Propofol sedation improves efficiency and optimizes patient satisfaction during colonoscopy
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* Hilary P. Grocott

Drs. Pace and Borgaonkar1 commented that deep sedation for colonoscopy is wasteful and unnecessary. This serves to highlight a complex perioperative issue and a need for balance in understanding the issues involved. The authors’ choice of references and interpretation of the varied literature on the subject results in a distorted picture of clinical reality. Many statements appear to be unsubstantiated, speculative and even contradictory. For example, the authors state that “there is no convincing evidence that the level of sedation affects the cecal intubation rate or the adenoma detection rate,” but then go on to suggest that deep sedation with propofol may adversely affect colonoscopy “quality.” They reference no study that supports any purported adverse effect of propofol on quality.

As for safety, they quote a meta-analysis that showed no difference in cardiopulmonary adverse effects when comparing propofol (i.e., deep sedation) with traditional agents (i.e., mild-to-moderate sedation).2 If using propofol for deep sedation does not adversely affect the adenoma detection rate, and shows no overall difference in cardiopulmonary adverse events, then we should look at other parameters to determine whether there is value in deep sedation.

The authors suggest that the recent increase in deep sedation practices in Ontario was for reasons of “improved efficiency gained from faster patient recovery.” This makes sense, as the use of propofol in experienced hands can show a substantially faster recovery profile3 compared with much longer-acting agents such as midazolam and fentanyl. The faster recovery also has an important effect directly to the patient. Indeed, this patient benefit is something conspicuously underemphasized in their commentary. This lack of patient centricity is a notable example of Pace and Borgaonkar’s choice of references where, for example, they omitted the high-quality Cochrane review that showed enhanced patient satisfaction with the use of propofol.3

Accordingly, the use of deep sedation with propofol can be argued to be efficient, to maintain patient safety and to increase patient satisfaction. Before advocating for its restriction, all of the evidence needs to be thoroughly examined in a more balanced fashion.

## Footnotes

*   **Competing interests:** None declared.

## References

1.  Pace D, Borgaonkar M. Deep sedation for colonoscopy is unneccessary and wasteful. CMAJ 2018; 190:E153–4.
    
    [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czoxMDoiMTkwLzYvRTE1MyI7czo0OiJhdG9tIjtzOjIyOiIvY21hai8xOTAvMjQvRTc1MS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

2.  Wadhwa V, Issa D, Garg S, et al. Similar risk of cardiopulmonary adverse events between propofol and traditional anesthesia for gastrointestinal endoscopy: a systematic review and meta-analysis. Clin Gastroenterol Hepatol 2017; 15: 194–206.
    
    

3.  Singh H, Poluha W, Cheung M, et al. Propofol for sedation during colonoscopy. Cochrane Database Syst Rev 2008;(4):CD006268.