Comparison of Propofol-nalbuphine and Propofol-fentanyl Sedation for Patients Undergoing Endoscopic Retrograde Cholangiopancreatography

A Double-blind, Randomized Controlled Trial

Peiqi Wang; Yan Chen; Ying Guo; Jiangbei Cao; Hong Wang; Weidong Mi; Longhe Xu

Disclosures

BMC Anesthesiol. 2022;22(47) 

In This Article

Background

Endoscopic retrograde cholangiopancreatography(ERCP) is performed by gastroenterologists or surgeons to investigate abnormalities of the common bile duct, pancreatic ducts, and ampulla. It can also be used to perform certain therapeutic interventions.[1] Although the decrease in diagnostic ERCP was largely precipitated by magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasound (EUS),[2,3] ERCP has been increasingly used to treat biliary/pancreatic duct blockage or narrowing by stones, tumours, or inflammation outside the operating room.[4–6] The procedure lasts from 30 to 60 min, and the patients need to be in the prone or semiprone position.[7] Patients usually cannot tolerate the procedure because of pain, the uncomfortable position, fear and nausea without adequate sedation.[8]Therefore, ERCP is generally performed under moderate to deep sedation with adequate analgesia to ensure the success of the procedure and improve patient comfort.[9] If used as the only anaesthetic agent, an increased dose of propofol may cause undesirable side effects while lacking adequate analgesic effects to inhibit visceral traction pain.[10] Compared to the administration of propofol alone, the application of propofol with fentanyl for ERCP can reduce the total dose of propofol, decrease the pain level, increase practitioner satisfaction, and provide haemodynamic stability but is more likely to induce respiratory depression, muscle stiffness and airway obstruction.[11,12]

Hypoxia is a common occurrence during upper GI endoscopy under sedation,[13,14] and prolonged hypoxia is the most common cause of cardiac arrhythmia and coronary ischaemia.[13] Avoiding respiratory depression is helpful to reducethe incidence of hypoxia and has been recommended by the American Society of Anesthesiologists and the American Society for Gastrointestinal Endoscopy.[15] Nalbuphine is a mixed agonist–antagonist opioid with a duration of action of approximately 3–6 h and causes less respiratory depression than fentanyl.[16,17] It has also been used to treat pain over the past 40 years.[18] Considering the unique pharmacology in pain management,[19] nalbuphine is possibly superior to fentanyl in ERCP due to the lower respiratory depression and adequate analgesia provided by nalbuphine.

In this prospective, double-blind, randomized controlled trial, we compared the analgesic efficacy and safety of propofol combined with nalbuphine or fentanyl in patients undergoing ERCP. We hypothesized that patients sedated with nalbuphine and propofol would have a lower rate of hypoxia during ERCP procedures than patients sedated with fentanyl and propofol.

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