Propofol-first sequence reduces hypoxemia in obese patients undergoing gastroscopy
Photo by David Trinks / Unsplash
Key Takeaway
Consider propofol-first sedation sequence to reduce hypoxemia risk in obese patients undergoing gastroscopy.
This randomized controlled trial at a single center compared two sedation sequences in obese patients scheduled for gastroscopy prior to bariatric surgery. In the propofol-first (P-R) sequence, propofol was administered before remifentanil; in the remifentanil-first (R-P) sequence, the order was reversed. The primary outcome was incidence of hypoxemia.
The authors observed a lower incidence of hypoxemia in the P-R group compared with the R-P group. The lowest peripheral oxygen saturation was also higher in the P-R group. These findings suggest that starting sedation with propofol may reduce the risk of oxygen desaturation in this population.
Key limitations include the single-center design and lack of blinding, which may introduce bias. The study did not report follow-up duration or serious adverse events. Minimal respiratory depression was noted in subgroups with higher body mass index. The sample size was relatively small, and the results may not generalize to other procedures or patient populations.
Clinicians should consider the sedation sequence when planning gastroscopy in obese patients. However, these findings require replication in larger, blinded, multicenter trials before practice changes can be recommended. The study does not establish a mechanism for the observed difference.
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View Original Abstract ↓
PURPOSE: Obesity is associated with an elevated risk of hypoxemia during endoscopic procedures performed under anesthesia. However, whether the sequence of drug administration - specifically the order of propofol and remifentanil - affects the incidence of hypoxemia remains unclear. This study was designed to evaluate whether a novel administration sequence, in which propofol precedes remifentanil, can decrease the incidence of hypoxemia in obese individuals during endoscopy.
PATIENTS AND METHODS: This prospective, single center, randomized controlled clinical trial recruited 296 obese patients scheduled for sedative/anesthesia gastroscopy prior to bariatric surgery. Patients were randomly assigned to either novel administration sequence with propofol-remifentanil (P-R) group or conventional administration of remifentanil-propofol (R-P) group. The primary outcome was the incidence of hypoxemia. Secondary outcomes included the lowest peripheral oxygen saturation (L-SpO) during the procedure, hemodynamic parameters at six time points, and additional perioperative events.
RESULTS: 284 patients were included in the analysis with 142 in each group. Hypoxemia occurred in 22 patients (15.5%) in the P-R group, and 42 patients (29.6%) in the R-P group (Relative Risk [RR], 1.44; 95% confidence interval [CI], 1.13 to 1.79; P = 0.007). The L-SpO during the procedure was significantly higher in the P-R group than in the R-P group (median [interquartile range, IQR], 94.0% [91.0 to 97.0] vs 93.0% [87.7 to 95.0]; P < 0.001). The P-R sequence technique was also associated with more stable hemodynamic profiles, shorter induction time, the start of drug administration to scope insertion and recovery time, improved patient's satisfaction. Particularly, minimal respiratory depression was observed in subgroups such as body mass index (BMI) ≥ 40 kg/m.
CONCLUSION: Propofol first and followed by remifentanil administration sequence significantly decreased the incidence of hypoxemia and increased the L-SpO in obese patients for their anesthesia/sedation gastroscopy.
CLINICAL TRIAL REGISTRATION: ChiCTR2400084998.
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