion: With this in mind, the golden rule of medicine always remains as such “Primum non nocere”.

Postoperative Sedation Options in ICU

This paper examines sedation options in ICU postoperative care. It highlights the necessity of sedation for patients’ physical and mental comfort, safety, and reduction of delirium. The article advocates light sedation, primarily with non-benzodiazepines like propofol or dexmedetomidine, to improve outcomes. It introduces novel sedatives like ciprofol and remimazolam, suggesting they may be future alternatives in ICU sedation, although more research is needed.

Impact of Sedation Protocols on Elderly Patients Undergoing Mechanical Ventilation and Off-Line Weaning

The proportion of elderly patients in intensive care is increasing, and a significant proportion of them require mechanical ventilation. How to implement safe and effective mechanical ventilation for elderly patients, and when appropriate off-line is an important issue in the field of critical care medicine. Appropriate sedation can improve patient outcomes, but excessive sedation may lead to prolonged mechanical ventilation and increase the risk of complications. Elderly patients should be closely monitored and evaluated on an individual basis while offline, and the sedation regimen should be dynamically adjusted. This requires the healthcare team to consider the patient’s sedation needs, disease status, and pharmacodynamics and pharmacokinetics of the drug to arrive at the best strategy. Although the current research has provided valuable insights and strategies for sedation and off-line management, there are still many problems to be further explored and solved.

Efficacy and safety of remimazolam-based sedation for intensive care unit patients undergoing upper gastrointestinal endoscopy:a cohort study

BACKGROUND:Remimazolam is a novel ultra-short-acting sedative,but its safety and adverse events(AEs)in high-risk patients in the intensive care unit(ICU)setting remain unknown.METHODS:This was a single-center,retrospective study that compared remimazolam to propofol and midazolam in patients undergoing upper gastrointestinal endoscopy.The primary outcome was the incidence of treatment-related AEs.The secondary outcomes were the time to extubation,the length of ICU stay,and the average cost of sedative per case.RESULTS:Of the 88 patients analyzed,47 were treated with remimazolam(mean dose,7.90±4.84mg),and 41 were treated with propofol(21.19±17.98 mg)or midazolam(3.08±2.17 mg).There was no statistically significant difference in the average duration of the endoscopic procedure(35.89±13.37 min vs.44.51±21.68 min,P=0.133)or the time to extubation(15.00±9.75 h vs.20.59±18.71 h,P=0.211)in the remimazolam group(group I)compared to the propofol or midazolam group(group II).ICU stays(5.40±2.93 d vs.4.63±3.31 d,P=0.072)and treatment-related AEs(48.61%vs.51.38%,P=0.056)were similar between groups.The average cost of sedative per case was significantly lower in the group I than in the group II(RMB 16.07±10.58 yuan vs.RMB 24.37±15.46 yuan,P=0.016).CONCLUSION:Remimazolam-based sedation was noninferior to the classic sedatives and had lower average cost per case,indicating that it may be used as a promising sedative for high-risk patients during endoscopic procedures in the ICU setting.

Caution in the use of sedation and endomyocardial biopsy for the management of pediatric acute heart failure caused by endocardial fibroelastosis

Endocardial fibroelastosis(EFE)is commonly considered to be an inflammatory reactive lesion of hyperplasia and deposition of tissue fibers and collagen in the endocardium and/or subendocardium,which is strongly associated with endocardial sclerosis,ventricular remodeling and acute and chronic heart failure,and is one of the important causes for pediatric heart transplantation.Early diagnosis and treatment are the key factors in determining the prognosis of the children.In this paper,we would like to highlight the potential unintended consequences of the use of sedation and biopsy for pediatric acute heart failure caused by EFE and the comprehensive considerations prior to clinical diagnosis.

Does Anesthesiologist-Directed Sedation Afford Superior Deep Cannulation Rates and Procedural Outcomes for ERCP in the Community Setting?

Aim: To compare outcomes by sedation class in community patients undergoing index endoscopic retrograde cholangiopancreatography (ERCP). Methods: Nineteen hundred sixteen consecutive patients underwent ERCP from May 2005 to May 2011. Eight hundred thirty seven patients were excluded due to prior papillary intervention or attempted ERCP. A total of 1079 patients were included. The 981 patients who underwent gastroenterologist directed sedation (GDS) served as the control population, while the 98 patients who received anesthesiologist directed sedation (ADS) served as the case population. Medical records were analyzed for patient demographics, procedure indication, adverse events, case complexity, procedural failure and sedation failure. Case complexity was defined by the grading system proposed by the working party of the ASGE Quality Committee. Sedation failure was defined by agitation or airway compromise prompting termination of the ERCP. Reasons for procedural failure included surgically altered anatomy, luminal obstruction, and technical failure. Study endpoint was defined as successful deep cannulation of the intended target duct. Results: Demographic distribution did not differ between the GDS and the ADS groups. Cannulation success rates were similar between the two groups, with 89.85% in the GDS group, and 89.58% in the ADS group (P = 0.864). There were no statistical differences between sedation groups in procedural or respiratory adverse events. Technical failure was the predominant basis for deep cannulation failure in both groups. Agitation and airway compromise accounted for deep cannulation failure similarly in both groups. The need for reversal agents was low but similar in both groups. There was no statistical advantage in deep cannulation success rate by complexity grade in either sedation class. Conclusion: Excellent procedural outcomes and low adverse event rates were achieved using GDS, a more accessible and cost-effective method in a community-based setting.

Study on Sedation of Dried Ginger

[Objective] The experiment aimed to explore sedation of dried ginger.[Method] By compared the experimental results before and after intragastric administration,the influences of decoction of dried ginger at different concentrations(1,2,3 mg/ml)on locomotor activities of white mice.[Result]When the decoction of dried ginger was 1 g/ml,the time of free movements and the number of raising forelimbs of mice were obviously detained(2.5 h after intragastric administration).When the decoction of dried ginger was 2 g/ml,the time of free movements and the number of raising forelimbs of mice were obviously influenced however the inhibition time is short than that of 1 g/ml.When the decoction of dried ginger was 3 g/ml,the inhibition is not obvious.[Conclusion] Dried ginger had some sedation effect which was related to its dosage.

Identifying who best tolerates moderate sedation:Results from a national database of gastrointestinal endoscopic outcomes

BACKGROUND With increasing volume and cost of gastrointestinal endoscopic procedures,the proper selection of patients for moderate sedation becomes increasingly relevant.The current literature lacks consistent findings that allow for appropriate selection of patients for moderate sedation.AIM To analyze a nationwide registry of patients to identify patient and procedural factors associated with lower sedation requirements for endoscopy.METHODS The Clinical Outcomes Research Initiative National Endoscopic Database was queried to assess adult patients undergoing moderate sedation for esophagogastroduodenoscopy(EGD)and colonoscopy from 2008 to 2014.Patients were stratified into two groups[low dose(LD)and high dose sedation]based on sedation requirements.Anthropometric,procedural,and anesthesia data were compared,and multivariable analysis was performed to identify factors associated with LD sedation.RESULTS Of the 371102 patients included in the study,63137 where stratified into the LD sedation group and 307965 were in the high dose group.Moderate sedation was managed primarily by endoscopists(50%)and anesthesia providers(47%).Patients undergoing EGDs and procedures performed in the inpatient setting,in ambulatory surgery centers,intensive care units or hospital wards,required less sedation than colonoscopies,outpatient procedures and procedures done in endoscopy suites,respectively(P<0.0001 for all).On multivariable analysis,factors predictive of tolerance with lower sedation requirements for EGDs and colonoscopies were female gender,age≥50,non-White race,Hispanic descent,body mass index≤25 kg/m^(2),and higher American Society of Anesthesia Class(P<0.0001 for all).CONCLUSION Clinicians should consider these patient profiles in determining which patients will better tolerate moderate sedation vs those better suited for alternative sedation methods.

Effectiveness of daily interruption of sedation in sedated patients with mechanical ventilation in ICU: A systematic review

Purpose:To evaluate the effectiveness of daily sedation interruption in patients with mechanical ventilation in intensive care unit(ICU).Methods:The randomized controlled trials(RCTs)on the application of daily interruption of sedation in sedated patients with mechanical ventilation in ICU were collected through databases including Cochrane library,MEDLINE,Web of Knowledge,Embase,CNKI,CBM and VIP Data.Two reviewers independently assessed the quality of studies and extracted the data.Meta-analysis was conducted on the included studies.Results:Eight RCTs involving 757 patients were included.The daily sedation interruptions could shorten the duration of mechanical ventilation(Z=5.36,p<0.0001),length of stay(Z=2.93,p=0.003<0.05)and reduce the rate of tracheotomy(Z=3.97,p<0.00001)in these patients.Additionally,daily sedation interruption was not associated with increased rate of unplanned extubation by the patients(Z=0.53,p=0.6<0.05).Conclusion:The application of daily interruption of sedation in patients with mechanical ventilation in ICU is safe and effective.

Sedation in gastrointestinal endoscopy: Current issues

Diagnostic and therapeutic endoscopy can successfully be performed by applying moderate(conscious) sedation.Moderate sedation,using midazolam and an opioid,is the standard method of sedation,although propofol is increasingly being used in many countries because the satisfaction of endoscopists with propofol sedation is greater compared with their satisfaction with conventional sedation.Moreover,the use of propofol is currently preferred for the endoscopic sedation of patients with advanced liver disease due to its short biologic half-life and,consequently,its low risk of inducing hepatic encephalopathy.In the future,propofol could become the preferred sedation agent,especially for routine colonoscopy.Midazolam is the benzodiazepine of choice because of its shorter duration of action and better pharmacokinetic profile compared with diazepam.Among opioids,pethidine and fentanyl are the most popular.A number of other substances have been tested in several clinical trials with promising results.Among them,newer opioids,such as remifentanil,enable a faster recovery.The controversy regarding the administration of sedation by an endoscopist or an experienced nurse,as well as the optimal staffing of en-doscopy units,continues to be a matter of discussion.Safe sedation in special clinical circumstances,such as in the cases of obese,pregnant,and elderly individuals,as well as patients with chronic lung,renal or liver disease,requires modification of the dose of the drugs used for sedation.In the great majority of patients,sedation under the supervision of a properly trained endoscopist remains the standard practice worldwide.In this review,an overview of the current knowledge concerning sedation during digestive endoscopy will be provided based on the data in the current literature.

Clinical analysis of propofol deep sedation for 1,104 patients undergoing gastrointestinal endoscopic procedures:A three year prospective study

AIM： To analyze the hemodynamic and respiratory effects of propofol on patients undergoing gastroscopy and colonoscopy. METHODS： In this prospective study, conducted over a period of three years, 1,104 patients referred for a same day GI endoscopy procedure were analyzed. All patients were given a propofol bolus （0.5-1.5 mg/kg）. Arterial blood pressure （BP） was monitored at 3 rain intervals and heart rate and oxygen saturation （SpO2） were recorded continuously by pulse oximetry. Analyzed data acquisition was carried out before, during, and after the procedure. RESULTS： A statistically significant reduction in mean arterial pressure was demonstrated （P〈0.001） when compared to pre-intervention values, but severe hypotension, defined as a systolic blood pressure below 60mmHg, was noted in only 5 patients （0.5%）. Oxygen saturation decreased from 96.5% to 94.4 % （P〈0.001）. A critical decrease in oxygen saturation （〈90%） was documented in 27 patients （2.4%）. CONCLUSION： Our results showed that propofol provided good sedation with excellent pain control, a short recovery time and no significant hemodynamic side effelts if carefully titrated. All the patients （and especially ASA Ⅲ group） require monitoring and care of an anesthesiologist.

Deep sedation during gastrointestinal endoscopy: Propofol-fentanyl and midazolam-fentanyl regimens

AIM: To compare deep sedation with propofol-fentanyl and midazolam-fentanyl regimens during upper gastrointestinal endoscopy. METHODS: After obtaining approval of the research ethics committee and informed consent, 200 patients were evaluated and referred for upper gastrointestinal endoscopy. Patients were randomized to receive propofol-fentanyl or midazolam-fentanyl (n = 100/group).We assessed the level of sedation using the observer's assessment of alertness/sedation (OAA/S) score and bispectral index (BIS). We evaluated patient and physician satisfaction, as well as the recovery time and complication rates. The statistical analysis was performed using SPSS statistical software and included the MannWhitney test, χ 2 test, measurement of analysis of variance, and the κ statistic. RESULTS: The times to induction of sedation, recovery, and discharge were shorter in the propofolfentanyl group than the midazolam-fentanyl group. According to the OAA/S score, deep sedation events occurred in 25% of the propofol-fentanyl group and 11% of the midazolam-fentanyl group (P = 0.014). Additionally, deep sedation events occurred in 19% of the propofol-fentanyl group and 7% of the midazolamfentanyl group according to the BIS scale (P = 0.039). There was good concordance between the OAA/S score and BIS for both groups (κ = 0.71 and κ = 0.63, respectively). Oxygen supplementation was required in 42% of the propofol-fentanyl group and 26% of the midazolam-fentanyl group (P = 0.025). The mean time to recovery was 28.82 and 44.13 min in the propofolfentanyl and midazolam-fentanyl groups, respectively (P < 0.001). There were no severe complications in either group. Although patients were equally satisfied with both drug combinations, physicians were more satisfied with the propofol-fentanyl combination. CONCLUSION: Deep sedation occurred with propofolfentanyl and midazolam-fentanyl, but was more frequent in the former. Recovery was faster in the propofol-fentanyl group.

Propofol sedation during endoscopic treatment for early gastric cancer compared to midazolam

Endoscopic submucosal dissection(ESD)has been proposed as the gold standard in the treatment of early gastric cancer because it facilitates a more accurate histological assessment and reduces the risk of tumor recurrence.However,the time course of ESD for large gastric tumors is frequently prolonged because of the tumor size and technical difficulties and typically requires higher doses of sedative and pain-controlling drugs.Sedative or anesthetic drugs such as midazolam or propofol are used during the procedure.Therapeutic endoscopy of early gastric cancers can often be performed with only moderate sedation.Compared with midazolam,propofol has a very fast onset of action,short plasma half-life and time to achieve sedation,faster time to recovery and discharge,and results in higher patient satisfaction.For overall success,maintaining safety and stability not only during the procedure but also subsequently in the recovery room and ward is necessary.In obese patients,it is recommended that the injected dose be based on a calculated standard weight.Cooperation between gastroenterologists,surgeons,and anesthesiologists is imperative for a successful ESD procedure.

Superiority of split dose midazolam as conscious sedation for outpatient colonoscopy

AIM: To elucidate the efficacy and safety of a split dose of midazolam in combination with meperidine for colonoscopy. METHODS: Eighty subjects undergoing outpatient colonoscopy were randomly assigned to group A or B. Group A (n = 40) received a split dose of midazolam in combination with meperidine. Group B (n = 40) received a single dose of midazolam in combination with meperidine. Outcome measurements were level of sedation, duration of sedation and recovery, degree of pain and satisfaction, procedure-related memory, controllability, and adverse events. RESULTS: Group A had a lower frequency of significant hypoxemia (P = 0.043) and a higher sedation score on withdrawal of the endoscope from the descending colon than group B (P = 0.043). Group B recovered from sedation slightly sooner than group A (P < 0.002). Scores for pain and memory, except insertion-related memory, were lower in group A one week after colonoscopic examination (P = 0.018 and P < 0.030, respectively). Poor patient controllability was noted by the endoscopist and nurse in group B (P = 0.038 and P = 0.032, respectively). CONCLUSION: Split dose midazolam in combination with meperidine resulted in a safer, more equable sedation status during colonoscopic examination and a reduction in procedure-related pain and memory, but resulted in longer recovery time.

Sedation and analgesia in gastrointestinal endoscopy: What’s new?

Various types of sedation and analgesia technique have been used during gastrointestinal endoscopy procedures.The best methods for analgesia and sedation during gastrointestinal endoscopy are still debated.Providing an adequate regimen of sedation/analgesia might be considered an art,influencing several aspects of endoscopic procedures: the quality of the examination,the patient’s cooperation and the patient’s and physician’s satisfaction with the sedation.The properties of a model sedative agent for endoscopy would include rapid onset and offset of action,analgesic and anxiolytic effects,ease of titration to desired level of sedation,rapid recovery and an excellent safety prof ile.Therefore there is an impulse for development of new approaches to endoscopic sedation.This article provides an update on the methods of sedation today available and future directions in endoscopic sedation.