Patient-controlled sedation for ERCP: a randomized double-blind comparison of alfentanil and remifentanil

Background and study aims: Self-administration of a propofol and opioid mixture by patients (patient-controlled sedation, PCS) could offer a practical alternative for individual sedation during endoscopic retrograde cholangiopancreatography (ERCP). However, what would be the most suitable sedative mixture for PCS is unknown. The aim of this study was to compare remifentanil and alfentanil in the PCS during ERCP.

Patients and methods: Eighty-one patients undergoing elective ERCP received PCS with propofol and opioid in three different regimens. The concentrations of opioids in the sedative mixture were 0.02 mg/mL in the remifentanil group (R) and 0.04 mg/mL and 0.08 mg/mL in the alfentanil 1 (A1) and alfentanil 2 (A2) groups, respectively. The infusion pump was adjusted to deliver a 1 mL single dose with zero lockout time. We considered PCS as successful if no procedure interruption due to sedation-related complications occurred or if additional propofol was not needed. The consumption of propofol was registered, and sedation levels and vital signs were monitored. Endoscopist and patient satisfaction with sedation were assessed using structured questionnaires.

Results: The consumption (SD) of propofol was 177 (105)mg in group R, 197 (88) mg in group A1 and 162 (70)mg in group A2. PCS was successful in 74 /81 (91 %) of sedations, without differences between the groups in terms of propofol consumption, sedation success rate, sedation levels, vital signs, postprocedural pain, and endoscopist and patient satisfaction. Respiratory depression and nausea were observed more frequently with remifentanil than with alfentanil (P < 0.05).

Conclusions: PCS is an acceptable method of sedation for ERCP. The combination of propofol and alfentanil should be recommended because a remifentanil – propofol mixture depresses spontaneous respiration more and produces nausea more frequently.

• References

• 1 Chainaki IG, Manolaraki MM, Paspatis GA. Deep sedation for endoscopic retrograde cholangiopacreatography. World J Gastrointest Endosc 2011; 3: 34-39
• 2 Martindale SJ. Anaesthetic considerations during endoscopic retrograde cholangiopancreatography. Anaesth Intens Care 2006; 34: 475-480
• 3 Nelson DB, Freeman ML, Silvis SE et al. A randomized, controlled trial of transcutaneous carbon dioxide monitoring during ERCP. Gastrointest Endosc 2000; 51: 288-295
• 4 Müller S, Prolla JC, Maguilnik I et al. Predictive factors of oxygen desaturation of patients submitted to endoscopic retrograde cholangiopancreatography under conscious sedation. Arqu Gastroenterol 2004; 41: 162-166
• 5 Coté GA, Hovis RM, Ansstas MA et al. Incidence of sedation-related complications with propofol use during advanced endoscopic procedures. Clin Gastroenterol Hepatol 2010; 8: 137-142
• 6 Berzin TM, Sanaka S, Barnett SR et al. A prospective assessment of sedation-related adverse events and patient and endoscopist satisfaction in ERCP with anesthesiologist-administered sedation. Gastrointest Endosc 2011; 73: 710-717
• 7 Quine MA, Bell GD, McCloy RF et al. Prospective audit of upper gastrointestinal endoscopy in two regions of England: safety, staffing, and sedation methods. Gut 1995; 36: 462-467
• 8 Sharma VK, Nguyen CC, Crowell MD et al. A national study of cardiopulmonary unplanned events after GI endoscopy. Gastrointest Endosc 2007; 66: 27-34
• 9 Metzner J, Domino KB. Risks of anesthesia or sedation outside the operating room: the role of the anesthesia care provider. Curr Opin Anaesthesiol 2010; 23: 523-531
• 10 Riphaus A, Wehrmann T, Weber B et al. S3 Guideline: Sedation for gastrointestinal endoscopy 2008. Endoscopy 2009; 41: 787-815
• 11 Vargo JJ. Procedural sedation. Curr Opin Gastroenterol 2010; 26: 421-424
• 12 European Society of Gastrointestinal Endoscopy, European Society of Gastroenterology and Endoscopy Nurses and Associates, and the European Society of Anaesthesiology. Guideline: Non-anesthesiologist administration of propofol for GI endoscopy. Endoscopy 2010; 42: 960-974
• 13 Position statement: Nonanesthesiologist administration of propofol for GI endoscopy. Gastroenterology 2009; 137: 2161-2167
• 14 Rex DK, Deenadayalu VP, Eid E et al. Endoscopist-directed administration of propofol: a worldwide safety experience. Gastroenterology 2009; 137: 1229-1237
• 15 Perel A. Non-anaesthesiologists should not be allowed to administer propofol for procedural sedation: a Consensus Statement of 21 European National Societies of Anaesthesia. Eur J Anaesthesiol 2011; 28: 580-584
• 16 Atkins JH, Mandel JE. Recent advances in patient-controlled sedation. Curr Opin Anaesthesiol 2008; 21: 759-765
• 17 Mazanikov M, Udd M, Kylanpaa L et al. Patient-controlled sedation with propofol and remifentanil for ERCP: a randomized, controlled study. Gastrointest Endosc 2011; 73: 260-266
• 18 Mandel JE, Tanner JW, Lichtenstein GR 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
• 19 Liu SY, Poon CM, Leung TL et al. Nurse-administered propofol-alfentanil sedation using a patient-controlled analgesia pump compared with opioid-benzodiazepine sedation for outpatient colonoscopy. Endoscopy 2009; 41: 522-528
• 20 Yoon HI, Kim JH, Lee JH et al. Comparison of propofol and the combination of propofol and alfentanil during bronchoscopy: a randomized study. Acta Anaesthesiol Scand 2011; 55: 104-109
• 21 Mandel JE, Lichtenstein GR, Metz DC et al. A prospective, randomized, comparative trial evaluating respiratory depression during patient-controlled versus anesthesiologist-administered propofol-remifentanil sedation for elective colonoscopy. Gastrointest Endosc 2010; 72: 112-117
• 22 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
• 23 Jowell P, Eisen G, Onken J et al. Patient-controlled analgesia for conscious sedation during endoscopic retrograde cholangiopancrea-tography: a randomized controlled trial. Gastrointest Endosc 1996; 43: 490-494
• 24 Manyam SC, Gupta DK, Johnson KB et al. When is a bispectral index of 60 too low? Rational processed electroencephalographic targets are dependent on the sedative-opioid ratio. Anesthesiology 2007; 106: 472-483
• 25 Aldrete JA. The post-anesthesia recovery score revisited. J Clin Anesth 1995; 7: 89-91
• 26 Alhashemi JA, Kaki AM. Anesthesiologist-controlled versus patient-controlled propofol sedation for shockwave lithotripsy. Can J Anaesth 2006; 53: 449-455
• 27 Cohen LB. Making 1+1=3: improving sedation through drug synergy. Gastrointest Endosc 2011; 73: 215-217
• 28 Kern SE, Xie G, White JL et al. Opioid-hypnotic synergy: a response surface analysis of propofol-remifentanil pharmacodynamic interaction in volunteers. Anesthesiology 2004; 100: 1373-1381
• 29 Guitron-Cantu A, Adalid-Martinez R, Gutierrez-Bermudez J et al. Does fentanyl hinder the cannulation of Vater’s papilla? A prospective and comparative study. Rev Gastroenterol Mexico 2010; 75: 142-148
• 30 Hsieh YH, Chou AL, Lai YY et al. Propofol alone versus propofol in combination with meperidine for sedation during colonoscopy. J Clin Gastroenterol 2009; 43: 753-757
• 31 Janzen PR, Christys A, Vucevic M. Patient-controlled sedation using propofol in elderly patients in day-case cataract surgery. Br J Anaesth 1999; 82: 635-636
• 32 Moerman AT, Struys MMRF, Vereecke HE et al. Remifentanil used to supplement propofol does not improve quality of sedation during spontaneous respiration. J Clin Anesth 2004; 16: 237-243
• 33 Joo HS, Perks WJ, Kataoka MT et al. A comparison of patient-controlled sedation using either remifentanil or remifentanil-propofol for shock wave lithotripsy. Anesth Analg 2001; 93: 1227-1232
• 34 Philip BK, Scuderi PE, Chung F et al. Remifentanil compared with alfentanil for ambulatory surgery using total intravenous anesthesia. The Remifentanil/Alfentanil Outpatient TIVA Group. Anesth Analg 1997; 84: 515-521
• 35 Jhaveri R, Joshi P, Batenhorst R et al. Dose comparison of remifentanil and alfentanil for loss of consciousness. Anesthesiology 1997; 87: 253-259
• 36 Dershwitz M, Michalowski P, Chang Y et al. Postoperative nausea and vomiting after total intravenous anesthesia with propofol and remifentanil or alfentanil: how important is the opioid?. J Clin Anesth 2002; 14: 275-278
• 37 Egan TD, Minto CF, Hermann DJ et al. Remifentanil versus alfentanil: comparative pharmacokinetics and pharmacodynamics in healthy adult male volunteers. Anesthesiology 1996; 84: 821-833
• 38 Gaszynski TM, Strzelczyk JM, Gaszynski WP. Post-anesthesia recovery after infusion of propofol with remifentanil or alfentanil or fentanyl in morbidly obese patients. Obesity Surg 2004; 14: 498-503