Sage Journals: Discover world-class research

Abstract

Background

Anxious patients and those with poor tolerance to previous esophagogastroduodenoscopy (EGD) usually have poor tolerance for EGD.

Aims

To investigate the effect of meperidine on these patients during EGD.

Methods

A total of 110 patients undergoing diagnostic EGD were randomized to receive either meperidine (n = 55) or placebo (n = 55) before EGD. The primary outcome was patient discomfort scores during esophageal intubation.

Results

Patients in the meperidine group reported less discomfort during esophageal intubation (median score of 5.0 and interquartile range (IQR) 1.5–7.0) compared with the control (median score of 6.0, IQR 5.0–8.5, P = .003). Patients in the meperidine group had better tolerance during the procedure (median score of 2 (IQR 1.0–3.0) versus 3 (IQR 1.0–4.0), P = .048), and the endoscopists reported higher overall satisfaction scores (median score of 9 (IQR 7.0–9.0) versus 8 (IQR 7.0–9.0), P = .043). There was significantly less increase in heart rate and blood pressure during the procedure in the meperidine group than in the placebo group (23 bpm (IQR 9–32) versus 30 bpm (IQR 18–52); P = .006); (7 mmHg (IQR 1–14) versus 18 mmHg (IQR 2–30); P = .008). Connect-the-numbers test showed comparable results before and after EGD between the two groups.

Conclusion

For patients expected to have poor tolerance during EGD, meperidine reduced discomfort, decreased cardiovascular distress, and improved endoscopist satisfaction, without adverse effects on their psychomotor function after the procedure.

Keywords

Discomfort esophagogastroduodenoscopy intolerance meperidine minimal sedation

Key summary

Minimal sedation with a single use of meperidine is a useful adjunct to improve patient tolerance and reduce discomfort during esophagogastroduodenoscopy (EGD).

The use of meperidine was beneficial for patients who are expected to have poor tolerance to EGD by reducing the discomforts during esophageal intubation.

Patients receiving meperidine achieved better tolerance and higher overall satisfaction scores as rated by the endoscopists.

Meperidine reduced cardiovascular distress during EGD.

Adverse effects, including psychomotor impairment, were compatible between meperidine and placebo.

Introduction

Esophagogastroduodenoscopy (EGD) is an important diagnostic tool for upper gastrointestinal disorders. Although sedation for EGD is widely utilized in the USA,¹ its use varies in Europe and Asia.^2–5 From the perspective of the patients, sedation for EGD has the benefit of improving satisfaction, eliminating anxiety and discomfort, and increasing the willingness to repeat the procedures.^6–8 For the endoscopists, sedation can improve the success rate and quality of examination for diagnostic EGD, as well as enhance the treatment outcomes of therapeutic EGD.⁸ Sedation, however, contributes to a significant proportion of morbidity and mortality associated with EGD.^5,7,9 Besides, sedation increases the cost and the time needed for preprocedure preparation, the procedure per se, and post-procedure recovery, not to mention the indirect costs in loss of work time in patients and their family caregivers.^5,7,9

Unsedated EGD, albeit without the drawbacks of sedation and well tolerated by a modest proportion (61%) of patients,¹⁰ is considered uncomfortable by many patients. Factors associated with discomfort during unsedated EGD include the presence of gag reflex, young age, high level of anxiety, female, and poor tolerance to prior examinations.^10–12 An alternative method that is effective for those patients expected to experience discomfort during EGD but without resorting to full sedation is desirable.Minimal sedation with a single use of meperidine has been reported to be a useful adjunct to EGD in improving patient tolerance and reducing discomfort.⁴ Its adverse effects were also comparable to that in the placebo group except more self-limited dizziness was observed.⁴ However, the previous study was targeted at the general population, a significant proportion of which would have good tolerance to EGD with or without meperidine anyway. The real challenge to meperidine lies in those who are expected to have poor tolerance during EGD. Furthermore, the psychomotor impairment by meperidine after EGD had not been assessed in the previous study.The aim of this double-blind, randomized, controlled trial was to investigate the use of meperidine as a single sedative agent for patients who were expected to have poor tolerance to EGD, including patients with high anxiety levels and/or poor tolerance to prior unsedated EGD. Our hypothesis is that meperidine could reduce the discomforts associated with esophageal intubation for these patients.

Materials and methods

This double-blind, randomized, controlled trial was conducted at Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taiwan, from September 2013 to March 2017. Patients undergoing unsedated diagnostic EGD performed by the participating endoscopists were considered for enrollment. Patients who had undergone previous EGD were asked about the experience of their last EGD. Only patients rating their previous experience very uncomfortable were invited to join this study. For patients undergoing EGD for the first time, anxiety level was assessed, and those with high anxiety levels (anxiety score ≥5; 0 = not anxious at all; 10 = extremely anxious) were enrolled. Patients were excluded if they had any of the following conditions: a therapeutic EGD, sedated EGD, bidirectional endoscopy, contraindication to hyoscine N-butylbromide, allergy to meperidine, American Society of Anesthesiology physical status classification Class 3 or higher, renal failure, decompensated cirrhosis, age less than 18 years or more than 65 years, being pregnant, or refusal to provide written informed consent. The EGDs were performed by three board-certified endoscopists with experience of more than 5000 to 10,000 diagnostic EGDs. All participants signed written informed consents. The study was approved by the Institutional Review Board of Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation on 20 March 2013 (IRB B10201018). The trial was registered in ClinicalTrials.gov# NCT01948921. The study protocol conforms to the ethical guidelines of the 1975 Declaration of Helsinki as reflected in a prior approval by the institution’s human research committee.

A total of 110 patients were allocated into two groups in a one-to-one ratio based on a random number list generated by a computer. The randomization codes were contained in prearranged opaque envelopes, which were opened immediately before insertion of the scope to reveal either meperidine or placebo by a research assistant. To blind the patients, endoscopists, and the study assistant, all subjects received a single unlabeled intramuscular (IM) injection 5–10 min before the procedure. Patients in the meperidine group received 25 mg of meperidine (National Bureau of Controlled Drugs, Department of Health, Taipei, Taiwan) and 20 mg of hyoscine N-butylbromide (Boehringer Ingelheim, Taipei, Taiwan) in the injection, whereas patients in the placebo group received 20 mg of hyoscine N-butylbromide only. The medications were prepared and administered by an endoscopy nurse who was not involved in the study. All patients then ingested 15 ml of dimethylpolysiloxane (Yungshin Pharmaceutical, Taichung, Taiwan) and received 10 puffs of 10% lidocaine spray (Xylocaine 10% Spray, AstraZeneca, Södertalje, Sweden) (1 puff = 10 mg of lidocaine) delivered to the soft palate, posterior part of the tongue, and pharynx.

The procedures were performed by using a standard video esophagogastroduodenoscope (EG-590; Fujinon, Tokyo, Japan; GIF-Q-260; Olympus Optical Co., Ltd, Tokyo, Japan). All procedures started with the patient in the left lateral decubitus position. During the examination, electrocardiogram, blood pressure, and oxygen saturation of the patient were monitored.

The primary outcome was the patient’s self-reported discomfort scores during esophageal intubation, assessed with a 0–10 (0 = none; 10 = unbearable) visual analog scale. The secondary outcomes were discomfort score during the procedure and overall satisfaction with the procedure (0 = not satisfied at all; 10 = very satisfied) as evaluated by the patients; patient tolerance to the procedure, ease of intubation of the endoscope, and satisfaction with the procedure as evaluated by the endoscopists; and number of coughing and retching episodes during the procedure counted by a blinded study assistant.

Demographic data (age, sex, height, and weight), indications for EGD, history of drinking or smoking, and anxiety level were obtained before EGD. After the procedure, patients assessed their discomfort induced by the lidocaine spray, during esophageal intubation, and during the procedure (0 = none; 10 = unbearable); overall satisfaction with the procedure (0 = not satisfied at all; 10 = very satisfied); and their willingness to receive EGD in the same way if needed in the future (yes or no). All patients were asked whether they had suffered from dizziness, nausea and/or vomiting, and sore throat after the procedure.

At the end of the procedure, the endoscopists were asked to respond to a questionnaire to rate whether the procedure was completed, the difficulty of intubation (0 = very easy; 10 = very difficult), patient tolerance to the procedure (0 = very well; 10 = extremely poor), and overall satisfaction with the procedure. One score was given to each of the four areas (esophagus, stomach, duodenum to 2nd portion, and retroflex for proximal stomach) if adequately examined and necessary biopsies performed (0 = not complete study in all four areas; or 4 = complete study in all four areas). The endoscopic findings, esophageal intubation time (the time from insertion of the endoscope into the patient’s mouth to passage through the cricopharyngeus), total procedure time, and the time patients spent in bed after EGD were also recorded.

To elevate the psychomotor function after the procedure, the number connection test A (NCT-A) was used.¹³ The NCT-A is a test of visual-spatial orientation and psychomotor speed. Each patient was shown an A4-sized piece of paper with 25 consecutively numbered circles (1–25) randomly arranged on the paper. The task was to connect the numbers in ascending order as fast as possible. The test result was the time needed, including error correction time, to complete the task. The test was administered before the EGD and was repeated 10 min after the procedure with another sheet of test paper with a different arrangement of the numbers. If a patient could not complete the task within 2 min, the test would be repeated 10 min later.

Statistical analysis

The sample size calculation was based on the data from our previous study,⁴ which showed that the difference in the patient discomfort score during esophageal intubation was 1.6 with a standard deviation (SD) of 2.9 between the two groups. Power calculations estimated that 55 patients in each arm would ensure an 80% power of detecting the difference (5% significance level, two-sided test). Statistical analysis was performed using SPSS version 19.0 software (SPSS Inc., Chicago, Illinois, USA). Normally and non-normally distributed data were represented by using mean (SD) and median (interquartile range; IQR), respectively. The Chi-squared test, with Yates’ correction for continuity or Fisher’s exact test, was used for the comparison of categorical data, as appropriate. The Mann–Whitney U test was used to compare differences in continuous variables between groups. A P value < .05 was considered significant.

Results

Baseline characteristics of enrolled patients

A flow diagram of enrollment and intervention allocation is shown in Figure 1. Of the 2031 patients considered for enrollment, 1921 patients were excluded. A total of 110 patients undergoing diagnostic EGD were enrolled in this study. The mean age of the patients was 48.6 y (SD = 14.2 y); the majority (87.3%) of the patients were female. The baseline characteristics of both groups are shown in Table 1. The two groups were similar in terms of sex, age, height, smoking status, use of alcohol, enrollment criteria, and indication for endoscopy. The mean body weight in the meperidine group was significantly higher than the placebo group (60.9 kg versus 55.9 kg; P = .023). The distribution of the indications was also comparable, with dyspepsia being the most common one (63.6%).

Figure 1.

Flow chart of enrollment and intervention allocation.

Table 1.

Baseline characteristics of patients undergoing esophagogastroduodenoscopy.

	Meperidine (n = 55)	Placebo (n = 55)	P value
Male, n (%)	9 (16.4)	5 (9.1)	.392
Age (years), mean (SD)	46.7 (14.4)	50.6 (13.7)	.149
Weight (kg), mean (SD)	60.9 (13.3)	55.9 (9.2)	.023
Height (cm), mean (SD)	157.6 (6.4)	156.5 (6.3)	.352
Smoking, n (%)	1 (1.8)	1 (1.8)	>.999
Use of alcohol, n (%)	0 (0)	1 (1.8)	>.999
Enrollment criteria			.141
Poor tolerance to previous EGD	35 (63.6)	43 (78.2)
First time EGD with high anxiety level	20 (36.4)	12 (21.8)
Indications, n (%)			.387
Dyspepsia	34 (61.8)	36 (65.4)
GERD	16 (29.1)	13 (23.6)
Dysphagia	0 (0)	1 (1.8)
Follow-up	1 (1.8)	4 (7.3)
Others	4 (7.3)	1 (1.8)

EGD: esophagogastroduodenoscopy; GERD: gastroesophageal reflux disease; SD: standard deviation.

P values for continuous variables were obtained by t-test. P values for categorical variables were obtained by Fisher’s exact test.

Patient evaluation scores

Results of the patient evaluation scores are shown in Table 2. The pre-EGD anxiety and discomfort induced by the lidocaine spray, as reported by the patients, were comparable between the two groups. The discomfort scores (median, IQR) during esophageal intubation were 5.0 (1.5–7.0) and 6.0 (5.0–8.5) in the meperidine group and the placebo group, respectively (P = .003). The meperidine group had numerically lower discomfort scores during the procedure compared to the placebo group (3.0 (IQR 1.0–6.0) versus 5.0 (IQR 3.0–6.0), P = .087). The overall satisfaction with the procedure and the number of patients willing to repeat EGD in the future if needed were similar in both groups (Table 2).

Table 2.

Patient evaluation scores for esophagogastroduodenoscopy.

	Meperidine (n = 55)	Placebo (n = 55)	P value
Pre-EGD anxiety score^a	6.5 (5.0–8.0)	5.5 (5.0–7.0)	.269
Discomfort induced by lidocaine spray score^b	2.0 (0–5.0)	3.0 (0–6.0)	.121
Discomfort of esophageal intubation score^b	5.0 (1.5–7.0)	6.0 (5.0–8.5)	.003
Discomfort during procedure score^b	3.0 (1.0–6.0)	5.0 (3.0–6.0)	.087
Satisfaction score^c	10.0 (9.0–10.0)	10.0 (9.0–10.0)	.997
Number of patients willing to repeat the procedure next time, n (%)	49 (89.1)	46 (83.6)	.580

EGD: esophagogastroduodenoscopy.

Data are expressed as median (interquartile range) unless otherwise specified.

P values for continuous variables were obtained by non-parametric Mann–Whitney U test. P values for categorical variables were obtained by Fisher’s exact test.

0 = not anxious at all; 10 = extremely anxious.

0 = none; 10 = unbearable.

0 = not satisfied at all; 10 = very satisfied.

Endoscopists’ evaluations and number of retching and coughing episodes

All patients successfully completed the procedure and achieved technical adequacy in both groups. The scores for difficulty of esophageal intubation were comparable between the two groups (Table 3). The patients tolerated the procedure better, as indicated by lower tolerance scores assessed by the endoscopists, in the meperidine group compared to the placebo group (2.0 (IQR 1.0–3.0) versus 3.0 (IQR 1.0–4.0), P = .048). The endoscopists rated a higher satisfaction score in the meperidine group than in the placebo group (9.0 (IQR 7.0–9.0) versus 8.0 (7.0–9.0), P = .043). Patients in the meperidine group had fewer retching episodes than those in the placebo group (3.0 (IQR 1.0–5.0) versus 5.0 (IQR 2.0–10.0), P = .004). There were similar numbers of coughing episodes in either of the groups. The esophageal intubation time, total procedure time, and time spent in bed after the procedure also were comparable between the two groups (Table 3).

Table 3.

Endoscopists’ evaluations and number of retching and coughing episodes encountered during esophagogastroduodenoscopy.

	Meperidine (n = 55)	Placebo (n = 55)	P value
Technical adequacy^a	4.0 (4.0–4.0)	4.0 (4.0–4.0)	>.999
Difficulty of intubation^b	2.0 (1.0–4.0)	2.0 (1.0–4.0)	.399
Patient tolerance during procedure score^c	2.0 (1.0–3.0)	3.0 (1.0–4.0)	.048
Satisfaction score^d	9.0 (7.0–9.0)	8.0 (7.0–9.0)	.043
Number of retching episodes during endoscopy	3.0 (1.0–5.0)	5.0 (2.0–10.0)	.004
Number of coughing episodes during endoscopy	0 (0)	0 (0)	.220
Esophageal intubation time (min)	0.3 (0.3–0.4)	0.3 (0.2–0.4)	.279
Total procedure time (min)	3.9 (3.4–4.6)	4.1 (3.5–4.8)	.603
Time spent in bed after EGD (min)	1.4 (0.9–3.0)	1.3 (0.9–2.7)	.744

EGD: esophagogastroduodenoscopy.

Data are expressed as median (interquartile range).

P values were obtained by non-parametric Mann–Whitney U test.

0 = not complete study in all four areas; or 4 = complete study in all four areas (esophagus, stomach, duodenum to 2nd portion, and retroflex for proximal stomach).

0 = very easy; 10 = very difficult.

0 = very well; 10 = extremely poor.

0 = not satisfied at all; 10 = very satisfied.

Psychomotor function, hemodynamic changes, and adverse effects

The time needed for NCT-A before and 10 min after EGD were similar in the meperidine group (38 (29.0–58.0) s versus 39.5 (29.0–65.0) s, P = .189) and the placebo group (46.0 (36.0–67.0) s versus 40.0 (30.0–59.0) s, P = .479). The decrease in oxygenation was minimal and comparable in both groups. The maximal increase in heart rate and blood pressure during the procedure in the meperidine group were significantly lower than those in the placebo group, with a median of 23 bpm (IQR 9–32) versus 30 bpm (IQR 18–52); P = .006; and a median of 7 mmHg (IQR 1–14) versus 18 mmHg (IQR 2–30); P = .008, for heart rate and blood pressure, respectively. A comparable minority of patients suffered from dizziness, nausea, or sore throat in both groups (Table 4).

Table 4.

Vital signs changes and adverse effects.

Variable	Meperidine (n = 55)	Placebo (n = 55)	P value
Oxygen saturation (%)
Before procedure	98 (97–99)	99 (98–99)	.277
Lowest during procedure	98 (96–99)	97 (96–99)	.551
Maximal decrease	0 (0–1)	1 (0–2)	.095
Heart rate (bpm)
Before procedure	90 (82–102)	89 (77–98)	.373
Lowest during procedure	97 (85–109)	98 (89–111)	.766
Highest during procedure	114 (101–130)	125 (106–136)	.064
Maximal increase	23 (9–32)	30 (18–52)	.006
Blood pressure (mmHg)
Before procedure	134 (114–149)	129 (109–144)	.373
Lowest during procedure	126 (104–141)	124 (103–143)	.969
Highest during procedure	142 (119–157)	140 (122–170)	.427
Maximal increase	7 (1–14)	18 (2–30)	.008
Dizziness (n, %)	10 (18.2)	10 (18.2)	>.999
Nausea/vomiting (n, %)	27 (49.1)	17 (30.9)	.079
Sore throat (n, %)	6 (10.9)	10 (18.2)	.418

bpm: beats per minute.

Data are expressed as median (interquartile range) unless otherwise specified.

P values for continuous variables were obtained by non-parametric Mann–Whitney U test. P values for categorical variables were obtained by Fisher’s exact test.

Discussion

In this double-blind, randomized, controlled study, we found that the IM injection of 25 mg of meperidine was useful in patients expected to poorly tolerate EGD by reducing discomfort during esophageal intubation, boosting endoscopists satisfaction through better patient tolerance, and decreasing cardiovascular stress. This type of patient generally suffers the most during unsedated EGD, and therefore is the most important target population for sedation, and usually full sedation. The current study offers an alternative method of sedation for these patients.

Meperidine is the most frequently administered opiate in sedated EGD.¹ It is usually used in combination with a benzodiazepine in the USA.¹ Dies et al. found that patients receiving meperidine, as compared with ketorolac, experienced less gagging and tachycardia, and required less midazolam during EGD.¹⁴ Diab et al. randomized 120 patients to receive either 50 mg of meperidine or 1 mg of midazolam, adding incremental doses of midazolam at the discretion of the endoscopist.¹⁵ Those receiving meperidine needed less midazolam and showed better tolerance than those receiving only midazolam.¹⁵ Laluna et al. compared midazolam alone with meperidine plus midazolam for sedating patients undergoing EGD.¹⁶ The endoscopists rated better tolerance for patients in the combination group, which also entailed a lower dose of midazolam. In short, adding meperidine to midazolam improves patient tolerance and reduces the dosage of midazolam.

There are sparse reports on the use of opiate as a single sedative agent for EGD. Ishido et al. showed that intravenous (IV) fentanyl, a short acting opiate, could increase the tolerance of patients during EGD, as reflected by less coughing and retching.¹⁷ Another report by Stephens et al. showed that fentanyl was even better than diazepam at enhancing the ease of procedure, as evaluated by the endoscopists.¹⁸ Our group had conducted a randomized, controlled trial comparing meperidine with placebo, with results showing that patients receiving meperidine had better tolerance, as reported by both the patients and the endoscopist. There were also fewer retching episodes in the meperidine group as reported by a third independent observer.⁴ In contrast, Wang and Lin reported that meperidine was not superior to placebo for sedation during EGD; however, their study was not a randomized, controlled trial, and no detailed information was provided.¹⁹ The present study focusing on the population with expected poor tolerance to EGD further verifies the benefit and safety of meperidine as a single agent for EGD sedation.

A rapid IV injection of meperidine may result in respiratory depression, hypotension, circulatory disorder, cardiac arrest, etc. Thus the use of IV route is advised to be restricted to settings in which a narcotic antagonist and facilities for assisted or controlled respiration are immediately available.⁸ IM administration of meperidine carries a lower risk of cardiopulmonary adverse effect and does not require IV cannulation. Therefore we chose IM administration of meperidine in our study. The analgesia of IM meperidine begins 5–10 min after injection and its peak plasma concentrations are measured at 15–60 min after IM injection.^20,21

The primary outcome of the current study was patient discomfort scores during esophageal intubation, which was reported to be the most important contributing factor to a poor overall tolerance during EGD.²² We found that meperidine significantly decreased the discomfort during esophageal intubation as compared to placebo (Table 2). Meperidine has the effect of suppressing the pharyngeal reflex. Our observation is compatible with a recent report by Yamasaki et al. evaluating the best sedation method for pharyngeal observation using transoral endoscopy by comparing meperidine with midazolam and placebo.²³ By suppressing the gag reflex without impairing the ability to vocalize, the meperidine group achieved the highest observation score. The meperidine group also had lower discomfort scores than that of the placebo group during pharyngeal observation. The suppressing effect of gag reflex by meperidine was also supported by our observation that significantly fewer episodes of retching were noted in the meperidine group.

In the current study, the endoscopists were more satisfied with the EGD when meperidine, instead of placebo, was injected at the start of the procedure, probably because the patients tolerated the procedure better with meperidine. On the other hand, the overall satisfaction of the patients with the procedure did not differ between the two groups. Although less discomfort during the procedure was associated with higher patient satisfaction, other factors might also play a part, such as personal manner and technical skills of the endoscopists, personal manner of the nurses, physical environment, and more time to discuss the procedure with the endoscopists.²⁴

Our results showed that a single injection of low dose (25 mg) meperidine did not adversely affect the psychomotor function of the patients after EGD, as shown by the NCT-A test. A previous cumulative-dosing study showed that opioids such as meperidine produced dose-related increases in the impairment of psychomotor function, whereas no detrimental effect was noted at a low dose (such as meperidine 17.5 mg/70 kg).²⁵ The psychomotor effects of meperidine, when present, were short-lived; they peaked at 5 min after drug injection and recovered, sometimes to baseline levels, within 55 min.²⁵ In line with the absence of psychomotor disturbance, the patients in the current study were fully alert during the procedure without requiring monitoring or assistance from an anesthesiologist. Most patients receiving meperidine could leave the examination table almost immediately, entailing minimal post-procedure monitoring. They were discharged without an escort but were instructed not to drive for at least 2 h after the procedure.²¹ However, there is no official recommendation about the use of meperidine and driving.

Due to the subjective nature of any assessment of patient tolerance and satisfaction, alternative methods for evaluating safety and tolerability would be preferable. Assessments of heart rate and blood pressure are both objective methods of evaluating tolerability of endoscopic procedures. Adachi et al. reported that cardiac stress increased during unsedated EGD as indicated by a 66% increase in rate-pressure product.²⁶ In the current study, the maximal increase in both heart rate and blood pressure were attenuated in the meperidine group as compared with the placebo group, reflecting a decrease in cardiac stress. The desaturation of arterial oxygen was minimal and there was no difference in arterial oxygen saturation between the meperidine group and the control group.

Several limitations of this study should be mentioned. First, as the study was conducted at a single center, the results need to be validated by other endoscopists in different clinical settings. Second, a relatively low dose of meperidine (25 mg) was injected intramuscularly in this study, and whether a different dose or a different administered route would be more effective will require further investigations. Third, as the Asian sample population of the current trial had a lower mean body weight (mean 58.4 kg; SD 11.6 kg), the findings might not be transferable to the Western population especially with higher body weight, for which a higher or weight-based dose of meperidine might be needed. Fourth, although meperidine could significantly reduce the discomfort score during esophageal intubation, the median score of 5 was still high. Future studies to further reduce the discomfort by using a more potent opiate or in combination with other modalities are warranted.

Conclusions

For patients expected to have poor tolerance during EGD, meperidine reduced their discomfort, decreased cardiovascular distress, and improved endoscopist satisfaction, without adverse effects on their psychomotor function after the procedure.

Footnotes

Author contributions

YHH and CWT defined the research theme, designed methods, carried out the study, interpreted the results, and wrote the paper. MK analyzed the data and revised the paper. KCT helped to collect the cases. All authors approved the final version of the paper.

Declaration of conflicting interests

The authors declare no conflict of interest.

Funding

This work was supported by a research fund from Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation.

Ethics approval

The study was approved by the Institutional Review Board of Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation on 20 March 2013 (IRB B10201018).

Informed consent

Written informed consent was obtained from each patient included in the study.

References

Cohen

Wecsler

Gaetano

Benson

Miller

Durkalski

et al.

Endoscopic sedation in the United States: results from a nationwide survey. Am J Gastroenterol 2006; 101(5): 967–974.

Pereira

Hussaini

Hanson

Wilkinson

Sladen

. Endoscopy: throat spray or sedation? J R Coll Physicians Lond 1994; 28(5): 411–414.

al-Atrakchi

. Upper gastrointestinal endoscopy without sedation: a prospective study of 2000 examinations. Gastrointest Endosc 1989; 35(2): 79–81.

Hsieh

Lin

Hsieh

Tseng

Hung

et al.

Meperidine as the single sedative agent during esophagogastroduodenoscopy, a double-blind, randomized, controlled study. J Gastroenterol Hepatol 2013; 28(7): 1167–1173.

Triantafillidis

Merikas

Nikolakis

Papalois

. Sedation in gastrointestinal endoscopy: current issues. World J Gastroenterol 2013; 19(4): 463–481.

Fisher

Bailey

Gibson

. A prospective, randomized controlled trial of sedation vs. no sedation in outpatient diagnostic upper gastrointestinal endoscopy. Endoscopy 1998; 30(1): 21–24.

Moon

. Sedation regimens for gastrointestinal endoscopy. Clin Endosc 2014; 47(2): 135–140.

Obara

Haruma

Irisawa

Kaise

Gotoda

Sugiyama

et al.

Guidelines for sedation in gastroenterological endoscopy. Dig Endosc 2015; 27(4): 435–449.

Cohen

DeLegge

Aisenberg

Brill

Inadomi

Kochman

et al.

AGA Institute review of endoscopic sedation. Gastroenterology 2007; 133(2): 675–701.

10.

Abraham

Barkun

Larocque

Fallone

Mayrand

Baffis

et al.

Predicting which patients can undergo upper endoscopy comfortably without conscious sedation. Gastrointest Endosc 2002; 56(2): 180–189.

11.

Campo

Brullet

Montserrat

Calvet

Moix

Rue

et al.

Identification of factors that influence tolerance of upper gastrointestinal endoscopy. Eur J Gastroenterol Hepatol 1999; 11(2): 201–204.

12.

Mulcahy

Kelly

Banks

Connor

Patchet

Farthing

et al.

Factors associated with tolerance to, and discomfort with, unsedated diagnostic gastroscopy. Scand J Gastroenterol 2001; 36(12): 1352–1357.

13.

Schomerus

Hamster

. Neuropsychological aspects of portal-systemic encephalopathy. Metab Brain Dis 1998; 13(4): 361–377.

14.

Dies

Clarkston

Schratz

. Intravenous ketorolac tromethamine versus meperidine for adjunctive sedation in upper gastrointestinal endoscopy: a pilot study. Gastrointest Endosc 1996; 43(1): 6–9.

15.

Diab

King

Barthel

Marshall

. Efficacy and safety of combined meperidine and midazolam for EGD sedation compared with midazolam alone. Am J Gastroenterol 1996; 91(6): 1120–1125.

16.

Laluna

Allen

Dimarino

Jr . The comparison of midazolam and topical lidocaine spray versus the combination of midazolam, meperidine, and topical lidocaine spray to sedate patients for upper endoscopy. Gastrointest Endosc 2001; 53(3): 289–293.

17.

Ishido

Kinoshita

Kitajima

Itoh

Nishiyama

Tojo

et al.

Fentanyl for sedation during upper gastrointestinal endoscopy. Gastrointest Endosc 1992; 38(6): 689–692.

18.

Stephens

Gibson

Jakobovits

Metz

Dudley

. Fentanyl and diazepam in endoscopy of the upper gastrointestinal tract. Med J Aust 1982; 1(10): 419–420.

19.

Wang

Lin

. Worldwide use of sedation and analgesia for upper intestinal endoscopy. Sedation for upper GI endoscopy in Taiwan. Gastrointest Endosc 1999; 50(6): 888–889; discussion 889–891.

20.

Clark

Wei

Anderson

. Meperidine: therapeutic use and toxicity. J Emerg Med 1995; 13(6): 797–802.

21.

Rex

. Review article: moderate sedation for endoscopy: sedation regimens for non-anaesthesiologists. Aliment Pharmacol Ther 2006; 24(2): 163–171.

22.

Walmsley

Montgomery

. Factors affecting patient tolerance of upper gastrointestinal endoscopy. J Clin Gastroenterol 1998; 26(4): 253–255.

23.

Yamasaki

Ishihara

Hanaoka

Matsuura

Kanesaka

Akasaka

et al.

Pethidine hydrochloride is a better sedation method for pharyngeal observation by transoral endoscopy compared with no sedation and midazolam. Dig Endosc 2017; 29(1): 39–48.

24.

Zhang

Telford

Enns

. Factors influencing patient satisfaction when undergoing endoscopic procedures. Gastrointest Endosc 2009; 69(4): 883–891.

25.

Walker

Zacny

. Subjective, psychomotor, and physiological effects of cumulative doses of opioid mu agonists in healthy volunteers. J Pharmacol Exp Ther 1999; 289(3): 1454–1464.

26.

Adachi

Yazawa

Owa

Koide

Hanazaki

Kajikawa

et al.

Quantification of cardiac stress during EGD without sedation. Gastrointest Endosc 2002; 55(1): 58–64.

Meperidine for patients expected to have poor tolerance to esophagogastroduodenoscopy: A double-blind,randomized,controlled study

Abstract

Background

Aims

Methods

Results

Conclusion

Keywords

Key summary

Introduction

Materials and methods

Statistical analysis

Results

Baseline characteristics of enrolled patients

Patient evaluation scores

Endoscopists’ evaluations and number of retching and coughing episodes

Psychomotor function, hemodynamic changes, and adverse effects

Discussion

Conclusions

Footnotes

Author contributions

Declaration of conflicting interests

Funding

Ethics approval

Informed consent

References