April 2024 ONCOLOGY CARTOON by DR KANHU CHARAN PATRO
JOURNAL CLUB Possible predictors related to the complications of propofol-based deep sedation for ERCP.
1. JOURNAL CLUB
PRESENTED BY
DR. M.ANEEQUE ALAM KHAN
aneeque86@gmail.com
DEPARTMENT OF ANAESTHESIA, SICU AND PAIN
MANAGEMENT
CIVIL HOSPITAL KARACHI / DOW UNIVERSITY OF HEALTH
SCIENCES
3. Introduction
• Endoscopic retrograde cholangiopancreatography
(ERCP) is a procedure used for diagnostic and
therapeutic purposes.
• It is a relatively uncomfortable and prolonged
procedure.
• Adequate sedation is usually beneficial for its
successful completion.
• Sometimes, general anesthesia even may be
indicated when sedation fails.
4. • Various sedatives, hypnotics, and narcotics have
been used for ERCP.
• Several studies have shown that propofol-based
sedation could provide a better recovery profile and
superiority to midazolam or meperidine during ERCP.
• A small increase in Prpofol dosage may cause a
patient to progress from deep sedation to general
anesthesia, during which hypoxemia and
hypotension may occurs.
5. • Considering these possible complications, the
aim of this study was to investigate the
possible predictors related to the
complications of propofol-based deep
sedation for ERCP.
6. MATERIAL & METHOD
• Study Design: Retrospective study
(Jan 2006-July 2010)
• Sample Size: 552 adult patients
• Setting: Far Eastern Memorial Hospital,
Taipei, Taiwan
9. • After obtaining the approval from the Institutional
ReviewBoard
• We retrospectively reviewed the anesthetic records, history
charts, and procedure records of the patients who underwent
ERCP under propofol-based deep sedation.
• The procedure was performed with patients in the prone
position.
• Monitoring was used for all patients including
electrocardiography, pulse oximetry, noninvasive blood
pressure measurements, and continuous respiratory rate
measurements.
• Supplemental oxygen at 4 L/min was offered via nasal cannula
throughout the procedure.
10. • All patients received an initial dose of 1-2.5 mg midazolam
and 20-50 mg propofol.
• Deep sedation was further maintained with titration of
continuous propofol infusion.
• A level of deep sedation was targeted by the
anesthesiologists to adjust the rate of propofol infusion
manually and boluses of propofol might be given.
• After the procedure, patients were sent to postanesthesia
care units for observation at least 60 minutes.
11. • Hypotension was defined by blood pressure dropping
significantly to < 20% of baseline blood pressure, which was
measured before sedation.
• Hypertension was defined by blood pressure significantly > 20%
of baseline blood pressure before sedation.
• Desaturation was defined by oxygen saturation dropped to <
90%.
• If the patient developed desaturation under supplemental
oxygen,
• The airway was opened by head-tilt/chin-lift and jaw-thrust
maneuvers.
• Nasal airway was inserted if the above maneuvers failed.
• If desaturation persisted, the procedure was terminated and
mask ventilation with 100% oxygen was adopted.
12. Results
• Almost 30% of patients experienced hypotension during the
procedure.
• Body mass index and other comorbidities such as diabetes
mellitus and biliary tract infection showed no statistical
difference between the two groups (Table 3)
13.
14.
15. Discussion
• Hypotension was the most frequent anesthetic complication during
propofol-based deep sedation for ERCP.
• We found that age, hypertension, sex, and anesthetic time are
predictors of hypotension during ERCP procedure under propofol-
based sedation.
• In this study Hypotension in the elderly is relatively high (33.3%).
• Only one patient with arterial oxygen saturation of 90% was
observed in our study, and the patient recovered immediately after
chin-lift and jaw-thrust
16. • Pulse oximetry provides an indirect measurement
of the respiratory function during ERCP, but
detection of abnormal ventilator activity can be
delayed, especially if supplemental oxygen is
provided.
• Capnography is a simple and inexpensive device,
but it was not used in our study.
• Capnography provides a continuous graphic record
of respiratory movement and is more reliable than
pulse oximetry in the early detection of respiratory
depression.
17. • Friedrich-Rust et al19 found that capnography
monitoring can reduce the incidence of
hypoxemia during propofol-based sedation for
colonoscopy. Therefore, capnography can be
considered another advance monitor during
ERCP.
• Chiang et al22 found that TCI of propofol
combined with opioids was associated with
better hemodynamic and respiratory stability
than manually controlled infusion of propofol
18. • In our study, propofol-based deep sedation
was provided during the procedure.
Hypotension and respiratory depression are
the most common adverse effects observed
during propofol continuous infusion.3,4
• The major complication observed with the use
of intravenous propofol is transient oxygen
desaturation during induction, and the mid-
procedural period.13
19. LIMITATION
• Some inaccurate and incomplete records were encountered.
• In conclusion, hypotension was the most frequent anesthetic
complication during the procedure under propofol-based deep
sedation.
• but this method was safe and effective with appropriate
monitoring.
• Age is the strongest predictor of hypotension and therefore
propofol-based deep sedation should be conducted with caution in
the elderly.
20. References
1. Kapoor H. Anaesthesia for endoscopic retrograde cholangiopancreatography. Acta Anaesthesiol Scand 2011;55:918e26.
2. Etzkorn KP, Diab F, Brown RD, Dodda G, Edelstein B, Bedford R, et al. Endoscopic retrograde cholangiopancreatography
under general anesthesia: indications and results. Gastrointest Endosc 1998;47:363e7.
3. Kongkam P, Rerknimitr R, Punyathavorn S, Sitthi-Amorn C, Ponauthai Y,Prempracha N, et al. Propofol infusion versus
intermittent meperidine and midazolam injection for conscious sedation in ERCP. J Gastrointestin Liver Dis 2008;17:291e7.
4. Seifert H, Schmitt TH, Gültekin T, Caspary WF, Wehrmann T. Sedation with propofol plus midazolam versus propofol alone for
interventional endoscopic procedures: a prospective, randomized study. Aliment Pharmacol Ther 2000;14:1207e14.
5. Vargo JJ, Zuccaro Jr G, Dumot JA, Shermock KM, Morrow JB, Conwell DL, et al.Gastroenterologist-administered propofol
versus meperidine and midazolam for advanced upper endoscopy: a prospective, randomized trial.
Gastroenterology2002;123:8e16.
6. Riphaus A, Stergiou N, Wehrmann T. Sedation with propofol for routine ERCP in high-risk octogenarians: a randomized,
controlled study. Am J Gastroenterol 2005;100:1957e63.
7. Garewal D, Waikar P. Propofol sedation for ERCP procedures: a dilemna? Observations from an anesthesia perspective.
Diagn Ther Endosc 2012;2012:639190.
8. Amornyotin S, Na-pomphet S, Wongwathanyoo T, Chalayonnavin V. Anesthesia for endoscopic retrograde
cholangiopancreatography (ERCP) from 1999e2003 in Siriraj Hospital: a retrospective study. J Med Assoc Thai
2004;87:1491e5.
9. Lee TH, Lee CK, Park SH, Lee SH, Chung IK, Choi HJ, et al. Balanced propofol sedation versus propofol monosedation in
therapeutic pancreaticobiliary endoscopic procedures. Dig Dis Sci 2012;57:2113e21.
10. Baksi AJ, Treibel TA, Davies JE, Hadjiloizou N, Foale RA, Parker KH, et al. A metaanalysis of the mechanism of blood
pressure change with aging. J Am CollCardiol 2009;54:2087e92.
11. O'Rourke MF, Nichols WW. Aortic diameter, aortic stiffness, and wave reflection increase with age and isolated systolic
hypertension. Hypertension2005;45:652e8
12. Gurven M, Blackwell AD, Rodríguez DE, Stieglitz J, Kaplan H. Does blood pressure inevitably rise with age? Longitudinal
evidence among forager-horticulturalists. Hypertension 2012;60:25e33.
21. .
13. Ong WC, Santosh D, Lakhtakia S, Reddy DN. A randomized controlled trial on use of propofol alone versus propofol
with midazolam, ketamine, and pentazocine “sedato-analgesic cocktail” for sedation during ERCP.
Endoscopy2007;39:807e12.
14. Wang CY, Ling LC, Cardosa MS, Wong AK, Wong NW. Hypoxia during upper gastrointestinal endoscopy with and
without sedation and the effect of preoxygenation
on oxygen saturation. Anaesthesia 2000;55:654e8.
15. Nimmagadda U, Chiravuri SD, Salem MR, Joseph NJ, Wafai Y, Crystal GJ. Preoxygenation with tidal volume and deep
breathing techniques: the
impact of duration of breathing and fresh gas flow. Anesth Analg 2001;92:1337e41.
16. Baraka AS, Taha SK, Aouad MT, El-Khatib MF, Kawkabani NI. Preoxygenation: comparison of maximal breathing and
tidal volume breathing techniques. Anesthesiology 1999;91:612e6.
17. Valentine SJ, Marjot R, Monk CR. Preoxygenation in the elderly: a comparison
of the four-maximal-breath and three-minute techniques. Anesth Analg 1990;71:516e9.
18. Cacho G, Perez-Calle JL, Barbado A, Lledo JL, Ojea R, Fernandez-Rodríguez CM. Capnography is superior to pulse
oximetry for the detection of respiratory depression during colonoscopy. Rev Esp Enferm Dig 2010;102:86e9.
19. Friedrich-Rust M, Welte M, Welte C, Albert J, Meckbach Y, Herrmann E. Capnographic monitoring of propofol-based
sedation during colonoscopy. Endoscopy 2014;46:236e44.
20. Fanti L, Agostoni M, Casati A, Guslandi M, Giollo P, Torri G, et al. Targetcontrolled
propofol infusion during monitored anesthesia in patients undergoing
ERCP. Gastrointest Endosc 2004;60:361e6.
21. Mazanikov M, Udd M, Kyl€anp€a€a L, Mustonen H, Lindstr€om O, F€arkkil€a M, et al.A randomized comparison of
target-controlled propofol infusion and patientcontrolled
sedation during ERCP. Endoscopy 2013;45:915e9.
22. Chiang MH, Wu SC, You CH, Wu KL, Chiu YC, Ma CW, et al. Target-controlled infusion vs. manually controlled infusion
of propofol with alfentanil for bidirectional endoscopy: a randomized controlled trial. Endoscopy 2013;45: 907e14.
23. Imagawa A, Hata H, Nakatsu M, Matsumi A, Ueta E, Suto K, et al. A targetcontrolled infusion system with bispectral
index monitoring of propofol sedation during endoscopic submucosal dissection. Endosc Int Open 2015;3: E2e6.
24. Graber RG. Propofol in the endoscopy suite: an anesthesiologist's perspective.Gastrointest Endosc 1999;49:803e6.
25. Fassoulaki A, Iatrelli I, Vezakis A, Polydorou A. Deep sedation for endoscopic cholangiopancreatography with or
without pre or intraprocedural opioids: a
double-blind randomised controlled trial. Eur J Anaesthesiol 2015;32:602e8