Propofol in patients with cirrhosis and minimal hepatic encephalopathy
Authors: Praveen Sharma, Shweta Singh, Barjesh Chander Sharma
Journal: Journal of Hepatology (2010)

Sub-clinical hepatic encephalopathy in cirrhotic patients is not aggravated by sedation with propofol compared to midazolam: A randomized controlled studyJournal of HepatologyVol. 54Issue 1PreviewThe risk of exacerbating sub-clinical hepatic encephalopathy (HE) by propofol has not been established. The aim of this study is to determine whether the use of propofol, for upper endoscopy in patients with cirrhosis, precipitates sub-clinical HE. Full-Text PDF Sub-clinical hepatic encephalopathy in cirrhotic patients is not aggravated by sedation with propofol compared to midazolam: A randomized controlled studyJournal of HepatologyVol. 54Issue 6PreviewThis is a reply to the Letter to the Editor by Sharma et al. Full-Text PDF Open Access We read with interest the article by Khamaysi et al. [[1]Khamaysi I. William N. Olga A. Alex I. Vladimir M. Kamal D. et al.Sub-clinical hepatic encephalopathy in cirrhotic patients is not aggravated by sedation with propofol compared to midazolam: a randomized controlled study.J Hepatol. 2010; ([Epub ahead of print])PubMed Google Scholar] in which it was concluded that sedation with propofol does not exacerbate subclinical hepatic encephalopathy (SHE), and allows a shorter recovery time and a shorter time to discharge than midazolam. We wish to highlight that based on a single abnormal psychometry test (NCT-A), they labeled 95% of their patients as having minimal hepatic encephalopathy (MHE); however, according to Ferenci et al. [[2]Ferenci P. Lockwood A. Mullen K. Tarter R. Weissenborn K. Blei A.T. Hepatic encephalopathy-definition, nomenclature, diagnosis, and quantification: final report of the working party at the 11th world congresses of gastroenterology, Vienna, 1998.Hepatology. 2002; 35: 716-721Crossref PubMed Scopus (1741) Google Scholar] two or more abnormal psychometric tests are needed to label patients with MHE which is a better terminology than SHE. Although it is not clear to us which sedation (propofol/midazolam) was given to them, they took 30 controls with no liver disease and found no deterioration/improvement in NCT-A tests; looking at the induction and recovery time it seems that they were given propofol. The primary result of the study that midazolam prolongs the psychometry tests in cirrhotics would be better appreciated if the effect of midazolam on psychometric tests was assessed in the control arm. The second end point of the study was that patients can be discharged early if an endoscopy was done under propofol. At what time patients can be discharged after endoscopy is a big question that has not been well addressed. The mean time of recovery was higher in the midazolam group compared to propofol (11.5 ± 5.0 vs 4.1 ± 1.9 min, p<0.001); the parameters taken to discharge the patients at 110.0 ± 42.0 min in the midazolam group and 38.0 ± 9.0 min in the propofol group was not clear. Some objective parameters before discharge like Post-Anesthetic Discharge Scoring System or the Aldrete scoring system should be used. The authors of this study planned to repeat a NCT-A after 1 h in sedated patients; however, this statement is contradicted by the fact that the mean time to discharge in the propofol group was 38.0 ± 9.0 min. We are also confused about what happened to the patients in the midazolam group who had an increased NCT-A after endoscopy. It would be important to know whether during follow up of 24–48 h in these patients there was any side effects related to sedation in either group. Previous studies have shown that a learning effect is associated with psychometry tests [3Riphaus A. Lechowicz I. Frenz M.B. Wehrmann T. Propofol sedation for upper gastrointestinal endoscopy in patients with liver cirrhosis as an alternative to midazolam to avoid acute deterioration of minimal encephalopathy: a randomized, controlled study.Scand J Gastroenterol. 2009; 44: 1244-1251Crossref PubMed Scopus (56) Google Scholar, 4Amorós A. Aparicio J.R. Garmendia M. Casellas J.A. Martínez J. et al.Deep sedation with propofol does not precipitate hepatic encephalopathy during elective upper endoscopy.Gastrointest Endosc. 2009; 70: 262-268Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar]. Consequently, a deterioration in the performance of patients in these tests would be difficult to pick up by repeating these tests. Tests like critical flicker frequency or inhibitory control test would be better adapted for this assessment. In addition, they observed transient hypoxemia (<90% saturation) in four patients (two in each group) but none in controls, implying that cirrhotic patients are more prone to transient hypoxemia after sedation. From the study, it was not clear whether patients under sedation received prophylactic oxygen; moreover, the patients' American Society of Anesthesiologists Physical Status (ASA) score was also not provided, as it might affect the outcome of psychometry tests and recovery time. In our experience (unpublished data) of more than 1000 endoscopies (both in cirrhotics and non-cirrhotics) performed over a year under propofol sedation (Modified Observer's Assessment of Alertness/Sedation Scale score 1), we agree with the results by Khamaysi et al. that propofol sedation is safe in performing upper gastrointestinal endoscopy in cirrhotic patients when given by anesthetist. In fact, all of our patients could be discharged at 2 h post-endoscopy. However, two or more psychometry tests/CFF/ICT need to be performed to evaluate cognitive function before and after endoscopy, as well as a longer follow up to ensure that propofol does not exacerbate MHE. The authors declared that they do not have anything to disclose regarding funding or conflict of interest with respect to this manuscript.