Propofol versus Midazolam for Upper Gastrointestinal Endoscopy in Cirrhotic Patients: A Meta-Analysis of Randomized Controlled Trials

Abstract

BackgroundSedation during gastrointestinal endoscopy is often achieved using propofol or midazolam in general population. However, impaired protein synthesis, altered drug metabolism, and compromised hepatic blood flow in patients with liver cirrhosis might affect the pharmacokinetics of sedatives, placing cirrhotic patients undergoing endoscopy at a greater risk of adverse events. The objective of this study was to assess comparative efficacies and safety of propofol and midazolam in cirrhotic patients undergoing endoscopy.MethodsRandomized, controlled trials comparing propofol with midazolam in cirrhotic patients undergoing gastrointestinal endoscopy were selected. We performed the meta-analysis, using a random-effect model, the Review Manager, Version 5.2, statistical software package (Cochrane Collaboration, Oxford, UK) according to the PRISMA guidelines.ResultsFive studies between 2003 and 2012, including 433 patients, were included. Propofol provided a shorter time to sedation (weight mean difference: -2.76 min, 95% confidence interval: -3.00 to -2.51) and a shorter recovery time (weight mean difference -6.17 min, 95% confidence interval: -6.81 to -5.54) than midazolam did. No intergroup difference in the incidence of hypotension, bradycardia, or hypoxemia was observed. Midazolam was associated with the deterioration of psychometric scores for a longer period than propofol.ConclusionThis meta-analysis suggests that Propofol sedation for endoscopy provides more rapid sedation and recovery than midazolam does. The risk of sedation-related side effects for propofol does not differ significantly from that of midazolam. The efficacy of propofol in cirrhotic patients undergoing endoscopy is superior to those of midazolam.

Electromagnetic-Guided Bedside Placement of Nasoenteral Feeding Tubes by Nurses Is Non-Inferior to Endoscopic Placement by Gastroenterologists: A Multicenter Randomized Controlled Trial

“…Th e use of sedation is considered a major advantage of endoscopy by patients and was therefore also one of the most frequently reported reasons for patients to decline participation in the trial. Conscious sedation is, however, associated with a small risk of cardiopulmonary complications such as hypoxia ( 34,35 ), which occurred in one patient in our trial, who was consequently admitted to the intensive care unit. On the other hand, recommendation scores were signifi cantly higher in the EM-guided group, presumably because the discomfort patients experience is not bothersome enough to advise others not to undergo the procedure.…”

Efficacy of Upper Gastrointestinal Endoscopic Examination to Identify Patients with Obstructive Sleep Apnea Syndrome: A Retrospective Cross-Sectional Study

“…Unlike our study, propofol was often used in previous studies conducted in Western countries [9,11,15]. Because of the limited analgesic effect, the use of propofol as a single agent for GI endoscopy tends to be required in higher sedation levels [28]. Moreover, the insertion route can alter outcomes.…”

Gastrointestinal endoscopy in the cirrhotic patient

“…Endoscopy is usually successfully performed with the use of moderate (conscious) sedation [10]. There are no specific sedation guidelines for patients with advanced liver disease, and the cirrhotic population is more susceptible to complications related to sedation than their counterparts, which is likely related to higher plasma levels of the drug or delayed clearance [2,6,11,48,49]. There is even less available data investigating sedation in patients with higher CPT scores and American Society for Anesthesiologists classifications, which can lead to a higher rate of complications and encephalopathy [3,7,48,50].…”

“…Both midazolam and propofol have similar side effect profiles, with sedation-related complications being similar [48,49,51]. However, they are metabolized differently, with propofol being conjugated by extrahepatic and hepatic tissues and then excreted by the kidneys, with liver disease not significantly altering its pharmacokinetic profile.…”