GuidelineSedation and anesthesia in GI endoscopy
Section snippets
Background
Sedation may be defined as a drug-induced depression in the level of consciousness. The purpose of sedation and analgesia is to relieve patient anxiety and discomfort, improve the outcome of the examination, and diminish the patient's memory of the event. Practice guidelines have been put forth by the American Society of Anesthesiologists (ASA) Committee for Sedation and Analgesia by Non-Anesthesiologists, and approved by the ASGE.1, 2
Four stages of sedation have been described, ranging from
Preprocedure preparation and assessment
Patients should be informed of and agree to the administration of sedation/analgesia/anesthesia, including discussion of its benefits, risks, and limitations and possible alternatives.
The anticipated level of sedation should be congruent with the patient's expectation of the sedation level whenever possible. There are no absolute guidelines as to timing of cessation of oral intake before administerion of sedation because of the absence of supporting data with regard to a direct relationship
Unsedated endoscopy
Selected patients may be able to undergo endoscopic procedures without sedation. Small-diameter endoscopes (less than 6 mm) can improve the tolerability of upper endoscopy when sedation is not used.6, 7 In general, topical anesthesia is used during unsedated endoscopy. Successful colonoscopy may be performed in selected patients who receive no sedation or sedation only if needed.8, 9 Older patients, men, patients who are not anxious, or patients without a history of abdominal pain may have
Topical anesthesia
Topical pharyngeal sprays with lidocaine, tetracaine, and benzocaine are often used for anesthetic purposes during upper endoscopy, particularly when unsedated endoscopy is performed. A meta-analysis of pharyngeal anesthesia use in conjunction with intravenous or intramuscular sedation was associated with improved ease of endoscopy or improved patient tolerance as judged by the endoscopist during upper endoscopy.10 Topical anesthetic agents have been associated with serious adverse effects,
Sedation and analgesia agents used for endoscopy
The level of sedation required to perform a successful procedure may range from minimal sedation to general anesthesia. Patient age, health status, concurrent medications, preprocedural anxiety, and pain tolerance influence the level of sedation required to achieve the desired result.
The procedural variables include the degree of invasiveness, the level of procedure-related discomfort, the need for the patient to lie relatively motionless (eg, EUS-FNA) and the duration of examination.
GD-P
GD-P includes propofol administered directly by gastroenterologists, administered by registered nurses under the direction of gastroenterologists (NAPS), and patient- controlled systems (PCS).
NAPS involves administration of propofol and patient monitoring by a trained registered nurse who has no other responsibilities to patient care.16 NAPS dosing protocols vary.5, 35, 36 Initial bolus doses of propofol of 10 to 60 mg are typically administered; additional bolus doses are administered after a
Intraprocedural monitoring
Monitoring may detect changes in pulse, blood pressure, ventilatory status, cardiac electrical activity, and clinical and neurologic status before clinically significant events occur. For both moderate and deep sedation, the level of consciousness must be periodically assessed in addition to documentation of heart rate, blood pressure, respiratory rate, and oxygen saturation. These physiologic parameters should be assessed and recorded at a frequency that depends on the type and amount of
Anesthesiologist assistance for endoscopic procedures
Sedation-related risk factors, the depth of sedation, and the urgency and type of endoscopic procedure play important roles in determining whether the assistance of an anesthesiologist is needed. Patient risk factors include significant medical conditions such as extremes of age; severe pulmonary, cardiac, renal, or hepatic disease; pregnancy; the abuse of drugs or alcohol; uncooperative patients; a potentially difficult airway for positive-pressure ventilation; and individuals with anatomy
Economics of GI endoscopy
Gastroenterologists in the United States have routinely sedated patients as a part of the endoscopic service. In recent years, a greater number of endoscopists use anesthesiologists or nurse anesthetists to provide sedation. Numerous factors are driving this transition, including increasing use of propofol, efforts to offset falling reimbursements, and effective marketing by anesthesiologists.72 The routine assistance of an anesthesiologist for average-risk patients undergoing standard upper
Recommendations
Refer to Table 1 for recommendation grades.
- 1.
Adequate and safe sedation can be achieved in most patients undergoing routine esophagogastroduodenoscopy and colonoscopy by using an intravenous benzodiazepine and opioid combination (1B).
- 2.
In patients who are not adequately sedated with an intravenous benzodiazepine and opioid combination, the addition of other intravenous agents such as droperidol, promethiazine, or diphenhydramine (Benadryl) may allow adequate and safe sedation to be achieved (1B).
- 3.
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Cited by (349)
Automated electronic health record–based application for sedation triage in routine colonoscopy
2023, Gastrointestinal EndoscopyDifferences in patient outcomes after outpatient GI endoscopy across settings: a statewide matched cohort study
2022, Gastrointestinal EndoscopyConsensus document for anaesthesiologist-assisted sedation in interventional cardiology procedures
2021, Revista Espanola de Anestesiologia y ReanimacionComplications of colonoscopy: common and rare-recognition, assessment and management
2023, BMJ Open Gastroenterology
This Guideline is being republished due to the fact that the original publication contained some duplicate material from an article that was originally published in Gastroenterology 2007;133:675-501 (DOI:10.1053).
This document is a product of the Standards of Practice Committee. This document was reviewed and approved by the Governing Board of the American Society for Gastrointestinal Endoscopy. This document was reviewed and endorsed by the Society of American Gastrointestinal and Endoscopic Surgeons Guidelines Committee and Board of Governors.