It is well established that moderate sedation results in a high level of both patient and physician satisfaction [1
] and may also improve the quality of upper GI endoscopy [5
]. Data on combined sedation with midazolam/propofol for gastrointestinal endoscopic procedures in elderly patients are very rare. In this retrospective analysis of midazolam/propofol sedation during 454 endoscopic procedures in 347 patients ≥ 70 years with high-level co-morbidity reflected by a 28 day mortality rate of 2.9% and an ASA score of class III or higher, we have found no procedure-associated mortality or major side effects. In comparison to patients of younger age, elderly patients needed lower propofol doses (i.e. showed a higher sensitivity to propofol) and but did not have a significantly higher number of minor complications.
While data on combined sedation with midazolam/propofol for elderly patients are rare, our study has limitations of a retrospective single-center study. Thus, a patient selection bias cannot be excluded and data on recovery times, quality of recovery or patient's satisfaction with sedation are lacking. Keeping these limitations in mind, the safety data for propofol/midazolam reported here are in line with data on the use of propofol alone or in combination with meperidine in geriatric patients with high-level of comorbidity. Thus, in a prospective observational study on propofol sedation in 351 patients > 85 years, oxygen desaturation was more frequent in the elderly and no major complication was reported [10
]. In another randomized prospective study, propofol/meperidine sedation was compared to midazolam/meperidine in 150 high risk octogenarians (91% ASA class III or higher) with no significant increase in complication rate but a better cooperation during ERCP and decreased recovery times [11
]. These data were confirmed in a recent study on 150 patients > 80 years undergoing ERCP, endoscopic ultrasound or double ballon enteroscopy who likewise did not experience major complications although the rate of minor complications was higher in patients receiving propofol [12
]. The effect of a combined sedation by adding propofol to midazolam was investigated in 24 elderly patients with coronary heart disease undergoing dentoalveolar surgery [21
]. Significantly lower systolic, diastolic and mean arterial pressures were observed but all patients had stable intraoperative hemodynamics and no major complication was reported.
While the data presented from this study, as well as the data from other studies suggest a favorable safety profile, the relatively small number of patients in these studies must be considered. Indeed, severe complications of propofol sedation seem to be rare if pooled data are analyzed from studies on patients with lower co-morbidity. In a recently published meta-analysis from major prospective studies, the complications rates of endoscopist-administered propofol sedation were 3-7% for transient hypoxia, 4-7% for transient hypotension and only 0.1-0.2% for clinically important events requiring assisted ventilation [22
]. Thus, the limited number of patients in this study, as well as in other published studies might not have been sufficient to estimate the true incidence of severe complications.
The other major finding of this retrospective analysis is that significant lower propofol doses were needed for elderly patients than for patients < 70 years (77.8 mg vs. 107.0 mg). While this difference might partially be due to the higher level of comorbidity in the elderly, a dose sparing synergistic effect of propofol/midazolam sedation has been reported for the induction of anaesthesia [23
], from an observational study for patients undergoing gastrointestinal endoscopy [15
] and randomized controlled trials on propofol vs. propofol/midazolam sedation for 239 patients undergoing upper GI endoscopy [16
] and 200 outpatients undergoing colonoscopy, respectively [18
]. The data from this study point to an increased sensitivity of the elderly population with respect to the propofol dose to be used in combination with midazolam. Further prospective data are needed to support this finding.