F. Dossa1, B. Medeiros2, S. A. Acuna1, N. N. Baxter1 1University Of Toronto,Division Of General Surgery,Toronto, ON, Canada 2Western University,Department Of Biology,London, ON, Canada
Introduction:
The use of propofol for sedation in colonoscopy adds considerable expense to the procedure. Proponents of propofol defend its use through claims of increased patient and endoscopist satisfaction and greater procedural efficiency; however, these outcomes have not been formally compared between propofol and the commonly used alternative combination of midazolam/fentanyl. We aimed to compare satisfaction and efficiency outcomes between these agents.
Methods:
We systematically searched MEDLINE, Embase, and the Cochrane Library (to March 28, 2017) to identify randomized controlled trials comparing outcomes between propofol +/- short-acting opioids (fentanyl, remifentanil, alfentanil) and midazolam/fentanyl used for colonoscopy. Outcomes included post-procedure and delayed recall of patient pain and satisfaction, endoscopist satisfaction, procedural time, and recovery time. Standardized mean differences (SMD) were meta-analyzed using random effects models.
Results:
We identified 5 studies reporting at least one satisfaction or efficiency outcome of interest. There were no statistically significant differences in post-procedure (SMD 0.44; 95% CI: -0.03, 0.90) or delayed assessment (SMD 0.39; 95% CI: -0.34, 1.11) of patient satisfaction between propofol and midazolam/fentanyl. Similarly, there were no significant differences in post-procedure (SMD -0.31; 95%CI -0.88, 0.26) or delayed recall (SMD -0.12; 95%CI -0.33, 0.08) of patient pain between midazolam/fentanyl and propofol. We were unable to meta-analyze endoscopist satisfaction due to a lack of studies reporting this outcome. Procedural time was shorter with propofol use (SMD -0.22; 95%CI: -0.40, -0.04); however, the absolute differences in procedure time within studies ranged from only 0.5 to 1.7 minutes. There were no significant differences in recovery time between sedative combinations. Notably, for all outcomes assessed, we found greater differences between than within studies, suggesting a greater effect of endoscopic technique or depth of sedation used than sedative administered.
Conclusion:
Despite the beliefs of greater patient satisfaction and procedural efficiency with propofol versus midazolam/fentanyl in colonoscopy, we did not find evidence to support these claims. Given the large between study differences observed in this study, satisfaction and efficiency may depend more greatly on endoscopist technique and depth of sedation used than on sedative selection. Given the increased cost associated with propofol use, these findings should be considered when selecting sedative agents for lower gastrointestinal endoscopy.