Target-controlled infusion vs. manually controlled infusion of propofol with alfentanil for bidirectional endoscopy: a randomized controlled trial

Min-Hsien Chiang; Shao-Chun Wu; Chia-Hsun You; Keng-Liang Wu; Yi-Chun Chiu; Chao-Wei Ma; Chin-Wei Kao; Kun-Chen Lin; Kuan-Hung Chen; Peng-Chih Wang; An-Kuo Chou

doi:10.1055/s-0033-1344645

Endoscopy, Table of Contents

Endoscopy 2013; 45(11): 907-914
DOI: 10.1055/s-0033-1344645

Original article

Target-controlled infusion vs. manually controlled infusion of propofol with alfentanil for bidirectional endoscopy: a randomized controlled trial

Min-Hsien Chiang^*

¹Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan

,

Shao-Chun Wu^*

¹Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan

,

Chia-Hsun You

¹Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan

,

Keng-Liang Wu

²Division of Hepatogastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan

,

Yi-Chun Chiu

²Division of Hepatogastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan

,

Chao-Wei Ma

¹Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan

,

Chin-Wei Kao

¹Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan

,

Kun-Chen Lin

¹Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan

,

Kuan-Hung Chen

¹Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan

,

Peng-Chih Wang

³Department of Anesthesiology, E-Da Hospital, I-Shou University, Kaohsiung County, Taiwan

,

An-Kuo Chou

¹Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan

› Author Affiliations

Abstract

Background and study aims: The best anesthesia methods for analgesia and sedation during gastrointestinal endoscopy are still debated. The aim of this study was to compare the recovery time, clinical presentations, and satisfaction between target-controlled infusion (TCI) and manually controlled infusion (MCI) in same-day bidirectional endoscopy (esophagogastroduodenoscopy followed by colonoscopy).

Patients and methods: A total of 220 patients with American Society of Anesthesiology physical status 1 or 2 were enrolled and randomized into the TCI or MCI groups. The clinical presentations, vasoactive drug demand, propofol consumption, and adverse events were recorded for both groups peri-procedurally. The concentrations of propofol in the plasma (C_p) and at the site of drug effect (C_e) by computerized simulation were also monitored in both groups. Finally, the satisfaction of patients, endoscopists, and nurse anesthetists was assessed by questionnaire after the examinations.

Results: Compared with the MCI group, the TCI group had a faster recovery time (17.91 ± 7.72 minutes vs. 14.58 ± 8.55 minutes; P = 0.002), less moderate hypotension (7.37 ± 15.46 % vs. 1.82 ± 5.15 %; P < 0.001), and shorter period of bradypnea (13.81 ± 15.92 % vs. 9.18 ± 12.00 %; P = 0.013). In addition, the TCI group reduced the relative risk of moderate desaturation by 50 % compared with the MCI group (30.9 % vs. 15.5 %; 95 % confidence interval 1.191 – 3.360; P = 0.007).

Conclusions: The study demonstrated that TCI of propofol combined with alfentanil was associated with a faster recovery time, and better hemodynamic and respiratory stability than MCI in same-day bidirectional endoscopy.

Clinical trial registration: CGMH IRB Identifier 97-0969B

Full Text

References

References
1 Fanti L, Testoni PA. Sedation and analgesia in gastrointestinal endoscopy: what’s new?. World J Gastroenterol 2010; 16: 2451-2457
2 Cohen LB, Delegge MH, Aisenberg J et al. AGA Institute review of endoscopic sedation. Gastroenterology 2007; 133: 675-701
3 Lubarsky DA, Candiotti K, Harris E. Understanding modes of moderate sedation during gastrointestinal procedures: a current review of the literature. J Clin Anesth 2007; 19: 397-404
4 LaPierre CD, Johnson KB, Randall BR et al. A simulation study of common propofol and propofol-opioid dosing regimens for upper endoscopy: implications on the time course of recovery. Anesthesiology 2012; 117: 252-262
5 Koshy G, Nair S, Norkus EP et al. Propofol versus midazolam and meperidine for conscious sedation in GI endoscopy. Am J Gastroenterol 2000; 95: 1476-1479
6 Sear JW, Uppington J, Kay NH. Haematological and biochemical changes during anaesthesia with propofol (‘Diprivan’). Postgrad Med J 1985; 61 (Suppl. 03) 165-168
7 Garewal D, Powell S, Milan SJ et al. Sedative techniques for endoscopic retrograde cholangiopancreatography. Cochrane Database Syst Rev 2012; 6: CD007274
8 Lysakowski C, Dumont L, Pellegrini M et al. Effects of fentanyl, alfentanil, remifentanil and sufentanil on loss of consciousness and bispectral index during propofol induction of anaesthesia. Br J Anaesth 2001; 86: 523-527
9 Thaharavanich R, Sintavanuruk K, Laosuwan S et al. Predicted EC50 of propofol using target controlled infusion with and without fentanyl for colonoscopy. J Med Assoc Thai 2011; 94: 813-818
10 Russell D, Wilkes MP, Hunter SC et al. Manual compared with target-controlled infusion of propofol. Br J Anaesth 1995; 75: 562-566
11 Cohen LB. Endoscopy: can computer-aided personalized sedation bridge troubled waters?. Nat Rev Gastroenterol Hepatol 2011; 8: 183-184
12 Tackley RM, Lewis GT, Prys-Roberts C et al. Computer controlled infusion of propofol. Br J Anaesth 1989; 62: 46-53
13 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
14 Gillham MJ, Hutchinson RC, Carter R et al. Patient-maintained sedation for ERCP with a target-controlled infusion of propofol: a pilot study. Gastrointest Endosc 2001; 54: 14-17
15 Moerman AT, Herregods LL, De Vos MM et al. Manual versus target-controlled infusion remifentanil administration in spontaneously breathing patients. Anesth Analg 2009; 108: 828-834
16 Sakaguchi M, Higuchi H, Maeda S et al. Dental sedation for patients with intellectual disability: a prospective study of manual control versus bispectral index-guided target-controlled infusion of propofol. J Clin Anesth 2011; 23: 636-642
17 De Vito A, Agnoletti V, Berrettini S et al. Drug-induced sleep endoscopy: conventional versus target controlled infusion techniques – a randomized controlled study. Eur Arch Otorhinolaryngol 2011; 268: 457-462
18 Passot S, Servin F, Allary R et al. Target-controlled versus manually-controlled infusion of propofol for direct laryngoscopy and bronchoscopy. Anesth Analg 2002; 94: 1212-1216
19 Muller T, Ludwig A, Biro P. Two distinct application habits for propofol: an observational study. Eur J Anaesthesiol 2010; 27: 265-269
20 Cohen LB, Hightower CD, Wood DA et al. Moderate level sedation during endoscopy: a prospective study using low-dose propofol, meperidine/fentanyl, and midazolam. Gastrointest Endosc 2004; 59: 795-803
21 Rudner R, Jalowiecki P, Kawecki P et al. Conscious analgesia/sedation with remifentanil and propofol versus total intravenous anesthesia with fentanyl, midazolam, and propofol for outpatient colonoscopy. Gastrointest Endosc 2003; 57: 657-663
22 Choi JS, Youn YH, Lee SK et al. Which should go first during same-day upper and lower gastrointestinal endoscopy? A randomized prospective study focusing on colonoscopy performance. Surg Endosc 2013; 27: 2209-2215
23 Cho JH, Kim JH, Lee YC et al. Comparison of procedural sequences in same-day bidirectional endoscopy without benzodiazepine and propofol sedation: starting at the bottom or the top. J Gastroenterol Hepatol 2010; 25: 899-904
24 Cong Y, Sun X. Mask adaptor – a novel method of positive pressure ventilation during propofol deep sedation for upper GI endoscopy. Gastrointest Endosc 2008; 68: 127-131
25 Meisel M. Use of Diprivan for digestive system endoscopy. Ann Fr Anesth Reanim 1994; 13: 579-584
26 Huang R, Eisen GM. Efficacy, safety, and limitations in current practice of sedation and analgesia. Gastrointest Endosc Clin N Am 2004; 14: 269-288
27 Molina-Infante J, Duenas-Sadornil C, Mateos-Rodriguez JM et al. Nonanesthesiologist-administered propofol versus midazolam and propofol, titrated to moderate sedation, for colonoscopy: a randomized controlled trial. Dig Dis Sci 2012; 57: 2385-2393
28 Dawes J. Do data characteristics change according to the number of scale points used? An experiment using 5-point, 7-point and 10-point scales. Int J Market Res 2008; 50: 61-104
29 Faul F, Erdfelder E, Lang AG et al. G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods 2007; 39: 175-191
30 Cohen LB, Wecsler JS, Gaetano JN et al. Endoscopic sedation in the United States: results from a nationwide survey. Am J Gastroenterol 2006; 101: 967-974
31 Leslie K, Clavisi O, Hargrove J. Target-controlled infusion versus manually-controlled infusion of propofol for general anaesthesia or sedation in adults. Cochrane Database Syst Rev 2008; CD006059
32 Levitzky BE, Lopez R, Dumot JA et al. Moderate sedation for elective upper endoscopy with balanced propofol versus fentanyl and midazolam alone: a randomized clinical trial. Endoscopy 2012; 44: 13-20
33 Hazeldine S, Fritschi L, Forbes G. Predicting patient tolerance of endoscopy with conscious sedation. Scand J Gastroenterol 2010; 45: 1248-1254
34 Patel S, Vargo JJ, Khandwala F et al. Deep sedation occurs frequently during elective endoscopy with meperidine and midazolam. Am J Gastroenterol 2005; 100: 2689-2695
35 Demiraran Y, Korkut E, Tamer A et al. The comparison of dexmedetomidine and midazolam used for sedation of patients during upper endoscopy: a prospective, randomized study. Can J Gastroenterol 2007; 21: 25-29
36 Roseveare C, Seavell C, Patel P et al. Patient-controlled sedation and analgesia, using propofol and alfentanil, during colonoscopy: a prospective randomized controlled trial. Endoscopy 1998; 30: 768-773
37 Kulling D, Fantin AC, Biro P et al. Safer colonoscopy with patient-controlled analgesia and sedation with propofol and alfentanil. Gastrointest Endosc 2001; 54: 1-7
38 Padmanabhan U, Leslie K. Australian anaesthetists’ practice of sedation for gastrointestinal endoscopy in adult patients. Anaesth Intensive Care 2008; 36: 436-441
39 Donnelly MB, Scott WA, Daly DS. Sedation for upper gastrointestinal endoscopy: a comparison of alfentanil–midazolam and meperidine–diazepam. Can J Anaesth 1994; 41: 1161-1165
40 Mazanikov M, Udd M, Kylanpaa L et al. Patient-controlled sedation for ERCP: a randomized double-blind comparison of alfentanil and remifentanil. Endoscopy 2012; 44: 487-492
41 Cho HB, Kwak HJ, Park SY et al. Comparison of the incidence and severity of cough after alfentanil and remifentanil injection. Acta Anaesthesiol Scand 2010; 54: 717-720
42 Yu H, Yang XY, Zhang X et al. The effect of dilution and prolonged injection time on fentanyl-induced coughing. Anaesthesia 2007; 62: 919-922
43 Cohen LB, Dubovsky AN, Aisenberg J et al. Propofol for endoscopic sedation: A protocol for safe and effective administration by the gastroenterologist. Gastrointest Endosc 2003; 58: 725-732
44 Stonell CA, Leslie K, Absalom AR. Effect-site targeted patient-controlled sedation with propofol: comparison with anaesthetist administration for colonoscopy. Anaesthesia 2006; 61: 240-247
45 Campbell L, Imrie G, Doherty P et al. Patient maintained sedation for colonoscopy using a target controlled infusion of propofol. Anaesthesia 2004; 59: 127-132
46 Heuss LT, Hanhart A, Dell-Kuster S et al. Propofol sedation alone or in combination with pharyngeal lidocaine anesthesia for routine upper GI endoscopy: a randomized, double-blind, placebo-controlled, non-inferiority trial. Gastrointest Endosc 2011; 74: 1207-1214
47 Liu CC, Lu CY, Changchien CF et al. Sedation-associated hiccups in adults undergoing gastrointestinal endoscopy and colonoscopy. World J Gastroenterol 2012; 18: 3595-3601
48 Seip B, Huppertz-Hauss G, Sauar J et al. Patients’ satisfaction: an important factor in quality control of gastroscopies. Scand J Gastroenterol 2008; 43: 1004-1011
49 Xiao D, Wang F, Wang X et al. Efficacy and security of sedation in upper gastrointestinal endoscopy in snoring patients. Zhong Nan Da Xue Xue Bao Yi Xue Ban 2010; 35: 1174-1177
50 Long Y, Liu HH, Yu C et al. Pre-existing diseases of patients increase susceptibility to hypoxemia during gastrointestinal endoscopy. PLoS One 2012; 7: e37614
51 Sieg A. Propofol sedation in outpatient colonoscopy by trained practice nurses supervised by the gastroenterologist: a prospective evaluation of over 3000 cases. Z Gastroenterol 2007; 45: 697-701
52 Froehlich F, Harris JK, Wietlisbach V et al. Current sedation and monitoring practice for colonoscopy: an International Observational Study (EPAGE). Endoscopy 2006; 38: 461-469
53 Schmidt GN, Bischoff P, Standl T et al. Comparative evaluation of the Datex-Ohmeda S/5 Entropy Module and the Bispectral Index monitor during propofol-remifentanil anesthesia. Anesthesiology 2004; 101: 1283-1290
54 Wu SC, Wang PC, Liao WT et al. Use of spectral entropy monitoring in reducing the quantity of sevoflurane as sole inhalational anesthetic and in decreasing the need for antihypertensive drugs in total knee replacement surgery. Acta Anaesthesiol Taiwan 2008; 46: 106-111
55 Riad W, Schreiber M, Saeed AB. Monitoring with EEG entropy decreases propofol requirement and maintains cardiovascular stability during induction of anaesthesia in elderly patients. Eur J Anaesthesiol 2007; 24: 684-688