Target-Controlled Infusion with Propofol and Remifentanil for Moderate Procedural Sedation in Medicine and Dentistry: A Review of Clinical Effectiveness, Cost-Effectiveness, and Guidelines [Internet]

Moderate sedation, also known as conscious sedation, is achieved by depressing the level of consciousness with drugs to reduce patient anxiety and discomfort and to improve examination procedure outcomes. While under moderate sedation, patients are able to respond purposefully to verbal cues alone or in conjunction with light tactile stimulation. Furthermore, cardiovascular function and spontaneous ventilation is typically maintained negating the need for patent airway management. Thus, moderate sedation is used for various outpatient procedures such as endoscopy, colonoscopy, bronchoscopy, and dental procedures.The use of sedation medications may cause inadvertent over-sedation resulting in patients that are not easily aroused and/or require interventions to maintain patient airway. Thus, clinicians performing moderate sedation should have the competence to manage adverse events related to unintentional over-sedation such as respiratory depression, blood pressure changes, and hypoxia. Common medications used in moderate sedation may include propofol, short-acting opioids (e.g., remifentanil), and/or benzodiazepines (e.g., midazolam) administered intravenously by intermittent hand-bolus titration or target-controlled infusion (TCI) pumps. The use of independent TCI pumps for the delivery of propofol and remifentanil allows trained operators to control and adjust the level of sedation during medical procedures. Precise control of both agents is important as propofol has a narrow therapeutic range and the addition of an opioid to propofol increases the risk of respiratory depression. Equipped with a microprocessor, TCI pumps allow operators to specify the drug, pharmacokinetic model, patient characteristics (e.g., age and weight), and the effect-site concentration.The aim of this report is to summarize and critically appraise the relevant literature and evidence-based guidelines regarding the clinical effectiveness, cost-effectiveness and recommended use of intravenous propofol and remifentanil administered by independent TCI pumps for patients undergoing moderate procedural sedation in medicine and dentistry.