Original Article

Sedation for Upper Endoscopy: Comparison of Midazolam Versus Fentanyl Plus Midazolam

Authors: Jose Barriga, MD, Mankanwal S. Sachdev, MD, Lee Royall, MD, Garrick Brown, MD, Claudio R. Tombazzi, MD

Abstract

ackground: The benefit of using one or two drugs for conscious sedation in upper endoscopy remains unproven. This study evaluates the adequacy of conscious sedation during upper endoscopy using midazolam alone compared with midazolam plus fentanyl.


Methods: Patients older than 18 years of age who underwent elective, outpatient upper endoscopy were included. They were randomized to receive either a combination of midazolam/fentanyl or midazolam alone. The adequacy of sedation obtained was assessed using a questionnaire answered by the physician at the end of the procedure, and by the patient 24 to 72 hours after endoscopy.


Results: From the endoscopist's perspective, following an intention-to-treat analysis, patients had better tolerance in the combination group (78.3% excellent/good tolerance M/F group versus 55.8% M group) (P = 0.043) (Table 2). Per patient's assessment excellent/good tolerance was found in 93% of M group and 94% in F/M group (P = 1.0). No difference in duration of the procedure was found between the two groups. No complications during endoscopies were reported.




Table 2

Table 2
Image Tools


Conclusions: In diagnostic upper endoscopy, an adequate level of sedation can be obtained safely either by midazolam or midazolam plus fentanyl. From an endoscopist's perspective, the combination is significantly better.


Key Points


* Conscious sedation is routinely used in endoscopy, and the medications used vary.


* From a patient perspective, the combination of midazolam and fentanyl plus midazolam are equally adequate for conscious sedation.


* From an endoscopist's perspective, the combination of midazolam and fentanyl is significantly better than midazolam alone.


* There were no differences in regards to side effects, complications, or patient discomfort when comparing single agent to double agent conscious sedation.


* Patient and provider opinions differ on comfort levels.

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References

1. Carey WD. Indications, Contraindications and Complications of Upper Gastrointestinal Endoscopy, in Sivak M (ed): Gastroenterologic Endoscopy. Philadelphia, WB Saunders, 1987, pp 296–306.
 
2. Freeman ML. Sedation and monitoring for gastrointestinal endoscopy. Gastroint Endosc Clin N Am 1994;4:475–499.
 
3. Waring JP, Baron TH, Hirota WK, et al. Guidelines for conscious sedation and monitoring during gastrointestinal endoscopy. Gastrointest Endosc 2003;58:317–322.
 
4. Jones MP, Ebert CC, Sloan T, et al. Patient anxiety and elective gastrointestinal endoscopy. J Clin Gastroenterol 2004;38:35–40.
 
5. Freeman ML. Sedation and Monitoring for Gastrointestinal Endoscopy, in Yamada T, Alpers DH, Laine L, et al (eds): Textbook of Gastroenterology. Philadelphia, Lippincott, 2003, ed 3, pp 2812–2824.
 
6. Whitwam JG, McCloy RF. Principles and Practice of Sedation. Oxford, Blackwell Publishing, 1998, ed 2.
 
7. Arrowsmith JB, Gerstman BB, Fleischer DE, et al. Results from the American Society for Gastrointestinal Endoscopy/U.S. Food and Drug Administration collaborative study on complication rates and drug use during gastrointestinal endoscopy. Gastrointest Endosc 1991;37:421–427.
 
8. Holm C, Rosenberg J. Pulse oximetry and supplemental oxygen during gastrointestinal endoscopy: a critical review. [see comment]. Endoscopy 1996;28:703–711.
 
9. Quine MA, Bell GD, McCloy RF, et al. Prospective audit of perforation rates following upper gastrointestinal endoscopy in two regions of England. Br J Surg 1995;82:530–533.
 
10. Bell GD, Spickett GP, Reeve PA, et al. Intravenous midazolam for upper gastrointestinal endoscopy: a study of 800 consecutive cases relating dose to age and sex of patient. Br J Clin Pharmacol 1987;23:241–243.
 
11. Lieberman DA, Wuerker CK, Katon RM. Cardiopulmonary risk of esophagogastroduodenoscopy. Role of endoscope diameter and systemic sedation. Gastroenterology 1985;88:468–472.
 
12. Zuccaro G Jr. Sedation and sedationless endoscopy. Gastrointest Endosc Clin N Am 2000 2000;10:1–20.
 
13. Brody DS. Physician recognition of behavioral, psychological, and social aspects of medical care. Arch Intern Med 1980;140:1286–1289.
 
14. Maguire GP, Julier DL, Hawton KE, et al. Psychiatric morbidity and referral on two general medical wards. BMJ 1974;1:268–270.
 
15. Bell GD. Review article: premedication and intravenous sedation for upper gastrointestinal endoscopy. Aliment Pharmacol Therapeut 1990;4:103–122.
 
16. Lauven PM. Pharmacology of drugs for conscious sedation. Scand J Gastroenterol Suppl 1990;179:1–6.
 
17. Laluna L, Allen ML, Dimarino AJ Jr. The comparison of midazolam and topical lidocaine spray versus the combination of midazolam, meperidine, and topical lidocaine spray to sedate patients for upper endoscopy. Gastrointest Endosc 2001;53:289–293.
 
18. Ciriza C, Garcia L, Fernandez A, et al. Sedation for gastrointestinal endoscopy. Analysis of tolerance and complications. Revista Espanola de Enfermedades Digestivas 2001;93:587–597.
 
19. Cohen J, Haber GB, Dorais JA, et al. A randomized, double-blind study of the use of droperidol for conscious sedation during therapeutic endoscopy in difficult to sedate patients. Gastrointest Endosc 2000;51:546–551.
 
20. Froehlich F, Schwizer W, Thorens J, et al. Conscious sedation for gastroscopy: patient tolerance and cardiorespiratory parameters.[see comment]. Gastroenterology 1995;108:697–704.
 
21. Kulling D, Bauerfeind P, Fried M, et al. Patient-controlled analgesia and sedation in gastrointestinal endoscopy. Gastrointest Endosc Clin N Am 2004;14:353–368.
 
22. Montes RG, Bohn RA. Deep sedation with inhaled sevoflurane for pediatric outpatient gastrointestinal endoscopy. J Pediatr Gastroenterol Nutr 2000;31:41–46.
 
23. Smith MR, Bell GD, Quine MA, et al. Small bolus injections of intravenous midazolam for upper gastrointestinal endoscopy: a study of 788 consecutive cases. Br J Clin Pharmacol 1993;36:573–578.
 
24. Vargo JJ, Zuccaro G Jr, Dumot JA, et al. Gastroenterologist-administered propofol versus meperidine and midazolam for advanced upper endoscopy: a prospective, randomized trial. [see comment]. Gastroenterology 2002;123:8–16.
 
25. Vicari JJ. Sedation and analgesia. Gastrointest Endosc Clin N Am 2002;12:297–311.
 
26. Martins NB, Wassef W. Upper gastrointestinal bleeding. Curr Opin Gastroenterol 2006;22:612–619.
 
27. Rex DK. Review article: moderate sedation for endoscopy: sedation regimens for non-anaesthesiologists. Aliment Pharmacol Therapeut 2006;24:163–171.
 
28. Vargo JJ, Holub JL, Faigel DO, et al. Risk factors for cardiopulmonary events during propofol-mediated upper endoscopy and colonoscopy. Aliment Pharmacol Therapeut 2006;24:955–963.