1. Maxim Mazanikov, MD, Marianne Udd, MD, PhD, Leena Kylänpää, MD, PhD, Outi Lindström, MD, Pekka Aho, MD, PhD, Jorma Halttunen, MD, PhD, Martti Färkkilä, MD, PhD, Reino Pöyhiä, MD, PhD Helsinki, Finland GASTROINTESTINAL ENDOSCOPY Volume 73, No. 2 : 2011 소화기내과 R2. 신재령 Patient-controlled sedation with propofol and remifentanil for ERCP: a randomized, controlled study Journal conference 2011.03.22

2. Deep sedation with propofol and an opioid is commonly used for ERCP Propofol sedation is associated with rapid onset of action, fast recovery, good patient cooperation, and a high satisfaction level However, propofol may easily lead to oversedation and cardiorespiratory instability, especially when infused  In many countries, propofol is restricted to anesthesiologists Delivery of propofol via a self-administration device to allow patient-controlled sedation (PCS) may be another option Background

3. Purpose Anesthesiologist-managed propofol-fentanyl sedation vs Patient-controlled propofol-remifentanil sedation Propofol and opioid consumption Ease of procedure performance Sedation depth Sedation-related complications Patient and endoscopist satisfaction with sedation during ERCP 100 mcg fentanyl ≒ 10 mg morphine ≒ 75 mg of pethidine (meperidine)

4. 80 patients (18-70 years of age) scheduled for elective ERCP PCS group(patient-controlled sedation) : 5mL of remifentanil (50 mcg/mL) + 20mL of propofol (10 mg/mL)  Self-administration device was programmed to deliver a 1mL(propofol 8mg)  3 to 5 doses before the start of ERCP (3~5 mL=propofol 24~40mg) PI group(propofol infusion group) : propofol 4mL(40 mg) + fentanyl 1mL(50 mcg)  propofol infusion was started at the rate of 0.5 mg/kg/hour  If a nociceptive stimulus was anticipated, additional fentanyl bolus of 1mL(50 mcg) could be given in the PI group. PATIENTS AND METHODS

5. PCS method to fail  1. additional propofol was administered by anesthesiologists 2. procedure was interrupted because of a sedation complication (eg, respiratory depression requiring mask ventilation) The total amount of propofol and opioids were calculated at the end of the procedure Endoscopist and patient satisfaction with the procedures was evaluated with a structured questionnaire Sedation level was estimated every 5 minutes throughout the procedure by using Ramsay and Gillham sedation scores PATIENTS AND METHODS

7. Results

9. Mean respiratory rate P<0.05 Peripheral oxygen saturation(spo2) End-expiratory carbon dioxide(EtCO2)

10. Results Mean Ramsay sedation score during ERCP P<0.001

11. Results The total mean(±SD) consumption of propofol was 175±98 mg and 249±138 mg in the PCS and the PI groups, respectively (P<0.01) The total mean(±SD) consumption of remifentanyl was 208±102 mcg in the PCS group and consumption of fentanyl was 111±33 mcg in the PI group.

12. Results The PCS method was successful, as defined by study criteria, in 38 of 40 (95%) patients Only 2 patients required additional doses of propofol administered by an anesthesiologist In one of these cases, PCS was converted to anesthesiologist-managed propofol sedation when the patient appeared confused In the other, ERCP was interrupted because of respiratory depression Patients’ and endoscopists’ satisfaction

13. Results

14. PCS(patient-controlled sedation) with propofol/remifentanil is a suitable and well-accepted sedation method for ERCP Anesthesiologist-managed propofol sedation with constant propofol infusion is associated with unnecessary deep sedation without any impact on the degree of patient or endoscopist satisfaction Further larger-scale studies are needed to assess the safety of PCS in ERCP patients Conclusion