Safety and effectiveness of anesthesiologist-administered Propofol versus Propofol and Nalbuphine for deep sedation during and after outpatient colonoscopy

Introduction: More than 90% of gastrointestinal endoscopy procedures are nowadays performed under propofol deep sedation in Western countries. This ratio is significantly lower in Hungary, despite of the obviously better patient satisfaction and the low risk of complications during deep sedation. The aim of our present study was to evaluate the safety and effectiveness of 1000 ambulatory colonoscopies carried out under propofol versus propofol and nalbuphine deep sedation with respect to endoscopic and anesthesiologists success rate, complications and patient satisfaction. Methods: Prospective collection and evaluation of patient database was performed. We investigated 190 patients receiving nalbuphine and propofol and another 810 patients receiving propofol alone. The cecal intubation rate, the incidence of major and minor cardiovascular and respiratory complications in terms of the mean of the highest and lowest blood pressure and heart rate values were measured as well as changes in oxygen saturation (SpO2) were calculated. The propofol induction and total dose, the time from induction to spontaneous awakening, the recovery time and Post Anesthetic Discharge Scoring System (PADSS) were also compared. Finally, patient satisfaction was evaluated, by comparing the results of visual analogue scales (VAS) filled by 55 patients receiving deep propofol sedation and by 55 patients who underwent conscious colonoscopy without any premedication. Results: No significant differences in the cecal intubation rate was demonstrated in the nalbuphine and propofol vs. propofol groups: 98.4% vs. 96.8% (p = 0.31). No major cardio-respiratory complications occurred. We observed desaturation to 80 – 90% of SpO2 lasting less than 2 min in 12 patients. SpO2 dropped under 80% and lasting less than 2 min occurred in 5 patients. The induction propofol dose was 40+13 mg vs. 117 ± 45 mg, and the corresponding mean total doses of Propofol was 80.5 ± 32.8 mg and 210.1 ± 93.2 mg in the two groups, respectively (p < 0.0001). There was no significant differences in the mean awakening time was 30 min ± 10.7 vs. 29.83 min ± 10.7, p = 0.5, and in the mean recovery time 51.7 min ± 23.4 vs. 49.5 min ± 21.7, p = 0.4 when we compared patients group with nalbuphine and Propofol versus Propofol administration alone, respectively. However, the PADSS was significantly lower demonstrating more symptoms which prevented timely patient discharge in the nalbuphine group: 9.85 ± 0.6 vs. 10 ± 0.0. On a 10-point validated VAS's scale, the mean patient satisfaction with colonoscopy was 9.66 ± 0.99 vs. 7.01 ± 2.23 (p < 0.0001) in the propofol vs. conscious nonsedated control group, respectively. Conclusions: Propofol deep sedation administered by an anesthesiologist with appropriate monitoring seems to be a safe procedure during outpatient colonoscopy with excellent patient satisfaction. Low-dose nalbuphine combined with propofol is an effective and economic alternative, but side effects of morphine agonists reduce PADSS and may prevent timely patient discharge.