Network meta-analysis of sedation strategies in therapeutic gastrointestinal endoscopy shows ketamine-propofol reduces hypoxia and bradycardia versus propofol-opioid.

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Frontiers in Medicine Published April 21, 2026 Medically reviewed April 25, 2026 DOI ↗ By Dr. Julia Lee, PhD · Oncology, Genomics & Drug Development

Key Takeaway

Consider ketamine-propofol for therapeutic GI endoscopy; moderate certainty for reduced hypoxia and bradycardia versus propofol-opioid.

This systematic review conducted as a network meta-analysis examined pharmacological sedation strategies for patients undergoing therapeutic gastrointestinal endoscopy. The analysis included data from 7,071 patients and compared various agents including propofol, opioid, ketamine, lidocaine, and midazolam against a propofol-opioid comparator. Secondary outcomes assessed included procedural interference events, hypoxia, hypotension, bradycardia, recovery time, induction time, satisfaction, and postoperative nausea and vomiting.

The primary synthesized findings demonstrated that ketamine-propofol regimens showed consistent advantages over propofol-opioid regarding specific adverse events. Specifically, the use of ketamine-propofol was associated with a reduction in hypoxia, with a relative risk of 0.12 (95% CI 0.03 to 0.59, P = 0.009). Similarly, bradycardia rates were reduced with a relative risk of 0.11 (95% CI 0.01 to 0.86, P = 0.035). The analysis also found a reduction in hypotension with a relative risk of 0.28 (95% CI 0.09 to 0.83, P = 0.021).

The authors assigned moderate certainty to the findings for hypoxia and bradycardia, while assigning low certainty to the finding for hypotension. Adverse events, serious adverse events, discontinuations, and tolerability were not reported in the source data. No specific limitations were explicitly noted by the authors in the provided text. Consequently, these findings support individualized regimen selection based on patient and procedural needs rather than establishing a single universal standard.

Study Details

Study typeMeta analysis

EvidenceLevel 1

PublishedApr 2026

View Original Abstract ↓

BackgroundTherapeutic gastrointestinal endoscopy, including endoscopic retrograde cholangiopancreatography and endoscopic submucosal dissection, requires effective sedation strategies to ensure procedural success and patient safety. However, optimal pharmacological regimens remain unclear, particularly for prolonged procedures.MethodsWe searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) for randomised controlled trials comparing pharmacological sedation strategies in patients undergoing therapeutic gastrointestinal endoscopy. Outcomes included procedural interference events, hypoxia, hypotension, bradycardia, recovery time, induction time, satisfaction, and postoperative nausea and vomiting. Risk of bias was assessed using the Cochrane RoB 2.0 tool, and certainty of evidence was rated using GRADE framework. A frequentist random-effects network meta-analysis was conducted, along with cluster ranking of co-primary outcomes to evaluate benefit-risk trade-offs.ResultsSixty randomised controlled trials involving 7,071 patients and 32 pharmacological regimens were included. Compared with propofol-opioid, which remained the reference standard, no regimen significantly reduced procedural interference events. Ketamine-propofol demonstrated consistent advantages across hypoxia (relative risk [RR] 0.12, 95% confidence interval [CI] 0.03 to 0.59, P = 0.009; moderate certainty), hypotension (RR 0.28, 95% CI 0.09 to 0.83, P = 0.021; low certainty), and bradycardia (RR 0.11, 95% CI 0.01 to 0.86, P = 0.035; moderate certainty). Cluster rank analyses identified ketamine-propofol and lidocaine-midazolam-propofol as the highest-ranking regimens in both efficacy and safety domains. Meta-regression revealed no significant effect modifiers.ConclusionWhile propofol-opioid remains the standard reference, alternative sedation strategies such as ketamine-propofol and lidocaine-midazolam-propofol offer favourable profiles for therapeutic gastrointestinal endoscopy. These findings support individualised regimen selection based on patient and procedural needs.Systematic Review Registrationhttps://www.crd.york.ac.uk/PROSPERO/, identifier CRD420251018215.