Top

Canadian Journal of Anesthesia/Journal canadien d'anesthésie

Published in:

09-10-2023 | Remifentanil | Reports of Original Investigations

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

Authors: Paula J. Joy, FRCA, Hannah J. Blanshard, FRCA

Published in: Canadian Journal of Anesthesia/Journal canadien d'anesthésie | Issue 11/2023

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.

Sidhu R, Turnbull D, Newton M, et al. Deep sedation and anaesthesia in complex gastrointestinal endoscopy: a joint position statement endorsed by the British Society of Gastroenterology (BSG), Joint Advisory Group (JAG) and Royal College of Anaesthetists (RCoA). Frontline Gastroenterol 2019; 10: 141–7. https://doi.org/10.1136/flgastro-2018-101145CrossRefPubMedPubMedCentral

Rees CJ, Thomsas Gibson S, Rutter MD, et al. UK key performance indicators and quality assurance standards for colonoscopy. Gut 2016; 65: 1923–9. https://doi.org/10.1136/gutjnl-2016-312044CrossRefPubMed

Portal J, Chalmers J, Smithson J, et al. Patient controlled propofol – do we need an anaesthetist? Gut 2013; 62: A145–6. https://doi.org/10.1136/gutjnl-2013-304907.327CrossRef

Roback MG, Green SM, Andolfatto G, Leroy PL, Mason KP. Tracking and reporting outcomes of procedural sedation (TROOPS): standardized quality improvement and research tools from the International Committee for the Advancement of Procedural Sedation. Br J Anaesth 2018; 120: 164–72. https://doi.org/10.1016/j.bja.2017.08.004CrossRefPubMed

Rostrom A, Ross ED, Dubé C, et al. Development and validation of a nurse-assessed patient comfort score for colonoscopy. Gastrointest Endosc 2013; 77: 255–61. https://doi.org/10.1016/j.gie.2012.10.003CrossRef

Williamson A, Hoggart B. Pain: a review of three commonly used pain rating scales. J Clin Nurs 2005; 14: 798–894. https://doi.org/10.1111/j.1365-2702.2005.01121.xCrossRefPubMed

Murugensan SV, Davies, MW, Nicholson J, et al. Evaluation of a new anaesthetist-led propofol sedation service for endoscopy within a UK day-case setting Frontline Gastroenterol 2013; 4: 73–81. https://doi.org/10.1136/flgastro-2012-100255CrossRef

Stonell CA, Leslie K, Absalom AR. Effect-site target patient-controlled sedation with propofol: comparison with anaesthetist administration for colonoscopy. Anaesthesia 2006; 61: 240–7. https://doi.org/10.1111/j.1365-2044.2005.04509.xCrossRefPubMed

Mazanikov M, Udd M, Kylänpää L, et al. A randomized comparison of target-controlled propofol infusion and patient-controlled sedation during ERCP. Endoscopy 2013; 45: 915–9. https://doi.org/10.1055/s-0033-1344712CrossRefPubMed

10.

Kreienbühl L, Elia N, Pfeil-Beun E, Walder B, Tramer M. Patient-controlled versus clinician-controlled sedation with propofol: systematic review and meta-analysis with trial sequential analyses. Anesth Analg 2018; 127: 873–80. https://doi.org/10.1213/ane.0000000000003361CrossRefPubMed

11.

Mandel JE, Tanner JW, Lichenstein GR, et al. A randomized, controlled, double-blind trial of patient-controlled sedation with propofol/remifentanil versus midazolam/fentanyl for colonoscopy. Anesth Analg 2008; 106: 434–9. https://doi.org/10.1213/01.ane.0000297300.33441.32CrossRefPubMed

12.

Bright E, Roseveare C, Dalgleish D, Kimble J, Elliott J, Shepherd H. Patient-controlled sedation for colonoscopy: a randomized trial comparing patient-controlled administration of propofol and alfentanil with physician-administered midazolam and pethidine. Endoscopy 2003; 35: 683–7. https://doi.org/10.1055/s-2003-41519CrossRefPubMed

13.

Heuss LT, Drewe J, Schnieper P, Tapparelli CB, Pflimlin E, Beglinger C. Patient-controlled versus nurse-administered sedation with propofol during colonoscopy. A prospective randomized trial. Am J Gastroenterol 2004; 99: 511–8. https://doi.org/10.1111/j.1572-0241.2004.04088.xCrossRefPubMed

14.

Lee DW, Chan AC, Sze TS, et al. Patient-controlled sedation versus intravenous sedation for colonoscopy in elderly patients: a prospective randomized controlled trial. Gastrointest Endosc 2002; 56: 629–32. https://doi.org/10.1067/mge.2002.128919CrossRefPubMed

15.

Adams MA, Saini SD, Gao Y, Wiitala WL, Rubenstein JH. Endoscopist-directed sedation rarely fails: implications for the value of anesthesia assistance for routine GI endoscopy. Am J Manag Care 2021; 27: 413–9. https://doi.org/10.37765/ajmc.2021.88796CrossRef

16.

Schelfout S, Fonck K, Coppens M. Patient-controlled sedation: a narrative review. Ambul Surg 2017; 23: 69–73.

17.

Green SM, Leroy PL, Roback MG, et al. An international multidisciplinary consensus statement on fasting before procedural sedation in adults and children. Anaesthesia 2020; 75: 374–85. https://doi.org/10.1111/anae.14892CrossRefPubMed

18.

Agostoni M, Fanti L, Gemma M, Pasculli N, Beretta L, Testoni PA. Adverse events during monitored anesthesia care for GI endoscopy: an 8-year experience. Gastrintest Endosc 2011; 74: 266–75. https://doi.org/10.1016/j.gie.2011.04.028CrossRef

19.

Beach M, Sites B. If a little bit is wrong, how much is alright? Interpreting the significance of small numerators in clinical trials. Anaesthesia 2015; 70: 249–52. https://doi.org/10.1111/anae.12980CrossRefPubMed

20.

Wall H, Smith C, Hubbard R. Body mass index and obstructive sleep apnoea in the UK: a cross-sectional study of the over-50s. Prim Care Respir J 2012; 21: 371–6. https://doi.org/10.4104/pcrj.2012.00053CrossRefPubMedPubMedCentral

21.

den Herder C, Schmeck J, Appelboom D, de Vries N. Risks of general anaesthesia in people with obstructive sleep apnoea. BMJ 2004; 329; 955–9. https://doi.org/10.1136/bmj.329.7472.955CrossRefPubMedCentral

22.

NHS Digital. Statistics on obesity, physical activity and diet, England, 2020. Available from URL: https://digital.nhs.uk/data-and-information/publications/statistical/statistics-on-obesity-physical-activity-and-diet/england-2020# (accessed April 2023).

23.

Nightingale CE, Margarson MP, Shearer E, et al. Peri-operative management of the obese surgical patient 2015: Association of Anaesthetists of Great Britain and Ireland Society for Obesity and Bariatric Anaesthesia. Anaesthesia 2015; 70: 859–67. https://doi.org/10.1111/anae.13101CrossRefPubMedPubMedCentral

24.

Nester CC, Sepúlveda PO, Irwin MG. Drug mixtures and infusion technology. MasterChef or Hell’s Kitchen? Anaesthesia 2022; 77: 260–3. https://doi.org/10.1111/anae.15561CrossRef

25.

Bagshaw O, McCormack J, Brooks P, Marriott D, Baxter A. The safety profile and effectiveness of propofol-remifentanil mixtures for total intravenous anaesthesia in children. Paediatr Anaesth 2020; 30: 1331–9. https://doi.org/10.1111/pan.14018CrossRefPubMed

26.

Stewart JT, Warren FW, Maddox FC, Viswanathan K, Fox JL. The stability of remifentanil hydrochloride and propofol mixtures in polypropylene syringes and polyvinylchloride bags at 22-24 degrees C. Anesth Analg 2000; 90: 1450–1. https://doi.org/10.1097/00000539-200006000-00037CrossRefPubMed

27.

O’Connor S, Zhang YL, Christians U, Morrison JE Jr, Friesen RH. Remifentanil and propofol undergo separation and layering when mixed in the same syringe for total intravenous anesthesia. Paediatr Anaesth 2016; 26: 703–9. https://doi.org/10.1111/pan.12917CrossRefPubMed

28.

Kern SE, Xie G, White JL, Egan TD. A response surface analysis of propofol-remifentanil pharmacodynamic interaction in volunteers. Anesthesiology 2004; 100: 1373–81. https://doi.org/10.1097/00000542-200406000-00007CrossRefPubMed

29.

Aldwinckle R, Florendo E. To dilute or not dilute: drug errors and consequences in the operating room, 2021. Available from URL: https://psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room (accessed April 2023).

Title: Propofol-remifentanil patient-controlled sedation for endoscopic procedures: a prospective service audit
Authors: Paula J. Joy, FRCA
Hannah J. Blanshard, FRCA
Publication date: 09-10-2023
Publisher: Springer International Publishing
Keywords: Remifentanil
Endoscopy
General Anesthesia
Published in: Canadian Journal of Anesthesia/Journal canadien d'anesthésie / Issue 11/2023
Print ISSN: 0832-610X
Electronic ISSN: 1496-8975
DOI: https://doi.org/10.1007/s12630-023-02593-1

2024 ASCO Annual Meeting

Springer Medicine

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

Abstract

Purpose

Methods

Results

Conclusion

2024 ASCO Annual Meeting

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusion

Please log in to get access to this content

Other articles of this Issue 11/2023

Landiolol for the prevention of postoperative atrial fibrillation after cardiac surgery: a systematic review and meta-analysis

Perioperative cortical hand stroke syndrome mimicking peripheral neuropathy: a case report

A comparison of sevoflurane waste anesthetic gas concentration across three Saskatoon health care facilities

Timeliness to definitive treatment to avoid severe neurologic complications associated with spontaneous intracranial hypotension

Intrathecal hematoma as a neuraxial complication of lumbar cerebrospinal fluid drainage for endovascular repair of a thoracic aortic aneurysm

Textbook of Critical Care, 8th Edition