Nurse-administered propofol–alfentanil sedation using a patient-controlled analgesia pump compared with opioid–benzodiazepine sedation for outpatient colonoscopy

Background and study aim: Nurse-administered propofol sedation (NAPS) and patient-controlled sedation using patient-controlled analgesia (PCA) pumps are gaining increasing popularity for gastrointestinal endoscopy. We compared the safety and efficacy of NAPS using PCA pumps with diazemuls–pethidine sedation (DPS) for outpatient colonoscopy.

Patients and methods: In a prospective randomized controlled trial patients underwent outpatient colonoscopy with sedation by either NAPS or DPS. For NAPS, following intravenous loading of 0.8 mg/kg propofol, mixtures of 14.3 mg propofol and 35 microgram alfentanil were titrated by nurses using a PCA pump. For DPS, 0.1 mg/kg diazemuls and 0.5 mg/kg pethidine were given as intravenous bolus; further titration was administered as half doses at the endoscopist’s discretion. Adequacy of sedation was measured by the Observer’s Scale for Sedation and Alertness (OSSA) score (range 1–5).

Results: Between July 2005 and June 2006, 88 patients were randomly allocated to NAPS and 90 to DPS. The groups were comparable for baseline characteristics and procedure time. With NAPS, levels of sedation both during colonoscopic intubation and at reaching the cecum were significantly deeper than with DPS (OSSA 3 vs. 5, P < 0.0001). There were no significant differences in cardiopulmonary complication rates, pain scores, satisfaction scores, and patients’ willingness to repeat colonoscopy with the same sedation. Drugs cost for NAPS was higher than for DPS (Hong Kong dollars [HKD] 98.34 vs. 5.01).

Conclusion: Despite higher costs, nurse-administered propofol–alfentanil sedation using a PCA pump can provide deeper conscious sedation, comparable satisfaction, and similar complication risks compared with conventional opioid–benzodiazepine sedation.

References

• 1 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
• 2 Horn E, Nesbit S A. Pharmacology and pharmacokinetics of sedatives and analgesics.  Gastrointest Endosc Clin N Am. 2004;  14 247-268
• 3 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
• 4 Kulling D, Fantin A C, Biro P. et al . Safer colonoscopy with patient-controlled analgesia and sedation with propofol and alfentanil.  Gastrointest Endosc. 2001;  54 1-7
• 5 Ng J M, Kong C F, Nyam D. Patient-controlled sedation with propofol for colonoscopy.  Gastrointest Endosc. 2001;  54 8-13
• 6 Lee D W, Chan A C, Sze T S. et al . Patient-controlled sedation versus intravenous sedation for colonoscopy in elderly patients: a prospective randomized controlled trial.  Gastrointest Endosc. 2002;  56 629-632
• 7 Bright E, Roseveare C, Dalgleish D. et al . Patient-controlled sedation for colonoscopy: a randomized trial comparing patient-controlled administration of propofol and alfentanil with physician-administered midazolam and pethidine.  Endoscopy. 2003;  35 683-687
• 8 Mandel J E, Tanner J W, Lichtenstein G R. et al . A randomized, controlled, double-blind trial of patient-controlled sedation with propofol/remifentanil versus midazolam/fentanyl for colonoscopy.  Anesth Analg. 2008;  106 434-439
• 9 Sipe B W, Rex D K, Latinovich D. et al . Propofol versus midazolam/meperidine for outpatient colonoscopy: administration by nurses supervised by endoscopists.  Gastrointest Endosc. 2002;  55 815-825
• 10 Ulmer B J, Hansen J J, Overley C A. et al . Propofol versus midazolam/fentanyl for outpatient colonoscopy: administration by nurses supervised by endoscopists.  Clin Gastroenterol Hepatol. 2003;  1 425-432
• 11 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
• 12 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
• 13 Külling D, Orlandi M, Inauen W. Propofol sedation during endoscopic procedures: how much staff and monitoring are necessary?.  Gastrointest Endosc. 2007;  66 443-449
• 14 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
• 15 Tohda G, Higashi S, Wakahara S. et al . Propofol sedation during endoscopic procedures: safe and effective administration by registered nurses supervised by endoscopists.  Endoscopy. 2006;  38 360-367
• 16 Walker J A, McIntyre R D, Schleinitz P F. et al . Nurse-administered propofol sedation without anesthesia specialists in 9152 endoscopic cases in an ambulatory surgery center.  Am J Gastroenterol. 2003;  98 1744-1750
• 17 Heuss L T, Drewe J, Schnieper P. et al . Patient-controlled versus nurse-administered sedation with propofol during colonoscopy. A prospective randomized trial.  Am J Gastroenterol. 2004;  99 511-518
• 18 Poon C M, Leung T L, Wong C W. et al . Safety of nurse-administered propofol sedation using PCA pump for outpatient colonoscopy in Chinese patients: a pilot study.  Asian J Surg. 2007;  30 239-243
• 19 American S ociety. Practice guidelines for sedation and analgesia by non-anesthesiologists.  Anesthesiology. 2002;  96 1004-1017
• 20 Thompson D G, Lennard-Jones J E, Evans S J. et al . Patients appreciate premedication for endoscopy.  Lancet. 1980;  2 469-470
• 21 Terruzzi V, Meucci G, Radaelli F. et al . Routine versus ”on demand” sedation and analgesia for colonoscopy: a prospective randomized controlled trial.  Gastrointest Endosc. 2001;  54 169-174
• 22 Takahashi Y, Tanaka H, Kinjo M, Sakumoto K. Sedation-free colonoscopy.  Dis Colon Rectum. 2005;  48 855-859
• 23 Hoffman M S, Butler T W, Shaver T. Colonoscopy without sedation.  J Clin Gastroenterol. 1998;  26 279-282
• 24 Cataldo P A. Colonoscopy without sedation.  Dis Colon Rectum. 1996;  39 257-261
• 25 Early D S, Saifuddin T, Johnson J C. et al . Patient attitudes toward undergoing colonoscopy without sedation.  Am J Gastroenterol. 1999;  94 1862-1865
• 26 Rex D K, Overley C A, Walker J. Registered nurse-administered propofol sedation for upper endoscopy and colonoscopy: Why? When? How?.  Rev Gastroenterol Disord. 2003;  3 70-80
• 27 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
• 28 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
• 29 Clarke A C, Hillman L C. Does the use of propofol require a specialist anaesthetist?.  Endoscopy. 2001;  33 95
• 30 Hansen J J, Ulmer B J, Rex D K. Technical performance of colonoscopy in patients sedated with nurse-administered propofol.  Am J Gastroenterol. 2004;  99 52-56
• 31 Vargo J J, Bramley T, Meyer K, Nightengale B. Practice efficiency and economics: the case for rapid recovery sedation agents for colonoscopy in a screening population.  J Clin Gastroenterol. 2007;  41 591-598
• 32 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