Improved sedation in diagnostic and therapeutic ERCP: Propofol is an alternative to midazolam

Background and Study Aims: Adequate sedation of the patient is required for diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP). The anesthetic propofol, with its shorter half-life, affording bett er control, offers an alternative to the benzodiazepine midazolam. The aim of this randomized, controlled, unblinded study was to compare prospectivel y the quality of sedation under propofol and midazolam in patients undergoi ng ERCP. Patients and Methods: A total of 80 patients were randomized to sedation wi th propofol alone (n = 40) or midazolam alone (n = 40). Blood pressure, pul se, and oxygen saturation were measured. Midazolam was given by the endosco pist and titrated to the patients' response during ERCP, to a maximum dose of 15 mg per patient. In the propofol group an anesthetist was present to a dminister the propofol and to observe the patient. Standardized testing pro cedures (Steward score, Trieger test) were used to determine the length of postendoscopy recovery time. Efficacy of sedation was assessed by investiga tors and patients, using scoring systems. Results: Complete ERCP and adequate sedation was possible in 80% of patient s (32 out of 40) with midazolam, and in 97.5% of patients (39 out of 40) wi th propofol (P < 0.01). The average propofol induction dose was 1.24 mg/kg body weight, with maintenance requiring a mean dose of 9 mg/kg body weight per hour, or the equivalent of 354 mg in total. The average dose of midazol am administered was 0.12 mg/kg body weight; the total dose averaged 8 mg. R ecovery time in the propofol patients was significantly shorter (P < 0.01). The investigators (P < 0.01) and the patients (P < 0.05) both judged the q uality of sedation to be better in the propofol group. There were no differ ences in blood pressure, pulse, or oxygen saturation between the two groups . One patient in the propofol group (79 years old) suffered a protracted ap neic phase accompanied by hypotension that was managed by manual ventilatio n and drug therapy, and led to no complications. Conclusions: Propofol proves to be an excellent sedative for ERCP and shows a shorter recovery time than midazolam. Because of the narrow therapeutic window, we recommend close patient monitoring.