Comparison of midazolam alone versus midazolam plus propofol during endoscopic submucosal dissection.

BACKGROUND/AIMS: For proper sedation during endoscopic submucosal dissection (ESD), propofol has been widely used. This study aimed to compare the levels of sedation and tolerance of patients treated with midazolam (M group) and a combination of midazolam and propofol (MP group) during ESD.
METHODS: A total of 44 consecutive patients undergoing ESD were randomly assigned to the two groups. In the M group, 2 mg of midazolam was given repeatedly to maintain after a loading dose of 5 mg. The MP group initially received 5 mg of midazolam and 20 mg of propofol. Then, we increased the dosage of propofol by 20 mg gradually.
RESULTS: The average amount of midazolam was 12 mg in the M group. In the M group, 10 patients were given propofol additionally, since they failed to achieve proper sedation. The average amount of propofol was 181 mg in the MP group. Procedure time, vital signs and rates of complications were not significantly different between two groups. Movement of patients and discomfort were lower in the MP group.
CONCLUSIONS: During ESD, treatment with propofol and a low dose of midazolam for sedation provides greater satisfaction for endoscopists compared to midazolam alone.

RCT Entities:   Population Interventions Outcomes

INTRODUCTION

Sedation during endoscopy is advantageous to patients for comfortable endoscopy without distress and to endoscopists for accurate and relaxed endoscopy. Conscious sedation endoscopy refers to the moderate level of sedation according to the American Society of Anesthesiologists (ASA) standard induced by administering a sedative, in order to maintain a patient in a responsive state to a slight touch or sound but capable of respiration at the same time for the adequate oxygen supply and respiration. Midazolam and propofol is most commonly used clinically for this purpose.1

Recently, endoscopic submucosal dissection (ESD), which requires relatively longer, deeper and more stable sedation than other endoscopy, is increasing for the treatment of early gastric cancer or gastric dysplasia. There are only few studies on the type, dose and safety of sedatives adequate for ESD. This study was performed to compare the sedative effect and safety between midazolam only and the combination of midazolam and propofol for sedation during the ESD.

MATERIALS AND METHODS

Patients

This study involved patients of the ASA physical status classification I and II among early gastric cancer or gastric dysplasia patients scheduled to receive ESD between 1 May 2008 and 30 May 2009 at Chungbuk National University Hospital. Patients who provided the informed consent and received the ESD were randomly assigned consecutively to either midazolam only group (M group) or midazolam and propofol combination group (MP group). Patients who had experienced side effects from premedication for sedation or medicinal poisoning; patients currently using drugs that could interact with midazolam or propofol; patients who cannot communicate due to psychological problems such as dementia, schizophrenia, or depression, or a gravida were excluded from the study.

Preparations before the procedure

Every patient fasted for eight hours. Scopolamine 20 mg and pethidine HCI 50 µg were injected before the endoscopy. Systolic and diastolic blood pressure, heart rate, respiration rate, and oxygen saturation were measured twice each, which was used as the baseline at rest.

Medication dose and periprocedural care

In case of M group, midazolam 5 mg was first injected intravenously for sedation, which was determined by the loss of eyelash reflex. Midazolam 2 mg was injected again if a patient does not achieve sedation 3 minutes after the first injection, and 1mg dose was injected continuously until sedation was achieved. The endoscope was inserted after the sedation, and additional 1 mg was injected when the patient stirs or shows signs of discomfort during insertion or procedure. The maximum total dose of midazolam was 15 mg, and propopol was injected thereafter instead of midazolam when the patient moves severely.

In case of MP group, midazolam 5 mg and propofol 20 mg was first injected intravenously for sedation. Additional 20 mg of propofol was injected when the sedation is not achieved 3 minutes later and 20 mg dose of propofol was injected repeatedly at 1 minute interval until sedation was achieved. The endoscope was inserted after the sedation, and additional 20 mg of propofol was injected intravenously when the patient stirs or shows signs of discomfort during the insertion or procedure.

Oxygen 2 L/min was provided through nasal cavity during the procedure, and pulse oxymetry was used to monitor the saturation level of oxygen.

Outcome measures

The duration of procedure was counted from the entry of the sedatives until the withdrawal of endoscope following submucosal dissection and confirmation of bleeding. Total dose of midazolam and propofol during the duration of procedure was measured. Safety was monitored by measuring systolic and diastolic blood pressure, heart rate, respiration rate, and oxygen saturation before and after the procedure and at 10 minute interval during the procedure. The patient's recovery grade was also evaluated after the procedure. The recovery grade was measured using Aldrete score consisting of 5 items, including activity, respiration, circulation, consciousness and color with a maximum total score of 10 points (2 points for each item). Recovery grade was evaluated by time from the completion of the procedure until when the Aldrete score reaches 10 points. Patients scored the degree of their pain such as pharyngolaryngeal discomfort and gag reflex on the visual analogue scale (VAS; 0, without discomfort; 10, most discomforting than any other experiences in one's life) one hour before the procedure and the next day, which was converted to a score system reflecting the patient's satisfaction. Sedative effect was evaluated by the degree of movement, aspiration rate, and the operator's satisfaction (very satisfying, quite satisfying, moderately satisfying, and dissatisfying). Post-procedure rebleeding or perforation was confirmed for the possibility of complications. Olympus GFS-Q260 was used for endoscopy, which was performed by one endoscopist.

Statistical analysis

Variables are expressed as mean±standard deviation. One-way ANOVA, t-test, Student's t-test, chi-square test, and Fisher's exact test were performed for statistical analysis of variables. A p-value of less than 0.05 was considered statistically significant. SPSS version 13.0 (SPSS Inc., Chicago, IL, USA) was used for statistical analysis.

RESULTS

Patient characteristics

A total of 44 patients enrolled in this study were randomized to either M group (n=22) or MP group (n=22). The mean ages of the two groups were similar as 61.1±8.5 years old and 62.5±10.5 years old in M group and MP group, respectively (p=0.63). Sex ratios were also similar between the two groups (male:female both 18:7 in M group and MP group; p=1.00). ASA classification was 1.45SA cl in M group and 1.36M gro in MP group, without significant difference (p=0.55)(Table 1).

Table 1

Comparison of Baseline Characteristics between Mida-zolam Alone (M Group) and a Combination of Midazolam and Propofol (MP Group)

ASA, American Society of Anesthesiologists.

Duration of procedure and dose of midazolam and propofol

The mean duration of procedure was 49.6±19.7 minutes in M group and 48.6±21.5 minutes in MP group, without statistically significant difference (p=0.87). The average dose of sedatives in M group was 12.5±2.5 mg for midazolam; 10 patients (45%) among them were not sedated until the total 15 mg of midazolam was injected and were switched to 154.0±122.5 mg of propofol. Every patient in MP group received midazolam 5 mg and the average total dose was 181.4±109.8 mg, which was not significantly different from the dose of propofol administered to 10 patients in M group (p=0.533)(Table 2).

Table 2

Comparison of Sedative Effects between Midazolam Alone (M Group) and a Combination of Midazolam and Propofol (MP Group)

VAS, visual analogue scale.

Sedative effect

Sedative effect was evaluated by counting the number of movements, which were measured on average 12.6 times in M group and 4.8 times in MP group. MP group patients moved significantly less than M group (p<0.004).

Safety

The systolic blood pressures of M group and MP group before and during the procedure were 131±22 vs. 138±20 mm Hg and 139±27 vs. 130±33 mm Hg. Six patients each from M group and MP group experienced decreased blood pressure of more than 20 mm Hg (both 27.3%). Heart rate was changed from 72±14/min at baseline to 100±13/min after medication in M group; 79±17/min and 97±22/min each in MP group; there was no statistically significant difference in the number of patients with 20% or more heart rate change between M group (n=2; 9.1%) and MP group (n=0) (p=0.49). There was also no significant difference in the change of respiration rate and the degree of oxygen saturation. There was 1 patient at each group whose oxygen saturation was decreased to less than 90%, without significant difference between the two groups. Total Aldrete score after the procedure were similar as 14.3±6.8s and 15.2±5.2s for M group and MP group, respectively (p=0.62)(Table 3).

Table 3

Comparison of Patient's Safety Index between Midazolam Alone (M Group) and a Combination of Midazolam and Propofol (MP Group)

BP, blood pressure; PR, pulse rate.

Patient and endoscopist satisfaction

Patient VAS was evaluated 1 hour before the procedure and the next day to measure the patient satisfaction indirectly, which was not significantly different between M group and MP group either 1 hour before the procedure (3.2±2.9 and 1.9±2.3; p=0.10) or 24 hours later (2.0±2.1 and 1.0±1.7; p=0.09). The percentage of very satisfying and quite satisfying cases by the endoscopist's evaluation was significantly higher in MP group (100%) compared to M group (50%) (p<0.001)(Fig. 1).

Fig. 1

Comparison of operator's satisfaction score between midazolam alone (M group) and a combination of midazolam and propofol (MP group).

Side effects

Post-procedure rebleeding occurred in 2 patients in each group (9.1% in M group, 9.1% in MP group), while perforation did not occur in either group (Table 4).

Table 4

Complications during and after ESD Procedure

ESD, endoscopic submucosal dissection.

DISCUSSION

It was found that MP group was more satisfying than M group by the endoscopist's evaluation, which is explained by less patient movement and no significant difference in procedure duration and side effects, contributing to a better procedural environment for the endoscopist's satisfaction. In case of M group, 45% of patients (10/22) could not achieve a sedative condition until the maximum dose of 15 mg was administered and had to be switched to propofol, which might have most affected the endoscopist's satisfaction. Patients switched to propofol did not have serious side effects such as high blood pressure or apnea, but they required as much dose of propofol as MP group, on top of the already maximum dose of midazolam.

Midazolam and propofol are currently the most commonly used sedatives for conscious sedation endoscope.1 Midazolam has 2-3 times stronger sedative effect with less phlebitis compared to diazepam of the same benzodiazepine class, and induces anterograde amnesia effect.2 Midazolam requires about 3 minutes after the IV administration before the sedative effect starts and more than 1 hour until the effect is waned away, which is why 1-2 hours of observation by a medical team is required for recovery after the endoscopy.3,4 Propofol which is popularly used for sedation during endoscopic examination has a chemical formula of 2,6-diisopropylphenol, comprised of 1% propofol, 10% bean oil, 2.25% glycerol, and 1.2% egg lecithin.5 When administered intravenously, propofol could rapidly pass the blood brain barrier and activates aminobutyric acid to induce sedation, amnesia, and sleeping. Sedative effects can occur within average 30-60 seconds after IV administration, and recover rapidly due to 1.3-1.4 minutes of short half-life.6 Various dosing is possible depending on the type and duration of procedure due to the short action time. Recommended loading dose for the first injection is 0.75-1.0 mg/kg and repeated administration is allowed at several minutes of interval.7

Effectiveness of propofol is well established in various literatures. Carlsson and Grattidge8 reported that propofol has better compliance and sedative effect than midazolam, more rapid recovery, and similar anterograde amnesia, arterial blood oxygen saturation, and patient comfort as midazolam. Koo et al.9 reported that low dose or high dose midazolam and propofol combination treatment induced similar sedative effect as high dose of midazolam single treatment, and there was no significant difference in recovery time. Propofol was also more effective than midazolam for endoscopic retrograde cholangiopancreatography, which requires longer procedure time; midazolam and propofol combination treatment was not more effective than propofol single treatment, but fewer side effects were induced by decreasing the dose of propofol.10 According to McClune et al.11 combination of midazolam and propofol induced synergy effect and the dose of propofol could be reduced. Reimann et al.12 also reported that low dose midazolam and propofol combination treatment induced synergy effect in preparation for colonoscopy in patients 60 years old or less, and better comfort during the procedure and shorter recovery time that midazolam and opioids combination treatment. These reports, combined with our study results, suggest that midazolam and propofol combination treatment could reduce the required dose of propofol, improves the patients' comfort, and provides better environment for endoscopists.

Although propofol in our study was not different in its stability between M group and MP group, it is generally known that propofol might increase the risk of hypotension, respiration or heart rate suppression, or pain at the injection site. It is important, therefore, to reduce the dose of propofol and carefully monitor the vital sings in order to prevent side effects when propofol was used with other sedatives. The risk of side effects is increased in older age, and it is recommended to provide oxygen through nasal cavity during the procedure.13 Rex et al.14 performed a non-anesthesiologist administered propofol in 2,000 patients and reported that hypoxia of less than 85% was occurred in 4 cases, all during endoscopy, which were soon recovered by using oxygen mask. Propofol was safely administered by a skilled nurse under the supervision of an endoscopist. Cho et al.15 performed gastrointestinal endoscopy using propofol in low risk group with ASA classification I and II and high risk group of ASA classification III and IV, and found that high risk group experienced significantly increased incidence of hypoxia but a single case of apnea during the procedure. Oxygen saturation was reduced to 90% or less in 1 patient at each group for a short period of time less than 10 seconds, but immediately returned to normal condition after using the oxygen mask.

The incidence of complication was relatively low, probably due to the exclusion of chronic patients with ASA III and IV, less older patients, and less dose of midazolam and propofol compared to other studies. The predictive factors of hypoxia include patient age, cardio pulmonary function before the procedure, obesity, rate of sedative administration, other diseases such as chronic obstructive pulmonary disease, and the expertness of the endoscopist. Hypoxia is assumed to be caused by respiratory suppression by sedatives, aspiration, diaphragmatic hypokinesia, bronchoconstriction, or transient closure during insertion of the endoscope.16 In this study, propofol 20 mg was first administered as an inductive dose and then additional 20 mg was repeatedly injected according to the patient's sedation. This dosage is equivalent to 1.13 mg/kg in ASA I patient and 1.15 mg/kg in ASA II patients, and relatively less than propofol 2 mg/kg recommended by the Korean Society of Anesthesiologists.17 Less dose of 1.0-1.75 mg/kg is recommended for patients of 60 years or older.17,18 High dose of propofol more than 2.5 mg/kg induced significantly more side effects than standard dose, such as reduced blood pressure and peripheral artery oxygen saturation and increased pulse rate.19 Although not included in this study, injection site pain, one of the most common complications of propofol, is a contributing factor to decrease the patient satisfaction. Some reporters suggested that injecting 1% lidocaine of 1 cc to the vessel before propofol injection, injecting cold propofol of 0-4℃, or injecting cool normal saline before sedation could be useful for pain relief.20

Both groups in this study reported good satisfaction at 1 hour and at 24 hours after the ESD, and few patients complained discomfort on the next day. It was suggested that midazolam and propofol combination treatment induced better sedation, based on the fact that less discomfort was reported both 1 hour and 24 hours after the ESD, compared to midazolam single treatment.

This study has several limitations that the sample size was small, older and high risk patients of ASA III and IV were excluded, double-blind design was not applicable in the endoscopist due to the different color of each sedative (midazolam is colorless transparent drug, while propofol is opaque white drug), which might have caused bias in the satisfaction of the endoscopist. The endoscopist's subjective judgement might have involved in the evaluation of his satisfaction, since only one endoscopist participated in the study. Further studies are needed in patients with various age groups to review the efficacy and stability of midazolam and propofol combination treatment.

In conclusion, low dose midazolam and propofol combination treatment induces better sedative effect and endoscopist's satisfaction compared to midazolam single treatment with similar degree of complication and consciousness recovery as a sedation strategy for ESD.