Hypotension during propofol sedation for colonoscopy: a retrospective exploratory analysis and meta-analysis

Abstract

Background: Intraoperative and postoperative hypotension occur commonly and are associated with organ injury and poor outcomes. Changes in arterial blood pressure (BP) during procedural sedation are not well described.

Methods: Individual patient data from five trials of propofol sedation for colonoscopy and a clinical database were pooled and explored with logistic and linear regression. A literature search and focused meta-analysis compared the incidence of hypotension with propofol and alternative forms of procedural sedation. Hypotensive episodes were characterised by the original authors' definitions (typically systolic BP <90 mm Hg).

Results: In pooled individual patient data (n=939), 36% of procedures were associated with episodes of hypotension. Longer periods of propofol sedation and larger propofol doses were associated with longer-lasting and more-profound hypotension. Amongst 380 patients for whom individual BP measurements were available, 107 (28%) experienced systolic BP <90 mm Hg for >5 min, and in 89 (23%) the episodes exceeded 10 min. Meta-analysis of 18 RCTs identified an increased risk ratio for the development of hypotension in procedures where propofol was used compared with the use of etomidate (two studies; n=260; risk ratio [RR] 2.0 [95% confidence interval: 1.37-2.92]; P=0.0003), remimazolam (one study; n=384; RR 2.15 [1.61-2.87]; P=0.0001), midazolam (14 studies; n=2218; RR 1.46 [1.18-1.79]; P=0.0004), or all benzodiazepines (15 studies; n=2602; 1.67 [1.41-1.98]; P<0.00001). Hypotension was less likely with propofol than with dexmedetomidine (one study; n=60; RR 0.24 [0.09-0.62]; P=0.003).

Conclusions: Hypotension is common during propofol sedation for colonoscopy and of a magnitude and duration associated with harm in surgical patients.

Keywords: colonoscopy; endoscopy; hypotension; midazolam; propofol; sedation.

Fig 1

Individual percentage change from baseline (black dotted line) in systolic BP for 380 patients receiving propofol sedation for elective colonoscopy., , Reference line (red solid line) indicates 20% reduction in BP.

Fig 2

Search process shown as a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart.

Fig 3

Propofol sedation vs midazolam. Risk ratios and 95% confidence intervals (CIs) were calculated using the Mantel–Haenszel (M–H) fixed-effect method of meta-analysis. Hypotension was significantly more frequent with propofol.