Critical Appraisal Topic

Critical Appraisal TopicCritical Appraisal Topic

Acquil Mohammad U. Alip, MDResidentDept. of AnesthesiologyUP-PGHManila, Philippines

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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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

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

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.

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

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

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

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.

Q2: Was allocation concealed?A- Not mentioned

Q3: Were baseline characteristics similar at the start of the trial?

A- Yes

Table 1: Demographic DataTable 1: Demographic Data

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

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

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

ResultsResultsQ1: How large was the treatment

effect?

Table 3: Haemodynamics (Blood Pressure And Table 3: Haemodynamics (Blood Pressure And

Heart Rate)Heart Rate)

Table 4: Respiratory Parameters (Mean Respiratory Table 4: Respiratory Parameters (Mean Respiratory Rate And Oxygen Saturation) Rate And Oxygen Saturation)

Table 5: Amnesia Table 5: Amnesia

Table 6: Sedation Score Table 6: Sedation Score

Table 7: Visual Analogue Score (Operator And Table 7: Visual Analogue Score (Operator And Patient) Patient)

Table 8: Recovery Score At 10 Minutes After Table 8: Recovery Score At 10 Minutes After Completion Of Procedure Completion Of Procedure

Table 9: Discharge Score Table 9: Discharge Score

Table 10: Adverse Effects Table 10: Adverse Effects

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,

◦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

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

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.

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

THANK YOU!THANK YOU!Assalamu Alaikom