Sedation with propofol for routine ERCP in high-risk octogenarians: a randomized, controlled study. Propofol infusion versus intermittent meperidine and midazolam injection for conscious sedation in ERCP. Sedation with propofol for interventional endoscopy by trained nurses in high-risk octogenarians: a prospective, randomized, controlled study. Safer colonoscopy with patient-controlled analgesia and sedation with propofol and alfentanil. Patient-controlled sedation for colonoscopy: a randomized trial comparing patient-controlled administration of propofol and alfentanil with physician-administered midazolam and pethidine. Sedation in uncooperative children undergoing dental procedures: a comparative evaluation of midazolam, propofol and ketamine. A double-blind randomized comparison of midazolam alone and midazolam combined with ketamine for sedation of pediatric dental patients. Sedation, topical pharyngeal anesthesia and cardiorespiratory safety during gastroscopy. A comparison of oral clonidine and oral midazolam as preanesthetic medications in the pediatric tonsillectomy patient.
Adequate patient sedation is mandatory for diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP). In this respect it is known that the short-acting anesthetic propofol offers certain potential advantages for sedation during ERCP, but there are no controlled studies concerning the feasibility and safety of propofol sedation in elderly, high-risk patients.
                One hundred and fifty consecutive patients aged >or=80 yr with high comorbidity (ASA score >or=III: 91 %), randomly received midazolam plus meperidine (n = 75) or propofol alone (n = 75) for sedation during ERCP. Vital signs were continuously monitored and procedure-related parameters, recovery time, and quality as well as patients' cooperation and tolerance of the procedure were assessed.
                Clinically relevant changes in vital signs were observed at comparable frequencies with a temporary oxygen desaturation (<90%) occurring in eight patients in the propofol-group and seven patients receiving midazolam/meperidine (n.s.). Hypotension was documented in two patients in the propofol group and one patient receiving midazolam/meperidine. Propofol provided a significantly better patient cooperation than midazolam/meperidine (p < 0.01), but the procedure tolerability was rated nearly the same by both groups. Mean recovery time was significantly shorter in the propofol group (22 +/- 7 min vs 31 +/- 8 min for midazolam/meperidine (p < 0.01)) while the recovery score was significantly higher under propofol (8.3 +/- 1.2 vs 6.1 +/- 1.1(p < 0.01)). During recovery a significant lower number of desaturation events (<90%) were observed in the propofol group (12%) than in the midazolam/meperidine group (26%, p < 0.01).
                Under careful monitoring the use of propofol for sedation during ERCP is superior to midazolam/meperidine even in high-risk octogenarians. ERCP generally requires longer time than standard endoscopy. Only few studies have shown benefit of intermittent propofol over conventional sedation. This study was conducted to compare satisfaction, recovery score, and recovery/safety profiles for ERCP sedation between continuous infusion of propofol and conventional sedation.
                One hundred thirty-four patients with ASA I-III underwent ERCP and were randomly assigned into two groups (n=67 each). Patients underwent propofol sedation or meperidine/midazolam sedation. Supplemental oxygen was offered only when oxygen saturation was lower than 90 %. Oxygen saturation, blood pressure, heart rate, recovery score, times for recovery and satisfaction score after procedure were recorded and analyzed.
                Average amount of meperidine, midazolam and propofol per each patient were 61.54 (+/- 27.29), 7.80 (+/- 3.73), 299.90 (+/- 146.15) mg, respectively. Time to regain full consciousness in the propofol arm was significantly shorter than in the conventional arm (17.24 +/- 5.99 versus 34.25 +/- 16.06 min, p<0.001). The rates of desaturation, bradycardia and hypotension in both arms were low and comparable. Propofol provided higher level of recovery scores at 15, 30, 45 and 60 min after the procedure (p < 0.001).
                Continuous infusion of propofol for ERCP by direction of gastroenterologist yields no difference in the completion rate and adverse profiles when compared with conventional technique but it provides a better recovery profile. The maintainance of appropriate level of sedation by well trained personnel is the key to achieve this success. Sedation with the short-acting anesthetic agent propofol has shown several advantages, particularly in interventional endoscopy. So far, however, there are no valid data on the safety of nurse-administered propofol sedation (NAPS) during interventional endoscopy in elderly high-risk patients.
                A total of 150 patients aged > 80 years with high comorbidity were randomized to receive midazolam plus meperidine (n = 75) or propofol alone (n = 76) for sedation during endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound (EUS), or double-balloon endoscopy (DBE). Sedation was supervised by a trained nurse and a trained physician both of whom were not involved in the endoscopic procedure. Vital signs were continuously monitored as well as patient cooperation and tolerance. Mortality and morbidity at 30 days was analyzed.
                The overall cardiopulmonary complication rate was 16 % in the midazolam group and 23.7 % in the propofol group ( P > 0.05). The mean decline in oxygen saturation (initial vs. lowest O (2) saturation) and the mean decline of blood pressure (initial vs. lowest blood pressure) were significantly greater with propofol (7 % +/- 3 % vs. 4 % +/- 2 % [ P < 0.05] and 10 % +/- 2 % vs. 8 % +/- 2 %, respectively [ P < 0.05]). No procedure had to be interrupted due to serious adverse events. Patient cooperation was statistically significantly better in the propofol group (7 +/- 2 vs. 5 +/- 2 points). Patients sedated with propofol showed a significantly lower oxygen saturation rate during recovery time (8 % vs. 28 %; P < or = 0.01).
                NAPS during interventional endoscopy is as safe as midazolam/pethidine sedation even in high-risk patients aged > 80 years. The aim of this study was to assess the efficacy of patient-controlled analgesia and sedation with propofol/alfentanil for colonoscopy compared with continuous drug infusion and conventional nurse-administered medication.
                One hundred fifty patients undergoing colonoscopy on an outpatient basis were randomly assigned to 1 of 3 medication regimens. To maintain blinding, all patients were connected to an infusion pump. Group I patients could self-administer boluses of 4.8 mg propofol and 125 microg alfentanil without restriction. Group II patients received a continuous infusion with 0.048 mg/kg propofol and 0.12 microg/kg alfentanil per minute. Group III patients received intravenous premedication with 0.035 mg/kg midazolam and 0.35 mg/kg meperidine.
                There were no differences between the groups with respect to pain (visual analogue scale) and procedure time. Patient-controlled analgesia and sedation with propofol/alfentanil (group I) resulted in less of an increase in the transcutaneous partial pressure of carbon dioxide (p = 0.0004) during colonoscopy and less of a decrease in mean arterial blood pressure (p = 0.0021) during recovery, as well as more complete recovery (p = 0.0019) after 45 minutes compared with conventional administration of midazolam/meperidine. Furthermore, patient-controlled analgesia and sedation yielded a higher degree of patient satisfaction than continuous infusion of propofol/alfentanil (p = 0.0033) or nurse-administered midazolam/meperidine (p = 0.0094).
                Patient-controlled administration of propofol and alfentanil for colonoscopy may provide a better margin of safety than conventional administration of midazolam and meperidine and results in a higher level of patient satisfaction and shorter recovery. Patient-controlled sedation (PCS) using propofol and alfentanil provides effective sedation for colonoscopy, with the advantage of a shorter recovery time in comparison with diazepam and pethidine. However, most endoscopy units in the United Kingdom are currently using midazolam (a shorter-acting benzodiazepine) as a sedative agent. This study compares the efficacy of sedation and recovery times between PCS and a combination of midazolam and pethidine.
                Sixty-seven patients undergoing colonoscopy were randomly assigned prospectively to receive sedation with either PCS, using propofol and alfentanil, or a bolus of midazolam and pethidine. Sedation and pain scores were recorded during the procedure by one specialist nurse. Patients' recollection of pain was recorded after the procedure. Recovery was assessed using number connection tests. The impact on subsequent activities and the level of amnesia, as well as overall satisfaction, were established by telephone call after 24 h.
                The sedation method had no impact on the success, difficulty, or duration of the colonoscopy. PCS could be set up by the specialist nurse without affecting the time between cases. Patients in the PCS group recovered significantly faster (median 5 min vs 35 min; P < 0.0001) and left the department more quickly (median 40 min vs 75 min; P < 0.0001). Patients in the PCS group had significantly higher pain scores and significantly more recall than those in the midazolam and pethidine group. All patients were satisfied with the sedation they received.
                PCS provides an acceptable alternative to sedation with midazolam and pethidine with the advantage of significantly faster recovery times, which are of relevance in the outpatient setting. Dentists usually face a common problem dealing with pediatric patients due to their high levels of anxiety and fear, associated with dental procedures. Such children are usually managed by various pharmacological methods. The efficacy and safety of conscious sedation, using intravenous short acting group of drugs (midazolam, propofol and ketamine) in uncooperative children, requiring oral rehabilitation was thus evaluated in this study. A total of 30 uncooperative children, aged 3-6 years, belonging to ASA I, II category formed the study group. The efficacy of the three group of drugs was evaluated on the basis of the onset of sedation, duration of action, side effects encountered, and the overall cooperative behavior of the child throughout the course of the procedure, after obtaining parental consent. Results showed that propofol was highly effective in terms of onset of sedation, although increased body movements and crying, pain on injection and intermittent cough was observed as the main side effects of the drug. Midazolam showed the longest duration of action, but was not very effective in terms of treatment completion due to increased movements and crying. Maximum cooperation during the procedure was obtained with ketamine and no adverse effects were encountered. We preferred ketamine from the results of our study and recommended future evaluation of ketamine in combination with other sedatives. The safety and efficacy of a new sedation technique for children having dental procedures under local anesthesia were evaluated.
                One hundred children between the ages of 2 and 7 years who required sedation for dental procedures were administered either a combination of midazolam (0.35 mg/kg) and ketamine (5 mg/kg) or midazolam alone (1 mg/kg) rectally 30 minutes before removal to the dental chair. Pulse rate, respiratory rate, arterial pressure, oxygen saturation, adverse reactions, postoperative recovery, and behavior were recorded.
                Satisfactory sedation and anxiolysis were achieved with both drugs used in the study. When evaluating postoperative recovery, statistically significantly more children receiving midazolam alone were fully awake on admission to the recovery room and 30 minutes later. Results of physiologic monitoring, behavioral ratings, and adverse effects are reported. Excessive salivation occurred in 26% of children receiving the combination of drugs, compared with 14% receiving midazolam alone. Seven (14%) of the children receiving the combination of drugs hallucinated, compared with 21 (42%) receiving midazolam alone. Both drug groups had reliably good anxiolysis and sedation without loss of respiratory drive or protective airway reflexes.
                The use of a combination of midazolam and ketamine or midazolam alone is a safe, effective, and practical approach to managing children for minor dental procedures under local anesthesia. With this technique, advanced airway management proficiency is recommended. In a prospective, double-blind study, we examined the effects of routine sedation and pharyngeal anesthesia on cardiorespiratory parameters during gastroscopy.
                Intravenous sedation and topical pharyngeal anesthesia are used to alleviate the discomfort during upper gastrointestinal endoscopy. Cardiorespiratory changes during gastroscopy are common.
                Two hundred fifty two consecutive outpatients undergoing gastroscopy were assigned into 4 groups: (1) sedation with intravenous midazolam and placebo throat spray (midazolam group), (2) placebo sedation and pharyngeal anesthesia with lidocaine throat spray (lidocaine group), (3) placebo sedation and placebo throat spray (placebo group), and (4) no intravenous cannula nor throat spray (control group). Arterial oxygen saturation (SaO2), systolic and diastolic blood pressure and continuous electrocardiogram were recorded before, during, and after the endoscopic procedure.
                Gastroscopy increased heart rate in all study groups. Premedication with intravenous midazolam or lidocaine spray alleviated this rise (P<0.001, repeated measures analysis of variance) and decreased the incidence of tachycardia. Similarly, sedation with midazolam or topical pharyngeal anesthesia decreased the rise in systolic blood pressure (P<0.001). Midazolam produced lower SaO2 values during gastroscopy compared with lidocaine, placebo or control groups (P<0.001). However, episodes of desaturation (SaO2 </=92) were no more common in the midazolam group than in other groups.
                Premedication with midazolam alleviated the rise in heart rate and systolic blood pressure but induced a statistically significant decrease in arterial oxygen saturation. However, gastroscopy proved to be a safe procedure both with and without sedation. We compared the effects of oral clonidine (4 microg/kg) and midazolam (0.5 mg/kg) on the preanesthetic sedation and postoperative recovery profile in children during tonsillectomy with or without adenoidectomy. In a double-blinded, double-dummy study design, 134 ASA physical status I-II children aged 4-12 yr were randomized to receive a combination of either clonidine and placebo (Group A), or placebo and midazolam (Group B) at 60-90 min and 30 min, respectively, before the induction of anesthesia. Children in the clonidine group exhibited more intense anxiety on separation and during induction of anesthesia via a mask as measured by the modified Yale Preoperative Anxiety Scores. They also had significantly lower mean intraoperative arterial blood pressures, shorter surgery, anesthesia, and emergence times, and a decreased need for supplemental oxygen during recovery compared with the midazolam group. However, the clonidine group had larger postoperative opioid requirements, maximum excitement and pain scores based on the Children's Hospital of Eastern Ontario scale in the Phase 1 postanesthetic care unit. There were no differences between the two groups in the times to discharge readiness, postoperative emesis, unanticipated hospital admission rates, postdischarge maximum pain scores, and 24 h analgesic requirements. The percentage of parents who were completely satisfied with the child's preoperative experience was significantly higher in the midazolam group. There were no differences in parental satisfaction with the recovery period. We conclude that under the conditions of this study, oral midazolam is superior to oral clonidine as a preanesthetic medication in this patient population. Implications: We compared preanesthetic sedation and postoperative recovery after oral clonidine (4 microg/kg) and midazolam (0.5 mg/kg) in children during tonsillectomy. The clonidine group had greater preoperative anxiety and shorter surgery and anesthesia times, but required more postoperative analgesia. Delayed recovery and discharge times did not differ. Midazolam was superior to clonidine as oral preanesthetic medication for these patients.
Results from individual studies suggested that patients have a better recovery profile after propofol sedation for ERCP procedures than after midazolam and meperidine sedation. As there was no difference between the two sedation techniques as regards safety, propofol sedation is probably preferred for patients undergoing ERCP procedures. However, in all of the studies that were identified only non-anaesthesia personnel were involved in administering the sedation. It would be helpful if further research was conducted where anaesthesia personnel were involved in the administration of sedation for ERCP procedures. This would clarify the extent to which anaesthesia personnel should be involved in the administration of propofol sedation.