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The Use of Nitrous Oxide Gas for Lower Gastrointestinal Endoscopy Sophie Welchman, Sean Cochrane, Gary Minto, Stephen Lewis

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The Use of Nitrous Oxide Gas for Lower Gastrointestinal Endoscopy Sophie Welchman, Sean Cochrane, Gary Minto, Stephen Lewis Systematic review: The use of nitrous oxide gas for lower gastrointestinal endoscopy Sophie Welchman, Sean Cochrane, Gary Minto, Stephen Lewis To cite this version: Sophie Welchman, Sean Cochrane, Gary Minto, Stephen Lewis. Systematic review: The use of nitrous oxide gas for lower gastrointestinal endoscopy. Alimentary Pharmacology and Therapeutics, Wiley, 2010, 32 (3), pp.324. 10.1111/j.1365-2036.2010.04359.x. hal-00552574 HAL Id: hal-00552574 https://hal.archives-ouvertes.fr/hal-00552574 Submitted on 6 Jan 2011 HAL is a multi-disciplinary open access L’archive ouverte pluridisciplinaire HAL, est archive for the deposit and dissemination of sci- destinée au dépôt et à la diffusion de documents entific research documents, whether they are pub- scientifiques de niveau recherche, publiés ou non, lished or not. The documents may come from émanant des établissements d’enseignement et de teaching and research institutions in France or recherche français ou étrangers, des laboratoires abroad, or from public or private research centers. publics ou privés. Alimentary Pharmacology & Therapeutic Systematic review: The use of nitrous oxide gas for lower gastrointestinal endoscopy ForJournal: Alimentary Peer Pharmacology Review & Therapeutics Manuscript ID: APT-0287-2010.R1 Manuscript Type: Systematic Review Date Submitted by the 13-May-2010 Author: Complete List of Authors: Welchman, Sophie; Derriford Hospital, Surgery Cochrane, Sean; Derriford Hospital, Gastroenterology Minto, Gary; Derriford Hospital, Anaesthesia Lewis, stephen; Derriford Hospital, Gastroenterology Large intestine < Organ-based, Colonoscopy < Topics, Endoscopy < Keywords: Topics, Sedation < Topics Page 1 of 28 Alimentary Pharmacology & Therapeutic 1 2 3 Systematic review: The use of nitrous oxide gas for lower gastrointestinal 4 5 endoscopy 6 7 8 9 10 Sophie Welchman 1, Sean Cochrane 2, Gary Minto 3, Stephen Lewis 2 11 12 13 14 1 2 3 15 Department of Surgery , Gastroenterology and Anaesthesia Derriford Hospital, 16 17 Plymouth, UK 18 For Peer Review 19 20 21 22 Corresponding Author : 23 24 Dr Stephen Lewis 25 26 27 Department of Gastroenterology 28 29 Derriford Hospital 30 31 Plymouth PL6 8DH 32 33 34 Tel: 01752 517649 35 36 Fax: 01752 792240 37 38 39 40 41 Email: [email protected] 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 1 Alimentary Pharmacology & Therapeutic Page 2 of 28 1 2 3 ACKNOWLEDGEMENTS 4 5 We would like to thank all the authors of the original papers who provided additional 6 7 8 data and answered our queries. 9 10 11 12 13 KEY WORDS 14 15 Sigmoidoscopy, Colonoscopy, Nitrous Oxide 16 17 18 For Peer Review 19 20 FUNDING 21 22 None 23 24 25 26 27 CONFLICTS OF INTEREST 28 29 None 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 2 Page 3 of 28 Alimentary Pharmacology & Therapeutic 1 2 3 4 5 ABSTRACT 6 7 8 Background 9 10 Nitrous oxide gas (N 2O) has been proposed as an alternative to intravenous (iv) 11 12 13 analgesia in patients undergoing lower gastrointestinal endoscopy . 14 15 AIMS 16 17 We performed a systematic review of randomized studies where N 2O had been 18 For Peer Review 19 20 compared against control in patients undergoing either flexible sigmoidoscopy or 21 22 colonoscopy. 23 24 Methods 25 26 27 Electronic databases were searched; reference lists checked and letters sent to authors 28 29 requesting data. Methodological quality was assessed. Data was tabulated on the 30 31 duration and difficulty of the procedure, quality of sedation and speed of patient 32 33 34 recovery. 35 36 Results 37 38 39 11 studies were identified containing 623 patients. No differences were seen between 40 41 groups for duration, difficulty of procedure or complications. Patient reported pain was 42 43 similar for N2O when undergoing flexible sigmoidoscopy vs no sedation and when 44 45 46 undergoing colonoscopy vs iv sedation. Differences in delivery of N2O were identified. 47 48 In all studies N2O was associated with a more rapid recovery than iv sedation. 49 50 Conclusion 51 52 53 For patients undergoing colonoscopy N2O provides comparable analgesia to iv sedation. 54 55 The rapid psychomotor recovery with N2O enables quicker patient discharge, and 56 57 58 removes the need for a patient to be chaperoned. Benefit was not seen from N2O in 59 60 3 Alimentary Pharmacology & Therapeutic Page 4 of 28 1 2 3 patients undergoing flexible sigmoidoscopy possibly because it was delivered on 4 5 demand rather than continuously. 6 7 8 9 10 11 12 13 14 15 16 17 18 For Peer Review 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 4 Page 5 of 28 Alimentary Pharmacology & Therapeutic 1 2 3 4 INTRODUCTION 5 6 7 Flexible sigmoidoscopy is often preformed without analgesia or sedation. The potential 8 9 for pain and discomfort are the main limitations1, 2 and can deter patients from returning 10 11 for repeat procedures, which may decrease their compliance in a bowel cancer- 12 13 14 screening program. Colonoscopy is less well tolerated than flexible sigmoidoscopy. 15 16 Pain and vasovagal reactions are common, such that the standard practice is to provide 17 18 intravenous analgesiaFor and sedation Peer to patients. Review This usually allows completion of the 19 20 21 procedure but at the risk of oxygen desaturation, prolonged recovery time in the 22 23 endoscopy department and the need for continued chaperoning at home. 24 25 26 Conscious sedation describes the physical state that allows patients to tolerate pain and 27 28 discomfort while maintaining adequate cardiorespiratory function and the ability to 29 30 respond purposefully to verbal commands 3. The therapeutic goal of conscious sedation 31 32 4 33 may be better described as a combination of sedation and analgesia . 34 35 Nitrous Oxide (N 20) is an inert gas that since 1844 has been valued in anaesthetic 36 37 practice for its analgesic, amnesic and sedative properties. It can be combined with 38 39 40 oxygen in equal volumes (Entonox ) and is widely used in this form as an analgesic in 41 42 obstetric and dental practice. It is fast acting (effect noted within 60 seconds on 43 44 45 inhalation) and has a short recovery time (being eliminated unchanged by the lungs in 1- 46 47 5 minutes). This potentially makes it an ideal agent outpatient procedures like lower 48 49 gastrointestinal endoscopy. 50 51 52 The purpose of this review is to consider the current evidence base for the use of nitrous 53 54 oxide gas for sedation in patients undergoing flexible sigmoidoscopy or colonoscopy. 55 56 57 58 59 60 5 Alimentary Pharmacology & Therapeutic Page 6 of 28 1 2 3 4 5 METHODS 6 7 8 Eligibility criteria 9 10 Clinical trials were eligible if adult patients undergoing either colonoscopy or flexible 11 12 13 sigmoidoscopy were randomly allocated to receive either sedation with nitrous oxide or 14 15 control. 16 17 Search strategy and trial identification 18 For Peer Review 19 20 We performed computerised searches of PubMed, Embase, the Cochrane library using 21 22 the search terms, “nitrous oxide”, “Entonox”, “sedation”, “analgesia”, “inhalational”, 23 24 “colonoscopy”, “sigmoidoscopy”. Following this the same search terms were entered 25 26 27 into Google® for additional information. Reference lists from eligible trials were checked 28 29 in an attempt to locate any further publications. Authors were contacted to request data 30 31 or information on trial methodology, which had not been reported. We also approached 32 33 34 the Linde group (Munich, Germany), owners of the British oxygen company (BOC) to 35 36 ask if they were aware of any unpublished data on the use of nitrous oxide in endoscopy 37 38 39 departments. 40 41 The titles of the articles located by the searches were scanned (SJL and SW) and where 42 43 the title was thought to be relevant the abstract was read (SJL and SW), and if the 44 45 46 article still appeared relevant a copy of the full manuscript was obtained. Full 47 48 manuscripts were reviewed (SJL and SW) and a final decision made about inclusion. 49 50 Data extraction and outcomes 51 52 53 Two authors (SJL and SW) extracted and tabulated data for each study, and 54 55 crosschecked for consistency. Disagreements were resolved by consensus. 56 57 58 59 60 6 Page 7 of 28 Alimentary Pharmacology & Therapeutic 1 2 3 Data was extracted on inclusion criteria, exclusion criteria, control regime, endoscopists 4 5 experience, study methodology (including randomization and blinding), age, sex and 6 7 8 baseline patient anxiety. Procedural data was recorded (depth of insertion, duration of 9 10 procedure, technical difficulty, length of stay after the procedure until fit for discharge 11 12 13 (recovery time)). Outcomes recorded included: pain, discomfort, requirement for 14 15 ‘breakthrough’ analgesia, satisfaction with the procedure and psychomotor recovery. 16 17 Adverse events were also recorded. 18 For Peer Review 19 20 Assessment of methodological quality 21 22 Several aspects of trial design have been shown to be associated with a reduction in 23 24 estimated bias of treatment effects 5, 6 : these include generation of the allocation 25 26 27 sequence and concealment of allocation from participants and outcome assessors. Both 28 29 authors (SJL and SW) independently assessed the methodological quality of the 30 31 included trials.
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