Propofol for sedation during colonoscopy

Colonoscopy is a common diagnostic and screening test used in the management of many gastrointestinal diseases. Colonoscopy can be uncomfortable, so there is an impetus to optimize sedative medications for test performance and patient comfort. Traditionally, a combination of opioids and benzodiazepines have been used to increase comfort during colonoscopy. Propofol is a potential alternative sedative agent for use during colonoscopy, though it often leads to deeper sedation than with traditional sedatives used for colonoscopy. Many jurisdictions require anesthesiologists to administer propofol.

The primary aim of this review was to assess the effects of propofol sedation for colonoscopy in adult patients compared to opioids or benzodiazepines, or both. Our secondary aim was to assess the effects of propofol sedation for adult patients undergoing colonoscopy administered by anesthesiologists compared to that administered by non-anesthesiologists.

In the previous iteration of this review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Embase, Cancerlit, CINAHL, LILACS, Biological Abstracts, and Web of Science databases for entries up to December 2010. In the current update, we searched CENTRAL (Ovid), Ovid MEDLINE, Ovid Embase, CINAHL (EBSCO), LILACS (VHL), Web of Science Core Collection (Clarivate), WHO ICTRP, and ClinicalTrials.gov from December 2010 until February 2024. We applied no language restrictions.

Randomized controlled trials (RCTs) comparing the use of propofol and traditional sedatives or administration of propofol by anesthesiologists versus non-anesthesiologists for sedation during colonoscopy. We defined traditional sedatives to include only sedative regimens consisting of opioids or benzodiazepines, or both. All other drugs were excluded.

Critical outcomes included cecal intubation rate (colonoscopy completion rate), post-procedure recovery time, time to discharge from the endoscopy unit, patient satisfaction, and pain control. Important outcomes included safety outcomes (hypoxia, apnea, respiratory events requiring intervention, hypotension, arrhythmias, colonic perforations, and death), hospital admissions (for outpatient procedures), level of sedation, procedure duration, sedation time (new in 2024 update), and adenoma detection rate (new in 2024 update).

We assessed risk of bias using Cochrane's RoB 2 tool for all critical outcomes.

We synthesized the results for each outcome using meta-analysis where possible. We used random-effects models for the meta-analysis. We calculated odds ratios (ORs) for dichotomous data and mean differences (MDs) or standardized mean differences (SMD) for continuous data, each with 95% confidence intervals (CI). We used GRADE to assess the certainty of evidence.

We included 33 unique studies (12 carried forward from the previous iteration of this review, 21 uniquely identified in this update) with a total of 12,485 participants. Thirty studies (12,036 participants) examined propofol compared to traditional sedatives during colonoscopy, five of which were published as abstracts only. Three studies (449 participants) compared anesthesiologist- to non-anesthesiologist-directed propofol sedation during colonoscopy, all of which were in full-text form.

Propofol sedation may improve recovery time (MD -3.09 minutes, 95% CI -4.88 to -1.30; 17 RCTs, 2661 participants; low-certainty evidence) and patient satisfaction score (MD 0.42, 95% CI 0.19 to 0.65; 14 RCTs, 1856 participants; low-certainty evidence) compared to traditional sedative agents. The effect is uncertain for discharge time (MD -3.65 minutes, 95% CI -6.93 to -0.37; 17 RCTs, 3131 participants; very low-certainty evidence) and pain score (MD -0.62, 95% CI -1.28 to 0.05; 9 RCTs, 1084 participants; very low-certainty evidence). Propofol likely results in little to no difference in cecal intubation rate (OR 0.99, 95% CI 0.36 to 2.72; 6 RCTs, 1856 participants; moderate-certainty evidence), and may result in little to no difference in respiratory events requiring intervention (OR 0.65, 95% CI 0.21 to 1.97; 10 RCTs, 1614 participants; low-certainty evidence) and colonic perforations (OR 2.87, 95% CI 0.60 to 13.83; 3 RCTs, 7978 participants; low-certainty evidence). The certainty of the evidence was limited by unexplained statistical heterogeneity, wide CIs, and some concerns regarding risk of bias, due primarily to lack of trial information. Non-anesthesiologist-directed propofol sedation resulted in little to no difference in cecal intubation rate (OR 0.73, 95% CI 0.23 to 2.28; 3 RCTs, 433 participants; high-certainty evidence) and patient satisfaction score (MD -0.02, 95% CI -0.13 to 0.09; 1 RCT, 277 participants; high-certainty evidence) compared to anesthesiologist-directed propofol sedation during colonoscopy, but may slightly reduce recovery time (MD -9 minutes, 95% CI -16.30 to -1.70; 1 RCT, 277 participants; low-certainty evidence). There is likely little to no difference between groups in pain scores (MD -0.02, 95% CI -0.26 to 0.22; 1 RCT, 277 participants; moderate-certainty evidence), and there may be little to no difference in respiratory events requiring intervention (OR 0.50, 95% CI 0.02 to 13.12; 2 RCTs, 327 participants; low-certainty evidence). Colonic perforations, apnea events, hospital admissions, and death were not reported in any study.

Propofol sedation for colonoscopy may improve recovery time and patient satisfaction scores, without affecting cecal intubation, perforations, or respiratory events requiring intervention, compared to traditional sedative regimens. Effects on time to discharge and pain score are uncertain. Evidence for this comparison was generally of low certainty, indicating the need for better-quality studies and more standardized outcome reporting. Non-anesthesiologist- compared to anesthesiologist-directed propofol sedation for colonoscopy results in little to no difference in cecal intubation rate and patient satisfaction, but may slightly reduce recovery times. There is likely little to no difference between groups in pain scores, and there may be little to no difference in respiratory events requiring intervention. The certainty of the evidence was high for many outcomes in this second comparison; however, there were very few studies, and many important safety outcomes were not examined.

This review was funded by operating grants from the George and Fay Yee Centre for Healthcare Innovation, the Department of Surgery, Section of General Surgery, and the Clinician Investigator Program, all at the University of Manitoba, Max Rady College of Medicine, Rady Faculty of Health Sciences, Winnipeg, Manitoba, Canada.

Protocol and previous versions available via https://doi.org/10.1002/14651858.CD006268, and https://doi.org/10.1002/14651858.CD006268.pub2.