0016-5107/92/3806-0689$03.00 GASTROINTESTINAL ENDOSCOPY Copyright © 1992 by the American Society for Gastrointestinal Endoscopy
Fentanyl for sedation during upper gastrointestinal endoscopy Satoshi Ishido, MD, Yoshikazu Kinoshita, Naoto Kitajima, MD, Toshio Itoh, Katsuhito Nishiyama, MD, Masahide Tojo, Takashi Yano, MD, Tetsuya Inatome, Hisashi Fukuzaki, MD, Tsutomu Chiba,
MD MD MD MD MD
Miki Hyogo-ken, Japan and Kobe Hyogo-ken, Japan
The effects of sedation by intravenous fentanyl on the rate-pressure product (pulse rate x systolic blood pressure/100), arterial oxygen saturation, electrocardiographic change, and serum cortisol concentration were studied during gastroduodenoscopy in 84 patients randomized to receive fentanyl or no intravenous sedative (controls). Fentanyl administration increased the tolerance of patients and attenuated the endoscopy-induced rise in rate-pressure product and serum cortisol concentration. Desaturation of arterial oxygen was minimal and there was no difference in arterial oxygen saturation between the fentanyl group and the control group. Therefore, fentanyl appears to be a favorable sedative for upper gastrointestinal endoscopy, since its administration increased the tolerance of patients and decreased cardiac oxygen consumption. (Gastrointest Endosc
1992;38:689-692)
It is well known that gastroduodenoscopy causes elevation of blood pressure and heart rate by inducing psychological stress and discomfort. 1-4 In our previous study, we demonstrated that blood pressure and heart rate increase abruptly just after endoscopic intubation. 4 These rapid increases in blood pressure and pulse rate might be hazardous for patients with cardiac disease. Several authors have reported an increased rate of electrocardiographic abnormalities during gastroduodenoscopy.1, 5, 6 Although sedation by some narcotics is reported to decrease psychological stress and discomfort, 4 there are few reports in the literature concerning the beneficial effects of fentanyl on endoscopy-induced cardiopulmonary changes. This study was designed to investigate the effects of sedation by fentanyl on patient discomfort, and endoscopy-induced alterations of blood pressure, pulse rate, and electrocardiogram. It was hoped that fentanyl could be added to the number of efficacious drugs used for Received November 21, 1991. For revision January 27, 1992. Accepted April 2, 1992. From the Department of Medicine, Miki City Hospital, Miki Hyogoken, Japan and Department of Geriatrics, Kobe University School of Medicine, Kobe Hyogo-ken, Japan. Reprint requests: Yoshikazu Kinoshita, MD, Department of Medicine, Miki City Hospital, 58-1 Kasa, Miki-shi, Hyogo-ken, 673-04 Japan. VOLUME 38, NO.6, 1992
endoscopy premedication. Fentanyl was selected for study because it has low cardiovascular depressant effects, and can be easily antagonized by injection of naloxane. 7- 1o MATERIALS AND METHODS
Patients
Eighty-four patients with no evident cardiopulmonary disease were included in the study. All of the patients demonstrated normal electrocardiographic and chest x-ray examination results, In addition, they were checked by a cardiologist to exclude any patient with cardiopulmonary disease. The patients were then randomized into two groups. There was no significant difference in age between the two groups-Group 1 (fentanyl group): 0,1 mg of fentanyl citrate was injected intravenously as a sedative approximately 3 min before the intubation ofthe endoscope. Group 2 (control group): No sedative was employed prior to intubation. Endoscopic study
The endoscopic studies were performed by one of our three experienced endoscopists using Olympus GIF-XQ20 or XQ10 instruments (9,8 mm in outer diameter). Before starting, 2 ml of venous blood were collected, separated, and stored at -300C for the measurement of serum cortisol concentration. Following anesthesia of the pharynx by 10 ml of 2% xylocaine jelly, 1 mg of glucagon was intravenously 689
injected approximately 5 min before the endoscopy. Just after the injection of glucagon, administration of 100% oxygen was started at 2 mljmin by nasal prongs. Oxygen administration was continued throughout the endoscopic study. Pre-treatment and endoscopy were performed with the patients in the left lateral decubitus position. Group 1 received 0.1 mg of fentanyl citrate intravenously. Pulse rate, arterial oxygen saturation, and blood pressure were recorded continuously in all patients at 1 min intervals beginning 3 min before the endoscopic procedure using a Pulsemate BX5 pulse oximeter (Nippon Colin Co., Ltd. Tokyo, Japan) with a finger probe. Electrocardiographic monitoring in 72 of 84 patients was done by a Holter electrocardiocorder (Fukudadenshi Co., Ltd. Tokyo, Japan) throughout the endoscopic study. In addition to cardiopulmonary monitoring, each procedure was graded for patient tolerance by an independent observer who did not know in which group the patients were entered. Patient tolerance was based on the number of coughs or retchings according to the report by Lavies et al. 11 The stress score was graded as follows: 0 = excellent (no cough or retching), 1 = good (one cough or retching), 2 = fair (two coughs or retchings), 3 = poor (three or four coughs or retchings), and 4 = very poor (more than five coughs or retchings). Ten minutes after the end of the procedure, 2 ml of venous blood were sampled for cortisol measurement and then 0.2 mg of naloxone was injected intravenously to patients in group 1 to antagonize the sedative effect of fentanyl. Permission to perform this study was given by the institutional ethical committee of Miki City Hospital.
investigated, there was a strong positive correlation (correlation coefficient = 0.70) between these two parameters (Fig. 1). Table 2 shows the maximal increases of systolic blood pressure, heart rate, RPP, and the maximal decrease of arterial oxygen saturation (8a02) during endoscopy. The maximal increase or decrease was employed partly because the basal values of systolic blood pressure, heart rate, RPP, and 8a02 were not different between the groups and partly because the maximal changes from the basal values represent the endoscopy-induced changes most clearly. In the fentanyl group, the endoscopy-induced increase in systolic blood pressure and heart rate tended to be smaller than those of the control group. Consequently, the rise in RPP in the fentanyl group was significantly attenuated in comparison with that in the control group. The time course changes in RPP during endoscopy are shown in Figure 2. Within 5 min after endoscope intubation, RPP reached the maximal value and then gradually returned to basal level. Pre-treatment of the patients with intravenous injection of fentanyl re-
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Table 1 shows the effect of fentanyl on the stress of the patients. Fentanyl significantly decreased the stress score and endoscopy-induced elevation of serum cortisol concentrations. Although cortisol increased from 11.5 ± 0.9 to 16.6 ± 0.9 during endoscopy in the control group, there was no increase in cortisol concentration in the fentanyl group. When the correlation between the stress score and endoscopy-induced increase in rate-pressure product (RPP) (pulse rate X systolic blood pressure/100) was
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stress score Figure 1. There is a strong positive correlation (correlation coefficient = 0.70) between stress score and maximal increase in rate-pressure product during endoscopy (R = 0.7, P < 0.01). e, control cases; D, cases receiving fentanyl.
Table 1. Effect of fentanyl on the endoscopy-induced rise of stress score and serum cortisol concentration Serum cortisol (/Lg/ dl)
Age
Group
Stress score Basal
1: fentanyl (N 2: control (N
= 43)
= 41)
55 ± 2] 60 ± 2
NS
1.2 ± 0.2 ]"
13.2 ± 0.9]
2.3 ± 0.2
11.5 ± 0.9
Post-endoscopy NS
12.7 ± 1.3] b 16.6 ± 0.9
"p < 0.05. b P < 0.01 significantly different.
690
GASTROINTESTINAL ENDOSCOPY
Table 2. Effect of fentanyl on the endoscopy-induced alterations of heart rate, systolic blood pressure, rate-pressure product, and 8a02 Group
1: fentanyl (N 2: control (N a
Maximal increase in systolic blood pressure (mm Hg)
Maximal increase in heart rate (/min)
= 43)
28 ± 3 ]
= 41)
28 ± 3 ]
NS
39 ± 5
NS
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Fentanyl for sedation during upper gastrointestinal endoscopy Satoshi Ishido, MD, Yoshikazu Kinoshita, Naoto Kitajima, MD, Toshio Itoh, Katsuhito Nishiyama, MD, Masahide Tojo, Takashi Yano, MD, Tetsuya Inatome, Hisashi Fukuzaki, MD, Tsutomu Chiba,
MD MD MD MD MD
Miki Hyogo-ken, Japan and Kobe Hyogo-ken, Japan
The effects of sedation by intravenous fentanyl on the rate-pressure product (pulse rate x systolic blood pressure/100), arterial oxygen saturation, electrocardiographic change, and serum cortisol concentration were studied during gastroduodenoscopy in 84 patients randomized to receive fentanyl or no intravenous sedative (controls). Fentanyl administration increased the tolerance of patients and attenuated the endoscopy-induced rise in rate-pressure product and serum cortisol concentration. Desaturation of arterial oxygen was minimal and there was no difference in arterial oxygen saturation between the fentanyl group and the control group. Therefore, fentanyl appears to be a favorable sedative for upper gastrointestinal endoscopy, since its administration increased the tolerance of patients and decreased cardiac oxygen consumption. (Gastrointest Endosc
1992;38:689-692)
It is well known that gastroduodenoscopy causes elevation of blood pressure and heart rate by inducing psychological stress and discomfort. 1-4 In our previous study, we demonstrated that blood pressure and heart rate increase abruptly just after endoscopic intubation. 4 These rapid increases in blood pressure and pulse rate might be hazardous for patients with cardiac disease. Several authors have reported an increased rate of electrocardiographic abnormalities during gastroduodenoscopy.1, 5, 6 Although sedation by some narcotics is reported to decrease psychological stress and discomfort, 4 there are few reports in the literature concerning the beneficial effects of fentanyl on endoscopy-induced cardiopulmonary changes. This study was designed to investigate the effects of sedation by fentanyl on patient discomfort, and endoscopy-induced alterations of blood pressure, pulse rate, and electrocardiogram. It was hoped that fentanyl could be added to the number of efficacious drugs used for Received November 21, 1991. For revision January 27, 1992. Accepted April 2, 1992. From the Department of Medicine, Miki City Hospital, Miki Hyogoken, Japan and Department of Geriatrics, Kobe University School of Medicine, Kobe Hyogo-ken, Japan. Reprint requests: Yoshikazu Kinoshita, MD, Department of Medicine, Miki City Hospital, 58-1 Kasa, Miki-shi, Hyogo-ken, 673-04 Japan. VOLUME 38, NO.6, 1992
endoscopy premedication. Fentanyl was selected for study because it has low cardiovascular depressant effects, and can be easily antagonized by injection of naloxane. 7- 1o MATERIALS AND METHODS
Patients
Eighty-four patients with no evident cardiopulmonary disease were included in the study. All of the patients demonstrated normal electrocardiographic and chest x-ray examination results, In addition, they were checked by a cardiologist to exclude any patient with cardiopulmonary disease. The patients were then randomized into two groups. There was no significant difference in age between the two groups-Group 1 (fentanyl group): 0,1 mg of fentanyl citrate was injected intravenously as a sedative approximately 3 min before the intubation ofthe endoscope. Group 2 (control group): No sedative was employed prior to intubation. Endoscopic study
The endoscopic studies were performed by one of our three experienced endoscopists using Olympus GIF-XQ20 or XQ10 instruments (9,8 mm in outer diameter). Before starting, 2 ml of venous blood were collected, separated, and stored at -300C for the measurement of serum cortisol concentration. Following anesthesia of the pharynx by 10 ml of 2% xylocaine jelly, 1 mg of glucagon was intravenously 689
injected approximately 5 min before the endoscopy. Just after the injection of glucagon, administration of 100% oxygen was started at 2 mljmin by nasal prongs. Oxygen administration was continued throughout the endoscopic study. Pre-treatment and endoscopy were performed with the patients in the left lateral decubitus position. Group 1 received 0.1 mg of fentanyl citrate intravenously. Pulse rate, arterial oxygen saturation, and blood pressure were recorded continuously in all patients at 1 min intervals beginning 3 min before the endoscopic procedure using a Pulsemate BX5 pulse oximeter (Nippon Colin Co., Ltd. Tokyo, Japan) with a finger probe. Electrocardiographic monitoring in 72 of 84 patients was done by a Holter electrocardiocorder (Fukudadenshi Co., Ltd. Tokyo, Japan) throughout the endoscopic study. In addition to cardiopulmonary monitoring, each procedure was graded for patient tolerance by an independent observer who did not know in which group the patients were entered. Patient tolerance was based on the number of coughs or retchings according to the report by Lavies et al. 11 The stress score was graded as follows: 0 = excellent (no cough or retching), 1 = good (one cough or retching), 2 = fair (two coughs or retchings), 3 = poor (three or four coughs or retchings), and 4 = very poor (more than five coughs or retchings). Ten minutes after the end of the procedure, 2 ml of venous blood were sampled for cortisol measurement and then 0.2 mg of naloxone was injected intravenously to patients in group 1 to antagonize the sedative effect of fentanyl. Permission to perform this study was given by the institutional ethical committee of Miki City Hospital.
investigated, there was a strong positive correlation (correlation coefficient = 0.70) between these two parameters (Fig. 1). Table 2 shows the maximal increases of systolic blood pressure, heart rate, RPP, and the maximal decrease of arterial oxygen saturation (8a02) during endoscopy. The maximal increase or decrease was employed partly because the basal values of systolic blood pressure, heart rate, RPP, and 8a02 were not different between the groups and partly because the maximal changes from the basal values represent the endoscopy-induced changes most clearly. In the fentanyl group, the endoscopy-induced increase in systolic blood pressure and heart rate tended to be smaller than those of the control group. Consequently, the rise in RPP in the fentanyl group was significantly attenuated in comparison with that in the control group. The time course changes in RPP during endoscopy are shown in Figure 2. Within 5 min after endoscope intubation, RPP reached the maximal value and then gradually returned to basal level. Pre-treatment of the patients with intravenous injection of fentanyl re-
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Table 1 shows the effect of fentanyl on the stress of the patients. Fentanyl significantly decreased the stress score and endoscopy-induced elevation of serum cortisol concentrations. Although cortisol increased from 11.5 ± 0.9 to 16.6 ± 0.9 during endoscopy in the control group, there was no increase in cortisol concentration in the fentanyl group. When the correlation between the stress score and endoscopy-induced increase in rate-pressure product (RPP) (pulse rate X systolic blood pressure/100) was
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stress score Figure 1. There is a strong positive correlation (correlation coefficient = 0.70) between stress score and maximal increase in rate-pressure product during endoscopy (R = 0.7, P < 0.01). e, control cases; D, cases receiving fentanyl.
Table 1. Effect of fentanyl on the endoscopy-induced rise of stress score and serum cortisol concentration Serum cortisol (/Lg/ dl)
Age
Group
Stress score Basal
1: fentanyl (N 2: control (N
= 43)
= 41)
55 ± 2] 60 ± 2
NS
1.2 ± 0.2 ]"
13.2 ± 0.9]
2.3 ± 0.2
11.5 ± 0.9
Post-endoscopy NS
12.7 ± 1.3] b 16.6 ± 0.9
"p < 0.05. b P < 0.01 significantly different.
690
GASTROINTESTINAL ENDOSCOPY
Table 2. Effect of fentanyl on the endoscopy-induced alterations of heart rate, systolic blood pressure, rate-pressure product, and 8a02 Group
1: fentanyl (N 2: control (N a
Maximal increase in systolic blood pressure (mm Hg)
Maximal increase in heart rate (/min)
= 43)
28 ± 3 ]
= 41)
28 ± 3 ]
NS
39 ± 5
NS
39 ± 5
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Lowest Sa02 (%)
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