Propofol vs midazolam sedation for elective endoscopy in patients with cirrhosis: A systematic review and meta-analysis of randomized controlled trials

Abstract

BACKGROUND Patients with cirrhosis frequently require sedation for elective endoscopic procedures. Several sedation protocols are available, but choosing an appropriate sedative in patients with cirrhosis is challenging. AIM To conduct a systematic review and meta-analysis to compare propofol and midazolam for sedation in patients with cirrhosis during elective endoscopic procedures in an attempt to understand the best approach. METHODS This systematic review and meta-analysis was conducted using the PRISMA guidelines. Electronic searches were performed using MEDLINE, EMBASE, Central Cochrane, LILACS databases. Only randomized control trials (RCTs) were included. The outcomes studied were procedure time, recovery time, discharge time, and adverse events (bradycardia, hypotension, and hypoxemia). The risk of bias assessment was performed using the Revised Cochrane Risk-of-Bias tool for randomized trials (RoB-2). Quality of evidence was evaluated by GRADEpro. The meta-analysis was performed using Review Manager. RESULTS The search yielded 3,576 records. Out of these, 8 RCTs with a total of 596 patients (302 in the propofol group and 294 in the midazolam group) were included for the final analysis. Procedure time was similar between midazolam and propofol groups (MD: 0.25, 95%CI: -0.64 to 1.13, P = 0.59). Recovery time (MD: -8.19, 95%CI: -10.59 to -5.79, P < 0.00001). and discharge time were significantly less in the propofol group (MD: -12.98, 95%CI: -18.46 to -7.50, P < 0.00001). Adverse events were similar in both groups (RD: 0.02, 95%CI: 0-0.04, P = 0.58). Moreover, no significant difference was found for bradycardia (RD: 0.03, 95%CI: -0.01 to 0.07, P = 0.16), hypotension (RD: 0.03, 95%CI: -0.01 to 0.07, P = 0.17), and hypoxemia (RD: 0.00, 95%CI: -0.04 to 0.04, P = 0.93). Five studies had low risk of bias, two demonstrated some concerns, and one presented high risk. The quality of the evidence was very low for procedure time, recovery time, and adverse events; while low for discharge time. CONCLUSION This systematic review and meta-analysis based on RCTs show that propofol has shorter recovery and patient discharge time as compared to midazolam with a similar rate of adverse events. These results suggest that propofol should be the preferred agent for sedation in patients with cirrhosis.

Efficacy and Safety of Remimazolam in Endoscopic Sedation—A Systematic Review and Meta-Analysis

“…At present, the sedative drugs used in clinical endoscopy are mainly midazolam and propofol. Midazolam has a long duration of action and slow recovery from anesthesia (6,7). In addition to the injection site pain, propofol also has strong respiratory and circulatory inhibitory effects, thus increasing the incidence of accidental risks such as hypoxemia, hypotension, and cardiac arrest (8,9).…”

Comparison of Lidocaine Spray and Lidocaine Ice Popsicle in Patients Undergoing Unsedated Esophagogastroduodenoscopy: A Single Center Prospective Randomized Controlled Trial

“…5,6,[11][12][13][17][18][19][20][21][22][23][24][25] Intravenous anesthesia is an option for EGD but holds the risk of adverse events such as bradycardia, hypotension, and respiratory depression, particularly when administered by non-anesthetists. 26,27,[30][31][32][33] The use of topical pharyngeal anesthesia reduced the use and risk of intravenous sedation and directed researcher's attention towards alleviating the gag reflex, pain, discomfort, and improving tolerability of unsedated patients and towards studies to ascertain how to improve tolerability.…”

Academy of Medicine, Singapore clinical guideline on the use of sedation by non-anaesthesiologists during gastrointestinal endoscopy in the hospital setting

“…Metaanalyses noted that propofol sedation produced deeper sedation than traditional agents. 5,[64][65][66][67][68][69][70][71][72] However, there was no difference in complications in respect to cardiorespiratory parameters, with the exception of 1 meta-analysis noting a higher incidence of hypotension in propofol sedation. 64 One meta-analysis noted lower cardiorespiratory complications (blood pressure, oxygen saturation and heart rate) in the group sedated with propofol for colonoscopy but there were no differences in complications for other endoscopic procedures.…”

“…19 Propofol sedation is efficacious and is equivalent to benzodiazepines for GI endoscopy in terms of peri-procedural haemodynamic changes and oxygenation. There is abundant medical literature in the form of randomised control trials as well as metaanalyses/systematic reviews 5,[64][65][66][67][68][69][70][71][72] comparing the use of propofol with benzodiazepines during GI endoscopy. Most studies were published from the year 2000 onwards with the majority concentrated in the last 10 years.…”