Age correlates with hypotension during Propofol-based anesthesia forEndoscopic Retrograde Cholangiopancreatography

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

2. Age correlates with hypotension during
Propofol-based anesthesia for
Endoscopic Retrograde
Cholangiopancreatography
Authors Chong-Sun Khoi 1, Jen-Jeng Wong 1, Hao-Chin Wang 1,
Cheng-Wei Lu 1, 2 , Tzu-Yu Lin 1, 2
1 Department of Anesthesiology, Far Eastern Memorial Hospital, Ban-Chiao, Taipei County,
Taiwan
2 Department of Mechanical Engineering, Yuan Ze University, Chung-Li, Taiwan
Copyright © 2015, Taiwan Society of Anesthesiologists. Published by Elsevier Taiwan LLC.

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

7. Sample Selection
• Inclusion criteria:
• ERCP procedure under propofol-based deep sedation
• ASA I-IV

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)

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.

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