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Critical Appraisal TopicCritical Appraisal Topic
Acquil Mohammad U. Alip, MDResidentDept. of AnesthesiologyUP-PGHManila, Philippines
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The Question:The Question:Is Propofol better than Midazolam in
giving conscious sedation to patients undergoing interventional radiology?
As a resident rotator in TCVS/Cath lab, I want to know which drug/s is/are more safe and effective in patient undergoing interventional radiological procedures.
Key words: Conscious Sedation, Propofol, Midazolam, Interventional radiology.
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Search EngineSearch Engine
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The findThe findConscious sedation in
interventional radiology: A comparison of Propofol versus Midazolam Anagha U. Manjrekar, M.D.Deepa Kane, M.DLalita Dewoolkar, M.D.Prerana Shroff, M.D. Department of Anaesthesiology Seth G.S.Medical College and K.E.M.Hospital Mumbai India
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TerminologyTerminologyConscious sedation-once referred
to as “twilight sleep”has become popular to describe a semi-conscious state that allows patients to be comfortable during certain surgical or medical procedures
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Stages of Sedation according to ASA:1.minimal sedation, you will feel relaxed, and
you may be awake. You can understand and answer questions and will be able to follow your physician’s instructions.
2.moderate sedation, you will feel drowsy and may even sleep through much of the procedure, but will be easily awakened when spoken to or touched. You may or may not remember being in the procedure room.
3.deep sedation, you will sleep through the procedure with little or no memory of the procedure room. Your breathing can slow, and you might be sleeping until the medications wear off. With deep sedation, supplemental oxygen is often given.
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Journal AbstractJournal AbstractMost interventional radiological
procedures are minimally painful, possibly prolonged and require relative patient immobility, and pose a challenge to the anesthesiologist of providing adequate sedation, immobilization and analgesia without compromising airway or consciousness and ensuring rapid recovery
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Journal AbstractJournal AbstractRandomized, double-blinded studyCompared Propofol and Midazolam
with respect to safety and efficacy 60 patients Grouped into :
A- Midazolam+FentanylB- Propofol+FentanylAll patients received 1μg.kg -1 fentanyl i.v. before access area was prepared and draped
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Group A patients received 15μg/kg Midazolam bolus followed by an infusion @ 0.5μg.kg/min
group B received a bolus of Propofol 0.5mg/kg followed by an infusion @ 25μg/kg/min
bolus dose of fentanyl 25μg was administered as needed for excessive pain
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Appraising ValidityAppraising ValidityQ1: Were patients randomly assigned to
treatment group?A- Yes
60 ASA 1/11/111 were assigned to group A and B for Interventional radiological procedure
Patients with anticipated difficult airway, hemodynamic instability, impaired vision; bronchial asthma, IHD, uncompensated hepatic or renal disease and pregnant or lactating patients were excluded from the study by a thorough pre-anesthetic evaluation.
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Q2: Was allocation concealed?A- Not mentioned
Q3: Were baseline characteristics similar at the start of the trial?
A- Yes
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Table 1: Demographic DataTable 1: Demographic Data
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Q4: Were patients blinded to treatment assignment?
A- Yes, they were not informed which drug will be given to them
Q5: Were caregivers blinded to the treatment assignment?
A- Not mentioned
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Q6: Were outcome assessors blinded to treatment assignment?A- Not mentioned
Q7: Were patients analyzed in the groups to which they were originally randomized?A- Yes
Steward’s score were assessed 10 minutes after the procedure completed
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Memory of seeing picture chart and needle prick were assessed at 30 minutes
Post Anesthesia Discharge Score (PADSS) 3 was assessed at six hours to assess intermediate recovery
No dropout nor non-compliant patient
Q8: Was follow-up rate adequate?A- Yes
No drop-outs or non-compliant patient
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ResultsResultsQ1: How large was the treatment
effect?
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Table 3: Haemodynamics (Blood Pressure And Table 3: Haemodynamics (Blood Pressure And
Heart Rate)Heart Rate)
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Table 4: Respiratory Parameters (Mean Respiratory Table 4: Respiratory Parameters (Mean Respiratory Rate And Oxygen Saturation) Rate And Oxygen Saturation)
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Table 5: Amnesia Table 5: Amnesia
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Table 6: Sedation Score Table 6: Sedation Score
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Table 7: Visual Analogue Score (Operator And Table 7: Visual Analogue Score (Operator And Patient) Patient)
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Table 8: Recovery Score At 10 Minutes After Table 8: Recovery Score At 10 Minutes After Completion Of Procedure Completion Of Procedure
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Table 9: Discharge Score Table 9: Discharge Score
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Table 10: Adverse Effects Table 10: Adverse Effects
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ConclusionConclusionAuthors found that both
techniques of conscious sedation, Midazolam and Propofol; with Fentanyl were satisfactory for interventional radiological procedures with respect to: ◦haemodynamics, ◦respiratory parameters, ◦sedation, ◦amnesia, ◦recovery,
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◦satisfaction of patient and operator and complications
◦Improving analgesia could possibly improve patient coopertion and thus operator comfort
◦Propofol though costlier, by ensuring rapid recovery and thus reducing hospital stay may emerge superior and cost effective compared to Midazolam
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Assessing ApplicabilityAssessing ApplicabilityThe results of this study can be
applied in our hospital in giving anesthesia to patient/s undergoing interventional radiological procedures
Drawback:◦The inclusion/exclusion was limited,
patient with IHD were excluded, the coronary angiogram was not included in the interventional procedure
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Drawbacks:◦In the study, it was not mentioned
what method they used to make sure that the patient and the operator were really blinded in the procedure.
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ConclusionConclusionboth techniques of conscious sedation,
Midazolam and Propofol; with Fentanyl were satisfactory for interventional radiological procedures with respect to haemodynamics, respiratory parameters, sedation, amnesia, recovery, satisfaction of patient and operator and complications. Improving analgesia could possibly improve patient co-opeartion and thus operator comfort
Propofol though costlier, by ensuring rapid recovery and thus reducing hospital stay may emerge superior and cost effective compared to Midazolam
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THANK YOU!THANK YOU!Assalamu Alaikom