Comparison of Meperidine Versus Hyoscine During Colonoscopy in the Elderly: A Prospective Randomized Study

Abstract

Background:

Colonoscopy is the gold standard in diagnosis of diseases of the colon. Sedation and antispasmodic agents are recommended during colonoscopy. Age is a limiting factor when the surgeon is deciding whether to use these medications or not.

Subjects and Methods:

One hundred twenty patients older than 65 years of age were randomized into two groups. The first group (n=60) received 2 mg of midazolam and 25 mg of meperidine intravenously. The second group (n=60) received 2 mg of midazolam and 20 mg of hyoscine N-butylbromide intravenously. The data collected were colonoscopy procedure time, time to cecum, visual analog pain scale, systolic blood pressure before and after the procedure, pulse, partial oxygen pressure, comfort of the endoscopist, the modified observer's assessment of alertness/sedation scale, and morbidity.

Results:

Total colonoscopy and cecal reach times were shorter in Group 2 (19.58±4.82 minutes and 10.57±2.54 minutes, respectively) than in Group 1 (25.05±5.93 minutes and 13.78±3.37 minutes, respectively) (P<.001). The sedation score of Group 2 (4.52±0.50) was better than that of Group 1 (3.45±0.75) (P<.001). Nine patients (15%) in Group 1 experienced diaphoresis, temporary memory loss, or lip smacking. Three patients in Group 1 and 1 patient in Group 2 had hypoxia. Three patients in Group 1 had hypotension; this was seen in 1 patient in Group 2. One patient had perforation in Group 1. The visual analog scale score was 4.37±1.38, and the endoscopist satisfaction was 6.72±0.99 in Group 1, while these values were 3.95±0.81 and 7.75±0.89, respectively, in Group 2 (P>.05).

Conclusions:

Use of midazolam and hyoscine N-butylbromide during colonoscopy is safe in the elderly and significantly reduces procedure time while increasing comfort for the endoscopist.

Introduction

Colonoscopy is the gold standard in differential diagnosis of diseases of the colon.¹ Colonoscopy is a painful procedure for the patient, thus usually requiring sedation and analgesia. The geriatric patient population has a higher likelihood of having co-morbid diseases such as renal dysfunction, chronic obstructive pulmonary disease, and coronary heart disease. This makes the endoscopist extra cautious about side effects of such medications during colonoscopy for this particular patient population.²

In this study, we compared effects of a benzodiazepine (midazolam) and a narcotic agent (pethidine/meperdine) combination with midazolam and an antispasmolytic (hyoscine N-butylbromide) combination in geriatric patients who underwent colonoscopy.

Subjects and Methods

This study was carried out between 2008 and 2010 in a university hospital endoscopy unit. Randomization was carried out with computerized selection. All subjects were included in the study after informed consent procedures. The study was approved by the hospital ethics committee, and the Helsinki Declaration was fulfilled. One hundred twenty people ≥65 years of age were included in the study. The World Health Organization defines geriatric age as ≥65 years.³ A Fujinon^® (Saitama, Japan) model EC-450WL5 fiberoptic colonoscope was used for the procedure. Exclusion criteria were a dirty colon, previous colonic resection, inability to reach the cecum, allergy to medications used in the study, and initial saturated oxygen level (SO₂) of <90%.

All patients were administered oral sodium phosphate for colon preparation. Patients were monitorized with noninvasive blood pressure, pulse oximetry, and electrocardiography, and values were recorded periodically. The beginning time of the colonoscopy was marked as the first visualization of the anal canal mucosa. The time up to the cecum was noted as cecal intubation. Total colonoscopy duration was noted by the time the colonoscope was pulled out from the patient. Patients were randomized into two groups: the first group (n=60) received 2 mg of midazolam and 25 mg of meperidine, both intravenously, and the second group (n=60) received 2 mg of midazolam and 20 mg of hyoscine N-butylbromide intravenously.

Patients were followed up for 4 hours after colonoscopy. Those who had side effects from the medications were followed up beyond 4 hours as an inpatient. Medication side effects during and after the procedure were recorded. All patients were discharged after the observation period. Pain during colonoscopy was graded with a visual analog scale (VAS) (where 0=no pain to 10=extreme pain), and sedation level was assessed with the Modified Observer's Assessment of Alertness/Sedation Scale,⁴ details of which are given in Table 1. The endoscopist's satisfaction score with the procedure (assessed with a 10-cm unscaled VAS where 0=not satisfied to 10=very satisfied) was recorded after each procedure.

Table 1.

Modified Observer's Assessment of Alertness/Sedation Scale

Score	Responsiveness
5	Responds readily to name spoken in normal tone
4	Lethargic response to name spoken in normal tone
3	Responds only after name is called loudly and/or repeatedly
2	Responds only after mild prodding or shaking
1	Responds only after painful trapezius squeeze
0	No response after painful trapezius squeeze

Statistical evaluation

SPSS version 13.0 for Windows (SPSS, Inc., Chicago, IL) was used for statistical analysis. Categorical variables are expressed as frequency and percentage; continous variables are given with mean, standard deviation, median, minimum, and maximum values. The Shapiro–Wilk test was used for normality tests. For statistical evaluation the chi-squared test, Student's t test, Mann–Whitney U test, Wilcoxon Signed-Rank Test, and Friedman tests were used where applicable. P<.05 was assumed as statistically significant.

Results

As shown in Table 2, mean ages of Group 1 and Group 2 were 72.33±5.6 years (minimum, 65 years; maximum, 87 years) and 73.3±6.1 years (minimum, 65 years; maximum, 88 years), respectively. The difference was not statistically significant (P>.05). Group 2 had a shorter total colonoscopy duration and cecal reach time than Group 1 (19.58±4.82 minutes and 10.57±2.54 minutes versus 25.05±5.93 minutes and 13.78±3.37 minutes, respectively) (P<.001).

Table 2.

Comparison of Variables in the Two Groups

	Mean±SD
	Group 1	Group 2	P
Age (years)	72.33±5.97	73.33±6.15	.348
Visual analog scale	4.37±1.38	3.95±0.81	.089
SO₂ (%)	96.60±3.64	96.78±2.52	.405
Systolic blood pressure (mm Hg)
Initial	130.67±9.32	131.83±8.73	.451
Final	124.50±6.49	127.58±5.64	.006^a
Pulse (minutes)
Initial	89.77±5.76	88.50±5.42	.179
Final	91.96±4.95	86.13±3.64	<.001^a
Endoscopist's satisfaction score	6.72±0.99	6.85±0.86	0.394
Sedation score	3.45±0.75	4.52±0.50	<.001^a
Time to cecum (minutes)	13.78±3.38	10.57±2.54	<.001^a
Total colonoscopy duration (minutes)	25.05±5.93	19.58±4.82	<.001^a

Statistically significant difference.

SD, standard deviation; SO₂, saturated oxygen value.

The mean sedation score of Group 1 was 3.45±0.75, whereas Group 2's mean was 4.52±0.50 (P<.001). Mean VAS scores in Group 1 and Group 2 were 4.37±1.38 and 3.95±0.81, respectively (P=.089). Mean SO₂ values measured were 96.60±3.64% in Group 1 and 96.78±2.52% in Group 2 (P=.405). Three patients in Group 1 and 1 patient in Group 2 had hypoxia (SO₂<90%). Three patients in Group 1 had transient hypotension, while this was seen in 1 patient in Group 2. Nine patients (15%) in Group 1 experienced diaphoresis, temporary memory loss, and lip smacking.

Mean systolic blood pressures before and after administration of medications in Group 1 were 130.67±9.32 mm Hg and 124.5±6.49 mm Hg, respectively. Corresponding values in Group 2 were 131.83±8.73 mm Hg and 127.58±5.64 mm Hg. The difference in final recordings was significant (P=.006). Pulse recordings in Group 1 before and after medications were 89.77±5.76/minute and 91.97±4.95/minute, respectively. For Group 2 the corresponding pulse measurements were 88.50±5.42/minute and 86.13±3.64/minute. Although the difference between the two groups in initial pulse measurements was not statistically significant (P=.179), the difference in final pulse recordings was (P<.001).

The endoscopist's satisfaction score was 6.72±0.99 in Group 1, while it was 6.85±0.86 in Group 2. The difference was not statistically significant (P>.05).

Colonic perforation occurred in 1 patient only in Group 1.

Discussion

The practical reason for using analgesia and antispasmodic agents during colonoscopy is to decrease pain and to achieve patient comfort and compliance. For the endoscopist, decreasing cecal reach time and total colonoscopy duration are the main concerns. The final aim is causing minimal harm to the patient and discharging the patient without complications. Traditionally, midazolam, propofol, fentanyl, and spasmolytics are used alone or in combination for this purpose. Studies about effects of these medications in the elderly are limited.^5–10

Spasm in the colon causes pain and prevents advance of the colonoscope, which further impairs visualization of the mucosa.¹¹ Antispasmolytics decrease colonic spasm. In our study, hyoscine N-butylbromide shortened cecal reach and total colonoscopy times. But, there is still not a consensus in the literature for using hyoscine N-butylbromide in colonoscopy.^12–14 In a previous study, the authors used 20 mg of hyoscine N-butylbromide intravenously and found that colonic spasm was less and colonoscopy duration was shorter.¹⁵ This study was done with a nonelderly population. In light of our findings, we think that the dose of 20 mg of hyoscine N-butylbromide is effective in the elderly population. Although not statistically significantly different, the VAS score and endoscopist satisfaction score were better in Group 2 than in Group 1 in our study. While meperidine is an analgesic, it has spasmogenic effects on the colon.¹⁶ This in turn lengthened the procedure time and caused worse VAS and endoscopist satisfaction scores in our study. Another finding worth mentioning in our study was higher sedation scores in Group 1 secondary to meperidine.

The other striking findings in the meperidine group were prolonged sedation and more patients with hypoxia and hypotension, although the difference between initial and final blood pressure measurements was not statistically significant. Lip smacking, temporary memory loss, and loss of orientation were additional findings in this group. These patients required longer hospitalization, although they were discharged the same day.

In a prospective randomized study, patients who were administered a combination of midazolam and meperidine had deep sedation (11%), hypotension (6%), and oxygen desaturation (>50%).¹² Robertson et al.¹⁷ showed that the long duration of action of meperidine adversely affected the recovery period.

The elderly patient population is more prone to develop iatrogenic complications in medical treatments and procedures. Defining the best practice is of paramount importance to decrease unwanted effects of medical interventions. In an attempt to find out the best sedation combination during colonoscopy in elderly patients, the randomized study we did showed that using 2 mg of midazolam and 20 mg of hyoscine N-butylbromide intravenously can achieve shorter procedure times, fewer side effects, good pain control, and maintainence of vital signs. These in return decrease hospitalization, reduce costs, and, more importantly, increase patient comfort and compliance. Thus, we recommend use of 2 mg of midazolam and 20 mg of hyoscine N-butylbromide combination intravenously during colonoscopy in the elderly.

Footnotes

Disclosure Statement

No competing financial interests exist.

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