|Year : 2015 | Volume
| Issue : 3 | Page : 327-333
The emergence profile of propofol sedation compared with dexmedetomidine injection during ultrasound-guided oocyte pickup for in-vitro fertilization
Mayar H Elsersi MD 1, Wessam M Abuelghar2, Ahmed K Makled2
1 Department of Anesthesia, Intensive Care Medicine, and Pain Management, Faculty of Medicine, Ain Shams University, Cairo, Egypt
2 Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
|Date of Submission||31-May-2014|
|Date of Acceptance||06-Nov-2013|
|Date of Web Publication||29-Jul-2015|
Mayar H Elsersi
Department of Anesthesia, Intensive Care Medicine, and Pain Management, Ain Shams University, Cairo
Source of Support: None, Conflict of Interest: None
The purpose of this study was to assess the quality, the recovery, and side effects of propofol sedation compared with dexmedetomidine in a very short minimally invasive procedure such as ultrasound-guided oocyte pickup for in-vitro fertilization.
Patients and methods
Sixty-two female patients undergoing 'ultrasound-guided oocyte pickup' were randomly enrolled in the study, conducted in a specialized center (Elite Fertility Center, Cairo, Egypt). The emergence profile of sedation with propofol+fentanyl versus dexmedetomidine +fentanyl was compared. The sedation level was assessed and titrated to an Observer's Assessment of Alertness/Sedation (OAAS) score of 1-2 (responds only after mild prodding or no response to prodding or shaking). Recovery was assessed objectively by OAAS and subjectively by visual analog scale (VAS).
There is no significant difference in intraoperative parameters regarding the heart rate, the mean arterial blood pressure, the respiratory rate, and SpaO 2 between group D (dexmedetomidine) and group P (propofol). Yet the induction time to the desired level of sedation was significantly shorter in group P compared with group D. Most of the group D patients returned postoperatively to an OAAS score of 5 earlier than group P patients. Group D showed a significantly lower VAS as compared with group P at 1 and 2 h postoperatively, whereas there was no significant difference in the VAS between the two groups at 3 h postoperatively.
Both propofol and dexmedetomidine are useful and safe for short-period procedural sedation; yet dexmedetomidine has a more rapid induction time of sedation than propofol, better analgesic effect with similar hemodynamic effects, better preservation of respiratory function, and rapid recovery. Thus, dexmedetomidine is a good alternative for short-period procedural sedation such as in ultrasound-guided oocyte pickup.
Keywords: fentanyl, fertilization, oocyte, propofol
|How to cite this article:|
Elsersi MH, Abuelghar WM, Makled AK. The emergence profile of propofol sedation compared with dexmedetomidine injection during ultrasound-guided oocyte pickup for in-vitro fertilization. Ain-Shams J Anaesthesiol 2015;8:327-33
|How to cite this URL:|
Elsersi MH, Abuelghar WM, Makled AK. The emergence profile of propofol sedation compared with dexmedetomidine injection during ultrasound-guided oocyte pickup for in-vitro fertilization. Ain-Shams J Anaesthesiol [serial online] 2015 [cited 2020 Jun 6];8:327-33. Available from: http://www.asja.eg.net/text.asp?2015/8/3/327/161693
| Introduction|| |
Sedation for surgical procedures is usually achieved by a variety of intravenous medications, such as benzodiazepines, narcotics, pentothal sodium, and propofol. Propofol is an intravenous anesthetic, which is chemically described as 2,6-di-isopropyl-phenol and has a molecular weight of 178.27. Propofol is slightly soluble in water and is prepared in a white, oil-in-water emulsion. Propofol has been used frequently for the induction of anesthesia because of its characteristic smooth and rapid induction  . It has numerous mechanisms of action, such as the potentiation of GABAA receptor activity, thereby slowing the channel-closing time, and also by acting as a sodium channel blocker  .
Propofol is useful for short procedures and facilitates quick recovery  .
The purpose of this investigation was to assess the quality, the clinical feasibility, the recovery, and side effects of propofol+fentanyl sedation compared with intravenous dexmedetomidine+fentanyl sedation.
Dexmedetomidine is a highly selective a-2-adrenoreceptor agonist having both sedative and analgesic properties and lacking the respiratory depressant effect  . Patients given dexmedetomidine are effortlessly arousable, and yet seem calm and comfortable. When they are unstimulated, patients go back to a hypnotic state. Also, dexmedetomidine offers hemodynamic stability and have no clinically significant adverse effects on respiration  . Dexmedetomidine is a striking agent for short-period procedural sedation and has been used securely in transesophageal echocardiography  , and in pediatric patients undergoing tonsillectomy  , awake carotid endarterectomy  , shockwave lithotripsy  , elective awake fiberoptic intubation  , vitreoretinal surgery  , colonoscopy  , and pediatric MRI  .
| Patients and methods|| |
Sixty-two patients (American Society of Anesthesiologists physical status I-II, aged 18-35 years) were enrolled, in a randomized investigation involving a protocol approved by the center's medical board. Written informed consent was obtained from all patients. Patients were scheduled for an elective minimally invasive procedure (ultrasound-guided oocyte pickup) of an estimated duration of 15-20 min and requested sedation and analgesia. Individuals were excluded from the study if they are taking opioids or sedatives within 24 h before enrollment; also, patients consuming a-2-adrenergic receptors antagonists, with dysrhythmia in the ECG, severe bradycardia (heart rate <50 beats/min) or heart block, hypovolemia or hypotension (systolic blood pressure <80 or mean arterial pressure <50 mmHg), or those at risk for aspiration were excluded. All patients fasted for a minimum of 6-8 h before intervention. No preoperative sedation, opioids or prophylactic antiemetics were given. Procetamol intravenous infusion 1 g was permitted for analgesia during the procedure in both groups.
Participants were randomized into either the propofol group (group P) (n = 31) or the dexmedetomidine group (group D) (n = 31). Patient treatment assignments were randomly selected by the closed-envelope method. All patients received an air-oxygen mixture at 3 l/min through a face mask connected to a semiclosed anesthetic circuit through a Datex Ohmeda Aestiva/5 (GE, Madison, USA) anesthesia machine, and 8-20 mg/kg of fentanyl narcotic was given intravenously. Patients were monitored with an ECG, noninvasive blood pressure, and pulse oxymetry.
Group P received 0.7 mg/kg of propofol (propofol 1% Fresenius, (Freseius-Kabi, Egypt) 10 mg/ml propofol) intravenously over 10 min, and then a maintenance infusion of 0.5-2 mg/kg/h.
Group D received an intravenous loading dose of 1 mg/kg dexmedetomidine (Precedex, 200 mg/2 ml; Abbott, Chicago, Illinois, USA) over 10 min and a maintenance dose of 0.2 to 0.5 mg/kg/h.
The sedation level was assessed every minute using the Observer's Assessment of Alertness/Sedation (OAAS) scale  and titrated to an OAAS score of 2 [Table 1]. Clinical assessment of the sedation depth was used to adjust the drug dose (clinical end point). Maintenance level was defined as three consecutive OAAS scores of 2; subsequent assessments were then made every 5 min. Inadequate sedation was treated by increasing increments of propofol or dexmedetomidine injection till the desired effect was reached. The level of sedation was maintained at an OAAS score of 2 throughout the procedure until the suction needle was removed or the procedure was completed. During the procedure, if apnea occurred or respiratory rate was less than 10 or SpaO 2 was 92% or less, 4 l/min of supplemental oxygen was administered through a nasal cannula. If bradycardia (heart rate <45 beats/min) occurred, 0.5 mg atropine was given with decreasing rate of infusion of the drug, targeting to awaken the patient and resume normal breath.
Administration of other sedating agents was prohibited and resulted in patient removal from data analysis. However, analgesia during the procedure was implemented using a paracetamol infusion (0.1 mg/kg/min). Paracetamol administration was allowed as a prophylaxis or to reduce any painful surgical stimuli.
The incidence of side effects (e.g. apnea, airway obstruction, headache, and agitation) was recorded.
The speed of awakening and the return of preoperative baseline cognitive functions were assessed by the OAAS score  .
A second anesthetist who was blinded to the identity of the study drug obtained baseline test scores preoperatively and repeated these tests at the end of the procedure in the operating room and several times postoperatively. The OAAS score was measured at 10, 20, 30 min, and again at 40 min.
Subjective self-assessment of the quality of recovery was measured by visual analog scale (VAS) determined at 1, 2, and 3 h of recovery.
Sample size calculations
We calculated the sample size on the basis of a previous audit of dexmedetomidine versus propofol for sedation in patients undergoing vitreoretinal surgery under sub-Tenon's anesthesia  . Thirty patients would be required in each group to achieve an α error of 5% and a β error of 1%. Thus, 30 patients in each group were considered sufficient.
IBM SPSS statistics (version 22.0, 2013; IBM Corp., Armonk, New York, USA) was used for data analysis. Data were expressed as mean ± SD for quantitative parametric measures in addition to both number and percentage for categorized data.
The following tests were performed:
- Comparison between two independent mean groups for parametric data using the Student t-test.
- The χ2 -test to study the association between each of the two variables or for a comparison between two independent groups with regard to their categorical data.
- The P of error at 0.05 was considered significant, whereas values of 0.01 and 0.001 were considered highly significant.
| Results|| |
There was no significant statistical difference between both groups regarding the age, the weight, and the duration of surgery [Table 2].
The induction time (the time from the start of the study drug to the first of three consecutive OAAS readings of 2) was significantly shorter in group P than in group D (P < 0.001): 11.72 ± 5.71 min in the propofol group and 18.65 ± 4.83 min in the dexmedetomidine group. Perfalgan was administered in both groups for all patients for analgesia and for the prophylaxis of painful stimuli [Table 3].
Intraoperative and postoperative parameters
Intraoperative and postoperative parameters were as follows: respiratory rate [Table 4], heart rate [Table 5], mean arterial blood pressure [Table 6], oxygen saturation (SpaO 2 ) [Table 7].
Return to an OAAS score of 5 after the study drug was discontinued was determined. No significant difference was observed between the groups in the first 20 min after drug discontinuation. After 30 min from drug discontinuation, 96.8% of the individuals in the dexmedetomidine group reached OAAS 5 compared with 29.0% in the propofol group, and after 40 min, nearly all propofol patients (29 of 31) and all dexmedetomidine patients (31 of 31) had returned to an OAAS score of 5 [Table 8] [Table 9] [Table 10] [Table 11]).
|Table 8: Observer's Assessment of Alertness/Sedation 10 min postoperatively|
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|Table 9: Observer's Assessment of Alertness/Sedation 20 min postoperatively|
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|Table 10: Observer's Assessment of Alertness/Sedation 30 min postoperatively|
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|Table 11: Observer's Assessment of Alertness/Sedation 40 min postoperatively|
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Self-assessment of recovery
The quality of recovery was assessed by VAS scores. Group D showed a significantly lower VAS in the first 2 h postoperatively in comparison with group P. Yet no significant difference was found in the VAS between both groups at 3 h postoperatively [Table 12] [Table 13] [Table 14]).
Complications and side effects
No significant differences were observed in the incidence of laryngospasm, anxiety, and dizziness between the two groups [Table 15]). Antiemetic requirements and the incidence of vomiting were compared in patients. Six (19.35%) propofol patients and one (3.23%) dexmedetomidine patients required antiemetics during or after the procedure (P < 0.05, significant). One (3.23%) propofol patient vomited at 5 min postoperatively and none dexmedetomidine patient vomited postoperatively (P > 0.05, not significant). There is highly significant difference regarding incidence of apnea where 6 patients in group P experienced apnea and none in group D.
| Discussion|| |
Transvaginal ultrasound-guided oocyte retrieval is quite a painful procedure; pain through this procedure is produced by penetration of the vaginal mucosa, ovaries capsule, and aspiration of the ovary. Thus, the drug used to enable this procedure should offer adequate pain relief to retain the patient immobilized throughout critical periods and to offer sedation for nervous patients  .
Promising analgesia with sedation and speedy recovery are preferred, which could be attained by using propofol because of its advantageous pharmacokinetic characteristics and recovery profile  .
While opioid analgesics can be used as the solitary supplement to local anesthesia, they do not provide reliable sedation without considerable respiratory depression. Therefore, opioids are frequently used in conjunction with sedative drugs to enhance the analgesia produced by local anesthetics  .
In the current study, we compared propofol+fentanyl with dexmedetomidine+fentanyl. Dexmedetomidine provides sedation and anxiolysis as well as amnesia with respect to intraoperative events  .
We used fentanyl, an opioid analgesic with a rapid onset of action and short elimination half life  .
The sedation level score achieved in both groups was similar as patients in both groups received similar amounts of fentanyl; this was attributed to the effectiveness of both medications used. This is in agreement with the study conducted by Gillham et al.  on 20 patients using a target-controlled infusion of propofol, who concluded that sedation maintained with target-controlled infusion propofol was safe and fully effective in 16 patients undergoing Endoscopic Retrograde Cholangiopancreatography (ERCP). Also, a study conducted by Mazanikov et al.  included 81 patients undergoing elective ERCP who received patient-controlled sedation with propofol and opioid in three different regimens; they concluded that the combination of propofol and alfentanil should be recommended as an acceptable method of sedation. Evidence of early cognitive function recovery among patients in the propofol group was obvious; this coincides with the studies conducted by White and Negus  , Mackenzie and Grant  , and Smith et al.  , who concluded that propofol infusions can be easily titrated to produce the desired level of sedation during procedures performed under local or general anesthesia and they are associated with less postoperative sedation, drowsiness, confusion, clumsiness and amnesia, as well as a more rapid recovery of cognitive function compared with midazolam.
In the recovery room and postoperatively, we found that the time to return to an OASS score of 5 was shorter in the dexmedetomidine group compared with propofol and dexmedetomidine, and showed better analgesic properties than propofol (lower VAS) at 1 and 2 h postoperatively.
It is now well defined that dexmedetomidine has analgesia-sparing properties when used for sedation in the ICU  . The half-life of dexmedetomidine being described as 2 h would explain why the analgesic-sparing properties persisted postoperatively  . This is in agreement with the study conducted by Ghali and colleagues. This study demonstrated that the use of dexmedetomidine at sedation levels similar to propofol during vitreoretinal surgery under local anesthesia was associated with equivalent thermodynamic effects, maintaining adequate respiratory function, better analgesic properties, similar surgeon's satisfaction with patients' sedation and higher patient satisfaction  . Similar results were reported in a previous study by Arain and Ebert  .
Also, Hashiguchi  performed a study on 40 patients to investigate the safety and the efficacy of dexmedetomidine for the sedation of patients undergoing routine upper gastrointestinal endoscopy. The results of this randomized study demonstrate that dexmedetomidine is as safe and effective as midazolam for producing and maintaining adequate short-term sedation in patients undergoing upper gastrointestinal endoscopy. Takimoto et al.  compared dexmedetomidine with propofol and midazolam for the sedation of 90 patients throughout endoscopic submucosal dissection of gastric cancer and established that dexmedetomidine is safe and effective.
Confounding factors, including the level of sedation, the type of memory tests, the intensity of the surgical stimulation, and the type of anesthesia (regional vs. local infiltration), contribute to the variable results. The lack of nausea and vomiting in the propofol group is owing to its antiemetic effect. Although the mechanism of propofol's antiemetic action is still unknown, it has been proposed that deeper levels of sedation by itself may be associated with less postoperative nausea and vomiting  .
| Conclusion|| |
Dexmedetomidine has a less rapid induction time of sedation than propofol, better analgesic effect with similar hemodynamic effects, better preservation of respiratory function and rapid recovery. Thus, dexmedetomidine can be used for short-period procedural sedation such as in ultrasound-guided oocyte pickup.
| Acknowledgements|| |
Conflicts of interest
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12], [Table 13], [Table 14], [Table 15]