The effectiveness of a low-dose esketamine versus an alfentanil adjunct to propofol sedation during endoscopic retrograde cholangiopancreatography

Abstract

BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is one of the most complex gastrointestinal endoscopic procedures. Currently, it is still unclear which sedation regimen best facilitates an ERCP. The N-methyl-d-aspartate receptor antagonist esketamine has anaesthetic, analgesic and sympathomimetic properties and is known to cause less cardiorespiratory depression than other sedatives. It could therefore be an ideal adjunct to propofol for deep sedation. OBJECTIVE To assess the effectiveness of esketamine versus alfentanil as an adjunct to propofol target-controlled infusion (TCI) for deep sedation during ambulant ERCP. DESIGN A randomised controlled multicentre study. SETTING Endoscopic intervention suite at an academic and general hospital in the Netherlands. PARTICIPANTS Adult, American Society of Anesthesiologists Physical Status I to III patients scheduled to undergo ERCP. INTERVENTION Consecutive patients were randomly assigned to receive sedation for an ERCP with propofol TCI and alfentanil (group A) or with propofol TCI and esketamine (group E). MAIN OUTCOME MEASURES The primary outcome was effectiveness of the sedation regimen expressed as the total dose of propofol – as a surrogate parameter – necessary to perform ERCP in a satisfactory manner for endoscopist and patients. Secondary outcomes were recovery time, patients’ and endoscopists’ satisfaction with sedation, side effects (e.g. psychotomimetic effects, nausea and vomiting) and the number of respiratory and cardiovascular adverse events. RESULTS Data from 162 patients were analysed. The total dose of propofol required was significantly lower in group E (n=83) (8.3 mg kg−1 h−1) than in group A (n=79) (10.5 mg kg−1 h−1) (P < 0.001). There were no significant differences in recovery time, patients’ and endoscopists’ satisfaction, side effects, psychotomimetic effects and the number of sedation-related adverse events. CONCLUSION Low-dose esketamine reduces the total amount of propofol necessary for sedation during ERCP in American Society of Anesthesiologists I and II patients without affecting recovery time, satisfaction of patients and endoscopists, side effects and respiratory or cardiovascular adverse events, when compared with alfentanil. TRIAL REGISTRATION The Netherlands Trial Register (NTR5486).

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

“…Esketamine, a N-methyl-D-aspartate receptor antagonist, has analgesic, anaesthetic and sympathomimetic properties. It is reported that esketamine cause less respiratory or cardiovascular depression than other sedatives due to an increase in sympathetic tone [12,32]. Jonkman K et al found that esketamine could counter opioid-induced respiratory depression [11].…”

“…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].…”

“…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].…”

“…Adjuvants are usually needed in many cases because co-administration can improve anaesthetic efficacy and reduce the incidences of adverse events caused by a single drug [9]. Esketamine, a noncompetitive, N-methyl-D-aspartate receptor antagonists [10], has analgesic, anaesthetic and sympathomimetic properties and is known to cause less cardiorespiratory depression [11,12]. Therefore, it could be an ideal adjunct to propofol for endoscopic procedures [12,13].…”

“…Esketamine, a noncompetitive, N-methyl-D-aspartate receptor antagonists [10], has analgesic, anaesthetic and sympathomimetic properties and is known to cause less cardiorespiratory depression [11,12]. Therefore, it could be an ideal adjunct to propofol for endoscopic procedures [12,13]. However, very few studies have been reported the effectiveness and safety of esketamine adjunct to propofol sedation during endoscopic procedures in elderly patients.…”