Sedation, surveillance, and preparation

A systematic review and meta-analysis of randomized, controlled trials of moderate sedation for routine endoscopic procedures (McQuaid & Laine, Gastrointest Endosc 2008 [1])

This important meta-analysis included 36 randomized, controlled trials (RCTs) of sedation efficacy, sedation-related complications, and procedure-related efficiency outcomes in patients (n = 3918) undergoing routine upper and lower gastrointestinal endoscopy under moderate sedation. Various intravenous sedation regimens were compared. Overall, the quality of the included studies was moderate, with only 11 of the 52 RCTs fulfilling the criteria for a Jadad quality score ≥ 4 [2]. Regarding the question of whether sedation is really helpful in performing upper and lower gastrointestinal endoscopy, the authors retrieved only two RCTs that investigated the sedation efficacy and safety during esophagogastroduodenoscopy (EGD) with or without sedation; results from both trails were in favor of performing sedation. Therefore, solid-based scientific evidence enabling us to answer this question is not currently available; however, worldwide endoscopic practice has seen a substantial increase in the use of sedation during the last decade [3] [4] [5].

The main results of the meta-analysis regarding efficacy, safety, and recovery of the different sedation regimens are summarized in [Table 1] – [3].

Table 1 Sedation efficacy (rated by physicians) of different intravenous sedation regimens evaluated in randomized controlled trials during upper and/or lower gastrointestinal endoscopy (adapted from McQuaid & Laine, Gastrointest Endosc 2008; 67 : 910 – 923). Sedation regimen 1 Sedation regimen 2 No. of studies Procedure Relative risk (95 % confidence interval) Midazolam Diazepam 3 EGD 1.2 (0.75 – 1.91) Midazolam plus opioids Diazepam plus opioids 2 Colonoscopy 1.06 (0.96 – 1.18) Midazolam Propofol 2 EGD 0.99 (0.86 – 1.14) Midazolam plus opioids Propofol 2 Colonoscopy 0.84 (0.68 – 1.04) EGD, Esophagogastroduodenoscopy.

Table 2 Sedation safety (by assessing the frequency of hypoxemic episodes) of different intravenous sedation regimens evaluated in randomized, controlled trials during upper and/or lower gastrointestinal endoscopy (adapted from McQuaid & Laine, Gastrointest Endosc 2008; 67 : 910 – 923). Sedation regimen 1 Sedation regimen 2 No. of studies Procedure Relative risk (95 % confidence interval) Midazolam plus opioids Diazepam plus opioids 2 Colonoscopy 0.97 (0.41 – 2.31) Midazolam Propofol 2 EGD 1.11 (0.71 – 1.74) Midazolam plus opioids Propofol 3 Both 0.82 (0.22 – 2.98) EGD, Esophagogastroduodenoscopy.

Table 3 Patient recovery time after different intravenous sedation regimens evaluated in randomized, controlled trials during upper and/or lower gastrointestinal endoscopy (adopted from McQuaid & Laine, Gastrointest Endosc 2008; 67 : 910 – 923). Sedation regimen 1 Sedation regimen 2 No. of studies Procedure Pooled mean recovery time, minutes(Regimen 1 vs. regimen 2) Midazolam plus opioids Diazepam plus opioids 3 Colonoscopy 36 vs. 36 Midazolam Propofol 2 EGD 52 vs. 40* Midazolam plus opioids Propofol 3 Colonoscopy 29 vs. 15* Midazolam plus opioids Propofol plus opioids 1 Colonoscopy 42 vs. 38 EGD, Esophagogastroduodenoscopy.*A significant difference was reported in all studies.

In conclusion, despite the known limitations of meta-analyses performed on clinical trials comparing very individualized sedation strategies (e. g. drug dosing not equivalent in different studies, different monitoring practices, and different definitions of quality parameters), the present meta-analysis allows several valid conclusions. First, the meta-analysis documented a sufficient efficacy and safety of all currently used intravenous sedation regimens. Second, regarding the use of propofol-based regimens for sedation during diagnostic upper and lower gastrointestinal endoscopy, the authors found only significant advantages over the use of benzodiazepine-based regimens with respect to the recovery time, whereas sedation efficacy and safety were nearly comparable. This stands somewhat in contrast to the results from another meta-analysis [6], which showed a significantly lower frequency of cardiorespiratory side effects under propofol sedation compared with the use of benzodiazepines during routine upper and lower gastrointestinal endoscopy. However, the present meta-analysis from McQuaid and Laine included only RCTs, whereas Quadeer et al. [6] also pooled data from noncomparative and retrospective studies. Therefore, there is clearly a need for further well-conducted prospective trials evaluating all aspects of endoscopic sedation.

References

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