Painless gastrointestinal endoscopy: intravenous anesthesia method

Painless gastrointestinal endoscopy: intravenous anesthesia method.  Research progress of painless gastrointestinal endoscopic intravenous analgesia and sedation methods.

Intravenous analgesia and sedation anesthesia can not only reduce the painful experience of patients, but also have better compliance.

With the improvement of endoscopy technology, gastrointestinal endoscopy has become an important part of patient management, especially in the screening of gastrointestinal tumors with increasing credibility. As an important part of gastrointestinal endoscopic surgery, intravenous analgesia and sedation play an important role in improving patient comfort, alleviating patient anxiety, reducing patients’ painful memories of events, and assisting gastrointestinal endoscopists to complete endoscopy. From traditional analgesia and sedation centered on fixed procedures to personalized analgesia and sedation with the help of computer algorithms, medical equipment continues to iterate with the improvement of technology.

The entire process of analgesia and sedation releases more procedures that should be completely implemented manually. Medical staff can focus more on the vital signs monitoring of the examinee to obtain more abundant and accurate monitoring data, so as to have a good control of the entire endoscopy and minimize the risk. Since the effect of analgesia and sedation is closely related to the depth of the level of analgesia and sedation, the depth of the level of analgesia and sedation depends on the complexity and possible duration of the entire endoscopy, the individual characteristics of the patient, the physical condition, the anesthesiologist and the stomach The subjective experience of colonoscopy physicians, etc. Therefore, how to achieve the right depth of analgesia and sedation on the basis of safety and comfort is the focus of anesthesiologists’ attention. The research progress of painless gastrointestinal endoscopic intravenous analgesia and sedation methods is reviewed.

1. Intensive (traditional) analgesia and sedation

Intensive analgesia and sedation is a technique based on a fixed program in which medical staff give patients continuous or intermittent intravenous injection of analgesic and sedative drugs within a specified period of time to achieve analgesic and sedative effects. Early intensive analgesia and sedation techniques were more mechanical in terms of drug dosage, medication time, and operating methods, and less considered individual differences in the subject. Even if the above factors are taken into account, it is usually based on the doctor’s experience level to judge the subject’s vital signs and their reflexes.

The information feedback of analgesia and sedation effect mainly comes from the subjective judgment made by medical staff on the degree of analgesia and sedation of the subject, and this judgment is usually biased. Especially when used in more complicated and time-consuming treatments such as radiofrequency treatment of gastroesophageal reflux disease, the depth of analgesia and sedation is more difficult to grasp, and the risk is significantly increased. Therefore, intensive analgesia and sedation may lead to overdose or insufficient medication by anesthesiologists. Overdose may lead to respiratory depression or hypoxemia, lower blood pressure, slower heart rate, delayed recovery and other complications due to excessive analgesia and sedation. Insufficient medication may This leads to poor analgesia and sedation, increases the patient’s pain and the inability to perform endoscopic examinations smoothly, and even causes serious complications such as gastrointestinal bleeding and perforation due to the patient’s physical movement. Therefore, intensive analgesia and sedation are mainly used for analgesia and sedation with underdeveloped analgesia and sedation techniques, as well as analgesia and sedation under special conditions or under specific conditions, such as short-term gastroscopy and colonoscopy.

However, due to the simple operation of intensive analgesia and sedation, the use of equipment is easy and economical and practical, it still has applicability for some primary hospitals and medical institutions with limited conditions. In addition, under certain conditions (such as treatment of patients with exacerbations of chronic obstructive pulmonary disease, anti-anxiety prevention of radial artery spasm, and short-term intensive analgesia and sedation after spontaneous cerebral hemorrhage), intensive analgesia and sedation are still applicable , And it is very helpful for patients with short-term intensive analgesia and sedation after spontaneous cerebral hemorrhage in the later recovery.

2. Patient controlled analgesia and sedation

Patient-controlled analgesia and sedation is a safer, more effective, comfortable and easy-to-control analgesia and sedation technique for patients undergoing endoscopy or surgery. Patient-controlled analgesia is a clinical application technology developed after patient-controlled analgesia, which is derived from patient-controlled analgesia. Through the use of pharmacological and non-pharmacological methods, the patient’s state of consciousness is minimized and the patient can maintain independently The continuous airway is unobstructed, has a certain response to language commands and physiological stimuli, and has little effect on breathing and circulation. It is especially beneficial for patients with hypertension and coronary heart disease, and can reduce myocardial oxygen consumption.

Compared with traditional intensive analgesia and sedation, patient-controlled analgesia and sedation takes more into consideration factors such as the patient’s physical characteristics, mental status, and drug sensitivity, and truly reflects on-demand administration. In the patient-controlled analgesia sedation system, the patient instructs the infusion system to release the drug until the set point. In the systematic study of patient-controlled analgesia and traditional intravenous analgesia, Lu et al. found that both methods are feasible and effective in terms of analgesia and sedation, but they are self-controlled in terms of pulse oximetry and hypotension. Analgesia and sedation have significant advantages.

At present, more patient-controlled analgesia and sedation are used in clinical practice, especially for younger and higher-risk patients, and it can also effectively reduce the adverse effects of patients during surgery. A prospective and randomized controlled study compared the analgesic and sedative effects of propofol and remifentanil in patient-controlled analgesia sedation. The results showed that patients who used propofol and remifentanil in patient-controlled sedation Pain sedation is a safe and widely accepted technique for analgesia and sedation by endoscopy subjects. In addition, the patient-controlled analgesia and recovery time of patients in the propofol and remifentanil group were significantly shorter than those of the patients in the remifentanil and midazolam group.

Studies have shown that the comprehensive analgesic and sedative effect of the combination of propofol and remifentanil is significantly better than that of the remifentanil and midazolam groups. Patient-controlled analgesia and sedation techniques also have certain limitations in the complicated environment and time-consuming gastrointestinal surgery, but in gastrointestinal endoscopy, both the subject and the examiner are widely recognized.

3. Target controlled infusion

Target-controlled infusion has become an established technology for the management of intravenous anesthetics since its commercial launch in 1996. Target-controlled infusion is to control the general anesthetic drugs injected into the body with the help of computers for patients of different genders, ages, and weights, so as to improve the controllability of general anesthesia to achieve the appropriate or expected depth of general anesthesia. Target-controlled infusion is based on the principles of pharmacokinetics and pharmacodynamics, and is programmed into a computer program with the concentration of the drug in the plasma or the effect chamber as an indicator. The electronic infusion pump controlled by the computer sets the infusion rate to administer the drug to maintain the body Appropriate and stable blood drug concentration to achieve stable plasma concentration or effect site concentration at the expected value (target concentration value).

Target-controlled infusion technology is more widely used in complex digestive endoscopic surgery. Therapeutic endoscopic retrograde is performed under sufentanil combined with midazolam and continuous infusion of propofol for analgesia, sedation, and analgesia. During cholangiopancreatography, the anesthesia effect of the patient is accurate, the speed of falling asleep and waking up is faster, and the adverse reactions such as nausea and pain are significantly reduced. At the same time, it can reduce the patient’s intraoperative anxiety, coughing, and restlessness, so that the patient’s heart rate, blood pressure, Vital signs such as breathing, pulse and blood oxygen saturation tend to be stable, and the safety is relatively ideal. More than 95% of patients have no bad memories of the entire process of therapeutic endoscopic retrograde cholangiopancreatography, which reduces patient anxiety and mental trauma, and makes patients satisfied with therapeutic endoscopic retrograde cholangiopancreatography improve.

Target-controlled infusion technology is used to provide the best analgesia and sedation in endoscopy. Modern target-controlled infusion systems are characterized by more and more additional options and features. For example, the choice between different pharmacokinetic models and application modes comprehensively describes the differences between the pharmacokinetic models, application modes and the effects of covariates and the consequences of drug delivery, and the purpose is to clarify for users of modern target-controlled infusion systems Relevance of underlying scientific concepts and clinical practice. Target-controlled infusion tries to provide the best analgesia and sedation solution, predicts the patient’s plasma through pharmacokinetic models, and allows the anesthesiologist to set a specific concentration so that the target-controlled infusion system can automatically reach the desired concentration. Quickly complete and maintain the pre-determined plasma or effect site concentration of the anesthesiologist, thereby effectively avoiding insufficient or excessive analgesic sedation during endoscopic surgery.

At present, target-controlled infusion devices for the administration of propofol have been approved in some countries and regions. The study by Chang et al. identified target-controlled infusion as a classic method for endoscopic surgical analgesia and sedation, through the use of anesthesia quality Scoring is used to evaluate the quality of different analgesia and sedation protocols, and the target-controlled infusion method allows rapid titration of drug concentration to achieve good results. Studies have confirmed that target-controlled infusion analgesia under endoscopy provides safe and effective analgesia and sedation, and the quality of analgesia and sedation is good. Wang et al. evaluated whether the target-controlled infusion of propofol can provide better analgesia and sedation than manual infusion, so as to train inexperienced anesthesiologists. The results show that for the analgesia and sedation of colonoscopy, the target Controlled infusion is a more effective and safe technique for anesthesia practice, which can resolve individual differences in sensitivity to analgesic and sedative drugs and different preferences for the degree of analgesia and sedation required, so as to provide the best analgesia and sedation for each patient Program.

4. Intelligent assisted personalized analgesia and sedation

At present, personalized medicine and precision medicine have become hot spots in the global medical community, and intelligent assisted personalized analgesia and sedation is one of them. The application of intelligent assistive technology has provided great convenience to medical staff, saving more effective working time, so that there is more time to evaluate patients, so that patients can recover and discharge faster and be discharged from the hospital, which greatly shortens the number of patients. The length of hospital stay reduces the financial burden of patients and their families. Intelligent assisted personalized analgesia and sedation is a technology that uses computer algorithms to deliver propofol to the patient’s blood based on the patient’s response to stimulation and physiological characteristics to achieve mild to moderate analgesia and sedation. By making corresponding adjustments to the drug delivery, signs of excessive analgesia and sedation can be detected, so as to automatically adjust or terminate the infusion process, realize comprehensive monitoring of the patient, and adjust the degree of analgesia and sedation; based on quantifiable physiological parameter calculations and Deliver an appropriate amount of propofol, seeking to make propofol analgesic and sedative delivery predictable, accurate, and safe.

After the American Society of Gastrointestinal Endoscopy Technical Committee evaluated new or emerging endoscopy techniques, it was found that the endoscopy group giving propofol and remifentanil analgesia and sedation may be inaccurate, because during the entire operation , Continuously judge the depth of analgesia and sedation, comfort and safety may be affected by the interference inherent in endoscopic surgery. Even if the anesthesiologist administers the drug during the colonoscopy, the therapeutic index is low, and excessive analgesia and sedation may occur. Based on the patient’s response to stimuli and physiological characteristics, intelligent assisted personalized analgesia and sedation provide a more effective method to determine safe and effective doses of propofol and remifentanil. Closed-loop target control systems or continuous EEG recordings are used to assess the depth of analgesia and sedation. Patient control platforms can also be used. These devices can help physicians titrate propofol administration and control physiological functions.

Studies have shown that smart-assisted personalized analgesia and sedation can improve the feasibility of accurate use of propofol and fentanyl by the endoscopy medical team. For routine endoscopy, the analgesia and sedation effect is better and the postoperative recovery time is faster. At present, the more popular intelligent auxiliary personalized analgesia and sedation systems are mainly the automatic anesthesia machine SEDASYS launched by Johnson & Johnson. The SEDASYS automatic anesthesia machine system can automatically provide the drugs propofol and remifentanil for moderate to severe analgesia Sedation, and can monitor the patient comprehensively, and adjust the depth of analgesia and sedation by controlling the corresponding drug delivery.

Therefore, from the perspective of clinical application advantages, the intelligent assisted personalized analgesia and sedation system provides feasible analgesia and sedation technical support for health care professionals who have not received general anesthesia training, especially in mild to moderate levels of propofol Phenol is more suitable for analgesia and sedation, and the device can be used for routine endoscopy. However, further research is still needed to determine the suitability of intelligent assisted personalized analgesia and sedation systems in high-risk patients and special procedures. For example, smart-assisted personalized analgesia and sedation show poor flexibility in emergency situations, which needs to be further improved; in addition, government supervision of related equipment may also become an important factor in mass clinical promotion.

5. Summary

Intravenous analgesia and sedation anesthesia can not only reduce the painful experience of patients, but also have better compliance. With the development of technology, new types of analgesia and sedative drugs and intelligent auxiliary devices provide convenience for related anesthesia practitioners, and at the same time pose a huge challenge to the future career of anesthesia practitioners.

In addition, as people’s requirements for comfort medical treatment continue to increase, the application of comfort medical technology in various examinations and treatments has attracted widespread attention.

Therefore, while rationally using new drug equipment, anesthesiologists should pay more attention to the detailed evaluation before anesthesia, the preparation of preoperative equipment and drugs, the applicability of drugs, strict intraoperative monitoring, emergency management, and post-anaesthesia management. At the same time, we should pay attention to the initiative of medical staff.

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