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

https://doi.org/10.1016/j.gie.2007.12.046Get rights and content

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.

Section snippets

Search strategy

We performed a systematic search of the medical literature for randomized controlled trials (RCTs) of moderate sedation in unselected adults undergoing upper endoscopy or colonoscopy. We searched the EMBASE (1980–January 2007) and MEDLINE (1950–January 2007) computerized bibliographic databases. We did not search for abstracts or unpublished data. The detailed search strategy is available from the authors on request. In brief, the search terms included endoscopy or individual procedure names

Results

Our initial search strategy yielded 1218 unique articles. After initial title and abstract review, 87 complete articles were retrieved for detailed review and 1 meta-analysis.14 Fifty studies were excluded for the following reasons: administration of fixed doses of medication (27), administration of oral agents (3), duplicate publication (2), administration of deep sedation or general anesthesia (3), patient-controlled analgesia (3), not an RCT (8), study of sedation for ERCP (2), a selected

Discussion

Because moderate sedation is so widely used for endoscopic procedures, we sought to assess the relative safety, efficacy, and efficiency of currently available therapies, focusing on the most widely used medications. We note that the marked variability in study design, methodologic quality, regimens tested, and outcomes assessed in the studies included in our systematic review limit the ability to define an “optimal” moderate sedation regimen. We emphasize that pooling results from multiple

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