Nurse-administered propofol versus midazolam and meperidine for upper endoscopy in cirrhotic patients.

OBJECTIVES: Upper GI endoscopy is often performed in patients with chronic liver disease to screen for esophageal and gastric varices. Propofol is currently under evaluation as an alternative to the combination of midazolam and meperidine for sedation during endoscopic procedures. The purpose of this study was to compare nurse-administered propofol to midazolam and meperidine for sedation in patients with chronic liver disease undergoing diagnostic upper GI endoscopy. METHODS: Twenty outpatients who had known chronic liver disease (Child-Pugh class A or B) and were undergoing variceal screening were randomized to receive propofol or midazolam plus meperidine for sedation. Administration of sedation was performed by a registered nurse and supervised by the endoscopist. Outcome measures studied were induction and recovery times, efficacy and safety of sedation, patient satisfaction, and return to baseline function. RESULTS: The mean dose of propofol and meperidine/midazolam administered was 203 mg (SD 43.7, range 150-280) and 71.3 mg (SD 17.7, range 50-100)/5.3 mg (SD 0.9, range 3.0-6.0), respectively. The mean time to achieve adequate sedation was 3.6 min (SD 1.2) for the propofol group in comparison to 7.3 min (SD 2.8) for the meperidine/midazolam group (p<0.05). Procedure times between the groups were similar: propofol, 3.9 min (SD 1.9); midazolam/meperidine, 2.7 min (SD 0.8) (p=0.11). The level of sedation achieved by the propofol group was greater (p=0.0001). Time to full recovery was faster in the propofol group: 34.9 min (SD 10.3) versus 51.6 min (SD 18.4) (p<0.05). The mean time to reach a maximal level of alertness on the Observer's Assessment of Alertness and Sedation Scale for the propofol group was 15 min (SD 3.6) versus 29 min (SD 10.5) (p=0.001). Although both groups recorded a high level of satisfaction, patients receiving propofol expressed greater overall mean satisfaction with the quality of their sedation at the time of discharge (p<0.05), and reported a return to baseline function sooner in the majority of cases. Propofol achieved comparable levels of efficacy and safety to meperidine/midazolam in our study group. Both were well tolerated with minimal complications. CONCLUSIONS: Propofol sedation administered by registered nurses in the setting of adequate patient monitoring is efficacious and well tolerated in patients with liver disease who are undergoing variceal screening by upper endoscopy. Patients were more satisfied with the quality of sedation, and return to baseline function was usually sooner compared to results achieved with midazolam/meperidine. Propofol offers advantages over meperidine/midazolam in cirrhotic patients.

Propofol versus midazolam/fentanyl for outpatient colonoscopy: administration by nurses supervised by endoscopists.

BACKGROUND & AIMS: Propofol is under evaluation as a sedative for endoscopic procedures. We compared nurse-administered propofol to midazolam plus fentanyl for outpatient colonoscopy. METHODS: One hundred outpatients undergoing colonoscopy were randomized to receive propofol or midazolam plus fentanyl, administered by a registered nurse and supervised only by an endoscopist. Endpoints were patient satisfaction, procedure and recovery times, neuropsychologic function, and complications. RESULTS: The mean dose of propofol administered was 277 mg; mean doses of midazolam and fentanyl were 7.2 mg and 117 microg, respectively. Mean time to sedation was faster with propofol (2.1 vs. 6.1 min; P<0.0001), and depth of sedation was greater (P<0.0001). Patients receiving propofol reached full recovery sooner (16.5 vs. 27.5 min; P=0.0001) and were discharged sooner (36.5 vs. 46.1 min; P=0.01). After recovery, the propofol group scored better on tests reflective of learning, memory, working memory span, and mental speed. Six minor complications occurred in the propofol group: 4 episodes of hypotension, 1 episode of bradycardia, and 1 rash. Five complications occurred with the use of midazolam and fentanyl: one episode of oxygen desaturation requiring mask ventilation and 4 episodes of hypotension. Patients in the propofol vs. midazolam and fentanyl groups reported similar degrees of overall satisfaction using a 10-cm visual analog scale (9.3 vs. 9.4, P>0.5). CONCLUSIONS: Nurse-administered propofol resulted in several advantages for outpatient colonoscopy compared with midazolam plus fentanyl, but did not improve patient satisfaction.

Safety of propofol administered by registered nurses with gastroenterologist supervision in 2000 endoscopic cases.

OBJECTIVES: Propofol has certain advantages over benzodiazepines plus narcotics as sedation for endoscopy. In a few centers, propofol has reportedly been used in endoscopic procedures and administered by nurses supervised by gastroenterologists without attendance by anesthesiologists or nurse anesthetists. METHODS: As part of our continuous quality improvement program, we prospectively recorded the doses of propofol and adverse reactions to the drug in our initial 2000 cases. In all cases propofol was administered by nurses who were supervised by gastroenterologists, with no involvement by an anesthesia specialist. RESULTS: The 2000 cases included 2222 procedures. There were five episodes of oxygen desaturation to <85%, four of which seemed to be related to excessive administration of propofol and were treated by brief (< 1 min) periods of mask ventilation. No patient required endotracheal intubation or hospital admission, or suffered long-term sequelae from propofol administration. There were no perforations in 977 colonoscopies. CONCLUSIONS: Propofol can be given safely by appropriately trained nurses under supervision by endoscopists. Technology that allows immediate detection of apnea would likely further improve its safety.