Clin Endosc > Volume 46(4); 2013 > Article
Ko and Hahm: Harmony of Duet over Solo: Use of Midazolam or Propofol for Sedative Endoscopy in Pediatric Patients
See "Propofol versus Midazolam for Sedation during Esophagogastroduodenoscopy in Children" by Ji Eun Oh, Hae Jeong Lee, Young Hwan Lee, on page 368-372
The aims of the sedation during endoscopic procedures are to increase the comfort of patients, to improve endoscopic performance, and to increase the satisfaction of both patient and performing endoscopist. The optimal level of sedation for endoscopy is conscious sedation, moderate degree of sedation, that is, a drug-induced depression of consciousness during which patients can respond purposefully to verbal commands. Therefore, adequate spontaneous ventilation and cardiovascular function is usually maintained.1 Midazolam is the drug most commonly used for sedation during gastrointestinal endoscopy (GIE) procedures. To date, several data have shown that when propofol is compared with midazolam in terms of their effectiveness, propofol is acknowledged to be superior for action time and recovery time. However, dark aspect of coin also exists that propofol has more serious cardiopulmonary depression compared to midazolam and more respiratory distress, apnea and hypotension than other sedatives.2,3
Endoscopic procedure is a well-established tool for diagnosis and treatment in pediatric gastroenterology as much as for adult patients. Majority of pediatric esophagogastroduodenoscopy performed under sedation using sedative drugs, such as midazolam, propofol, and ketamine, to avoid restraining and the recall of unpleasant GIE, because procedural sedation guarantee optimum comfort for and cooperation from children undergoing GIE.4 Endoscopic procedures with sedatives provide comfort not only for the patient but also for the endoscopist. As much as benefits, the safety should be the first priority to be considered during the endoscopy, especially for younger pediatric patients. Propofol has limitations, when used in sedative endoscopy, in its narrow safety zone, which makes moderate sedation rapidly shift to deep sedation and general anesthesia without antidote. For this reason, propofol was permitted to be used only by anesthesiologist in the early period of sedative endoscopy; however, American Gastroenterological Association, American College of Gastroenterology, and American Society for Gastrointestinal Endoscopy denoted that propofol administered by endoscopists is effective and safe irrespective of the patient's age.5 Recent data showed that not only anesthesiologists but endoscopists could control propofol safely during endoscopy.6-8 Complications, such as local pain from propofol injection and unpleasant feeling after recovery,2,3 may be overcome by decreasing the dose of propofol. Several studies reported that premedication with midazolam could ameliorate the level of patient discomfort compared to when using propofol alone.5,9,10 A study from Canada demonstrated that sedation with propofol alone or propofol combined with fentanyl or midazolam in children was safe and effective. Propofol in combination with fentanyl or midazolam provided better sedation and ease of endoscopy than propofol alone.11
In this issue of Clinical Endoscopy, Oh et al.12 compared midazolam and propofol for the sedative endoscopy in children, revealing that propofol had shorter recovery time and little increment of heart rate compared to midazolam. These results are similar to a previous report.13 According to the data, local pain occurred only in 17.6% of the propofol group, much lower compared to 60% reported in a previous study,14 but no difference was found in terms of respiratory distress. As limitations of the study by Oh et al.,12 the study was retrospective and single center experience with relatively small sample size, possibly causing a selection bias. Total dosage of sedatives associated with the incidence of complications, especially for the respiratory distress, was not mentioned at all. Moreover, as the authors stated in the discussion, data on induction time and patient's satisfaction in each sedation group are lacking. Nonetheless, this report might be the first one which compared the efficacy and safety of intravenously administered midazolam and propofol for sedation in children during endoscopy in Korea. These data support that the use of propofol under the supervision of an endoscopist in the pediatric endoscopy setting is safe compared to midazolam.
In contrast to adult patients, the necessity for sedative endoscopy in children is much higher and a prerequisite to achieve the purpose of GIE. Traditional enema sedation or restraint yielded quite lower level of satisfaction to both parents and doctors. Considering the incidence of diseases associated with social stress and early puberty, no way to avoid sedation for pediatric endoscopy is secured from this study. However, prospective study with considerable number of patients with subcategory evaluation using combination of midazolam and/or propofol with other sedatives is required to minimize complications of propofol. As harmony of duet over solo, appropriate combination of propofol and midazolam might reduce the existing risks of respiratory distress and others.


The authors have no financial conflicts of interest.


1. American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology 2002;96:1004–1017. 11964611.
crossref pmid pdf
2. Wehrmann T, Kokabpick S, Lembcke B, Caspary WF, Seifert H. Efficacy and safety of intravenous propofol sedation during routine ERCP: a prospective, controlled study. Gastrointest Endosc 1999;49:677–683. 10343208.
crossref pmid
3. Searle NR, Sahab P. Propofol in patients with cardiac disease. Can J Anaesth 1993;40:730–747. 8403158.
crossref pmid
4. van Beek EJ, Leroy PL. Safe and effective procedural sedation for gastrointestinal endoscopy in children. J Pediatr Gastroenterol Nutr 2012;54:171–185. 21975965.
crossref pmid
5. Cohen LB, Wecsler JS, Gaetano JN, et al. Endoscopic sedation in the United States: results from a nationwide survey. Am J Gastroenterol 2006;101:967–974. 16573781.
crossref pmid
6. Tohda G, Higashi S, Wakahara S, Morikawa M, Sakumoto H, Kane T. Propofol sedation during endoscopic procedures: safe and effective administration by registered nurses supervised by endoscopists. Endoscopy 2006;38:360–367. 16680635.
crossref pmid pdf
7. Heuss LT, Froehlich F, Beglinger C. Changing patterns of sedation and monitoring practice during endoscopy: results of a nationwide survey in Switzerland. Endoscopy 2005;37:161–166. 15692932.
crossref pmid
8. Khoshoo V, Thoppil D, Landry L, Brown S, Ross G. Propofol versus midazolam plus meperidine for sedation during ambulatory esophagogastroduodenoscopy. J Pediatr Gastroenterol Nutr 2003;37:146–149. 12883300.
crossref pmid
9. Paspatis GA, Charoniti I, Manolaraki M, et al. Synergistic sedation with oral midazolam as a premedication and intravenous propofol versus intravenous propofol alone in upper gastrointestinal endoscopies in children: a prospective, randomized study. J Pediatr Gastroenterol Nutr 2006;43:195–199. 16877984.
crossref pmid
10. Elitsur Y, Blankenship P, Lawrence Z. Propofol sedation for endoscopic procedures in children. Endoscopy 2000;32:788–791. 11068839.
crossref pmid pdf
11. Disma N, Astuto M, Rizzo G, et al. Propofol sedation with fentanyl or midazolam during oesophagogastroduodenoscopy in children. Eur J Anaesthesiol 2005;22:848–852. 16225720.
crossref pmid
12. Oh JE, Lee HJ, Lee YH. Propofol versus midazolam for sedation during esophagogastroduodenoscopy in children. Clin Endosc 2013;46:368–372.
crossref pmid pmc
13. Carlsson U, Grattidge P. Sedation for upper gastrointestinal endoscopy: a comparative study of propofol and midazolam. Endoscopy 1995;27:240–243. 7664702.
crossref pmid pdf
14. Jalota L, Kalira V, George E, et al. Prevention of pain on injection of propofol: systematic review and meta-analysis. BMJ 2011;342:d1110. 21406529.
crossref pmid
PDF Links  PDF Links
PubReader  PubReader
ePub Link  ePub Link
XML Download  XML Download
Full text via DOI  Full text via DOI
Download Citation  Download Citation
Related articles
Comparison of Fentanyl versus Meperidine in Combination with Midazolam for Sedative Colonoscopy in Korea  2020 September;53(5)
Propofol versus Midazolam for Sedation during Esophagogastroduodenoscopy in Children  2013 July;46(4)
Editorial Office
Korean Society of Gastrointestinal Endoscopy
#817, 156 Yanghwa-ro (LG Palace, Donggyo-dong), Mapo-gu, Seoul, 04050, Korea
TEL: +82-2-335-1552   FAX: +82-2-335-2690    E-mail:
Copyright © Korean Society of Gastrointestinal Endoscopy.                 Developed in M2PI
Close layer