Carbon dioxide accumulation during analgosedated colonoscopy: comparison of propofol and midazolam.
OBJECTIVE
To characterize the profiles of alveolar hypoventilation during colonoscopies performed under sedoanalgesia with a combination of alfentanil and either midazolam or propofol.


METHODS
Consecutive patients undergoing routine colonoscopy were randomly assigned to sedation with either propofol or midazolam in an open-labeled design using a titration scheme. All patients received 4 μg/kg per body weight alfentanil for analgesia and 3 L of supplemental oxygen. Oxygen saturation (SpO₂) was measured by pulse oximetry (POX), and capnography (PcCO₂) was continuously measured using a combined dedicated sensor at the ear lobe. Instances of apnea resulting in measures such as stimulation of the patient, a chin lift, a mask maneuver, or withholding of sedation were recorded. PcCO₂ values (as a parameter of sedation-induced hypoventilation) were compared between groups at the following distinct time points: baseline, maximal rise, termination of the procedure and 5 min after termination of the procedure. The number of patients in both study groups who regained baseline PcCO₂ values (± 1.5 mmHg) five minutes after the procedure was determined.


RESULTS
A total of 97 patients entered this study. The data from 14 patients were subsequently excluded for clinical procedure-related reasons or for technical problems. Therefore, 83 patients (mean age 62 ± 13 years) were successfully randomized to receive propofol (n = 42) or midazolam (n = 41) for sedation. Most of the patients were classified as American Society of Anesthesiologists (ASA) II [16 (38%) in the midazolam group and 15 (32%) in the propofol group] and ASA III [14 (33%) and 13 (32%) in the midazolam and propofol groups, respectively]. A mean dose of 5 (4-7) mg of IV midazolam and 131 (70-260) mg of IV propofol was used during the procedure in the corresponding study arms. The mean SpO₂ at baseline (%) was 99 ± 1 for the midazolam group and 99 ± 1 for the propofol group. No cases of hypoxemia (SpO₂ < 85%) or apnea were recorded. However, an increase in PcCO₂ that indicated alveolar hypoventilation occurred in both groups after administration of the first drug and was not detected with pulse oximetry alone. The mean interval between the initiation of sedation and the time when the PcCO₂ value increased to more than 2 mmHg was 2.8 ± 1.3 min for midazolam and 2.8 ± 1.1 min for propofol. The mean maximal rise was similar for both drugs: 8.6 ± 3.7 mmHg for midazolam and 7.4 ± 3.2 mmHg for propofol. Five minutes after the end of the procedure, the mean difference from the baseline values was significantly lower for the propofol treatment compared with midazolam (0.9 ± 3.0 mmHg vs 4.3 ± 3.7 mmHg, P = 0.0000169), and significantly more patients in the propofol group had regained their baseline value ± 1.5 mmHg (32 of 41 vs 12 of 42, P = 0.0004).


CONCLUSIONS
A significantly higher number of patients sedated with propofol had normalized PcCO₂ values five minutes after sedation when compared with patients sedated with midazolam.
Ludwig T Heuss, Shajan Peter Sugandha, Christoph Beglinger, Department of Gastroenterology, University Hospital, 4031 Basel, Switzerland. ltheuss@hin.ch
Ludwig T
LT
Heuss
Shajan Peter
SP
Sugandha
Christoph
C
Beglinger
D000368:Aged; D015760:Alfentanil / Q000008:administration & dosage; D000701:Analgesics, Opioid / Q000008:administration & dosage; D015415:Biomarkers / Q000097:blood; D001785:Blood Gas Monitoring, Transcutaneous; D002245:Carbon Dioxide / Q000097:blood*; D003113:Colonoscopy / Q000379:methods*; D054810:Deep Sedation / Q000009:adverse effects* / Q000379:methods; D004311:Double-Blind Method; D005260:Female; D006801:Humans; D006993:Hypnotics and Sedatives / Q000008:administration & dosage / Q000009:adverse effects*; D007040:Hypoventilation / Q000097:blood / Q000139:chemically induced* / Q000175:diagnosis; D008297:Male; D008874:Midazolam / Q000008:administration & dosage / Q000009:adverse effects*; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D015742:Propofol / Q000008:administration & dosage / Q000009:adverse effects*; D011446:Prospective Studies
D000701:Analgesics, Opioid; D015415:Biomarkers; D006993:Hypnotics and Sedatives; D002245:Carbon Dioxide; D015760:Alfentanil; D008874:Midazolam; D015742:Propofol