Ponad 7000 publikacji medycznych!
Statystyki za 2021 rok:
odsłony: 8 805 378
Artykuły w Czytelni Medycznej o SARS-CoV-2/Covid-19

Poniżej zamieściliśmy fragment artykułu. Informacja nt. dostępu do pełnej treści artykułu
© Borgis - Nowa Medycyna 1/2017, s. 27-36
*Jacek Wadełek
Pharmacology of analgosedation in adult patient during colonoscopy
Farmakologia analgosedacji u dorosłego pacjenta do kolonoskopii
Anaesthesiology and Intensive Therapy Department, St. Anna Trauma Surgery Hospital, STOCER Mazovia Rehabilitation Center Sp. z o.o., Warsaw
Head of Department: Elżbieta Kurmin-Gryz MD
Streszczenie
Kolonoskopia jest często uważana przez pacjentów za inwazyjną procedurę, która wkracza w intymność pacjenta i powoduje dyskomfort, dolegliwości bólowe i obawę związaną z wynikiem badania. Zastosowanie analgosedacji do kolonoskopii nie tylko poprawia tolerancję i satysfakcję pacjenta, ale również wolę pacjentów poddania się powtarzanym badaniom. Jedne ośrodki endoskopowe preferują głęboką analgosedację do kolonoskopii, która powoduje całkowite zniesienie dyskomfortu kolonoskopii, ale i utratę kontaktu słownego. Inne ośrodki endoskopowe preferują lekką analgosedację, kiedy pacjent ma zachowane zdolności kontaktu logiczno-słownego i spełnia polecenia, zmieniając ułożenie ciała podczas badania. Szeroko stosowanym sposobem analgosedacji do kolonoskopii jest połączenie propofolu z opioidem. Takie połączenie leków zwiększa komfort pacjentów, ale synergistyczne działanie depresyjne na układ oddechowy i układ krążenia obu leków może powodować zagrażające życiu działania niepożądane. Głębszy stopień analgosedacji pozwala lekarzowi na dokładniejsze i kompletne badanie kolonoskopowe. Kwalifikacja pacjenta do kolonoskopii z zastosowaniem analgosedacji nie różni się od kwalifikacji rutynowo przeprowadzanej przed znieczuleniem ogólnym. Podstawowe znaczenie mają dokładnie zebrany wywiad chorobowy i badanie fizykalne. Przed rozpoczęciem analgosedacji niezbędne jest uzyskanie świadomej zgody pacjenta lub jego opiekuna, wyrażonej na piśmie.
Summary
Colonoscopy is often viewed by patients as an invasive procedure which enters the patient’s intimate zone, causes discomfort and concerns about potential findings. These concerns can lead to anxiety, which affects patient cooperation and satisfaction with the procedure. The use of analgosedation for colonoscopy not only enhances patient tolerance and satisfaction, but also increases the willingness of patients to return for repeated examination. Deep sedation for colonoscopy, in which the colonoscopy-related discomfort is eliminated, but the verbal contact is lost, may be routinely practised in some countries and centres as opposed to conscious sedation, when the verbal contact is maintained and the patient responds to instructions, e.g. by changing body position during the examination. A combination of propofol with an opioid is widely used in analgosedation during colonoscopy. Although this combination increases patient comfort, the synergistic respiratory and circulatory depressant effects of both these agents may induce life-threatening adverse effects. This level of sedation may allow the colonoscopist to dedicate more time and attention to examining the colon during colonoscopy. It has been found that with the use of deep rather than conscious sedation, more advanced lesions may be found and more patients are likely to undergo complete colonoscopies. Qualification for colonoscopy with analgosedation does not differ from routinely used qualification before general anaesthesia. Most important are: detailed anamnesis and physical examination. Before starting anagosedation it is imperative to obtain informed consent from a patient or his/her legal guardian, expressed in writing.



Introduction
A screening colonoscopy is a validated tool for early diagnosis of colorectal cancer. This is an important reason why colonoscopy belongs to the most common endoscopic gastrointestinal examinations. However, motivating patients to participate in colonoscopy screening continues to be a challenge. The lack of knowledge about the procedure may be a significant barrier preventing patients from undergoing screening. Patients complain about disruption of normal daily activities by bowel preparation for colonoscopy, prolonged analgosedation after colonoscopy, as well as the need to be accompanied when returning home. There is an ongoing discussion on sedation-free colonoscopy, and there is no consensus in this regard. While in some countries it is a common practice to perform colonoscopy without sedation, this type of management is considered unfeasible and is not recommended in other countries. In countries where colonoscopy is performed under analgesia, a trend towards deeper levels of sedation may be observed (1). Sedation in colonoscopy increases the costs of examination. Also, the costs associated with absenteeism, additional personnel, the use of equipment for analgosedation and general anaesthesia as well as monitoring and surveillance of patients after colonoscopy under analgosedation should be considered. Additionally, patients complain about the need to be accompanied when returning home, about limited physical activity as well as the risk of anaesthesia-related complications. Analgosedation in colonoscopy should be considered for at least two reasons: 1) the patient may be anxious and afraid of violation of their physical intimacy, 2) due to colonoscopy-related pain. Each of these reasons requires the use of two different agents, with benzodiazepines being an appropriate choice for patients with fear and anxiety associated with intimacy, and opioids recommended for pain. Deep sedation using propofol or even general anaesthesia is another method used in some countries. Colonoscopy may be well-tolerated by some patients, with high levels of satisfaction and only minor or no pain, whereas in other cases the procedure may require deep sedation. The underlying causes are multifactorial and include such elements as previous abdominal surgeries and the resulting adhesions, individual anatomy of each patient, the skillfulness of an endoscopist, patient expectations, local traditions, endoscopic insertion technique and the type of endoscopic equipment.
Pain and discomfort during colonoscopy
Pain during colonoscopy is considered to be visceral, resulting from the activation of sensory afferent nerves that innervate the intestines. The main triggering factors include stretching of the sigmoid wall and mesenteric attachments due to excessive intestinal distension and colonoscope looping (2). Visceral pain often triggers autonomous reflexes, such as perspiration, bradycardia, vertigo, hypotension and nausea. Although pain is a physiological response to tissue damage, it also includes emotional and behavioural responses depending on the individual experiences and cultural background, which are often resistant to analgesic treatment. Young women with low body mass index (BMI) show lower pain tolerance as opposed to older patients. It is difficult to predict pain intensity in each patient.
Pain management and sedation for colonoscopy
Analgosedation for colonoscopy is currently a widely discussed issue. Sedation in colonoscopy is a standard management in the USA, with different studies recommending either moderate or deep sedation. Other parts of the world argue for medication-free colonoscopy (3). Eckardt et al. showed in their study including 2,500 patients that analgosedation-free colonoscopy was possible in 95% of patients if performed by an experienced endoscopist using optimal equipment. However, no reports on patient satisfaction with the performed endoscopic procedure were presented (4). Nowadays, the use of colonoscopes employing the water method, and experienced endoscopists make colonoscopy without sedation possible for a motivated group of patients (5-7). Success rates depend on appropriate patient selection. Male gender, higher levels of education, low preprocedural anxiety, and patient’s preference for procedures without sedation are predictors of a successful sedation-free procedure. However, unpredictable individual anatomical differences can lead to unacceptable discomfort for the patient and poor procedural conditions for analgosedation-free colonoscopy.
Methods of analgosedation
Levels of sedation, ranging from moderate to deep, are defined in sedation guidelines. Deep sedation is usually achieved using intravenous propofol, which has a rapid onset and short duration of action, allowing for a reduced recovery time. Therefore, there is an increasing interest in propofol-based sedation among gastroenterologists. It should be noted, however, that propofol has a relatively narrow therapeutic range, which increases the risk of sedation-related adverse effects. Most states in the United States do not allow the use of propofol by non-anaesthesiologists. In Poland, this anaesthetic is also used only by anaesthesiologists (8-12). The European guidelines allow for the administration of propofol by trained nurses or endoscopists who do not perform colonoscopy at the same time (13). However, this permission only concerns moderate, and not deep sedation. Deep sedation requires specialist equipment and training, and it may be performed only by trained personnel and under appropriate monitoring (14). The rates of colonoscopies performed by specialised anaesthetic teams increased from 23.9% in 2007 to 53.4% in 2015, respectively, and are still rising (15). Deep sedation may cause spontaneous ventilation failure, which may require assistance to maintain patent airways. An analysis of aesthetic-related adverse events registry demonstrated that serious adverse events can occur during deep sedation, even when performed by properly trained personnel (16). The most common adverse effects include respiratory depression, cardiovascular events, delayed recovery of consciousness, and prolonged time between analgosedation and hospital discharge. Deeply sedated patients are not able to change their body position during examination, which makes it difficult to maneuver the patient. Moderate sedation is defined as a drug-induced depression of consciousness. Moderately sedated patients are able to purposefully respond to verbal commands. Spontaneous ventilation is adequate, and there is no the risk of airway obstruction. Agents that are most commonly used for moderate sedation include midazolam and other benzodiazepines or midazolam combined with an opioid. Although combination of a sedative and an opioid is excellent for colonoscopy, it increases the risk of unintentional deep sedation and more common respiratory depression. The duration of analgosedatives may be longer than the duration of the procedure, resulting in prolonged recovery with a delay in hospital discharge, increased costs, and disruption of daily activities of the patients.
The ideal analgosedative agent

Powyżej zamieściliśmy fragment artykułu, do którego możesz uzyskać pełny dostęp.
Mam kod dostępu
  • Aby uzyskać płatny dostęp do pełnej treści powyższego artykułu albo wszystkich artykułów (w zależności od wybranej opcji), należy wprowadzić kod.
  • Wprowadzając kod, akceptują Państwo treść Regulaminu oraz potwierdzają zapoznanie się z nim.
  • Aby kupić kod proszę skorzystać z jednej z poniższych opcji.

Opcja #1

24

Wybieram
  • dostęp do tego artykułu
  • dostęp na 7 dni

uzyskany kod musi być wprowadzony na stronie artykułu, do którego został wykupiony

Opcja #2

59

Wybieram
  • dostęp do tego i pozostałych ponad 7000 artykułów
  • dostęp na 30 dni
  • najpopularniejsza opcja

Opcja #3

119

Wybieram
  • dostęp do tego i pozostałych ponad 7000 artykułów
  • dostęp na 90 dni
  • oszczędzasz 28 zł
Piśmiennictwo
1. Vaessen HH, Knape JT: Considerable Variability of Procedural Sedation and Analgesia Practices for Gastrointestinal Endoscopic Procedures in Europe. Clin Endosc 2016; 49: 47-55.
2. Shah SG, Brooker JC, Thapar C et al.: Patient pain during colonoscopy: an analysis using real-time magnetic endoscope imaging. Endoscopy 2002; 34(6): 435-440.
3. Takahashi Y, Tanaka H, Kinjo M, Sakumoto K: Sedation-free colonoscopy. Dis Colon Rectum 2004; 48: 855-859.
4. Eckardt VF, Kanzler G, Schmitt T et al.: Complications and adverse effects of colonoscopy with selective sedation. Gastrointest Endosc 1999; 49: 560-565.
5. Leung FW, Leung JW, Mann SK et al.: The water method significantly enhances patient-centered outcomes in sedated and unsedated colonoscopy. Endoscopy 2011; 43: 816-821.
6. Lee DW, Li AC, Ko CW et al.: Use of a variable-stiffness colonoscope decreases the dose of patient-controlled sedation during colonoscopy: a randomized comparison of 3 colonoscopes. Gastrointest Endosc 2007; 65: 424-429.
7. Rex DK, Imperiale TF, Portish V: Patients willing to try colonoscopy without sedation: associated clinical factors and results of a randomized controlled trial. Gastrointest Endosc 1999; 49: 554-559.
8. Rozporządzenie Ministra Zdrowia z dnia 2 lutego 2011 r. w sprawie wymagań, jakim powinny odpowiadać pod względem fachowym i sanitarnym pomieszczenia i urządzenia zakładu opieki zdrowotnej (Dz. U. 2011, nr 31, poz. 158). Załącznik nr 1 w sprawie wymagań szczegółowych, jakim powinny odpowiadać pod względem fachowym i sanitarnym pomieszczenia i urządzenia szpitala.
9. Rozporządzenie Ministra Zdrowia z dnia 27 lutego 1998 r. w sprawie standardów postępowania oraz procedur medycznych przy udzielaniu świadczeń zdrowotnych z zakresu anestezjologii i intensywnej terapii w zakładach opieki zdrowotnej (Dz. U. 1998, nr 37, poz. 215).
10. Piechota M, Kusza K: Standardy postępowania medycznego w dziedzinie anestezjologii i intensywnej terapii. Anest Ratow 2013; 7: 100-112.
11. Kusza K, Kübler A, Maciejewski D et al.: Wytyczne Polskiego Towarzystwa Anestezjologii i Intensywnej Terapii określające zasady, warunki oraz organizację udzielania świadczeń zdrowotnych w dziedzinie anestezjologii i intensywnej terapii. Anest Intens Ter 2012; 44: 201-212.
12. Rozporządzenie Ministra Zdrowia z dnia 20 grudnia 2012 r. w sprawie standardów postępowania medycznego w dziedzinie anestezjologii i intensywnej terapii dla podmiotów wykonujących działalność leczniczą. Dz. U. 13.15 z dnia 7 stycznia 2013 r.
13. Knape JT, Adriaensen H, van Aken H et al.: Guidelines for sedation and/or analgesia by non-anaesthesiology doctors. Eur J Anaesthesiol 2007; 24: 563-567.
14. Aisenberg J, Brill JV, Ladabaum U, Cohen LB: What’s new in GI sedation for gastrointestinal endoscopy: new practices, new economics. Am J Gastroenterol 2005; 2: 996-1000.
15. Inadomi JM, Gunnarsson CL, Rizzo JA, Fang H: Projected increased growth rate of anesthesia professional-delivered sedation for colonoscopy and EGD in the United States: 2009 to 2015. Gastrointest Endosc 2010; 20: 1-7.
16. Bhananker SM, Posner KL, Cheney FW et al.: Injury and liability associated with monitored anesthesia care: a closed claims analysis. Anesthesiology 2006; 104: 228-234.
17. Zakko SF, Seifert HA, Gross JB: A comparison of midazolam and diazepam for conscious sedation during colonoscopy in a prospective double-blind study. Gastrointest Endosc 1999; 49(6): 684-689.
18. Hayee B, Dunn J, Loganayagam A et al.: Midazolam with meperidine or fentanyl for colonoscopy: results of a randomized trial. Gastrointest Endosc 2009; 69: 681-687.
19. Dere K, Sucullu I, Budak ET et al.: A comparison of dexmedetomidine versus midazolam for sedation, pain and hemodynamic control, during colonoscopy under conscious sedation. Eur J Anaesthesiol 2010; 27(7): 648-652.
20. Cotè GA, Hovis RM, Ansstas MA et al.: Incidence of sedation-related complications with propofol use during advanced endoscopic procedures. Clin Gastroenterol Hepatol 2010; 8: 137-142.
21. Paspatis GA, Tribonias G, Manolaraki MM et al.: Deep sedation compared with moderate sedation in polyp detection during colonoscopy: a randomized controlled trial. Colorectal Dis 2011; 13: 137-144.
22. Slavik VC, Zed PJ: Combination ketamine and propofol for procedural sedation and analgesia. J Human Pharmacol Drug Therapy 2007; 27(11): 1588-1598.
23. Koruk S, Mizrak A, Gul R et al.: Dexmedetomidine-ketamine and midazolam-ketamine combinations for sedation in pediatric patients undergoing extracorporeal shock wave lithotripsy: A randomized prospective study. J Anesth 2010; 24: 858-863.
24. Robertson DJ, Jacobs DP, Mackenzie TA et al.: Clinical trial: a randomized, study comparing meperidine (pethidine) and fentanyl in adult gastrointestinal endoscopy. Aliment Pharmacol Ther 2009; 15: 817-823.
25. Lazaraki G, Kountouras J, Metallidis S et al.: Single use of fentanyl in colonoscopy is safe and effective and significantly shortens recovery time. Surg Endosc 2007; 21: 1631-1636.
26. Van Natta ME, Rex DK: Propofol alone titrated to deep sedation versus propofol in combination with opioids and/or benzodiazepines and titrated to moderate sedation for colonoscopy. Am J Gastroenterol 2006; 101: 2209-2217.
27. Di Palma JA, Herrera JL, Weis FR et al.: Alfentanil for conscious sedation during colonoscopy. South Med J 1995; 88(6): 630-634.
28. Akcaboy ZN, Akcaboy EY, Albayrak D et al.: Can remifentanil be a better choice than propofol for colonoscopy during monitored anesthesia care? Acta Anaesthesiol Scand 2006; 50: 736-741.
29. Collado V, Nicolas E, Faulks D, Hennequin M: A review of the safety of 50% nitrous oxide/oxygen in conscious sedation. Expert Opin Drug Saf 2007; 6: 559-571.
30. Løberg M, Furholm S, Hoff I et al.: Nitrous oxide for analgesia in colonoscopy without sedation. Gastrointest Endosc 2011; 74: 1347-1353.
31. Ibrahim AE, Ghoneim MM, Kharasch ED et al.: Speed of recovery and side-effect profile of sevoflurane sedation compared with midazolam. Anesthesiology 2001; 94: 87-94.
32. White PF, Tang J, Wender RH et al.: Desflurane versus sevoflurane for maintenance of outpatient anesthesia: the effect on early versus late recovery and perioperative coughing. Anesth Analg 2009; 109: 387-393.
otrzymano: 2017-02-02
zaakceptowano do druku: 2017-02-21

Adres do korespondencji:
*Jacek Wadełek
Oddział Anestezjologii i Intensywnej Terapii Szpital Chirurgii Urazowej św. Anny w Warszawie Mazowieckie Centrum Rehabilitacji „STOCER” Sp. z o.o.
ul. Barska 16/20, 02-315 Warszawa
tel.: +48 (22) 579-52-58
WAD_jack@poczta.fm

Nowa Medycyna 1/2017
Strona internetowa czasopisma Nowa Medycyna