Use of midazolam during transrectal ultrasonography guided prostate biopsy: Effects of sedation and retrograde amnesia

Transrektal ultrason eşliğinde yapılan prostat biyopsisinde midazolam kullanımı: Sedasyon ve retrograd amnezinin etkileri

Abstract

Introduction: Urologists perform approximately 500.000 prostate biopsies per year in United States of America. Currently there is no universally agreed standard of analgesia. Several studies evaluating the tolerance of transrectal ultrasound (TRUS) guided biopsies showed that moderate to severe pain was associated with the procedure. Patients may not return for repeat biopsies due to unpleasant experience with prior biopsies. Large number of patients perceives the procedure painful with major psychological trauma. Midazolam is used for gastrointestinal endoscopies because of its sedative and amnestic effects. To this end, we evaluated the feasibility of midazolam and retrograde amnesia effect in patients undergoing transrectal prostate biopsy. Materials and Methods: A total of 52 patients undergoing TRUS-guided prostate biopsy were enrolled into the study. Indications for biopsy were increased prostate specific antigen (PSA) or abnormal digital rectal examination of the prostate. Patients were given midazolam as a bolus injection (70 mcg/kg, maximum total dosage: 5 mg) before the biopsy procedure. All patients were examined in left lateral decubitus position and TRUS biopsies were performed with a 7 MHz probe. Four core biopsies were obtained from the each lobe of the prostate. After completion of biopsy, flumazenil (0.5 mg IV) was used to reverse the effects of midazolam. All patients were placed on oxygen saturation monitorization during the procedure. The degree of sedation, degree of pain, side effects and retrograde amnesia were evaluated with a validated questionnaire by the surgeon and patient. A visual analog scale (VAS) was used to asses the pain score and Ramsey sedation score was used to asses the sedation score. The Ramsey sedation scale scores between 2 and 4 were accepted as satisfactory degree of sedation. Results: After injection of midazolam, sedation was achieved in all patients in a short period of time. Ninety-six percent of patients exhibited procedural amnesia, characterized by an inability to recall neither the initial probe insertion nor the biopsy procedure. Only two patients remembered some parts of the procedure. Forty four patients (%85) were willing to undergo re-biopsy if needed. These patients stated that they will undergo a second biopsy only under the same conditions. Eight patients (%15) refused to undergo any further diagnostic test or examination. The mean pain score of patients was 1.96±0.69. The Ramsey sedation scale scores ranged between 2 and 4 in all patients. Nausea and vomiting due to midazolam were not observed in our study, and we did not see any complication related to midazolam usage. Conclusion: In this study we found high satisfaction rates, lower pain scores and lower anxiety in patients undergoing TRUS guided biopsies due to sedative and amnestic effects of midazolam. This resulted in higher acceptability of a repeat biopsy procedure, if indicated. Besides its sedative properties, midazolam can be used as an effective agent during TRUS-guided prostate biopsies due to its procedural amnesia effect, which results in minimal psychological trauma to patients.

Özet

Transrektal ultrason eşliğinde yapılan prostat biyopsileri, hastaların bir çoğu tarafından ağrılı ve psikolojik açıdan oldukça travmatik bir işlem olarak tanımlanmaktadır. Bu çalışmada transrektal prostat biyopsisi yapılacak olan hastalarda midazolamın uygulanabilirliğini ve hastalarda oluşturduğu retrograd amnezinin etkilerini araştırdık. Transrektal prostat biyopsisi yapılan 52 hastaya işlem öncesinde maksimum doz 5 mg olacak şekilde intravenöz midazolam (70 mcg/kg) verildi. İşlem esnasında hastanın ağrı derecesi, sedasyon derecesi, yan etkiler ve retrograd amnezi hem işlemi yapan doktor tarafından hem de işlem bittikten iki saat sonra hasta tarafından doldurulan soru formları ile değerlendirildi. Hastaların %96'sında retrograd amnezi oluştuğu saptandı. Amnezi oluşan hastaların tamamı ultrason probunun rektuma yerleştirilişini veya biyopsi işlemini hatırlamadılar. 52 hastanın tamamında Ramsey sedasyon skalasına göre orta derecede sedasyon oluştuğu saptandı. Hastaların ortalama vizüel ağrı skoru (VAS); 1.96±0.69 olarak saptandı. Hastaların %85'i gerekirse ikinci bir biyopsi işlemini aynı şartlar altında yaptırabileceklerini belirttiler. Bu çalışmada midazolamın sedatif ve amnestik etkilerinden dolayı hastalarda azalmış anksiyete, düşük ağrı skorları ve yüksek oranda hasta memnuniyeti oluştuğunu saptadık. Bunun neticesinde olası ikinci biyopsilerin hastalar tarafından yüksek oranda kabul edileceğini tespit ettik. Sedatif özelliğinin yanı sıra oluşturduğu retrograd amnezi ile hastalarda psikolojik travmayı da azaltan midazolam, transrektal ultrason eşliğinde yapılan prostat biyopsilerinde uygun bir ilaç olarak kullanılabilir.