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A systematic review and meta-analysis of randomized, controlled trials of moderate sedation for routine endoscopic procedures

  • Kenneth R. McQuaid
    Correspondence
    Reprint requests: Kenneth R. McQuaid, MD, GI Section, 111B, VA Medical Center, 4150 Clement St, San Francisco, CA 94121.
    Affiliations
    Current affiliations: Veterans Affairs Medical Center and Department of Medicine, University of California San Francisco (K.R.M.), University of Southern California, Los Angeles, California, USA (L.L.)
    Search for articles by this author
  • Loren Laine
    Affiliations
    Current affiliations: Veterans Affairs Medical Center and Department of Medicine, University of California San Francisco (K.R.M.), University of Southern California, Los Angeles, California, USA (L.L.)
    Search for articles by this author

      Background

      Numerous agents are available for moderate sedation in endoscopy.

      Objective

      Our purpose was to compare efficacy, safety, and efficiency of agents used for moderate sedation in EGD or colonoscopy.

      Design

      Systematic review of computerized bibliographic databases for randomized trials of moderate sedation that compared 2 active regimens or 1 active regimen with placebo or no sedation.

      Patients

      Unselected adults undergoing EGD or colonoscopy with a goal of moderate sedation.

      Main Outcome Measurements

      Sedation-related complications, patient assessments (satisfaction, pain, memory, willingness to repeat examination), physician assessments (satisfaction, level of sedation, patient cooperation, examination quality), and procedure-related efficiency outcomes (sedation, procedure, or recovery time).

      Results

      Thirty-six studies (N = 3918 patients) were included. Sedation improved patient satisfaction (relative risk [RR] = 2.29, range 1.16-4.53) and willingness to repeat EGD (RR = 1.25, range 1.13-1.38) versus no sedation. Midazolam provided superior patient satisfaction to diazepam (RR = 1.18, range 1.07-1.29) and less frequent memory of EGD (RR = 0.57, range 0.50-0.60) versus diazepam. Adverse events and patient/physician assessments were not significantly different for midazolam (with or without narcotics) versus propofol except for slightly less patient satisfaction (RR = 0.90, range 0.83-0.97) and more frequent memory (RR = 3.00, range 1.25-7.21) with midazolam plus narcotics. Procedure times were similar, but sedation and recovery times were shorter with propofol than midazolam-based regimens.

      Limitations

      Marked variability in design, regimens tested, and outcomes assessed; relatively poor methodologic quality (Jadad score ≤3 in 23/36 trials).

      Conclusions

      Moderate sedation provides a high level of physician and patient satisfaction and a low risk of serious adverse events with all currently available agents. Midazolam-based regimens have longer sedation and recovery times than does propofol.

      Abbreviations:

      RCT (randomized controlled trial), RR (relative risk)
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