The Korean journal of internal medicine

The Korean Association of Internal Medicine (대한내과학회)
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Is propofol safe when administered to cirrhotic patients during sedative endoscopy?

  • Suh, Sang Jun (Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Ansan Hospital) ;
  • Yim, Hyung Joon (Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Ansan Hospital) ;
  • Yoon, Eileen L. (Division of Hepatology, Department of Internal Medicine, Korea University Guro Hospital) ;
  • Lee, Beom Jae (Division of Hepatology, Department of Internal Medicine, Korea University Guro Hospital) ;
  • Hyun, Jong Jin (Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Ansan Hospital) ;
  • Jung, Sung Woo (Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Ansan Hospital) ;
  • Koo, Ja Seol (Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Ansan Hospital) ;
  • Kim, Ji Hoon (Division of Hepatology, Department of Internal Medicine, Korea University Guro Hospital) ;
  • Kim, Kyung Jin (Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Ansan Hospital) ;
  • Choung, Rok Son (Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Ansan Hospital) ;
  • Seo, Yeon Seok (Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Anam Hospital) ;
  • Yeon, Jong Eun (Division of Hepatology, Department of Internal Medicine, Korea University Guro Hospital) ;
  • Um, Soon Ho (Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Anam Hospital) ;
  • Byun, Kwan Soo (Division of Hepatology, Department of Internal Medicine, Korea University Guro Hospital) ;
  • Lee, Sang Woo (Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Ansan Hospital) ;
  • Choi, Jai Hyun (Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Ansan Hospital) ;
  • Ryu, Ho Sang (Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Anam Hospital)
  • Received : 2013.05.05
  • Accepted : 2013.07.18
  • Published : 2014.01.01
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Abstract

Background/Aims: In patients with liver cirrhosis, drugs acting on the central nervous system can lead to hepatic encephalopathy and the effects may be prolonged. Recently, misuse of propofol has been reported and the associated risk of death have become an issue. Propofol is commonly used during sedative endoscopy; therefore, its safety in high-risk groups must be further investigated. We performed a pilot study of the safety and efficacy of propofol during endoscopy in Korean patients with cirrhosis. Methods: Upper gastrointestinal endoscopy was performed under sedation with propofol along with careful monitoring in 20 patients with liver cirrhosis and 20 control subjects. The presence or development of hepatic encephalopathy was assessed using the number connection test and neurologic examination. Results: Neither respiratory depression nor clinically significant hypotension were observed. Immediate postanesthetic recovery at 5 and 10 minutes after the procedure was delayed in the cirrhotic patients compared with the control group; however, at 30 minutes, the postanesthetic recovery was similar in both groups. Baseline psychomotor performance was more impaired in cirrhotic patients, but propofol was not associated with deteriorated psychomotor function even in cirrhotic patients with a minimal hepatic encephalopathy. Conclusions: Sedation with propofol was well tolerated in cirrhotic patients. No newly developed hepatic encephalopathy was observed.

Keywords

References

  1. Cheung RC, Cooper S, Keeffe EB. Endoscopic gastrointestinal manifestations of liver disease. Gastrointest Endosc Clin N Am 2001;11:15-44.
  2. Sarin SK, Lahoti D, Saxena SP, Murthy NS, Makwana UK. Prevalence, classification and natural history of gastric varices: a long-term follow-up study in 568 portal hypertension patients. Hepatology 1992;16:1343-1349. https://doi.org/10.1002/hep.1840160607
  3. Sarin SK, Sreenivas DV, Lahoti D, Saraya A. Factors influencing development of portal hypertensive gastropathy in patients with portal hypertension. Gastroenterology 1992;102:994-999. https://doi.org/10.1016/0016-5085(92)90188-5
  4. Liao WC, Hou MC, Chang CJ, Lee FY, Lin HC, Lee SD. Potential precipitating factors of esophageal variceal bleeding: a case-control study. Am J Gastroenterol 2011;106:96-103. https://doi.org/10.1038/ajg.2010.342
  5. Haq MM, Faisal N, Khalil A, Haqqi SA, Shaikh H, Arain N. Midazolam for sedation during diagnostic or therapeutic upper gastrointestinal endoscopy in cirrhotic patients. Eur J Gastroenterol Hepatol 2012;24:1214-1218. https://doi.org/10.1097/MEG.0b013e328356ae49
  6. Rivera Ramos JF, Rodriguez Leal C. Review of the final report of the 1998 Working Party on definition, nomenclature and diagnosis of hepatic encephalopathy. Ann Hepatol 2011;10 Suppl 2:S36-S39.
  7. Vargo JJ. Propofol: a gastroenterologist's perspective. Gastrointest Endosc Clin N Am 2004;14:313-323. https://doi.org/10.1016/j.giec.2004.01.005
  8. Riphaus A, Gstettenbauer T, Frenz MB, Wehrmann T. Quality of psychomotor recovery after propofol sedation for routine endoscopy: a randomized and controlled study. Endoscopy 2006;38:677-683. https://doi.org/10.1055/s-2006-925244
  9. Servin F, Cockshott ID, Farinotti R, Haberer JP, Winckler C, Desmonts JM. Pharmacokinetics of propofol infusions in patients with cirrhosis. Br J Anaesth 1990;65:177-183. https://doi.org/10.1093/bja/65.2.177
  10. Costela JL, Jimenez R, Calvo R, Suarez E, Carlos R. Serum protein binding of propofol in patients with renal failure or hepatic cirrhosis. Acta Anaesthesiol Scand 1996;40:741-745. https://doi.org/10.1111/j.1399-6576.1996.tb04521.x
  11. Riphaus A, Lechowicz I, Frenz MB, Wehrmann T. Propofol sedation for upper gastrointestinal endoscopy in patients with liver cirrhosis as an alternative to midazolam to avoid acute deterioration of minimal encephalopathy: a randomized, controlled study. Scand J Gastroenterol 2009;44:1244-1251. https://doi.org/10.1080/00365520903194591
  12. Amoros A, Aparicio JR, Garmendia M, Casellas JA, Martinez J, Jover R. Deep sedation with propofol does not precipitate hepatic encephalopathy during elective upper endoscopy. Gastrointest Endosc 2009;70:262-268. https://doi.org/10.1016/j.gie.2008.10.038
  13. Correia LM, Bonilha DQ, Gomes GF, et al. Sedation during upper GI endoscopy in cirrhotic outpatients: a randomized, controlled trial comparing propofol and fentanyl with midazolam and fentanyl. Gastrointest Endosc 2011;73:45-51. https://doi.org/10.1016/j.gie.2010.09.025
  14. Khamaysi I, William N, Olga A, et al. Sub-clinical hepatic encephalopathy in cirrhotic patients is not aggravated by sedation with propofol compared to midazolam: a randomized controlled study. J Hepatol 2011;54:72-77. https://doi.org/10.1016/j.jhep.2010.06.023
  15. Weissenborn K, Ruckert N, Hecker H, Manns MP. The number connection tests A and B: interindividual variability and use for the assessment of early hepatic encephalopathy. J Hepatol 1998;28:646-653.
  16. Aldrete JA, Kroulik D. A postanesthetic recovery score. Anesth Analg 1970;49:924-934.
  17. Beppu K, Inokuchi K, Koyanagi N, et al. Prediction of variceal hemorrhage by esophageal endoscopy. Gastrointest Endosc 1981;27:213-218. https://doi.org/10.1016/S0016-5107(81)73224-3
  18. Weston BR, Chadalawada V, Chalasani N, et al. Nurse-administered propofol versus midazolam and meperidine for upper endoscopy in cirrhotic patients. Am J Gastroenterol 2003;98:2440-2447. https://doi.org/10.1111/j.1572-0241.2003.08668.x
  19. Assy N, Rosser BG, Grahame GR, Minuk GY. Risk of sedation for upper GI endoscopy exacerbating subclinical hepatic encephalopathy in patients with cirrhosis. Gastrointest Endosc 1999;49:690-694. https://doi.org/10.1016/S0016-5107(99)70283-X
  20. Ferenci P, Lockwood A, Mullen K, Tarter R, Weissenborn K, Blei AT. Hepatic encephalopathy: definition, nomenclature, diagnosis, and quantification: final report of the working party at the 11th World Congresses of Gastroenterology, Vienna, 1998. Hepatology 2002;35:716-721. https://doi.org/10.1053/jhep.2002.31250
  21. Das A, Dhiman RK, Saraswat VA, Verma M, Naik SR. Prevalence and natural history of subclinical hepatic encephalopathy in cirrhosis. J Gastroenterol Hepatol 2001;16:531-535. https://doi.org/10.1046/j.1440-1746.2001.02487.x
  22. Ortiz M, Jacas C, Cordoba J. Minimal hepatic encephalopathy: diagnosis, clinical significance and recommendations. J Hepatol 2005;42 Suppl:S45-S53. https://doi.org/10.1016/j.jhep.2004.11.028
  23. Romero-Gomez M, Cordoba J, Jover R, et al. Value of the critical flicker frequency in patients with minimal hepatic encephalopathy. Hepatology 2007;45:879-885. https://doi.org/10.1002/hep.21586
  24. Romero-Gomez M, Boza F, Garcia-Valdecasas MS, Garcia E, Aguilar-Reina J. Subclinical hepatic encephalopathy predicts the development of overt hepatic encephalopathy. Am J Gastroenterol 2001;96:2718-2723. https://doi.org/10.1111/j.1572-0241.2001.04130.x
  25. Li YY, Nie YQ, Sha WH, et al. Prevalence of subclinical hepatic encephalopathy in cirrhotic patients in China. World J Gastroenterol 2004;10:2397-2401. https://doi.org/10.3748/wjg.v10.i16.2397
  26. Bajaj JS, Saeian K, Schubert CM, et al. Minimal hepatic encephalopathy is associated with motor vehicle crashes: the reality beyond the driving test. Hepatology 2009;50:1175-1183. https://doi.org/10.1002/hep.23128
  27. McCrea M, Cordoba J, Vessey G, Blei AT, Randolph C. Neuropsychological characterization and detection of subclinical hepatic encephalopathy. Arch Neurol 1996;53:758-763. https://doi.org/10.1001/archneur.1996.00550080076015
  28. Amodio P, Del Piccolo F, Marchetti P, et al. Clinical features and survivial of cirrhotic patients with subclinical cognitive alterations detected by the number connection test and computerized psychometric tests. Hepatology 1999;29:1662-1667. https://doi.org/10.1002/hep.510290619
  29. Dhiman RK, Saraswat VA, Verma M, Naik SR. Figure connection test: a universal test for assessment of mental state. J Gastroenterol Hepatol 1995;10:14-23. https://doi.org/10.1111/j.1440-1746.1995.tb01041.x
  30. Kranioti EF, Mavroforou A, Mylonakis P, Michalodimitrakis M. Lethal self administration of propofol (Diprivan): a case report and review of the literature. Forensic Sci Int 2007;167:56-58. https://doi.org/10.1016/j.forsciint.2005.12.027
  31. Kirby RR, Colaw JM, Douglas MM. Death from propofol: accident, suicide, or murder? Anesth Analg 2009;108:1182-1184. https://doi.org/10.1213/ane.0b013e318198d45e
  32. Iwersen-Bergmann S, Rosner P, Kuhnau HC, Junge M, Schmoldt A. Death after excessive propofol abuse. Int J Legal Med 2001;114:248-251. https://doi.org/10.1007/s004149900129
  33. Yoon HJ, Kim SG, Na HS, et al. Safety and efficacy of propofol for sedative endoscopy in patients with compensated liver cirrhosis. Korean J Med 2008;75:546-552.
  34. Jeong S, Lee HG, Kim WM, et al. Increase of paradoxical excitement response during propofol-induced sedation in hazardous and harmful alcohol drinkers. Br J Anaesth 2011;107:930-933. https://doi.org/10.1093/bja/aer275

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