Moderate-to-deep sedation technique, using propofol and ketamine, allowing synchronised breathing for magnetic resonance high-intensity focused ultrasound (MR-HIFU) treatment for uterine fibroids: a pilot study

Abstract

BackgroundMagnetic resonance high-intensity focused ultrasound (MR-HIFU) treatment for uterine fibroids is rapidly gaining popularity as a treatment modality. This procedure is generally uncomfortable, painful, and requires minimal or absence of movement and an MR-HIFU synchronised breathing pattern of the patient. Procedural sedation and analgesia protocols have become the standard practice in interventional radiology departments worldwide. The aim of this study was to explore if a sedation regimen with low-dose propofol and ketamine performed by trained non-medical sedation practitioners could result in relief of discomfort for the patient and in adequate working conditions for MR-HIFU treatment for uterine fibroids.MethodsIn this study, conducted from August 2013 until November 2014, 20 patients were subjected to MR-HIFU treatment of uterine fibroids. Patients were deeply sedated using intravenous propofol and esketamine according to a standardised hospital protocol to allow synchronisation of the breathing pattern to the MR-HIFU. The quality of sedation for MR-HIFU and complications were recorded and analysed. The side effects of the sedation technique, the propofol and esketamine consumption rate, the duration of recovery, and patient satisfaction after 24 h were examined.ResultsA total of 20 female patients (mean age 42.4 [range 32–53] years) were enrolled. Mean propofol/esketamine dose was 1309 mg/39.5 mg (range 692–1970 mg/ 23.6–87.9 mg). Mean procedure time was 269 min (range 140–295 min). Application of the sedation protocol resulted in a regular breathing pattern, which could be synchronised with the MR-HIFU procedures without delay. The required treatment was completed in all cases. There were no major adverse events. Hypoxemia (oxygen desaturation <92%) and hallucinations were not observed.ConclusionsThe use of a specific combination of IV propofol and esketamine for procedural sedation and analgesia reduced the discomfort and pain during MR-guided HIFU treatments of uterine fibroids. The resulting regular breathing pattern allowed for easy synchronisation of the MR-HIFU procedure. Based on our results, esketamine and propofol sedation performed by trained non-medical sedation practitioners is feasible and safe, has a low risk of major adverse events, and has a short recovery time, avoiding a session of general anaesthesia.Electronic supplementary materialThe online version of this article (doi:10.1186/s40349-017-0088-9) contains supplementary material, which is available to authorized users.

Lessons learned during implementation of MR-guided High-Intensity Focused Ultrasound treatment of uterine fibroids

“…To reduce failures as a result of experienced pain by the patient, our sedation protocol was optimized. Procedural Sedation and Analgesia (PSA) is increasingly used during uncomfortable radiological interventions and is also suitable for the MR-HIFU treatment of fibroids [ 22 , 23 ]. Sedation is performed to prevent the patient from deep visceral pain, hot sensations on the skin and motion artifacts.…”

The median effective concentration of propofol with different doses of esketamine during gastrointestinal endoscopy in elderly patients：a randomized controlled trial

“…It is also reported that esketamine nasal spray could cause transient and asymptomatic blood pressure elevations [33]. Therefore, there has been growing interest in the use of esketamine as an ideal adjunct to propofol for procedural sedation and analgesia [12,34]. It was reported that the use of a combination of propofol and esketamine for procedural analgesia and sedation during MR-guided HIFU treatments of uterine fibroids is feasible and safe, with a short recovery time and a low risk of major adverse events [34].…”

“…Therefore, there has been growing interest in the use of esketamine as an ideal adjunct to propofol for procedural sedation and analgesia [12,34]. It was reported that the use of a combination of propofol and esketamine for procedural analgesia and sedation during MR-guided HIFU treatments of uterine fibroids is feasible and safe, with a short recovery time and a low risk of major adverse events [34]. Recently, Eberl, S. et al demonstrated low-dose esketamine reduces the requirement of propofol for sedation during ERCP in ASA I-II patients without affecting recovery time, side effects, cardiovascular or respiratory adverse events and satisfaction of endoscopists and patients, when compared with alfentanil [12].…”

Comparison of effectiveness of epidural analgesia and monitored anesthesia care for high-intensity focused ultrasound treatment of adenomyosis

“…Although HIFU treatment of uterine adenomyosis may be less invasive than treatment of other intraabdominal organs, it still requires appropriate control of both visceral and somatic pain in addition to the administration of sedatives. The MAC procedure that utilized remifentanil, fentanyl, midazolam, and a combination of antiemetics may be more popular than EA in the HIFU treatment of uterine adenomyosis [27]. However, intravenous infusion of remifentanil could not satisfactorily eliminate nociceptive pain such as somatic pain in the abdominal wall or visceral pain originating from the parietal peritoneum during HIFU treatment [28].…”