Critical Appraisal Topic Acquil Mohammad U. Alip, MD Resident Dept. of Anesthesiology UP-PGH Manila, Philippines

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 find Conscious sedation in interventional radiology: A comparison of Propofol versus Midazolam Anagha U. Manjrekar, M.D. Deepa Kane, M.D Lalita Dewoolkar, M.D. Prerana Shroff, M.D. Department of Anaesthesiology Seth G.S.Medical College and K.E.M.Hospital Mumbai India

Terminology Conscious 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 Abstract Most 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 Abstract Randomized, double-blinded study Compared Propofol and Midazolam with respect to safety and efficacy 60 patients Grouped into : A- Midazolam+Fentanyl B- Propofol+Fentanyl  All patients received 1 μ g.kg -1 fentanyl i.v. before access area was prepared and draped

Group A patients received 15 μ g/kg Midazolam bolus followed by an 0.5 μ g.kg/min group B received a bolus of Propofol 0.5mg/kg followed by an 25 μ g/kg/min bolus dose of fentanyl 25 μ g was administered as needed for excessive pain

Appraising Validity Q1: 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 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

Results Q1: How large was the treatment effect?

Table 3: Haemodynamics (Blood Pressure And Heart Rate)

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

Table 5: Amnesia

Table 6: Sedation Score

Table 7: Visual Analogue Score (Operator And Patient)

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

Table 9: Discharge Score

Table 10: Adverse Effects

Conclusion Authors 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 Applicability The 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.

Conclusion 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 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! Assalamu Alaikom