Sedative techniques for endoscopic retrograde cholangiopancreatography.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is an uncomfortable therapeutic procedure that cannot be performed without adequate sedation or general anaesthesia. A considerable number of ERCPs are performed annually in the UK (at least 48,000) and many more worldwide. OBJECTIVES: The primary objective of our review was to evaluate and compare the efficacy and safety of sedative or anaesthetic techniques used to facilitate the procedure of ERCP in adult (age > 18 years) patients. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 8); MEDLINE (1950 to September 2011); EMBASE (1950 to September 2011); CINAHL, Web of Science and LILACS (all to September 2011). We searched for additional studies drawn from reference lists of retrieved trial materials and review articles and conference proceedings. SELECTION CRITERIA: We considered all randomized or quasi-randomized controlled studies where the main procedures performed were ERCPs. The three interventions we searched for were (1) conscious sedation (using midazolam plus opioid) versus deep sedation (using propofol); (2) conscious sedation versus general anaesthesia; and (3) deep sedation versus general anaesthesia. We considered all studies regardless of which healthcare professional administered the sedation. DATA COLLECTION AND ANALYSIS: We reviewed 124 papers and identified four randomized trials (with a total of 510 participants) that compared the use of conscious sedation using midazolam and meperidine with deep sedation using propofol in patients undergoing ERCP procedures. All sedation was administered by non-anaesthetic personnel. Due to the clinical heterogeneity of the studies we decided to review the papers from a narrative perspective as opposed to a full meta-analysis. Our primary outcome measures included mortality, major complications and inability to complete the procedure due to sedation-related problems. Secondary outcomes encompassed sedation efficacy and recovery. MAIN RESULTS: No immediate mortality was reported. There was no significant difference in serious cardio-respiratory complications suffered by patients in either sedation group. Failure to complete the procedure due to sedation-related problems was reported in one study. Three studies found faster and better recovery in patients receiving propofol for their ERCP procedures. Study protocols regarding use of supplemental oxygen, intravenous fluid administration and capnography monitoring varied considerably. The studies showed either moderate or high risk of bias. AUTHORS' CONCLUSIONS: Results from individual studies suggested that patients have a better recovery profile after propofol sedation for ERCP procedures than after midazolam and meperidine sedation. As there was no difference between the two sedation techniques as regards safety, propofol sedation is probably preferred for patients undergoing ERCP procedures. However, in all of the studies that were identified only non-anaesthesia personnel were involved in administering the sedation. It would be helpful if further research was conducted where anaesthesia personnel were involved in the administration of sedation for ERCP procedures. This would clarify the extent to which anaesthesia personnel should be involved in the administration of propofol sedation.

Intrathecal fentanyl, sufentanil, or placebo combined with hyperbaric mepivacaine 2% for parturients undergoing elective cesarean delivery.

UNLABELLED: Worldwide, long-acting bupivacaine is the most popular local anesthetic for spinal anesthesia in parturients undergoing elective cesarean delivery. With advances in surgical techniques, e.g., the Misgav Ladach method, and shorter duration of surgery, the local anesthetic mepivacaine, with an intermediate duration of action, may be a reasonable alternative. Our aim in the present study was to evaluate the effects of 2% hyperbaric mepivacaine alone, or combined with either intrathecal fentanyl (5 and 10 microg), or sufentanil (2.5 and 5 microg), on sensory, motor, and analgesic block characteristics, hemodynamic variables, and neonatal outcome in a randomized, prospective, and double-blinded study (n = 100, 20 parturients per group, singleton pregnancy, >37 wk of gestation). No parturient experienced intraoperative pain. The average duration of motor block Bromage 3 in all groups was 68 min, and resolution time to Bromage 0 was 118 min. Maximal cephalad sensory block level was T3-6 and could be established within 6 min. Complete analgesia was significantly prolonged in all groups receiving intrathecal opioids, yet, with sufentanil 5 microg, even the duration of effective analgesia was significantly extended. Neonatal outcome was not affected by intrathecal opioid administration. In conclusion, 2% hyperbaric mepivacaine is a feasible local anesthetic for spinal anesthesia in parturients undergoing elective cesarean delivery, particularly with short duration of surgery. IMPLICATIONS: Sensory, motor, and analgesic block characteristics of the local anesthetic mepivacaine alone or combined with intrathecal opioids were studied in parturients undergoing elective cesarean delivery in a randomized, double-blinded clinical trial. Mepivacaine was found to be an acceptable local anesthetic for spinal anesthesia in parturients undergoing cesarean delivery. In combination with sufentanil 5 microg, complete and effective analgesia were significantly prolonged.