Published online Oct 16, 2021. doi: 10.12998/wjcc.v9.i29.8763
Peer-review started: June 11, 2021
First decision: June 25, 2021
Revised: June 26, 2021
Accepted: August 31, 2021
Article in press: August 31, 2021
Published online: October 16, 2021
Processing time: 126 Days and 5.1 Hours
Midazolam is commonly used for sedation during gastrointestinal procedures. However, some patients experience paradoxical reactions characterized by excessive movement or excitement.
To investigate the rate of recurrence of paradoxical reactions to midazolam during an upper endoscopy.
We retrospectively reviewed 122152 sedative endoscopies among a total of 58553 patients at the Seoul National University Hospital, Healthcare System Gangnam Center, from July 2013 to December 2018. Among them, 361 patients with a history of paradoxical reaction during sedative upper endoscopy were enrolled. The characteristics of patients in the recurrent and non-recurrent groups were compared via multivariable analysis using logistic regression.
Paradoxical reactions occurred in 0.86% (1054/122152) of endoscopies, and in 1.51% (888/58553) of patients. Among the 361 subjects with previous paradoxical reactions in sedative endoscopies, 111 (30.7%) experienced further paradoxical reactions. Univariable analysis revealed that the total midazolam dose used was higher in the recurrent group (6.74 ± 2.58 mg) than in the non-recurrent group (5.49 ± 2.04 mg; P < 0.0001). Patients were administered a lower dose of midazolam than previous doses: 1 mg less in the recurrent group and 2 mg less in the non-recurrent group. Multivariable analysis showed that the midazolam dose difference was an independent risk factor for recurrent paradoxical reaction (odds ratio: 1.213, 95%CI: 1.099-1.338, P = 0.0001).
The rate of recurrence of paradoxical reactions is significantly associated with midazolam dosage. The dose of midazolam administered to patients with previous paradoxical reactions should be less than that previously used.
Core Tip: A paradoxical reaction refers to an unexpectedly increased excitement and excessive movement, as opposed to the anxiolytic or sedative effect of midazolam. This is the first study to investigate the recurrence rate of paradoxical reactions to midazolam during upper endoscopy under sedation. We report that the rate of recurrence of paradoxical reactions is significantly associated with the dose of midazolam administered. To avoid the recurrence of such reactions, we recommend reducing the total dose of midazolam administered to patients with previous paradoxical reactions by ≥ 2 mg compared to the dose previously used.