Gastroenterologist-administered propofol versus meperidine and midazolam for advanced upper endoscopy: A prospective, randomized trial

Background & Aims: Propofol is increasingly used for gastrointestinal endoscopy because of its rapid recovery profile. There has been no prospective, randomized comparison of gastroenterologist-administered propofol to meperidine and midazolam for endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography. Additionally, its cost-effectiveness has not been studied. Methods: Seventy-five randomized patients received either gastroenterologist-administered propofol (n = 38) or meperidine/midazolam (n = 37) for endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography. Monitoring with capnography allowed for rapid titration of propofol at the earliest signs of respiratory depression. Visual analogue scales measured tolerance and satisfaction. A cost-effectiveness analysis was performed by using return to baseline for both activity and food intake 24 hours after the procedure as the effectiveness measure. Results: The groups had similar physiological outcomes and satisfaction. Patients receiving propofol had shorter recovery times (P < 0.001) and a higher recovery of both baseline activity level and dietary intake 24 hours after the procedure (P = 0.028). With incremental cost-effectiveness analysis, gastroenterologist-administered propofol cost an additional $403.00 per additional patient at 100% of baseline for both activity level and food intake when compared with standard sedation and analgesia. Sensitivity analysis indicated that the only model in which propofol administration would become the dominant strategy was with its administration by a registered nurse. Conclusions: Gastroenterologist-administered propofol using monitoring with capnography is similar to meperidine/midazolam for both physiological outcomes and patient/endoscopist satisfaction. Propofol leads to significantly improved recovery of baseline activity and food intake 24 hours after the procedure. Our model suggests that propofol would be more cost-effective than meperidine and midazolam for endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography if registered nurse administration were possible.