Midazolam for sedation during diagnostic or therapeutic upper gastrointestinal endoscopy in cirrhotic patients

The objective of this study was to determine the frequency of clinically overt hepatic encephalopathy (HE) in cirrhotic patients undergoing diagnostic or therapeutic upper gastrointestinal endoscopy (UGE) who received midazolam for sedation.

This was an interventional study carried out at Liaquat National Hospital, Karachi. Consecutive patients presenting to the service of a single consultant gastroenterologist for diagnostic or therapeutic UGE between January 2009 and January 2011, who fulfilled the inclusion and exclusion criteria, were prospectively recruited for the study. The administration of intravenous midazolam was carried out in an incremental manner, whereas pulse and oxygen saturation was monitored during every procedure. During the recovery period, the degree of alertness was measured at 2, 4, and 6 h by the resident using the observer's assessment of alertness and sedation score and time to full recovery was determined.

A total of 191 consecutive patients who underwent diagnostic or therapeutic UGE fulfilling the inclusion and exclusion criteria were recruited. The mean age was 51.30 ± 10.7 years, with an age range of 12-75 years. The majority of the patients were men (n=108, 56.5%), with 83 women (43.5%). A total of eight patients (4.2%) remained drowsy and developed clinically overt HE after the procedure on assessment at 2 and 4 h. However, all of these patients regained full consciousness at 6 h spontaneously. Among those eight patients who developed clinically overt HE, seven (87.5%) were Child-Pugh class C and one patient (12.5%) was Child-Pugh class B. Overt HE was significantly related to Child-Pugh class (P=0.005) and the dose of midazolam (P=0.02).

We concluded that intravenous midazolam can be used safely in cirrhotic patients of Child-Pugh class A and B undergoing UGE for conscious sedation, but caution should be exercised for patients with advanced liver disease.