Advertisement

Cardiovascular and Respiratory Safety of Sedation Strategies Used in Transesophageal Echocardiography: A Systematic Review Incorporating Network Meta-Analysis

  • Tiago Manuel Freitas
    Affiliations
    Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
    Search for articles by this author
  • Claúdio David
    Affiliations
    Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal

    Serviço de Cardiologia, Hospital Universitário de Santa Maria – CHULN, Lisbon, Portugal
    Search for articles by this author
  • Ana G. Almeida
    Affiliations
    Serviço de Cardiologia, Hospital Universitário de Santa Maria – CHULN, Lisbon, Portugal

    Centro Cardiovascular da Universidade de Lisboa–CCUL, CAML, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
    Search for articles by this author
  • Fausto J. Pinto
    Affiliations
    Serviço de Cardiologia, Hospital Universitário de Santa Maria – CHULN, Lisbon, Portugal

    Centro Cardiovascular da Universidade de Lisboa–CCUL, CAML, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
    Search for articles by this author
  • João Costa
    Affiliations
    Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal

    Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
    Search for articles by this author
  • Daniel Caldeira
    Correspondence
    Address correspondence to Prof. Daniel Caldeira, Laboratório de Farmacologia Clínica e Terapêutica/CCUL, Faculdade de Medicina de Lisboa, Av. Prof. Egas Moniz, 1649-028 Lisboa, Portugal.
    Affiliations
    Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal

    Serviço de Cardiologia, Hospital Universitário de Santa Maria – CHULN, Lisbon, Portugal

    Centro Cardiovascular da Universidade de Lisboa–CCUL, CAML, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal

    Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal

    Centro de Estudos de Medicina Baseada na Evidência (CEMBE), Faculdade de Medicina, Universidade de Lisboa, Portugal.
    Search for articles by this author
      TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) is carried out in various clinical settings, with an increasing importance, and sedation usually is required to perform it. Several sedative agents are available, and the authors aimed to compare the cardiovascular and respiratory safety of the strategies used for sedation in TEE through a systematic review with network meta-analysis (NMA). The MEDLINE, CENTRAL, EMBASE, and PsycInfo databases were searched in December 2020 for randomized clinical trials (RCTs) comparing sedation strategies for patients undergoing TEE. The authors assessed variations in systolic blood pressure (SBP), heart rate (HR), and peripheral oxygen saturation (SpO2), along with the incidences of hypotension, bradycardia, and desaturation. A random-effect meta-analysis was performed. Nine RCTs (N = 881 patients) with 20 active arms (5 dexmedetomidine; 4 propofol; 4 midazolam; 3 midazolam + opioid; 2 ketamine + propofol; 1 midazolam + ondansetron; 1 midazolam + metoclopramide) and 1 placebo arm were included. Dexmedetomidine was associated with decreases in SBP (mean difference [MD] = -18.78 mmHg; 95% CI [-26.27 to -11.28]) and HR (MD = -11.15 beats/min; 95% CI [-16.15 to -6.15]). Dexmedetomidine significantly reduced the HR compared with ketamine + propofol (-16.90 beats/min; 95% CI: -33.21 to -0.58]) and midazolam + opioid (-24.15 beats/min; 95% CI: -42.67 to -5.63). Midazolam was found to reduce SBP (-12.09 mmHg; 95% CI: -20.43 to -3.74) and was shown to reduce SpO2 compared with the placebo (-1.00%; 95% CI -1.74 to -0.26). Based on the NMA, the drugs with a higher likelihood of decreasing both SBP and HR were dexmedetomidine and midazolam. All of the drugs led to a small decrease (only statistically significant for midazolam) in SpO2, with the systematic use of supplemental O2 in some trials. The risks of hypotension, bradycardia, or desaturation were not significantly different among the evaluated drugs.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Cardiothoracic and Vascular Anesthesia
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Daniel WG
        • Erbel R
        • Kasper W
        • et al.
        Safety of transesophageal echocardiography. A multicenter survey of 10,419 examinations.
        Circulation. 1991; 83: 817-821
        • Hahn RT
        • Abraham T
        • Adams MS
        • et al.
        Guidelines for performing a comprehensive transesophageal echocardiographic examination: Recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists.
        J Am Soc Echocardiogr. 2013; 26: 921-964
        • Hinkelbein J
        • Lamperti M
        • Akeson J
        • et al.
        European Society of Anaesthesiology and European Board of Anaesthesiology guidelines for procedural sedation and analgesia in adults.
        Eur J Anaesthesiol. 2018; 35: 6-24
      1. Wheeler R, Steeds RP, Wharton G, et al. Recommendations for safe practice in sedation during transoesophageal echocardiography: A report from the education committee of the British Society of Echocardiography. Available at: https://www.bsecho.org/common/Uploaded%20files/Education/Protocols%20and%20guidelines/Safe%20sedation.pdf. Accessed.

        • Flachskampf FA
        • Badano L
        • Daniel WG
        • et al.
        Recommendations for transoesophageal echocardiography: Update 2010.
        Eur J Echocardiogr. 2010; 11: 557-576
        • Sruthi S
        • Mandal B
        • Rohit MK
        • et al.
        Dexmedetomidine versus ketofol sedation for outpatient diagnostic transesophageal echocardiography: A randomized controlled study.
        Ann Card Anaesth. 2018; 21: 143-150
        • Alizadehasl A
        • Sadeghpour A
        • Totonchi Z
        • et al.
        Comparison of sedation between dexmedetomidine and propofol during transesophageal echocardiography: A randomized controlled trial.
        Annals of Cardiac Anaesthesia. 2019; 22: 285-290
        • el Mourad MB
        • Shaaban AE
        • el Sharkawy SI
        • et al.
        Effects of propofol, dexmedetomidine, or ketofol on respiratory and hemodynamic profiles in cardiac patients undergoing transesophageal echocardiography: A prospective randomized study.
        J Cardiothorac Vasc Anesth. 2021; 35: 2743-2750
        • Hutton B
        • Salanti G
        • Caldwell DM
        • et al.
        The PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions: Checklist and explanations.
        Ann Intern Med. 2015; 162: 777-784
      2. Rohatgi A. WebPlotDigitizer: Version 4.4. Available at: https://automeris.io/WebPlotDigitizer. Accessed December 2021.

        • Sterne JAC
        • Savović J
        • Page MJ
        • et al.
        RoB 2: A revised tool for assessing risk of bias in randomised trials.
        BMJ. 2019; 366: l4898
        • Aeschbacher BC
        • Portner M
        • Fluri M
        • et al.
        Midazolam premedication improves tolerance of transesophageal echocardiography.
        Am J Cardiol. 1998; 81: 1022-1026
        • Aydin A
        • Yilmazer MS
        • Gurol T
        • et al.
        Ondansetron administration before transoesophageal echocardiography reduces the need for sedation and improves patient comfort during the procedure.
        Eur J Echocardiogr. 2010; 11: 752-755
        • Cooper L
        • Candiotti K
        • Gallagher C
        • et al.
        A randomized, controlled trial on dexmedetomidine for providing adequate sedation and hemodynamic control for awake, diagnostic transesophageal echocardiography.
        J Cardiothorac Vasc Anesth. 2011; 25: 233-237
        • Schelling V
        • Daniel M
        • Christoph S
        • et al.
        Sedation during transoesophageal echocardiography.
        Cardiovascular Medicine. 2015; 18: 215-219
        • Banihashem N
        • Omran SO
        • Jalalian R.
        Sedative effect of dexmedetomidine and midazolam in transesophageal echocardiographic examination.
        J Mazandaran Univ Med Sci. 2015; 25: 130-136
        • Toman H
        • Erkılınc A
        • Kocak T
        • et al.
        Sedation for transesophageal echocardiography: Comparison of propofol, midazolam and midazolam-alfentanil combination.
        Med Glas (Zenica). 2016; 13: 18-24
        • Pieri M
        • Landoni G
        • Cabrini L.
        Noninvasive ventilation during endoscopic procedures: Rationale, clinical use, and devices.
        J Cardiothorac Vasc Anesth. 2018; 32: 928-934
        • Sahinovic MM
        • Struys MMRF
        • Absalom AR.
        Clinical pharmacokinetics and pharmacodynamics of propofol.
        Clin Pharmacokinet. 2018; 57: 1539-1558
        • Aldrete JA.
        The post-anesthesia recovery score revisited.
        J Clin Anesth. 1995; 7: 89-91