Bispectral Index-guided Sedation for Flexible Bronchoscopy
Keywords
Coimriú
Cur síos
It is well known that patients undergoing bronchoscopy could be less suffering and the procedures could be carried on more smoothly if the patients have adequate sedation and analgesia. The preferred sedative and analgesic drugs are Midazolam and opioid, like Alfentanil or Morphine, which were titrated according to physicians' judgment on patients' clinical responsiveness. However, due to the pharmacokinetic characteristic of midazolam while used in intravenous injection (onset time 4-6 minutes, effective time 2-4 hours), the effective onset time may be too slow for repeated injection while patients already suffered from the bronchoscopic procedure. It is also noted that when over-sedation occurred the side effects like apnea/hypopnea, hypoxemia, and hypotension could last from dozen minutes to few hours. Although events mentioned above could be handled properly under experienced medical staff, it is still very difficult to predict the oncoming events as the pharmacokinetic effect is variant individually. Ideally, it will be more safe and efficient, during invasive procedure like bronchoscope, if the sedative drug could be onset or vanish fast and the drug effect could be titrated with an objective device directly monitoring the depth of sedation or anesthesia.
Propofol is a short-acting intravenous sedative agent used for the induction of general anesthesia for children and adults; maintenance of general anesthesia; and sedation in medical contexts, such as intensive care unit (ICU) sedation for intubated, mechanically ventilated adults, and in procedures such as colonoscopy. Its mechanism of action is uncertain, but it is postulated that its primary effect may be potentiation of the Gamma-Amino Butyric Acid-A receptor, possibly by slowing the channel closing time. It has a fast onset time (1~2 minutes) but a short working duration (8~10 minutes), which vanished fast after stop administration. Bispectral Index (BIS), an non-invasive neurophysiologic monitor instrument, can transform the electroencephalogram (EEG) and electromyography of the patient to a continual numeral, ranging from 0 to 99, which provides a direct and real-time sedative depth monitor. A BIS value of 0 equals EEG silence, near 100 is the expected value in a fully awake adult, and below70 indicated the patient lose explicit memory recall but still has the ability to maintain his own vital signs.
In this study, we design a sedative technique for bronchoscopy, a BIS-guided propofol administration, to compare with the traditional sedative technique, clinical-judged midazolam administration. Through the combination of the advantages of unique pharmacokinetics of propofol and real time monitor of sedative level from BIS, we hope to provide patients undergoing bronchoscopy a more satisfied and safety sedative procedure.
Dátaí
Fíoraithe Deireanach: | 03/31/2010 |
Cuireadh isteach den chéad uair: | 11/09/2008 |
Clárú Measta Curtha isteach: | 11/11/2008 |
Arna chur suas ar dtús: | 11/12/2008 |
Nuashonrú Deireanach Curtha isteach: | 08/02/2017 |
Nuashonrú Deireanach Postáilte: | 08/07/2017 |
Dáta na gcéad torthaí a cuireadh isteach: | 02/02/2010 |
Dáta na dtorthaí QC a cuireadh isteach den chéad uair: | 03/31/2010 |
Dáta na gcéad torthaí a cuireadh sa phost: | 04/19/2010 |
Dáta Tosaigh an Staidéir Iarbhír: | 03/31/2008 |
Dáta Críochnaithe Bunscoile Measta: | 08/31/2009 |
Dáta Críochnaithe an Staid Mheasta: | 08/31/2009 |
Coinníoll nó galar
Idirghabháil / cóireáil
Device: BIS-guided propofol infusion
Drug: Clinical-judged midazolam administration
Céim
Grúpaí Láimhe
Lámh | Idirghabháil / cóireáil |
---|---|
Active Comparator: BIS-guided propofol infusion In the study group, induction was started using alfentanil 4~5μg/kg bolus following repeated propofol boluses (0.5~1.5 mg/kg) until the BIS level reached 70. During maintenance, propofol infusion (3~12 mg/kg/hour) was given using a syringe pump (Injectomat Agilia, Fresenius Kabi, France), which was titrated to keep the BIS level between 65 and 75. | Device: BIS-guided propofol infusion Induction:
Alfentanil: 5μg/kg slowly push. Propofol: 0.5-1.5mg/kg slowly push till BIS value 70.
Maintenance:
Propofol infusion (3~12 mg/kg/hour) to maintain BIS around 65~75. Alfentanil: 5μg/kg slowly push Q15min prn if severe cough. |
Active Comparator: Clinical-judged midazolam administration In the control group, induction was started using alfentanil 4~5μg/kg bolus following 2 mg midazolam bolus. After 2 minutes, if the patient was not well sedated, midazolam boluses were repeat by increments of 2 mg/2min until conscious sedation was achieved | Drug: Clinical-judged midazolam administration Induction:
Alfentanil: 5μg/kg slowly push. Midazolam: 2 mg slowly push followed by increments of 2 mg/ 2min till OAA/S* 2~3.
Maintenance:
Midazolam: 2 mg/ 2min prn to keep OAA/S* 2~3 or if intolerance of procedure. Alfentanil as study arm.
*Observer's assessment of alertness/sedation (OAA/S):
Class 5: Responds readily to name spoken in normal tone.
Class 4: Lethargic response to name called in normal tone.
Class 3: Responds only to name called loudly.
Class 2: Responds only to shaking.
Class 1: No response to shaking. |
Critéir Incháilitheachta
Aois Incháilithe le haghaidh Staidéir | 18 Years Chun 18 Years |
Gnéas Incháilithe le haghaidh Staidéir | All |
Glacann Oibrithe Deonacha Sláintiúla | Sea |
Critéir | Inclusion Criteria: - Patients (>18 years old) requiring elective flexible bronchoscopy or Real time endobronchial ultrasound with transbronchial needle aspiration. Exclusion Criteria: - American Society of Anesthesiologists classification of physical status 4 and 5, including hepatic or renal failure, severe obstructive sleep apnea and severe chronic obstructive pulmonary disease. - Significant Central nervous system disorders or other factors contributing to access consciousness difficultly. - Allergic history to study drugs. - A history of glaucoma in the midazolam arm. |
Toradh
Bearta Toraidh Príomhúla
1. The Number of Participants With Any Hypoxemia Event During Flexible Bronchoscopy [From the time when bronchoscope introducing patients' nose or mouth to the time when bronchoscope leaving patients' nose or mouth]
2. The Number of Participants With Any Hypotension Event During Flexible Bronchoscopy [From the time when bronchoscope introducing patients' nose or mouth to the time when bronchoscope leaving patients' nose or mouth]
3. The Global Tolerance for Flexible Bronchoscopy by Verbal Analogus Scale [After patients recovered orientation and before they leaved the scope room.]
Bearta Torthaí Tánaisteacha
1. The Number of Participants Causing Any Procedure Interference by the Patients' Movement During Flexible Bronchoscocopy [From the time when bronchoscope introducing patients' nose or mouth to the time when bronchoscope leaving patients' nose or mouth]
2. The Number of Participants Causing Any Procedure Interference by Cough [From the time when bronchoscope introducing patients' nose or mouth to the time when bronchoscope leaving patients' nose or mouth]
3. The Recovery Time to Orientation [After the bronchoscope leaving patients' nose or mouth to the time patients returned orientation]
4. The Recovery Time to Ambulation [After the bronchoscopy]
5. Patients Willing Return if Repeated Bronchoscopy is Indicated. [After patients recovered orientation and before they leaved the scope room.]