Clinical Studies Of Nalbuphine Combined With Etomidate In Painless Gastrointestinal Endoscopy

Background:As patients suffer and can’t tolerate the ordinary gastrointestinal endoscopy,more patients choose painless gastrointestinal endoscopy.Propofol has been widely used in gastrointestinal endoscopy.However,by using propofol alone or in combination with low-dose opioids,there are still high chance of cardiopulmonary adverse events.Etomidate is also one of the commonly used drugs for general anesthesia induction,the most obvious advantage is that it has little effect on circulation and respiration.However,when it is used for anesthesia induction,the most adverse reaction of etomidate is that it can cause myoclonus.The evident has shown that opioids are the best way to reduce incidence of myoclonus.Nalbuphine which is the agonist/antagonist of opioids receptor has a lower risk of respiratory depression rate than traditional opioids.At present,there is a lack of evaluation of the effect of nalbuphine combined with etomidate in painless gastrointestinal endoscopy.Objective:This study is divided into two parts.The first part of the research is to find out the anesthetic effect of different doses of nalbuphine combined with etomidate in painless gastrointestinal endoscopy.Based on the first part of the research,the second part of the study will explore the preventive effect of intravenous administration of low doses of scopolamine or palonosetron alone,and the combination of the two on nausea and vomiting after anesthesia with nalbuphine-etomidate,and saline will act as a control.Method:Part one:From April to October 2018,320 patients who age from 18-65 years old underwent painless gastrointestinal endoscopy in the digestive endoscopy center of our hospital were selected,patients with body mass index(BMI)18.5-30 kg/m~2,ASA graded as I-II,were randomly allocated to 4 groups:0.04 mg/kg(group A),0.06mg/kg(group B),0.08 mg/kg(group C),and 0.1 mg/kg(group D).After each group were administered with nalbuphine for 5 minutes,then introduced with etomidate(1ml/5 s)until the patients loss conscious.Single dose of 20-30 mg propofol may be needed during the examination.Record the following details:Number of occurrence of myoclonus within 2 minutes after the injection of etomidate among the 4 groups;Incidence and intensity of choking cough and body movements at the initial placement gastroscopy and within 5 minutes of the gastroscopy examination;The BPS-NI score is also recorded when the colonoscopy pass the spleen flexure and the hepatic flexure;The amount of etomidate and propofol consumption;Time of examination,awakening time and exit time;Cardiopulmonary adverse events during anesthesia and adverse reactions after recovery.Part two:This part of the research is a randomized double-blind study.A total of 456patients underwent painless gastrointestinal endoscopy were randomly assigned to group P(palonosetron),group S(scopolamine),group PS(palonosetron plus scopolamine)and group C(Saline).Palonosetron(3 ml)or saline(3 ml)was intravenous administered 30 min before anesthesia induction,and scopolamine(1 ml)or saline(1 ml)was given 3 min before induction.Incidence and severity of nausea and/or vomiting,and rescue anti-emetic requirements,were evaluated for PACU periods,0-8 h,8-24 h,0-24 h and 24-48 h after leaving the recovery room.The doses of etomidate and propofol consumption,subjective satisfaction score,dizziness time,drowsiness time,the incidence of cardiopulmonary adverse events during anesthesia and adverse reactions after recovery were compared between the groups.Result:Part one:There was no significant differences in the time of examination,recovery time,time of exit,the amount of etomidate and propofol consumption between the four groups(p>0.05).The frequency of cardiopulmonary adverse events did not reveal significant statistical difference among the four groups(p>0.05).The incidence of myoclonus was the lowest in group D,and there was a statistical significant difference when compared with group A and B.The myoclonus incidence in group C was also lower compared to group A.Body movement and choking cough were significantly lower in group D compared with group A(p<0.05).Among the four groups,group D has the lowest BPS-NI score(p<0.05).However,in the incidence of nausea and vomiting after recovery,group C and group D were significantly higher than that of group A(p<0.05).Part two:The incidence of nausea,vomiting or PDNV was significantly lower in group PS than that in group P and C at 0-8 h after discharge(p<0.001).The incidence of nausea,vomiting or PDNV was also lower in group S compared with group C(p<0.05).In the incidence of PDNV,the group S is lower than the group P(p<0.05).At 0-24 h,the incidence of nausea,vomiting or PDNV was the lowest in group PS,which was statistically significant compared with the other three groups.The incidence of nausea,vomiting or PDNV was also lower in group S at 0-24 h compared with group C(p<0.05),and group S has lower nausea occurence rate than group P(p<0.05).Patients satisfaction rate was the greatest in the group PS among all four groups.The drowsiness and dizziness time of the group PS were the shortest,and there was a statistically significant difference compared with the group C(p<0.001),the dizziness time was also significantly shorter compared with group P.Compared with group C,dizziness and drowsiness time were significantly shorter in group S(p<0.05),and dizziness time was also less than group P(p<0.05).Group PS and S were significantly lower in VAS score of nausea and vomiting than the other two groups,but group PS has the lowest score.There was no difference about overall cardiopulmonary adverse events and the anticholinergic adverse reactions in each group.There was no difference in the incidence of all aspects between the group P and C in all time periods.Conclusion:1.0.1 mg/kg nalbuphine combined with etomidate has the best clinical effect on painless gastrointestinal endoscopy,but the medication to prevent nausea and vomiting should be considered.2.Intravenous injection of 0.1 mg of scopolamine before anesthesia induction could reduce the incidence of nausea and vomiting after nalbuphine and etomidate anesthesia,but it works better when it is combined with palonosetron.3.The use of 0.075 mg palonosetron alone is almost effective-less.