Tuesday, February 15, 2011

Give Me Propofol, Straight Up

There is a study in Gastrointestinal Endoscopy this month advocating the use of balanced propofol sedation (BPS) over what the authors call conventional sedation (CS). BPS consists of propofol along with the use of midazolam and meperidine while CS is just BPS without the propofol component. The study consisted of 222 patients who underwent therapeutic EGD or ERCP. At the conclusion of the study, they found that there was no statistical difference in complication rates. However BPS was found to statistically improve patient cooperation along with health care provider and sedation nurse satisfaction with the procedure.

Now I have to admit that I've only read the abstract that's available on the Gastro Endo website. I don't have a subscription to the journal. What do you expect, I'm an anesthesiologist. But I found their rate of cardiopulmonary complications quite appalling. The abstract does not delve into their definition of cardiopulmonary complication (hypotension? MI? Aspiration?). For BPS the rate of complications was 8.8% while for CS it was 5.8%. Transient interruption of procedure was 2.9% for BPS vs. zero for CS. Neither sedation caused termination of the procedure or required assisted ventilation.

Again I haven't read the entire article. I'll have to go to the medical library to see if they even subscribe to it. But a 9% cardiopulmonary complication rate seems quite excessive. Even 5.8% sounds high. My question is, why use a cocktail at all? My preferred sedation for endoscopies, including therapeutic procedures like ERCP and EUS, is straight propofol, and nothing but. Let me tell you my experience from giving thousands of sedations for GI docs.

I find that Versed adds virtually nothing to propofol sedation. You might give it for excessively anxious patients in preop or pediatric patients, but most adults can handle the brief 2 minute or less transport from preop into the procedure room. They may say that they need something to calm them down but when you explain to them that Versed will prolong their post procedure stay for up to an hour, most people won't mind a little anxiety before the start of the procedure.

I rarely give narcotics either. Again narcotics add almost nothing to the propofol sedation. Some procedures that are excessively painful, such as biliary or pancreatic duct dilation, may require narcotics during the course of the procedure. In those cases I would only give short acting narcotics such as fentanyl. But giving narcotics routinely for sedation only increases the risk of intraop apnea, hypotension, hypoxia, and postop nausea and vomiting. The last thing you want as a GI anesthesiologist is a PACU full of unhappy wretching patients that the nurses are unable to discharge home.

So this study asks the wrong question. It's not which sedation cocktail is better for therapeutic GI cases. It's whether anything besides propofol is required to sedate a patient adequately for the gastroenterologist to complete his procedure. Trust me. You don't need to complicate your life by giving anything else besides propofol. Cheers.

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