Tables
- Table 1. Ramsay sedation scale
1 Patient is anxious and agitated or restless, or both 2 Patient is cooperative, oriented and tranquil 3 Patient responds to commands only 4 Patient exhibits brisk response to light glabellar tap or loud auditory stimulus 5 Patient exhibits a sluggish response to light glabellar tap or loud auditory stimulus 6 Patient exhibits no response - Table 2. Pre-sedation flexible bronchoscopy checklist
Patient identifier (name, date of birth) Consent form signed Responsible adult available to escort the patient post-procedure Adequate fasting period Allergies Hepatic and renal function (if the clinical history suggests these could be abnormal) Observations (vital signs) Continuous pulse oximetry available Intravenous access functioning Medications checked Resuscitation trolley available with emergency drugs Reversal drugs available (flumazenil and naloxone) Oxygen available (including variety of oxygen delivery devices) All staff ready for the procedure to commence Data from [22].
- Table 3. Pharmacological properties of common sedatives used in bronchoscopy
Drug Fentanyl Alfentanil Morphine Midazolam Lorazepam Diazepam Propofol 1% Fospropofol Dose i.v. Initial: 25–50 μg Initial: 250 μg Initial: 2.5 mg Initial: 2–2.5 mg
(0.5–1 mg in the elderly)Initial dose: 1.5–2 mg Initial dose: 5–10 mg Initial: 10–50 mg titrated to effect Initial: 6.5 mg·kg−1 Supplemental: 25 μg Supplemental: 250 μg Supplemental: 2.5 mg Supplemental: 1 mg (0.5–1 mg in the elderly) at 2–5 min intervals Supplemental: usually not required
Wait at least 10 minSupplemental: usually not required
Wait at least 10 minSupplemental: 25% of initial dose Supplemental: 1.6 mg·kg−1 Infusion: 25–100 μg·kg−1·min−1 Onset of action 3–5 min Immediate 5–10 min 30–60 s 8–15 min 1 min 30–60 s 6.5 min Peak effect 5 min Immediate 15–30 min 5–10 min 15–30 min 2–3 min 2 min 12 min Duration of action 1–2 h 1–2 h 1–6 h 30–120 min 8 h 1–3 h 4–8 min 17 min Metabolism Hepatic Hepatic Hepatic Hepatic Hepatic Hepatic Hepatic Hepatic Renal excretion <5% <1% 90% <1% <1% <1% 70% 70% Elimination half-life 3–4 h 1–2 h 2 h 1.5–2.5 h 11–22 h 20–50 h 3–12 h 45 min Major/common adverse evens Respiratory depression, nausea and vomiting See fentanyl See fentanyl Respiratory depression, hypotension See midazolam See midazolam Respiratory depression, bradycardia, hypotension, pain at the injection site Respiratory depression, hypotension, paraesthesiae, pruritus Antagonists Naloxone 100–200 μg (1.5-3 μg·kg−1) with supplemental doses of 100 μg every 2 min until reversal occurs Flumazenil 0.2 mg, repeated every 60 s up to 1 mg; if a continuous infusion is required the dose is 0.1–0.4 mg·h−1 No antagonist available Comments Combination with benzodiazepines may enhance respiratory depression
Administer prior to the benzodiazepines, as a lower dose of benzodiazepine will be required to achieve the desired degree of sedationSee fentanyl See fentanyl Combination with opiates may enhance respiratory depression See midazolam See midazolam Combination with opiates may enhance respiratory depression
Dose and rate of administration should be adjusted according to desired level of sedation and response
For patients >65 years or with severe systemic disease reduce the dose by 25%See propofol Adapted from [10, 18, 36].
- Table 4. Summary of clinical studies of propofol in flexible bronchoscopy
Article Study type Drug Main results Clarkson [54] Randomised, double-blind, prospective-controlled study Propofol (n=21) versus midazolam (n=20) More rapid onset and recovery from sedation seen in the propofol group
No significant difference in the amount of topical anaesthetic required or in oxygen desaturationCrawford [55] Randomised, double-blind, prospective-controlled study Propofol (n=21) versus midazolam–alfentanil (n=21) In three patients in the midazolam–alfentanil and five in the propofol group the depth of sedation exceeded the moderate level
Recovery to an appropriate level was more rapid in the latter group
Oxygen saturations decreased in both groups and there were no significant differences in blood pressure
Those in the midazolam group had more amnesia and longer recovery timeGonzalez [5] Randomised, single-blind, prospective-controlled study Propofol (n=9) versus no sedation (n=9) Less cough, pain, sensation of asphyxiation, total amnesia and improved tolerance of the procedure in the propofol group
No differences in oxygen saturations between the groupsHwang [47] Randomised, double-blind, prospective-controlled study Propofol–alfentanil (n=138) versus propofol–ketamine (n=138) for patient-controlled sedation Patients in the propofol–ketamine group reported greater amnesia and satisfaction
Haemodynamic stability and adequate oxygenation during the procedure in both groups; however, a significant drop in oxygen saturations below 90% was seen in both groups immediately before the procedure
This was transient and with no sequelaeClark [20] Randomised, double-blind, prospective-controlled study Propofol (n=43) versus midazolam (n=39) Propofol resulted in faster recovery from sedation and patient tolerance and satisfaction were improved
There were no differences in operator satisfaction
Safely administered by non-anaesthetisStoltz [56] Randomised, non-blinded, prospective-controlled study Propofol (n=100) versus midazolam–hydrocodone (n=100) Mean oxygen saturation and desaturation below 90% were similar in both groups
Patients receiving propofol had less tachycardia during the procedure and faster recovery from sedationGrendelmeier [12] Prospective case series Propofol (n=440) Systolic blood pressure dropped below 90 mmHg in 15.4% and oxygen saturation dropped below 90% in 16.4% of patients but some of these had higher American Society of Anesthesiology scores and were already hypotensive or hypoxaemic prior to the sedation
None of the patients required intubationLo [21] Randomised, non-blinded, prospective-controlled study Propofol (n=243) versus midazolam (n=249) Bispectral index-guided propofol infusion is as safe as clinically judged midazolam sedation
The proportion of patients with hypoxemia or hypotensive events were not different in the two groups but those in propofol group had the lowest mean arterial blood pressure and oxygen saturation readings
Those in the propofol group had less cough, improved procedure tolerance and faster recovery from sedationYoon [57] Randomised, double-blind, prospective-controlled study Propofol (n=32) versus propofol–alfentanil (n=32) They did not find differences in patient or bronchoscopist satisfaction or in degree of coughing but those in the alfentanil group had significantly lower oxygen saturation levels. However, the lower levels of oxygen saturation reported in the alfentanil are most likely not clinically significant Schlatter [58] Randomised, double-blind, prospective-controlled study Propofol (n=154) versus propofol–hydrocodone (n=146) This combination suppressed coughing and reduced patient discomfort during flexible bronchoscopy compared to placebo alone with no differences in complication rates Carmi [59] Randomised, non-blinded, prospective-controlled study Propofol (n=56) versus midazolam–alfentanil (n=59) Those in the midazolam–alfentanil group rather than the propofol group had higher carbon dioxide tension values and required more oxygen supplementation or airway support; however, both were considered equally safe and effective
Vol 22 Issue 128
Table of Contents
Sedation for flexible bronchoscopy: current and emerging evidence
