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Short-Acting Sedative Agents During Endoscopic Retrograde Cholangiopancreatography: A Review of Clinical Effectiveness and Guidelines

Last updated: August 17, 2020
Project Number: RC1301-000
Product Line: Rapid Response
Research Type: Drug
Report Type: Summary with Critical Appraisal
Result type: Report

Question

  1. What is the clinical effectiveness of short-acting sedative agents during endoscopic retrograde cholangiopancreatography?
  2. What are the evidence-based guidelines for moderate procedural sedation during endoscopic retrograde cholangiopancreatography?

Key Message

Thirteen randomized controlled trials and one retrospective cohort study provided information regarding the clinical effectiveness of short-acting sedative agents during endoscopic retrograde cholangiopancreatography. The studies covered a wide range of short-acting sedatives, including propofol alone, etomidate alone, and remifentanil alone. Others were propofol-based combinations (i.e., propofolalfentanil, propofolesketamine, propofolfentanyl, propofolketamine, propofolmeperidine, midazolampropofol, and propofolremifentanil), midazolam-based combinations (i.e., midazolametomidate, midazolamfentanyl, midazolamketamine, midazolammeperidine, midazolampethidine, and midazolamremifentanil), and dexmedetomidine-based combinations (dexmedetomidineketamine and dexmedetomidineremifentanil).Therefore, although 14 studies were included in this report, they were spread over several unique intervention-comparator pairs. In effect, there was a limited quantity of evidence for each comparison. Also, doses of sedative agents used tended to vary from study to study, so that even where drugs appeared to be the same in two or more studies, they usually differed in doses. Other sources of limitations included inadequate determination of sample sizes to ensure that studies were adequately powered to determine differences in treatment effects between competing groups, the use of unvalidated methods to assess satisfaction with sedation and pain during the ERCP procedure, lack of adequate blinding in some randomized trials, and the use of data from different historical periods in the retrospective cohort study. Although each of the agents investigated in the included studies demonstrated some effectiveness, given the limitations discussed here and elsewhere in the report, a definitive conclusion could not be drawn about the optimal choice of short-acting sedative agents during ERCP due to the qualitative and quantitative limitations of the evidence that was available for this report. No relevant evidence-based guidelines were identified for moderate procedural sedation during endoscopic retrograde cholangiopancreatography.