Evaluation of sedation depth and reliability by integrated pulmonary index (IPI) monitoring of drugs used in endoskopic retrograd colangiopancreatography (ERCP) interventions with sedoanalgesia

Introduction and Aim: Integrated Pulmonary Index is a parameter makes respiratory monitoring easy and safe for clinicians, which offers heart rate, respiratory rate, saturation and end-tidal carbon dioxide measurements as a single value used to evaluate ventilation and oxygenation. In our study, we aimed to evaluate the respiration, hemodynamics, sedation depth and reliability of fentanyl-propofol and ketofol, which will be measured instantly during the procedure, in patients who underwent ERCP with sedoanalgesia. Materials and Methods: A total of 210 patients, 105 in each group, were included in the study, randomized by the closed-envelope method. In our prospective randomized controlled study, the patients were injected with 1-2 mg/kg propofol and 0.5-1 μg/kg fentanyl in the fentanyl-propofol group (Group F), and a 20 cc injector in the ketofol group (Group K), using a pre-prepared ketofol mixture (1: 2) 0.15-0.20 ml/kg was administered. In both groups, 2-3 mg/kg/h iv propofol was used for maintenance. When an additional dose was needed, 0.25 mg/kg propofol iv push was administered. In sedation follow-up, capnography was included in addition to routine monitoring. Sedation level was followed by BIS. In the recovery unit follow-ups, MAS was used, and patients who reached 9 points were discharged. Results: There was no significant difference between the demographic data of both groups. In the intraoperative follow-ups, statistically significantly higher data were obtained in the HR, SBP, DBP and OBP values in the K group than in the F group, close to the entry values. There was no significant difference in SpO2, EtCO2 and SS data. When we compared the IPI measurements, only the 35th minute IPI level of the F group was found to be higher than the K group. BIS values in the K group were higher than those in the F group. Intraoperative complications were recorded in 85 patients (40.5%), the most common being desaturation, hypotension and hypercarbia. Hypotension and tachypnea were found to be statistically significantly higher in the F group, which had a higher frequency of complications. As a result of ROC analysis, SpO2, BIS, HR, DBP, OBP and SBP measurements, respectively, with the highest IPI, were determined to be statistically significant alone in all intraoperative complications. IPI was found to have the highest sensitivity and specificity after SpO2 in detecting desaturation alone. However, it was observed that IPI alone was not a determinant in hypotension and hypercarbia. In the results of the correlation analysis, it was found that the mean IPI value was negatively correlated with HR, SS and BIS, and positively correlated with SpO2 and EtCO2. There was no statistically significant difference in SBP, HR and SpO2 data in RU follow-ups. It was observed that DBP and OBP levels were higher in group K than in group F. In the MAS measurements, it was determined that the F group was significantly higher than the K group. MAS 9 and the duration of discharge were statistically significantly shorter in Group F than in Group K in RU. Although there was no statistically significant difference between the groups in RU follow-ups, the number of patients with nausea/vomiting was found to be higher in the K group, and nystagmus was recorded in one patient in the K group. Conclusion: Although both fentanyl-propofol and ketofol combinations are used effectively and safely in applications requiring deep sedoanalgesia such as ERCP, we believe that the ketofol combination would be preferable because of its superiority in providing stable respiration and hemodynamics. However, the fact that the recovery time of ketofol is later than that of the fentanyl-propofol combination may cause delays in same-day discharge in shorter NOA procedures. It is seen that IPI monitoring is an accurate and safe monitoring technique in NOA applications with a single data monitoring facility in patient follow-up, detecting complications and predicting the need for intervention. Keywords: Bispectral Index (BIS), Endoscopic Retrograde Cholangiopancteratography (ERCP), Integrated Pulmonary Index (IPI).