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La séedation et i’anesthésie pour i’endoscopie digestive

Sedation and analgesia for gastrointestinal endoscopy

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Résumé

En Belgique, la majorité des sédations pour endoscopies digestives est effectuée par l’endoscopiste. L’anesthésiste n’est généralement requis que pour des examens spéciaux, longs ou douloureux.

L’utilisation correcte des benzodiazépines (BZD) et des opiacés nécessite la connaissance de leur pharmacologic Le diazepam (D) et le midazolam (M) procurent le même degré de sédation et de cooperation de la part du patient. Lorsqu’une seule dose équivalente est injectée, la recouvrance se fait dans un temps similaire, dépendant du temps de distribution (T 1/2 α D: 15-25 min; M: 14-18 min). Le M est 1,7 à 2 fois plus puissant que D, agit plus vite et est plus vite éliminé (T 1/2 β D: 25-50 H; M: 2-4 H). A doses répétées, le D agit plus longtemps, la recouvrance et les tests psychomoteurs sont davantage et plus longtemps perturbes. Son metabolite actif, le desméthyldiazepam a une longue 1/2 vie d’élimination (T 1/2 β 36-200 h). La dépression respiratoire est semblable pour les 2 drogues, trés marquee et de longue durée chez les patients souffrant d’affection respiratoire obstructive chronique. Le M déprime davantage le systéme cardiovasculaire. L’amnesie de type antérograde est plus marquée avec M.

La péthidine est l’opiacé le plus communément utilisé par les endoscopistes. Elle déprime la respiration et le systéme cardiovasculaire de facon marquee. Son métabolite la norpéthidine, est un psychostimulant et un convulsivant.

L’âge, le sexe, les antécédents, l’etat général (insuffisance hépatique, rénale, hypoprotéinémie, hypovolémic...) peuvent influencer la pharmacocinétique et la pharmacodynamic des BZD et des opiacés. La bonne connaissance du dossier du patient est done indispensable. Dans ce but, une solution concernant les patients ambulants est suggérée.

Les antagonistes flumazénil et naloxone sont efficaces, mais donnent un sentiment de fausse sécurité, vu leur courte durée d’action.

Certains opiacés puissants et de courte durée d’action (fentanyl, alfentanil), les anesthésiques généraux intraveineux (barbituri-ques, étomidate, propofol) ou par inhalation sont du domaine exclusif des anesthésiologistes. Parmi ces drogues, le propofol, par sa maniabilité et la qualité du réveil, est une drogue de choix, mais non dépourvue d’effets secondaires (apnée, dépression cardiovascu-laire). Les régies de sécurité appliquées au bloc opératoire doivent être respectées en salle d’endoscopie: surveillance du patient par une personne compétente, appareillage adéquat, source d’oxygéne, monitoring, matériel et drogues de réanimation cardiorespiratoire.

Après ’intervention, le patient doit pouvoir bénéficier d’une surveillance dans une salle de réveil ou de repos avant que son retour en salle ou á domicile ne soit autorisé. Il ne peut ni conduire, ni manipuler de machines pendant 24 h. La responsabilité médico-légale de ’endoscopiste et de l’anesthesiste est rappelee.

Summary

In Belgium the great majority of sedations for GI endoscopies are performed by the endoscopist himself. The anesthesiologist is generally required for special, long or painful procedures.

The proper use of benzodiazepines (BZD) and opiates depends on the knowledge of their pharmacology. Diazepam (D) and Midazolam (M) provide the same degree of sedation and cooperation from the patient.

When one bolus of an equipotent dose is injected, recovery time is similar for both drugs, depending on the time of distribution (T 1/2 α D: 15-25 min; M: 14-18 min). M is 1.7 to 2 times more potent than D, its onset of action is shorter and it is rapidly eliminated ( T 1/2 β D: 25-50 H; M: 2-4 H). When larger or repeated doses of D are injected, recovery time is longer and psychomotor tests are more affected and delayed. Its active metabolite desmethyldiazepam has a long elimination half-line (T 1/2 36-200 h).

Respiratory depression exists for both drugs, more pronounced and of greater duration in the COPD patient. Cardiovascular system is more depressed with M. Anterograde amnesia is more marked with M.

Pethidine is the most commonly used opioid by endoscopists. Both respiration and cardiovascular system are markedly depressed. Its metabolite norpethidine is a psychostimulant and convulsivant drug.

Age, sex, the medical history, the general status (hepatic and renal failure, hypoproteinemia, hypovolemia...) can influence the pharmacokinetics and the pharmacodynamics of BZD and opiates. The good knowledge of the patient's record is thus mandatory. In this respect a solution for out- patients scheduled for endoscopy is suggested.

The antagonists flumazenil and naloxone are effective but can give a false sense of security because of their short half-life. Some potent and short-acting opioids (fentanyl, alfentanil), general intravenous anesthetics (barbiturates, etomidate, propofol) or inhalational anesthetics are strictly reserved to anesthesiologists. Among these drugs, propofol seems to be a drug of choice: it can be used as repeated bolus or as a continuous infusion which can be easily modulated according to the desired depth of anesthesia. It is not devoid of adverse effects (apnea and cardiovascular depression). As the forensic responsability of the endoscopist and the anesthesiologist is involved, the safety rules recommended in the operating theater must be of application in the endoscopy room, which must be equipped with oxygen, suction, a good monitoring (EKG, pulseoxymeter, capnometer) a blood pressure monitor, all the material and drugs for CPR ressuscitation, an anesthesia machine if necessary, and first of all a trained person must take care of the patient during the procedure.

After the procedure, the patient must be watched closely in a recovery or rest room before he is allowed to return to the ward or to leave the hospital. He is not authorized to drive or to operate machinery for 24 h.

Resumen

En Belgica, la mayoria de les sedaciones en endoscopia digestiva son realizadas por los endospistas. El anesthesiologo es requerido en procedimientos especiales, largos o dolorosos.

Para usar correctamente las Benzodiacepinas (BZD) y opiáceos es necesario el conocimiento de su farmacologiá. Diacepam (D) y Midazolam (M) tienes mismo-grado de sedatión y de cooperatión por parte del paciente. Quando se inyecta una sola dosis equivalente, la recuperatión es en tiempo similar, de-pendiendo del tiempo de distributión (t 1/2 α D: 15-25 min; M: 14-18 min). El MMZ es 1,7 a 2 veces mas potente que el D, actua mas rápido y es eliminado también más rapidamente (t 1/2 β D: 25-50 H; M: 2–4 H). Cuando se dan dosis repetidas, el D act mas tiempo, los test psicomotores tardan más en normalizarse. El desmethydiace-pam (metabolito activo de D) tiene una 1/2 vida eliminacion muy larga (T 1/2 β 36-200 H). La depresión respiratoria es identica para las dos drogas; mucho más marcada en aquellos pacientes afectos de BNCO. EI M deprime más el sisteme cardiovascular asi como tiene mayor poder de amnesia anterograda.

La pethidina es el mórfico mas utilizado por los endoscopistas. Tiene una accion depresiva cardiovascular y respiratoria importante. La norpethidina (su metabolito) es psicoestimulante y convulsivante.

La edad, sexo, antecedentes, estado general (Insuf. hepatica, renal, hipoproteinemia, hipovolemia...) pueden influenciar la farmacocinetica y farmacodinamica de las BZD y opiáceos. El buen conocimiento del dossier del paciente es indispensable. Con este objetivo hay que tomar soluciones con los pacientes ambulatorios.

Los antagonistas flumazenil y naloxona son eficaces; pero dan la impresión de falsa seguridad en relatión con su corta acción.

Algunos mórficos potentes y de corta acción (Fentanyl, alfentanil), los anesthesicos grales. Intravenosos (barbituricos, etomidato, propofol) ó inhalatorios son de uso exclusivo de los anesthesistes. Entre todas estas drogas, el propofol, por su manejabilidad, calidad del despertar, es de electión. Sin embargo no esta desprovista de efectos secundarios (apnéa, depression cardiovascular). Las reglas de seguridad aplicadas en quirofano tienen que serlo tambien en la sala de endoscopia: vigilancia por personal competente, monitorage adecuado, fúente O2, material y drogas para reanimación cardiorespiratoria.

Al finalizar la interventión el patiente debe ser controlado en una sala de despertar antes de su vuelta a la habitatión o domicilio. Se le desautoriza a conducir o manipular máquinas durante 24 h. A tener en cuenta la responsabilidad médico-legal del anesthesiólogo y del endoscopista.

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Correspondence to M. De Rood or L. Barvais or P. Ewalenko or A. Vandesteene.

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De Rood, M., Barvais, L., Ewalenko, P. et al. La séedation et i’anesthésie pour i’endoscopie digestive. Acta Endosc 20, 51–66 (1990). https://doi.org/10.1007/BF02966601

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Mots-clés

  • benzodiazépines
  • endoscopic digestive
  • opiaces
  • règies de sécurité
  • sédation/anesthésie

Key-words

  • benzodiazepines
  • GI endoscopy
  • opioids
  • safety rules
  • sedation/anesthesia