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Abstract

We read with interest Dr. Sharma's comments. We designed a prospective study with cirrhotic outpatients to compare the safety, efficacy, and recovery time during upper GI endoscopy with 2 sedation schemes: midazolam plus fentanyl and propofol plus fentanyl.1Correia L. Bonilha D. Gomes G. 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: 45-51Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar There are the 4 main points to be related. According to the protocol, we excluded all patients with emergency procedures and American Society of Anesthesiologists (ASA) class IV or V because they present a higher risk of complications, and assistance of an anesthesiologist during sedation is recommended. Most patients enrolled were Child A and B, ASA class II and III because we included only cirrhotic outpatients. The minority of these patients were Child C and ASA III, as was expected. We recognized that patients with end-stage of liver disease and ASA class III patients may have a higher risk of complications related to sedation.2Thuluvath P. Toward safer sedation in patients with cirrhosis: have we done enough?.Gastrointest Endosc. 2009; 70: 269-270Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar Further studies involving these patients could be conducted to confirm this observation. However, because the majority of cirrhotic outpatients are Child A/B and ASA class II, according to our results, both sedation schemes are safe, and propofol plus fentanyl can be effective for upper GI endoscopy in these patients. We did not evaluate hepatic encephalopathy because it was not the purpose of this study. There are studies that have shown that midazolam can worsen or even trigger encephalopathy in cirrhotic patients, and this does not occur with propofol.3Riphaus A. Lechowicz I. Frenz M. et al.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: 1244-1251Crossref PubMed Scopus (49) Google Scholar We did not evaluate whether β-blockers could have interfered with sedation or even whether they could increase the risk of cardiovascular complications during sedation for upper GI endoscopy. No guideline suggests that β-blockers are specific risk factors for cardiovascular complications during sedation.4Lichtenstein D. Jagannath S. Baron T. et al.Sedation and anesthesia in GI endoscopy.Gastrointest Endosc. 2008; 68: 815-826Abstract Full Text Full Text PDF PubMed Scopus (325) Google Scholar In Brazil, according to current recommendations, propofol can be used by nonanesthesiologists, provided that there are 2 doctors in attendance during the procedure, 1 of whom is dedicated exclusively to sedation. In our study, there was a gastroenterologist dedicated to sedation, and in this situation, both sedation schemes were safe. Alternatively, sedation may be administered by a nurse, but we understand that there are specific rules for each country. Safety evaluation of propofol administered by nonanesthesiologists was not our objective, but this was recorded during the study. Finally, we concluded that both sedation schemes were safe for the group of patients included in our study. Further studies are needed to determine with certainty the optimal regimen for sedation of patients with more serious or emergency conditions, which was not evaluated in our study. Propofol in upper GI endoscopy in patients with cirrhosisGastrointestinal EndoscopyVol. 73Issue 6PreviewWe read with interest the article by Correia et al.1 We wish to make the point that before we draw conclusions, we need more data to assess the safety of propofol on patients with Child-Pugh scores of B and C. A majority of patients enrolled in this study were given a Child-Pugh score of A (only 8% of patients were score C) and were recruited from outpatient departments as in other similar studies.2,3 The study included outpatients classified as American Society of Anesthesiologists Physical Status Classification System (ASA) categories 2 and 3, whereas sicker patients classified as ASA 3 or patients with Child-Pugh score C are usually inpatients, and the safety of propofol in this subset of patients needs more data. Full-Text PDF