Patient-Controlled Sedation and Analgesia with Propofol and Alfentanil: A Preliminary Safety Evaluation Prior to Use of Non-Anaesthesiology Doctors

Andreas Nilsson, Folke Sjöberg, Susanne Öster, Hanne Bek-Jensen, Claes Lennmarken

Department of Anesthesiology and Intensive Care, Link?ping University Hospital, Link?ping, Sweden.
Department of Urology, Link?ping University Hospital, Link?ping, Sweden.

DOI: 10.4236/ojanes.2012.22012                

Abstract

Background: The aim was to evaluate safety aspects of patient-controlled sedation and analgesia (PCS) for extracorporeal shockwave lithotripsy (ESWL) and PCS to be handled by non-anaesthesiology doctors. Methods: Thirty-four ASA I-III patients used PCS with propofol and alfentanil for ESWL in this interventional study. Strict safety limits were defined regarding respiratory rate (RR), heart rate (HR), mean arterial blood pressure (MAP), oxygen saturation from pulse oximetry (SpO₂), and transcutaneous partial pressures of oxygen (PtcO₂) and carbon dioxide (PtcCO₂). The patients' levels of consciousness was graded on a five-point scale and monitored with Bispectral Index (BIS). A nurse anaesthetist was supervising the procedure but was instructed to intervene only if safety limits were breached. No supplementary oxygen was given. Results: All patients responded to verbal stimuli during treatment. Cardiovascular stability was maintained, but respiratory variables were affected. Two patients with SpO₂ < 90% and two cases of RR ≤ 8 were diagnosed, and seven patients became hypercarbic (PtcCO₂ ≥ 6.5 kPa). In 18 patients hypoxaemia was indicated as PtcO₂ ≤ 8.0 kPa. All these 18 patients were given supplementary oxygen. There was no correlation between dose of drugs, age, weight or any vital variable. The 34 patients would use PCS again in the case of future treatment. Conclusions: During ESWL treatment PCS can be used with good patients’ satisfaction, and maintained cardiovascular stability, but PCS had an indisputable effect on pulmonary function with hypoxemia (resulting in need for supplementary oxygen) or hypercarbia. The person in charge of PCS must therefore be trained to perform according to the guidelines for sedation and/or analgesia by non-anaesthesiology doctors.

Keywords

Anaesthesia; Patient-Controlled Sedation; Safety; European Guidelines

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	J. A. Alhashemi and A. M. Kaki, “Anesthesiologist-Controlled versus Patient-Controlled Propofol Sedation for Shockwave Lithotripsy,” Canadian Journal of Anesthesia, Vol. 53, No. 5, 2006, pp. 449-455. doi:10.1007/BF03022616
[2]	M. A. Burmeister, et al., “A Comparison of Anaesthetic Techniques for Shock Wave Lithotripsy: The Use of a Remifentanil Infusion Alone Compared to Intermittent Fentanyl Boluses Combined with a Llow Dose Propofol Infusion,” Anaesthesia, Vol. 59, No. 9, 2002, pp. 877-881. doi:10.1046/j.1365-2044.2002.02820.x
[3]	M. Coloma, et al., “Fast-Tracking after Immersion Lithotripsy: General Anesthesia versus Monitored Anesthesia Care,” Anesthesia & Analgesia, Vol. 91, No. 1, 2000, pp. 92-96.
[4]	T. G. Monk, J. M. Rater and P. F. White, “Comparison of Alfentanil and Ketamine Infusions in Combination with Midazolam for Outpatient Lithotripsy,” Anesthesiology, Vol. 74, No. 6, 1991, pp. 1023-1028. doi:10.1097/00000542-199106000-00009
[5]	E. Bright, et al., “Patient-Controlled Sedation for Colonoscopy: A Randomized Trial Comparing Patient-Controlled Administration of Propofol and Alfentanil with Physician-Administered Midazolam and Pethidine,” Endoscopy, Vol. 35, No. 8, 2003, pp. 683-687. doi:10.1055/s-2003-41519
[6]	I. A. Herrick, et al., “Patient-Controlled Propofol Sedation for Elderly Patients: Safety and Patient Attitude toWard Control,” Canadian Journal of Anesthesia, Vol. 43, No. 10, 1996, pp. 1014-1018. doi:10.1007/BF03011902
[7]	R. G. Dell and A. H. Cloote, “Patient-Controlled Sedation during Transvaginal Oocyte Retrieval: An Assessment of Patient Acceptance of Patient-Controlled Sedation Using a Mixture of Propofol and Alfentanil,” European Journal of Anaesthesiology, Vol. 15, No. 2, 1998, pp. 210-215.
[8]	C. Coimbra, M. Choiniere and T. M. Hemmerling, “Patient-Controlled Sedation Using Propofol for Dressing Changes in Burn Patients: A Dose-Finding Study,” Anesthesia & Analgesia, Vol. 97, No. 3, 2003, pp. 839-842. doi:10.1213/01.ANE.0000074236.76333.53
[9]	C. A. Stonell, K. Leslie and A. R. Absalom, “Effect-Site Targeted Patient-Controlled Sedation with Propofol: Comparison with Anaesthetist Administration for Colonoscopy,” Anaesthesia, Vol. 61, No. 3, 2006, pp. 240-247. doi:10.1111/j.1365-2044.2005.04509.x
[10]	A. Nilsson, et al., “Patient Controlled Sedation Using a Standard Protocol for Dressing Changes in Burns: Patients’ Preference, Procedural Details and a Preliminary Safety Evaluation,” Burns, Vol. 34, No. 7, 2008, pp. 929934.
[11]	J. T. A. Knape, et al., “Guidelines for Sedation and/or Analgesia by Non-Anaesthesiology Doctors: Section and Board of Anaesthesiology1. European Union of Medical Specialists,” European Journal of Anaesthesiology, Vol. 24, No. 7, 2007, pp. 563-567. doi:10.1017/S0265021506002092
[12]	C. Larsson and P. Staun, “Evaluation of a New Fibre-Optical Monitor for Respiratory Rate Monitoring,” Journal of Clinical Monitoring and Computing, Vol. 15, No. 5, 1999, pp. 295-298. doi:10.1023/A:1009967122272
[13]	P. S. Myles, et al., “Bispectral Index Monitoring to Prevent Awareness during Anaesthesia: The B-Aware Randomised Controlled Trial,” The Lancet, Vol. 363, No. 9423, 2004, pp. 1757-1763. doi:10.1016/S0140-6736(04)16300-9
[14]	J. Liu, H. Singh and P. F. White, “Electroencephalographic Bispectral Index Correlates with Intraoperative Recall and Depth of Propofol-Induced Sedation,” Anesthesia & Analgesia, Vol. 84, No. 1, 1997, pp. 185-189.
[15]	V. L. Oei-Lim, et al., “Patient-Controlled versus Anesthesiologist-Controlled Conscious Sedation with Propofol for Dental Treatment in Anxious Patients,” Anesthesia & Analgesia, Vol. 86, No. 5, 1998, pp. 967-972.
[16]	E. N. Evans, K. Ganeshalingam and P. Ebden, “Changes in Oxygen Saturation and Transcutaneous Carbon Dioxide and Oxygen Levels in Patients Undergoing Fibreoptic Bronchoscopy,” Respiratory Medicine, Vol. 92, No. 5, 1998, pp. 739-742. doi:10.1016/S0954-6111(98)90005-1
[17]	J.-P. Janssens, et al., “Non-Invasive (Transcutaneous) Monitoring of PCO2 (TcPCO2) in Older Adults,” Gerontology, Vol. 51, No. 3, 2005, pp. 174-178. doi:10.1159/000083990
[18]	B. W. Palmisano and J. W. Severinghaus, “Transcutaneous PCO2 and PO2: A Multicenter Study of Accuracy,” Journal of Clinical Monitoring and Computing, Vol. 6, No. 3, 1990, pp. 189-195. doi:10.1007/BF02832145
[19]	K. K. Tremper and S. J. Barker, “Transcutaneous Oxygen Measurement: Experimental Studies and Adult Applications,” International Anesthesiology Clinics, Vol. 25, No. 3, 1987, pp. 67-96. doi:10.1097/00004311-198702530-00006
[20]	D. Külling, D., et al., “Safer Colonoscopy with PatientControlled Analgesia and Sedation with Propofol and Alfentanil,” Gastrointestinal Endoscopy, Vol. 54, No. 1, 2001, pp. 1-7. doi:10.1067/mge.2001.116174
[21]	I. L. Tyler, et al., “Continuous Monitoring of Arterial Oxygen Saturation with Pulse Oximetry during Transfer to the Recovery Room,” Anesthesia & Analgesia, Vol. 64, No. 11, 1985, pp. 1108-1112. doi:10.1213/00000539-198511000-00013
[22]	K. K. Tremper and S. J. Barker, “Pulse Oximetry,” Anesthesiology, Vol. 70, No. 1, 1989, pp. 98-108. doi:10.1097/00000542-198901000-00019
[23]	H. S. Joo, et al., “A Comparison of Patient-Controlled Sedation Using Either Remifentanil or Remifentanil-Propofol for Shock Wave Lithotripsy,” Anesthesia & Analgesia, Vol. 93, No. 5, 2001, pp. 1227-1232. doi:10.1097/00000539-200111000-00037
[24]	J. B. Yee, et al., “Propofol and Alfentanil for Sedation during Placement of Retrobulbar Block for Cataract Surgery,” Journal of Clinical Anesthesia, Vol. 8, No. 8, 1996, pp. 623-626. doi:10.1016/S0952-8180(96)00137-7
[25]	M. N. Avramov and P. F. White, “Use of Alfentanil and Propofol for Outpatient Monitored Anesthesia Care: Determining the Optimal Dosing Regimen,” Anesthesia & Analgesia, Vol. 85, No. 3, 1997, pp. 566-572.
[26]	N. W. Goodman, A. M. S. Black and J. A. Carter, et al., “Some Ventilatory Effects of Propofol as Sole Anaesthetic Agent,” British of Journal Anaesthesia, Vol. 59, No. 12, 1987, pp. 1497-1503. doi:10.1093/bja/59.12.1497
[27]	L. M. Bigatello and E. George, “Hemodynamic Monitoring,” Minerva Anestesiology, Vol. 68, No. 4, 2002, pp. 219-225.
[28]	J. B. Henry, et al., “Mean Arterial Pressure (MAP): An Alternative and Preferable Measurement to Systolic Blood Pressure (SBP) in Patients for Hypotension Detection during Hemapheresis,” Journal of Clinical Apheresis, Vol. 17, No. 2, 2002, pp. 55-64. doi:10.1002/jca.10022
[29]	C. W. Cheung, et al., “An Audit of Postoperative Intravenous Patient-Controlled Analgesia with Morphine: Evolution over the Last Decade,” European Journal of Pain, Vol. 13, No. 5, 2008, pp. 464-471.
[30]	F. Kucukemre, et al., “Remifentanil Compared with Morphine for Postoperative Patient-Controlled Analgesia after Major Abdominal Surgery: A Randomized Controlled Trial,” European Journal of Anaesthesiology, Vol. 22, No. 5, 2005, pp. 378-385. doi:10.1017/S0265021505000657