Safety and Clinical Effectiveness of Midazolam versus Propofol for Procedural Sedation in the Emergency Department: A Systematic Review

Abstract

Objectives: To synthesize the evidence comparing the adverse event (AE) profile and clinical effectiveness of midazolam and propofol for procedural sedation (PS) in adults in the emergency care setting. Methods:The authors conducted a systematic review of randomized controlled trials (RCTs) and observational studies reporting the use of either midazolam and ⁄ or propofol for adult PS in the emergency department (ED). A systematic search strategy was developed and applied to six bibliographic reference databases. Three emergency medicine journals, the Canadian Adverse Drug Reaction Newsletter, and conference proceedings were hand-searched. Retrieved articles were reviewed and data were abstracted using standardized data collection. Trial quality was assessed using the Jadad score. The outcomes assessed were the proportion of patients with AEs and the pooled mean difference in the proportion of patients with successful PS.Results: Of 229 articles identified, 28 met the inclusion criteria for the analysis of AEs. Only one major AE to PS was found, resulting in no statistically significant difference in the proportion of major AEs between agents. Four studies were RCTs that met the inclusion criteria for the analysis of clinical effectiveness. Two trials met criteria for good quality. The RCTs enrolled between 32 and 86 patients, and the most common indications for PS were orthopedic reductions and cardioversions. There was a nonsignificant difference in the proportion of patients with successful PS in favor of propofol (effect difference 2.9%, 95% confidence interval (CI) = -6.5 to 15.2). Conclusions:The authors found no significant difference in the safety profile and the proportion of successful PS between midazolam and propofol for adults in the ED.ACADEMIC EMERGENCY MEDICINE 2008; 15:1-8 ª

A Cost‐effectiveness Analysis of Propofol versus Midazolam for Procedural Sedation in the Emergency Department

“…By far, the most commonly used agents in adults are propofol and midazolam. 7 In a previous analysis and systematic review, we concluded that the proportion of procedural success and the safety profiles of midazolam and propofol were not significantly different when used for adults for PS in the ED. 7 Because of this, a rational choice of which agent to use should be based on the cost of treatment.…”

“…The reference population in this study represents patients who were enrolled in randomized controlled trials (RCTs) and prospective observational studies that were included in the analysis from which we derived estimates of clinical effectiveness and AEs. 7 The reference population consisted of adult patients who presented to the ED with an indication for routine PS, such as cardioversion or an orthopedic reduction. The patients were adults, had minimal comorbidities (American Society for Anesthesiology Grade I or II), and were pretreated with a short-acting narcotic before PS.…”

“…This included a structured search strategy, a priori defined inclusion and exclusion criteria, standardized data abstraction, and trial quality assessment described previously. 7 Our search yielded three RCTs with sufficient data for entry into our analysis. 8,9,11 We used a random effects model to pool the data.…”

“…They included aspiration pneumonitis, intubation, any discernible morbidity or disability beyond the length of the procedure, prolonged ED stay, and admission to hospital or death. 7 The probability of major AEs was derived from the analysis. 7 Given that zero AEs were observed among patients who received midazolam, 0.5 was added to the number of AEs observed (a and b parameters) for both midazolam and propofol to enable modeling.…”

Advantages of Endosopic Retrograde Cholangiopancreatography with Procedural Sedation and Analgesia Technique

“…Hohl CM., provided effectiveness of midazolam versus propofol for 2574 patients undergoing a variety of endoscopic procedures and found a better safety profile of bensodiasepines. Clarke et al also report a beter safety profile of bensodiasepines in over 28000 patients (5). All patients who were in our study who underwent the endoscopic procedure in day-case settings were exceptionally satisfied, thanks to administration of procedural sedation and analgesia.…”