The effect of moderate sedation on exocrine pancreas function in normal healthy subjects: a prospective, randomized, cross-over trial using the synthetic porcine secretin stimulated Endoscopic Pancreatic Function Test (ePFT).
BACKGROUND
We have developed a purely endoscopic collection method for the assessment of pancreatic secretory function (ePFT). The pancreatic secretory effects of sedation medications utilized during endoscopic procedures are not completely known.


OBJECTIVE
To study the effect of moderate sedation on the exocrine pancreas gland in a prospective, randomized trial.


METHODS
Healthy volunteers were randomized by computers to one of two treatments (A-no sedation, B-sedation) in period 1 and crossed-over to the other treatment in period 2 with a minimal washout interval of 7 days. Sedation dosage was standardized for each patient based on age, gender and weight from a previously published dosing nomogram. Synthetic porcine secretin (ChiRhoClin, Inc., Burtonsville, Maryland) was used as the pancreatic stimulant. Duodenal fluid samples were aspirated via the endoscope every 5 min for 1 h and sent on ice to our hospital laboratory for the measurement of pancreatic secretory electrolyte concentrations by autoanalyzer.


RESULTS
A total of 17 healthy volunteers were enrolled. Sixteen subjects (8 males and 8 females) completed the randomized prospective trial. Median intravenous meperidine and midazolam sedation dose was 62.5 mg and 2.5 mg, respectively. Maximum pancreatic juice flow occurred during the early phase of secretion and maximum bicarbonate concentration occurred during the late phase of secretion. Analysis of the electrolyte composition of the endoscopically collected duodenal drainage fluid revealed a constant cation concentration for both sodium and potassium over the 1 h collection period. The anions, chloride and bicarbonate, exhibited a reciprocal relationship identical to that seen in traditional gastroduodenal tube collection studies. There was no statistical difference observed between the sedation and no sedation groups. The estimated total bicarbonate output (area under curve, AUC) for the sedated and non-sedated groups were 5,017 meq + 724 (range 3,663-6,173) and 5,364 meq +/- 583 (range 4,323-6563) respectively (p= 0.0656). The mean peak bicarbonate concentrations for sedated (n = 8) versus non-sedated (n = 8) groups were 103 +/- 11 meq/L (range 78-125) and 106 +/- 11 meq/L (range 87-138), respectively (p= 0.1346). There was excellent correlation of peak bicarbonate concentrations when sedation and no sedation groups were compared (r= 0.744, p < 0.05; Spearman rank correlation). There were no episodes of pancreatitis.


CONCLUSIONS
(a) Moderate sedation used for upper endoscopy does not effect the clinical diagnostic parameters (peak bicarbonate concentration or total bicarbonate output) utilized to diagnose pancreatic insufficiency. (b) Analysis of duodenal drainage fluid collected endoscopically after synthetic secretin stimulation produces an identical pancreatic secretory curve described with traditional gastroduodenal tube collection methods.
Conwell
Darwin L
DL
The Pancreas Clinic, Section of Endoscopy and Pancreaticobiliary Disease, Department of Gastroenterology and Hepatology, and Laboratory Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
Zuccaro
Gregory
G
Purich
Edward
E
Fein
Seymor
S
Vanlente
Frederick
F
Vargo
John
J
Dumot
John
J
O'laughlin
Cathy
C
Trolli
Patricia
P
D000328:Adult; D000818:Animals; D001639:Bicarbonates / Q000032:analysis; D002712:Chlorides / Q000032:analysis; D016292:Procedural Sedation; D018592:Cross-Over Studies; D004384:Duodenoscopy; D004386:Duodenum; D005260:Female; D005765:Gastrointestinal Agents / Q000494:pharmacology*; D006801:Humans; D006993:Hypnotics and Sedatives / Q000008:administration & dosage / Q000494:pharmacology*; D007419:Intestinal Secretions / Q000737:chemistry; D008297:Male; D008614:Meperidine / Q000008:administration & dosage / Q000494:pharmacology; D008874:Midazolam / Q000008:administration & dosage / Q000494:pharmacology; D046790:Pancreas, Exocrine / Q000187:drug effects* / Q000378:metabolism; D010189:Pancreatic Juice / Q000187:drug effects / Q000378:metabolism; D011188:Potassium / Q000032:analysis; D011446:Prospective Studies; D012633:Secretin / Q000494:pharmacology*; D012964:Sodium / Q000032:analysis; D013552:Swine
D001639:Bicarbonates; D002712:Chlorides; D005765:Gastrointestinal Agents; D006993:Hypnotics and Sedatives; D012633:Secretin; D008614:Meperidine; D012964:Sodium; D008874:Midazolam; D011188:Potassium