Luo HR, Chen AD, Lin JF, Ye P, Chen YJ, Lin MX, Chen PZ, Chen XH, Zheng XC. Effect of etomidate added to propofol target-controlled infusion in bidirectional endoscopy: A randomized clinical trial. World J Gastrointest Endosc 2025; 17(2): 100722 [DOI: 10.4253/wjge.v17.i2.100722]
Corresponding Author of This Article
Xiao-Hui Chen, MD, Chief Physician, Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, No. 134 East Street, Fuzhou 350000, Fujian Province, China. chenxh@fjmu.edu.cn
Research Domain of This Article
Anesthesiology
Article-Type of This Article
Randomized Clinical Trial
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Hui-Rong Luo, Department of Anesthesiology, Fujian Medical University Union Hospital, Fuzhou 350000, Fujian Province, China
An-Di Chen, Jing-Fang Lin, Peng Ye, Ying-Jie Chen, Ming-Xue Lin, Pin-Zhong Chen, Xiao-Hui Chen, Xiao-Chun Zheng, Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fuzhou 350000, Fujian Province, China
Author contributions: Luo HR contributed to study conception, design, data collection and write the manuscript; Chen AD contributed to data collection and write the manuscript; Lin JF contributed to implementation of clinical anesthesia and the revision of the manuscript; Ye P, Chen YJ, Lin MX and Chen PZ contributed to data collection; Chen XH contributed to study design, supervised the work, performed the analysis, contributed data and analysis tools; Zheng XC contributed to study design, revised the manuscript; All authors made critical revisions and approved the final version to be published. Luo HR and Chen AD contributed equally to this work as co-first authors; Chen XH and Zheng XC contributed equally to this work as co-corresponding authors. The reasons for designating Chen XH and Zheng XC as co-corresponding authors are that Zheng XC is responsible for coordination and quality control; Chen XH is responsible for design of the project.
Institutional review board statement: The study was reviewed and approved by the Institutional Review Boards of Fujian Provincial Hospital of Fujian Medical University (Approval No. K2021-05-036).
Clinical trial registration statement: This study is registered at https://www.chictr.org.cn/searchproj.html. The registration identification number is ChiCTR2100044884.
Informed consent statement: All study participants, or their legal guardian, provided informed written consent prior to study enrollment.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
CONSORT 2010 statement: The authors have read the CONSORT 2010 Statement, and the manuscript was prepared and revised according to the CONSORT 2010 Statement.
Data sharing statement: Consent was not obtained but the presented data are anonymized and risk of identification is low.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Xiao-Hui Chen, MD, Chief Physician, Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, No. 134 East Street, Fuzhou 350000, Fujian Province, China. chenxh@fjmu.edu.cn
Received: August 28, 2024 Revised: January 6, 2025 Accepted: January 18, 2025 Published online: February 16, 2025 Processing time: 169 Days and 10.3 Hours
Abstract
BACKGROUND
Propofol has been widely used in bidirectional gastrointestinal endoscopy sedation; however, it frequently leads to cardiovascular adverse events and respiratory depression. Propofol target-controlled infusion (TCI) can provide safe sedation but may require higher dosages of propofol. On the contrary, etomidate offers hemodynamic stability.
AIM
To evaluate the effect of different dose etomidate added to propofol TCI sedation during same-visit bidirectional endoscopy.
METHODS
A total of 330 patients from Fujian Provincial Hospital were randomly divided into three groups: P, 0.1EP, and 0.15EP. Patients in the P group received propofol TCI only, with an initial effect-site concentration of the propofol TCI system of 3.0 mg/mL. Patients in the 0.1EP and 0.15EP groups received 0.1 and 0.15 mg/kg etomidate intravenous injection, respectively, followed by propofol TCI.
RESULTS
Patients in the 0.15EP group had higher mean blood pressure after induction than the other groups (P group: 78 mmHg, 0.1EP group: 82 mmHg, 0.15EP group: 88 mmHg; P < 0.05). Total doses of propofol consumption significantly decreased in the 0.15EP group compared with that in the other groups (P group: 260.6 mg, 0.1EP group: 228.1 mg, 0.15EP group: 201.2 mg; P < 0.05). The induction time was longer in the P group than in the other groups (P group: 1.9 ± 0.7 minutes, 0.1EP group: 1.2 ± 0.4 minutes, 0.15EP group: 1.1 ± 0.3 minutes; P < 0.01). The recovery time was shorter in the 0.15EP group than in the other groups (P group: 4.8 ± 2.1 minutes, 0.1EP group: 4.5 ± 1.6 minutes, 0.15EP group: 3.9 ± 1.4 minutes; P < 0.01). The incidence of hypotension (P group: 36.4%, 0.1EP group: 29.1%, 0.15EP group: 11.8%; P < 0.01) and injection pain was lower in the 0.15EP group than in the other groups (P < 0.05). Furthermore, the incidence of respiratory depression was lower in the 0.15EP group than in the P group (P < 0.05). Additionally, the satisfaction of the patient, endoscopist, and anesthesiologist was higher in the 0.15EP group than in the other groups (P < 0.05).
CONCLUSION
Our findings suggest that 0.15 mg/kg etomidate plus propofol TCI can significantly reduce propofol consumption, which is followed by fewer cardiovascular adverse events and respiratory depression, along with higher patient, endoscopist, and anesthesiologist satisfaction.
Core Tip: This randomized controlled trial compared the effect of different dose etomidate added to propofol target-controlled infusion (TCI) sedation in 330 patients during same-visit bidirectional endoscopy. Adding 0.15 mg/kg etomidate to propofol TCI during endoscopy reduces incidence of hypotension, injection pain, and respiratory depression while improving satisfaction among patients, endoscopists, and anesthesiologists. There was no difference in the adverse events among three groups.
Citation: Luo HR, Chen AD, Lin JF, Ye P, Chen YJ, Lin MX, Chen PZ, Chen XH, Zheng XC. Effect of etomidate added to propofol target-controlled infusion in bidirectional endoscopy: A randomized clinical trial. World J Gastrointest Endosc 2025; 17(2): 100722
Gastrointestinal endoscopy has been considered an important method for providing preventive measures and diagnosing digestive tract diseases, in which polyps and adenomas can be removed[1-3]. However, endoscopy is an invasive procedure that can cause anxiety, fear, and nausea in almost all patients[4]. Sedative endoscopy can minimize discomfort during endoscopy.
Several types of sedation and analgesia regimens, such as fentanyl, midazolam, and propofol, are used during gastrointestinal endoscopy[5-7]. Propofol is the most commonly used intravenous anesthetic agent as it has a short biological half-life and rapid, complete recovery[8]. However, propofol causes hypotension through direct or indirect vasodilatory effects by relaxing vascular smooth muscle cells[9]. A previous study revealed that over one-third of patients who received propofol sedation experienced hypotension during colonoscopy[10]. In contrast, propofol-induced injection pain is a persistent problem that frequently causes intense discomfort and anxiety in patients[11,12]. According to previous reports, the incidence of propofol-induced injection pain is between 28% and 90%[13], resulting in higher levels of anxiety and stress. Therefore, it is necessary to identify a safe and effective anesthetic technique with rapid recovery for this procedure.
Target-controlled infusion (TCI) is based on the three-compartment pharmacokinetic model, aiming to achieve the target drug concentration in the plasma or effect site via an automatic administration system[14]. Current TCI systems include the Marsh and Schnider pharmacokinetic models. In the Marsh model, the infusion rate remains fixed, whereas in the Schnider model, the dose and infusion rates are adjusted based on sex, age, weight, and height[15]. Theoretically, TCI maintains a more stable blood concentration than manual dependency injection, preventing blood concentration fluctuations. It can adjust the target plasma or effect site to maintain the desired level of sedation, which offers convenience in controlling the depth of anesthesia[16]. Recent reports have shown that propofol TCI can provide safe sedation for patients undergoing gastrointestinal endoscopy[17-20]. However, attention to hypoxemia and hypotension is necessary when using propofol TCI as the sole approach for patients[21].
Etomidate is an imidazole-based intravenous hypnotic agent that possesses a safe pharmacologic profile, providing hemodynamic stability; it has become the first choice for patients with valvular heart disease and elderly individuals during induction[22]. According to previous reports, the use of propofol has an increased risk ratio for hypotension compared with the use of etomidate during endoscopy[23,24]. However, etomidate is limited by myoclonus and postoperative nausea and vomiting (PONV), and there are also concerns regarding its cortisol suppressive function[25]. Therefore, etomidate is considered a two-edged sword when used for induction[26]. However, there have been few studies on propofol TCI combined with etomidate in painless gastrointestinal endoscopy. Considering the inconsistent effects above, we hypothesize that a combined regimen might reduce adverse responses and lead to faster recovery.
MATERIALS AND METHODS
Ethical approval for the study protocol
This prospective, randomized controlled parallel study was performed from June 2021 to November 2022 at Fujian Provincial hospital after the Ethics Committee of Fujian Provincial Hospital of Fujian Medical University (K2021-05-036) approval on May 27, 2021, and informed consent was obtained from each patient. This study was registered in the Chinese Clinical Trial Registry (ChiCTR2100044884) on March 31, 2021. This study adhered to the applicable Consolidated Standards for Reporting Trials (CONSORT) guidelines. The methods and outcomes after trial commencement had no changed.
Participants
A total of 330 patients [American Society of Anesthesiologists (ASA) physical status I-III; age: 18-75 years; Mallampati classification I-II] from Fujian Provincial Hospital scheduled to undergo painless gastrointestinal endoscopy were enrolled. Exclusion criteria were as follows: Serious heart (New York Heart Association functional class III or IV), liver (a score of Child-Pugh greater than five)[27], kidney (serum creatinine level > 2 mg/dL) dysfunction, and other important organ dysfunction; allergy to propofol or fat emulsion; acute upper respiratory infection; obstructive sleep apnea-hypopnea syndrome; body mass index ≥ 28 kg/m2; and adrenal insufficiency.
Randomization and masking
The 330 enrolled in this study were randomly allocated to three groups: P (n = 110), 0.1EP (n = 110), and 0.15EP (n = 110), using a computer-generated sequence. The randomization sequence was retained in an opaque envelope by a nurse who was not involved in data collection. All patients received treatment from the same anesthetist, who had 10 years of experience and was not masking. But the endoscopist was unaware of patient allocation. Outcome recording and post-anesthesia care unit (PACU) interviews were performed by another observer who was blinded to the treatment regimen.
Outcomes and perioperative data collection
The primary outcome was the incidence of hypotension. The secondary endpoints were hemodynamic changes, perioperative duration and recovery, the dosage of anesthetic, adverse events during the procedure and patient, endoscopist, and anesthesiologist satisfaction. Preoperative bowel preparation was completed before the procedure. A peripheral venous channel was established in the upper limb. After the patient entered the operating room, blood pressure (BP, 1-minute cycle), electrocardiography (three lead), heart rate (HR), and oxygen saturation (SpO2) were monitored continuously. Baseline vital signs were recorded for all patients before the procedure. Oxygen (3 L/minute) was supplied throughout the procedure. The sedation depth was monitored by bispectroscopy (BIS). The P group received propofol (10 mg/mL; B Braun Melsungen AG, Germany) and TCI (Schnider model) alone (B Braun Melsungen AG, perfusor space, model number 8713030CN). The initial effect-site concentration of the propofol TCI system was set at 3.0 g/mL. Patients in the 0.1EP and 0.15EP groups received 0.1 mg/kg or 0.15 mg/kg etomidate (2 mg/mL, Enhua, H20020511, batch number 20170823) intravenous injection (IV) with an injection speed of 3 second/mL before propofol TCI. The effect-site concentration of TCI propofol was adjusted within 0.5-2.0 μg/mL to maintain a BIS value of 40-60. Ask the patient how painful the injection is during IV administration. The procedure began when the BIS value was < 60 and showed no reaction to verbal inquiry. Up to this point, the amount of propofol consumed was defined the induction dose of propofol. All patients received a gastroscopy first, followed by a colonoscopy. Once the colonoscopy was completed, the patients were transferred to the PACU. The induction time was defined as the time from induction to the start of gastroscopy. The duration of gastroscopy or colonoscopy was defined as the time from the insertion of the gastroscope or colonoscopy to its removal. The awakening time was defined as the time from colonoscopy removal to when the patient was completely awake[28]. The recovery time was defined as the time from when the patient was awake to when they left the PACU, which was when they achieved a Modified Aldrete score system of ≥ 9. Records of satisfaction from the gastroscopists, anesthetists, and patients (excellent, general, and bad) were obtained, along with reasons for dissatisfaction.
If the patients expressed discomfort (involuntary movement, grimaces), an additional dose of propofol (30-40 mg) was administered as rescue therapy in each group. Simultaneously, the effect-site concentration of TCI propofol was increased to 0.5 μg/mL. Slight respiratory depression was defined as SpO2 < 95% or a reduction > 5% from baseline; in such cases, the anesthesiologist lifted the lower jaw and opened the airways. Severe respiratory depression was defined as SpO2 < 90% that persisted for ≥ 1 second, and in such cases, the anesthesiologist lifted the lower jaw and employed mask ventilation to assist breathing if necessary. Hypotension was defined as a mean BP (MBP) < 60 mmHg or a decrease of 20% from baseline during the procedure; severe hypotension was defined as a MBP < 40 mmHg[29], when these occurred, ephedrine 6 mg, IV (30 mg/mL, Shen Yang Frist Medicine, batch number 200504-1), was administered. Bradycardia was defined as HR < 50 bpm, and in such cases, 0.5 mg atropine, IV (0.5 mg/mL, Xing Hua Medicine, H42020590), was administered. Injection pain was classified according to the Ambesh classification: Score 0 indicated that patients were nonresponsive to questioning; score 1 indicated no signs of behavior, and pain was reported in response to questioning only; score 2 indicated pain reported spontaneously without questioning or in response to questioning and accompanied by a behavior; and score 3 indicated a response accompanied by arm withdrawal, tears, or strong reactions[30]. Muscular tremor was graded according to the Blitt classification: Grade 0, muscular tremor could not be seen by the naked eye; grade 1, weak contraction of the extremities; grade 2, mild contraction of the facial, body, and limb muscles; and grade 3, strong contraction of the facial, body, and limb muscles[31].
Calculation of sample size
A pilot study was conducted including 30 patients to calculate the minimum sample size. The incidence of hypotension in the P group was 40%, that in the 0.1EP group was 32%, and that in the 0.15EP group was 16%. We calculated 264 as the smallest sample size needed to obtain an error of 0.05 and power of 90% by PASS 15.0 (NCSS, Kaysville, UT, United States). Considering a loss to follow-up of 20%, 110 patients were needed for each group.
Statistical analysis
Statistical analyses were carried out by SPSS 25.0 (IBM, Armonk, NY, United States). Normality testing was conducted using the Kolmogorov-Smirnov test. Continuous variables with a normal distribution are expressed as mean ± SD. Data on hemodynamic parameters were compared by repeated measures analysis of variance in the same group and one-way analysis of variance in different groups. For ranked data, the Kruskal-Wallis test was used. Categorical variables were compared with the χ2 test. P values < 0.05 were considered significantly different.
RESULTS
Basic characteristics
A total of 355 patients were included for study participation, and 25 patients were unqualified (17 cases refuse to join trial, 4 cases of ASA IV grade, 4 cases with a BMI ≥ 28 kg/m2). Finally, 330 patients were recruited for this trial. The CONSORT flow diagram is shown in Figure 1. The demographic data, ASA class, alcohol intake history, smoking history, BP baseline value, and HR did not differ among the three groups (Table 1).
Figure 1 The Consolidated Standards for Reporting Trials flow diagram.
ASA: American Society of Anesthesiologists; BMI: Body mass index.
Table 1 The basic characteristics of three groups, n (%).
P group
0.1EP group
0.15EP group
P value
Age (years)
52.1 ± 11.4
49.6 ± 13.6
52.2 ± 12.9
0.213
Sex
0.686
Male
60 (54.5)
59 (53.6)
54 (49.1)
Female
50 (45.5)
51 (46.4)
56 (50.9)
BMI (kg/m2)
22.6 ± 1.8
22.8 ± 2.0
22.8 ± 1.9
0.601
MBP (mmHg)
93.3 ± 13.9
90.4 ± 11.3
92.6 ± 11.4
0.183
HR (bpm)
74.8 ± 10.4
76.6 ± 11.6
74.8 ± 10.3
0.360
SpO2
98.4 ± 1.3
98.6 ± 1.2
98.5 ± 1.0
0.389
Smoking
0.799
Smokers
37 (33.6)
31 (28.1)
36 (32.7)
Previous smokers
10 (9.1)
15 (13.6)
12 (10.9)
Nonsmokers
63 (57.3)
64 (58.2)
62 (56.4)
ASA
0.851
1
54 (49.1)
47 (42.7)
49 (44.5)
2
46 (41.8)
54 (49.1)
50 (45.5)
3
10 (9.1)
9 (8.2)
11 (10.0)
Hemodynamic changes
There were no severe complications, such as severe hypotension or intubation, during the trial. With respect to cardiovascular events, the intraoperative MBP was higher in the 0.15EP group than in the other groups. Patients in the 0.15EP group (11.8%, 13/110) had significantly fewer hypotension episodes than those in the other groups (P group: 36.4%, 48/110; 0.1EP group: 29.1%, 32/110; P < 0.001). HR was higher in the 0.15EP group than in the P group after induction, whereas it did not differ among the three groups at other times. Bradycardia was noted in 24.5% (27/110), 13.6% (15/110), and 8.2% (9/110) of patients in the P, 0.1EP, and 0.15EP groups, respectively (P = 0.002; Figure 2A and B, Table 2).
Figure 2 Comparison three groups at different time points.
A: The mean blood pressure changes among three groups at different time points; B: The heart rate changes among three groups at different time points; C: The consumption of propofol among three groups. aP < 0.05, P group vs 0.1EP group; bP < 0.05, P group vs 0.15EP group; cP < 0.05, 0.1EP group vs 0.15EP group; MBP: Mean blood pressure; HR: Heart rate.
Table 2 Comparison of adverse events in three groups, n (%).
The average induction doses of propofol in the P, 0.1EP, and 0.15EP groups were 104.6 mg, 75.4 mg, and 65.3 mg, respectively, and the total doses of propofol were 260.6 mg, 228.1 mg, and 201.2 mg, respectively. The results indicated a significant reduction in the 0.15EP group compared with that in the other groups (Figure 2C).
Perioperative duration and recovery
The time of procedure and awakening were similar among the three groups. In addition, the induction time was longer in the P group (1.9 ± 0.7 minutes) than in the other groups (0.1EP group: 1.2 ± 0.4 minutes; 0.15EP group: 1.1 ± 0.3 minutes; P < 0.01). The recovery time was shorter in the 0.15EP group (3.9 ± 1.4 minutes) than in the other groups (P group: 4.8 ± 2.1 minutes; 0.1EP group: 4.5 ± 1.6 minutes; P < 0.01; Table 3).
Table 3 Comparison of perioperative duration and recovery in three groups.
The incidence of slight respiratory depression was higher in the P group (30.9%, 34/110) than in the other groups (0.1EP group: 16.3%, 18/110; 0.15EP group: 10.9%, 12/110; P = 0.001). The incidence of severe respiratory depression was lower in the 0.15EP group (4.5%, 5/110) than in the P group (15.5%, 17/110). In contrast, there was no significant difference between the P and 0.1EP groups or between the 0.1EP and 0.15EP groups. The incidence and classification of injection pain were lower in the 0.15EP group than in the P group (P < 0.001). There was no significant difference in the rates of myoclonus, nausea, and vomiting among the three groups (P = 0.671, 0.725, 0.581, respectively; Table 2).
Patient, endoscopist, and anesthesiologist satisfaction
The satisfaction scores of patients, endoscopists and anesthesiologists were higher in the 0.15EP group than in the other groups (P < 0.001). Most of the reasons for patient dissatisfaction in the P and 0.1EP groups were pain from the injection (P group: 9 cases, 0.1EP group: 4 cases). Endoscopist dissatisfaction was mostly due to severe respiratory depression. The procedure was interrupted when the anesthesiologist lifted the lower jaw and employed mask ventilation to assist breathing (P group: 6 cases, 0.1EP group: 3 cases, 0.15EP group: 3 cases). The anesthesiologist’s dissatisfaction was mostly due to hemodynamic (P group: 4 cases, 0.1EP group: 2 cases) and respiratory (P group: 6 cases, 0.1EP group: 1 case) adverse reactions (Table 4).
Table 4 Comparison of satisfaction in patients, endoscopists and anesthesiologists, n (%).
This study was conducted to investigate the efficacy and safety of propofol TCI combined with etomidate in painless gastrointestinal endoscopy. Overall, all gastrointestinal endoscopies were completed successfully. Patients in the 0.15EP group had fewer cardiovascular adverse events and respiratory depression with fewer propofol dosages than those in the other regimens. Meanwhile, there was no difference in myoclonus, nausea, or vomiting among the three groups.
The ideal sedation drug for gastrointestinal endoscopy should have a rapid onset of action and a short half-life while also being free of side effects and ensuring high safety[32]. In clinical settings, propofol sedation is widely used for painless gastrointestinal endoscopy. However, propofol is a cardiovascular depressant and can lead to adverse reactions such as hypotension and bradycardia; these reactions may be attributed to a decrease in cardiac output, peripheral vascular resistance, or both, as well as an increase in venous capacitance or a decrease in sympathetic nervous system basal activity[9]. Meanwhile, the injection pain of propofol is a common adverse reaction[33]. According to previous report, the incidence of injection pain caused by propofol can reach 28%-90% and averages approximately 60%-70%[34]. The injection pain mechanism of propofol remains unclear and may be related to the stimulation of the kallikrein-kinin system, activation of the nociceptive cis-receptor potential ion channels, and changes in osmotic pressure[35].
In contrast, injection pain associated with etomidate has been rarely reported. The mechanism of injection pain caused by etomidate is not an nonspecific effect of hyperosmolarity but rather a specific action mediated by activated nociceptive transient receptor potential A1 (TRPA1) and TRPV1 ion channels in sensory neurons[36]. Ye et al[37] described that patients undergoing gastrointestinal endoscopy and sedated with etomidate experienced a lower incidence of injection pain than those sedated with propofol.
Etomidate acts as an agonist at alpha2-adrenoceptors, leading to an alpha2B-receptor-mediated increase in BP. This effect of etomidate may contribute to the reliable cardiovascular stability observed in patients after induction with etomidate. Previous studies have reported similar findings of improved hemodynamic stability with etomidate compared to propofol alone[38,39]. This study's results further support this, with the 0.15EP group demonstrating higher MBP after induction and fewer episodes of hypotension compared to the other groups. Probably because patients in the 0.15EP group used more etomidate and fewer propofol which reduced the circulatory inhibition induced by propofol. Nevertheless, etomidate is associated with the side effect of myoclonus, with reported incidence rates ranging from 50% to 80%[40]. The mechanism of etomidate-induced myoclonus remains uncertain but may be related to the disruption of gamma-aminobutyric acid neurons, which can lead to increased sensitivity in skeletal muscle control, resulting in spontaneous nerve transmissions. This can manifest as seizure-like activity and a suppression of inhibitory neuronal circuits before the activation of excitatory neuronal circuits. Furthermore, the incidence of myoclonus is related to the injection speed[41]. According to previous reports, propofol can prevent etomidate-induced myoclonus, as propofol alone suppresses the cortex, inhibiting the inhibitory subcortex and promoting the seizure activity of subcortical regions, thereby reducing the incidence of myoclonus[42]. This is consistent with the results of this study.
TCI makes use of the pharmacokinetic model of the administered medications, along with the specific attributes of the patient, to attain a preestablished drug concentration. It can provide a more stable blood concentration than manual controlled injection, which avoids the fluctuations in blood concentration. However, TCI is associated with higher total doses of propofol and a significantly longer induction time. In this study, propofol TCI combined with etomidate not only reduced the dosage of propofol but also shortened the induction time.
Safety is paramount in sedation for gastrointestinal endoscopy, as adverse events can impact patient outcomes and procedural success. Propofol is associated with respiratory depression and injection pain, while etomidate may cause myoclonus and PONV. The combined regimen in the current study resulted in reduced respiratory depression, injection pain, and faster recovery, suggesting an improved safety profile compared to propofol alone.
Patients, endoscopists, and anesthesiologists have different concerns. Ko et al[43] described that doctor-patient communication, waiting time before the procedure, and bedside manner affected patient satisfaction during endoscopy. Moreover, this study found that injection pain, PONV, and other adverse reactions were factors affecting patient satisfaction. In the P group, the procedure had to be temporarily paused due to respiratory depression, which sometimes needed jaw lifting and mask ventilation; this may affect the satisfaction levels of both the endoscopist and the anesthesiologist. Meanwhile, the P group had a longer induction time, which affected the procedure speed, which may lead to dissatisfaction among endoscopists. The anesthesiologists are more concerned about safety. Patients in the 0.15EP group exhibited more stable intraoperative hemodynamics, which may enhance anesthesiologist satisfaction. Injection pain is a crucial factor that influences patient satisfaction. The 0.15EP group had a lower incidence of injection pain, which may enhance patient satisfaction and improve the medical experience. Overall, etomidate combined with propofol TCI appeared to offer multiple clinical benefits, including improved hemodynamic stability, reduced propofol consumption, faster recovery, and enhanced satisfaction for patients and doctors. In this study, we used two different doses of etomidate during anesthesia induction. However, the specific dosage of etomidate needs further exploration.
This study has some limitations that must be noted. First, capnography has been demonstrated to detect depressed respiratory activity during deep sedation procedures[3], but it was unavailable in this study. Second, much attention has been given to the effects of etomidate on adrenal suppression recently, which was not evaluated in this study. Ask the patient how painful the injection is during IV administration, this may have caused performance bias, as assessors may not have been masked. It is possible that assessors were not masked in the same way concerning procedural satisfaction. Finally, there was no further detailed subgrouping for the application of propofol TCI combined with etomidate.
CONCLUSION
In conclusion, 0.15 mg/kg etomidate plus propofol TCI can significantly reduce propofol consumption, which is followed by fewer cardiovascular adverse events and respiratory depression, with higher patient, endoscopist, and anesthesiologist satisfaction. Furthermore, it alleviates injection pain and reduces the induction and recovery time. Hence, propofol TCI combined with 0.15 mg/kg etomidate can be considered suitable for painless gastrointestinal endoscopy.
ACKNOWLEDGEMENTS
The authors thank the patients for their consent to share the whole treatment and follow-up procedures.
Footnotes
Provenance and peer review: Unsolicited article; Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Gastroenterology and hepatology
Country of origin: China
Peer-review report’s classification
Scientific Quality: Grade B
Novelty: Grade B
Creativity or Innovation: Grade B
Scientific Significance: Grade B
P-Reviewer: Chand A S-Editor: Li L L-Editor: A P-Editor: Zhang L
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