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

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 I 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.