title: Bolus Administration of Fentanyl and Midazolam for Colonoscopy Increases Endoscopy Unit Efficiency and Safety Compared With Titrated Sedation.
abstract: OBJECTIVE
  Guidelines recommend slow titration of sedatives for moderate sedation. Bolus sedation, in which a larger weight-based dose of medication is given upfront, has been shown in a single trial to be beneficial. We evaluated the effects of bolus sedation on procedural safety, efficiency, and patient experience.
  
  
  METHODS
  We performed a retrospective analysis of colonoscopies performed between April 2010 and April 2011 at Duke Medical Center. Colonoscopies before October 2010 were performed with nurse-directed titration of sedative (n = 966); colonoscopies performed after October 2010 were performed with physician-directed administration of bolus sedative (n = 699). We compared sedation and recovery times, medication doses, and adverse events between groups. We also compared patient satisfaction in a subset of patients from each group. Data were compared using the chi-square test for categorical variables and Wilcoxon rank sum test for continuous and ordinal categorical variables.
  
  
  RESULTS
  Patients in the bolus group had a shorter sedation time (6.0 min) than patients in the titration group (13.0 min; P < .01) and a slightly longer colonoscopy time (25.0 min vs 24.0 min in the titration group; P < .01). Recovery time did not differ significantly between groups (53.0 min in the bolus group vs 52.1 min in the titration group; P = .07). Patients in the bolus group received lower weight-adjusted doses of fentanyl (1.71 μg/kg vs 1.89 μg/kg in the titration group) and midazolam (0.065 mg/kg vs 0.075 mg/kg in the titration group). A smaller proportion of patients in the bolus sedative group developed hypotension (12.7% vs 17.9% in the titration group; P < .01). These findings persisted even after adjustment for baseline patient age, race, sex, smoking status, alcohol use, body mass index, and American Society of Anesthesiologists' classification.
  
  
  CONCLUSIONS
  In a retrospective study of patients undergoing colonoscopy, we found that compared with titrated administration of sedative, bolus dosing improves endoscopy unit efficiency and safety and decreases the amount of sedative required. This benefit does not come at the expense of the patient experience.
authors.affiliation: Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina.
authors.forename: R Thomas
authors.initials: RT
authors.lastname: Finn
authors.affiliation: Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina.
authors.forename: Amanda
authors.initials: A
authors.lastname: Boyd
authors.affiliation: Duke Clinical Research Institute, Durham, North Carolina.
authors.forename: Li
authors.initials: L
authors.lastname: Lin
authors.affiliation: Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina; Durham VA Medical Center, Durham, North Carolina. Electronic address: z.gellad@duke.edu.
authors.forename: Ziad F
authors.initials: ZF
authors.lastname: Gellad
mesh_terms: D000759:Adjuvants, Anesthesia / Q000008:administration & dosage* / Q000009:adverse effects; D000293:Adolescent; D000328:Adult; D000368:Aged; D003113:Colonoscopy / Q000379:methods*; D054810:Deep Sedation / Q000009:adverse effects / Q000379:methods*; D005260:Female; D005283:Fentanyl / Q000008:administration & dosage* / Q000009:adverse effects; D006785:Hospitals, University; D006801:Humans; D006993:Hypnotics and Sedatives / Q000008:administration & dosage* / Q000009:adverse effects; D008297:Male; D008874:Midazolam / Q000008:administration & dosage* / Q000009:adverse effects; D008875:Middle Aged; D009657:North Carolina; D017060:Patient Satisfaction; D012189:Retrospective Studies; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D000759:Adjuvants, Anesthesia; D006993:Hypnotics and Sedatives; D008874:Midazolam; D005283:Fentanyl
keywords: Colonoscopy; Comparison; Efficiency; Sedation