How to improve patient satisfaction during midazolam sedation for gastrointestinal endoscopy?

Table 1 Baseline characteristics of patients according to procedure group n (%)

	EGD (n = 167)	Colonoscopy (n = 167)	Combined group1 (n = 122)	P value
Sex				0.099
Male	71 (42.5)	89 (53.3)	64 (52.5)
Female	96 (57.5)	78 (46.7)	58 (47.5)
Age (yr)				0.878
≤ 50	43 (25.7)	44 (26.3)	29 (76.2)
> 50	124 (74.3)	123 (73.7)	93 (76.2)
Body mass index (kg/m2)	22.6	22.9	23.3 (76.2)	0.245
Previous sedation endoscopy				0.310
Yes	137 (82.5)	135 (80.8)	92 (75.4)
No	29 (17.5)	32 (19.2)	30 (24.6)
Midazolam (mg)
First dose	4.1	4.3	4.4	0.014
Second dose	1.5	1.6	1.7	0.055
Third dose	1.0	1.6	1.5	0.269
Fourth dose	1.5	1.5	1.9	0.881
Total midazolam dose (mg)	4.4	5.0	6.4	< 0.005
No. of midazolam injections	1.2	1.4	2.2	< 0.005
Time (min)
Midazolam injection to procedure start	5.1	4.5	4.7	0.327
Total procedure time	3.5	23.7	42.4	< 0.005
Inter-procedure gap			19.5
Procedure finish to antidote injection	12.8	13.1	12.1	0.482
Satisfaction with sedation during endoscopy				0.016
Very satisfied	81 (48.5)	51 (30.5)	46 (37.7)
Satisfied	74 (44.3)	86 (51.5)	58 (47.5)
Neutral	7 (4.2)	19 (11.4)	11 (9.0)
Dissatisfied	5 (3)	11 (6.6)	7 (5.7)
Very dissatisfied	-	-	-

¹Combined group: Esophagogastroduodenoscopy and colonoscopy together. EGD: Esophagogastroduodenoscopy.

Table 2 Patient anxiety and expected sedation depth before endoscopy n (%)

Anxiety before endoscopy
No anxiety	280 (61.4)
Mild anxiety	149 (32.7)
Moderate anxiety	19 (4.2)
No answer	8 (1.8)
Cause of anxiety
Fear of endoscopy procedure	69 (41.1)
Fear of abdominal pain during endoscopy	34 (20.2)
Fear of insufficient sedation	19 (11.3)
Fear of paradoxical response	9 (5.4)
None of the above	36 (21.4)
Expected sedation depth1
Drowsy	19 (4.2)
Light sedation	191 (41.9)
Moderate sedation	229 (50.2)
No answer	9 (2)

¹Drowsy: Not fully alert, but experiences sustained wakening to voice; Light sedation: Briefly awakens to voice; Moderate sedation: Movement or eye-opening to voice.

Table 3 Factors associated with sedation satisfaction in the esophagogastroduodenoscopy group

	Univariate analysis				Multivariate analysis
	Beta	SE (β)	P value	OR (95%CI)	Beta	SE (β)	P value	OR (95%CI)
Sex (Female)	0.063	0.302	0.834	1.07 (0.59-1.92)
Body mass index (kg/m2)	0.001	0.005	0.798	1.00 (0.99-1.01)
Previous sedation endoscopy	0.642	0.395	0.104	1.90 (0.88-4.12)
Midazolam, first dose (mg)	-0.094	0.143	0.509	0.91 (0.69-1.20)
Midazolam, total dose (mg)	-0.022	0.116	0.852	0.98 (0.78-1.23)
Time (min)
Midazolam injection to procedure start	-0.033	0.052	0.525	0.98 (0.78-1.23)
Total procedure time	0.127	0.062	0.041	0.97 (0.87-1.07)	0.127	0.062	0.041	0.97 (0.87-1.07)
Procedure finish to antidote injection	-0.036	0.024	0.127	1.14 (1.01-1.28)

Table 4 Factors associated with sedation satisfaction in the colonoscopy group

	Univariate analysis				Multivariate analysis
	Beta	SE (β)	P value	OR (95%CI)	Beta	SE (β)	P value	OR (95%CI)
Sex (female)	0.197	0.294	0.503	1.22 (0.68-2.17)
Age (> 50 yr)	-0.937	0.339	0.006	0.39 (0.20-0.76)	-0.956	0.341	0.005	0.38 (0.20-0.75)
Midazolam, first dose (mg)	0.253	0.165	0.127	1.29 (0.93-1.78)
Midazolam, total dose (mg)	0.223	0.108	0.039	1.25 (1.01-1.54)
No. of midazolam injections	0.441	0.244	0.070	1.55 (0.96-2.51)
Time (min)
Midazolam injection to procedure start	0.009	0.051	0.863	1.01 (0.91-1.12)
Procedure time
Colonoscopy insertion time	0.015	0.036	0.670	1.02 (0.95-1.09)
Colonoscopy withdrawal time	0.030	0.014	0.035	1.03 (1.00-1.06)	0.030	0.014	0.036	1.03 (1.00-1.06)
Procedure finish to antidote injection	0.016	0.020	0.447	1.02 (0.98-1.06)

Table 5 Patients’ satisfaction through active monitoring and intervention by endoscopist during colonoscopy

	Active monitoring (n = 39)	Non-active monitoring (n = 128)	P value
Sex (Male, %)	19 (48.7)	70 (54.7)	0.584
Age (mean ± SD)	56.1 ± 13.0	57.7 ± 13.5	0.514
Proportion of EMR, n (%)	32 (82.1)	51 (39.8)	< 0.001
Satisfaction, n (%)			0.968
Very satisfied	12 (30.8)	39 (30.5)
Satisfied	20 (51.3)	66 (51.6)
Fair	5 (12.8)	14 (10.9)
Unsatisfied	2 (5.1)	9 (7.0%)
Midazolam, first dose (mg, mean ± SD)	4.5 ± 1.0	4.2 ± 0.9	0.159
Midazolam, total dose (mg, mean ± SD)	5.8 ± 1.2	4.8 ± 1.5	0.002
Midazolam, No. of injections (mean ± SD)	1.6 ± 0.5	1.4 ± 0.7	0.025
Procedure time (min, mean ± SD)	28.8 ± 12.2	22.3 ± 12.2	0.005

Table 6 Factors associated with sedation satisfaction in the combined esophagogastroduodenoscopy and colonoscopy group

	Univariate analysis				Multivariate analysis
	β	SE (β)	P value	OR (95% CI)	β	SE (β)	P value	OR (95%CI)
Sex (Female)	0.689	0.349	0.049	1.99 (1.00-3.95)
Age (> 50 yr)	-0.868	0.407	0.033	0.42 (0.19-0.93)	-0.978	0.427	0.022	0.38 (0.16-0.87)
Body mass index (kg/m2)	-0.001	0.006	0.878	1.00 (0.99-1.01)
Previous sedation endoscopy	-0.013	0.395	0.974	0.99 (0.46-2.14)
Midazolam, first dose (mg)	0.105	0.210	0.619	1.11 (0.74-1.68)
Midazolam, total dose (mg)	0.278	0.113	0.014	1.32 (1.06-1.65)
No. of midazolam injections	0.690	0.284	0.015	1.99 (1.14-3.48)
Time (min)
Midazolam injection to procedure start	0.041	0.033	0.215	1.04 (0.98-1.11)
Procedure time
Inter-procedure time gap	0.021	0.010	0.043	1.02 (1.00-1.04)	0.024	0.011	0.027	1.02 (1.00-1.05)
Colonoscopy insertion time	0.084	0.038	0.027	1.09 (1.01-1.17)
Colonoscopy withdrawal time	0.069	0.025	0.006	1.07 (1.02-1.13)	0.081	0.027	0.002	1.08 (1.03-1.14)
Procedure finish to antidote injection	0.014	0.029	0.637	1.01 (0.96-1.07)