Meta-Analysis
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. Aug 16, 2020; 12(8): 241-255
Published online Aug 16, 2020. doi: 10.4253/wjge.v12.i8.241
Propofol vs midazolam sedation for elective endoscopy in patients with cirrhosis: A systematic review and meta-analysis of randomized controlled trials
John Alexander Lata Guacho, Diogo Turiani Hourneaux de Moura, Igor Braga Ribeiro, Alberto Machado da Ponte Neto, Shailendra Singh, Marina Gammaro Baldavira Tucci, Wanderley Marques Bernardo, Eduardo Guimarães Hourneaux de Moura
John Alexander Lata Guacho, Diogo Turiani Hourneaux de Moura, Igor Braga Ribeiro, Alberto Machado da Ponte Neto, Marina Gammaro Baldavira Tucci, Wanderley Marques Bernardo, Eduardo Guimarães Hourneaux de Moura, Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403-010, Brazil
Shailendra Singh, Division of Gastroenterology, Department of Internal Medicine, West Virginia University, Charleston, WV 25304, United States
Author contributions: Guacho JAL and de Moura DTH contributed to acquisition of data, analysis, interpretation of data, drafting the article, revising the article, final approval; Ribeiro IB, da Ponte Neto AM and Singh S contributed to analysis and interpretation of data, revising the article; Tucci M contributed to acquisition of data drafting the article, final approval; Bernardo WM contributed to analysis and interpretation of data, drafting the article, final approval; de Moura EGH contributed to analysis and interpretation of data, drafting the article, revising the article, final approval.
Conflict-of-interest statement: The authors deny any conflict of interest.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised in accordance with this checklist.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Igor Braga Ribeiro, MD, Research Fellow, Surgeon, Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av. Dr Enéas de Carvalho Aguiar, 225, 6o andar, bloco 3, Cerqueira Cesar, São Paulo 05403-010, Brazil. igorbraga1@gmail.com
Received: March 31, 2020
Peer-review started: March 31, 2020
First decision: June 7, 2020
Revised: June 12, 2020
Accepted: July 18, 2020
Article in press: July 18, 2020
Published online: August 16, 2020
Abstract
BACKGROUND

Patients with cirrhosis frequently require sedation for elective endoscopic procedures. Several sedation protocols are available, but choosing an appropriate sedative in patients with cirrhosis is challenging.

AIM

To conduct a systematic review and meta-analysis to compare propofol and midazolam for sedation in patients with cirrhosis during elective endoscopic procedures in an attempt to understand the best approach.

METHODS

This systematic review and meta-analysis was conducted using the PRISMA guidelines. Electronic searches were performed using MEDLINE, EMBASE, Central Cochrane, LILACS databases. Only randomized control trials (RCTs) were included. The outcomes studied were procedure time, recovery time, discharge time, and adverse events (bradycardia, hypotension, and hypoxemia). The risk of bias assessment was performed using the Revised Cochrane Risk-of-Bias tool for randomized trials (RoB-2). Quality of evidence was evaluated by GRADEpro. The meta-analysis was performed using Review Manager.

RESULTS

The search yielded 3,576 records. Out of these, 8 RCTs with a total of 596 patients (302 in the propofol group and 294 in the midazolam group) were included for the final analysis. Procedure time was similar between midazolam and propofol groups (MD: 0.25, 95%CI: -0.64 to 1.13, P = 0.59). Recovery time (MD: -8.19, 95%CI: -10.59 to -5.79, P < 0.00001). and discharge time were significantly less in the propofol group (MD: -12.98, 95%CI: -18.46 to -7.50, P < 0.00001). Adverse events were similar in both groups (RD: 0.02, 95%CI: 0-0.04, P = 0.58). Moreover, no significant difference was found for bradycardia (RD: 0.03, 95%CI: -0.01 to 0.07, P = 0.16), hypotension (RD: 0.03, 95%CI: -0.01 to 0.07, P = 0.17), and hypoxemia (RD: 0.00, 95%CI: -0.04 to 0.04, P = 0.93). Five studies had low risk of bias, two demonstrated some concerns, and one presented high risk. The quality of the evidence was very low for procedure time, recovery time, and adverse events; while low for discharge time.

CONCLUSION

This systematic review and meta-analysis based on RCTs show that propofol has shorter recovery and patient discharge time as compared to midazolam with a similar rate of adverse events. These results suggest that propofol should be the preferred agent for sedation in patients with cirrhosis.

Keywords: Sedation, Midazolam, Propofol, Cirrhosis, Endoscopic, Endoscopy, Meta-analysis

Core tip: Patients with cirrhosis often require elective endoscopic procedures, but choosing an appropriate sedative is challenging. We performed a systematic review and meta-analysis of randomized controlled trials to compare propofol and midazolam for sedation in patients with cirrhosis during elective endoscopic procedures. We concluded propofol has shorter recovery and patient discharge time as compared to midazolam with a similar rate of adverse events, suggesting that propofol should be the preferred agent for sedation in patients with cirrhosis.