Elsevier

Gastrointestinal Endoscopy

Volume 68, Issue 5, November 2008, Pages 815-826
Gastrointestinal Endoscopy

Guideline
Sedation and anesthesia in GI endoscopy

https://doi.org/10.1016/j.gie.2008.09.029Get rights and content

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.

First page preview

First page preview
Click to open first page preview

References (72)

  • J. Cohen et al.

    A randomized, double-blind study of the use of droperidol for conscious sedation during therapeutic endoscopy in difficult to sedate patients

    Gastrointest Endosc

    (2000)
  • P. Yimcharoen et al.

    Droperidol, when used for sedation during ERCP, may prolong the QT interval

    Gastrointest Endosc

    (2006)
  • L.B. Cohen et al.

    AGA Institute review of endoscopic sedation

    Gastroenterology

    (2007)
  • W.A. Qureshi et al.

    ASGE guideline: guidelines for endoscopy in pregnant and lactating women

    Gastrointest Endosc

    (2005)
  • K.K. Lee et al.

    Standards of Practice Committee, American Society for Gastrointestinal Endoscopy: Modifications in endoscopic practice for pediatric patients

    Gastrointest Endosc

    (2008)
  • R. Chutkan et al.

    Training guideline for use of propofol in gastrointestinal endoscopy

    Gastrointest Endosc

    (2004)
  • T.G. Short et al.

    Hypnotic and anaesthetic interactions between midazolam, propofol and alfentanil

    Br J Anaesth

    (1992)
  • D.B. Nelson et al.

    American Society for Gastrointestinal Endoscopy Technology Committee: propofol use during gastrointestinal endoscopy

    Gastrointest Endosc

    (2001)
  • M.B. Kimmey et al.

    Technology assessment status evaluation: monitoring equipment for endoscopy: American Society for Gastrointestinal Endoscopy

    Gastrointest Endosc

    (1995)
  • D.K. Rex et al.

    Safety of propofol administered by registered nurses with gastroenterologist supervision in 2000 endoscopic cases

    Am J Gastroenterol

    (2002)
  • L.T. Heuss et al.

    Risk stratification and safe administration of propofol by registered nurses supervised by the gastroenterologist: a prospective observational study of more than 2000 cases

    Gastrointest Endosc

    (2003)
  • D.K. Rex et al.

    Trained registered nurses/endoscopy teams can administer propofol safely for endoscopy

    Gastroenterology

    (2005)
  • L.B. Cohen et al.

    Moderate level sedation during endoscopy: a prospective study using low-dose propofol, meperidine/fentanyl, and midazolam

    Gastrointest Endosc

    (2004)
  • D. Kulling et al.

    Safer colonoscopy with patient controlled analgesia and sedation with propofol and alfentanil

    Gastrointest Endosc

    (2001)
  • J.M. Ng et al.

    Patient-controlled sedation with propofol for colonoscopy

    Gastrointest Endosc

    (2001)
  • M.J. Gillham et al.

    Patient-maintained sedation for ERCP with a target-controlled infusion of propofol: a pilot study

    Gastrointest Endosc

    (2001)
  • K.R. McQuaid et al.

    A systematic review and meta-analysis of randomized, controlled trials of moderate sedation for routine endoscopic procedures

    Gastrointest Endosc

    (2008)
  • B.J. Ulmer et al.

    Propofol versus midazolam/fentanyl for outpatient colonoscopy: administration by nurses supervised by endoscopists

    Clin Gastroenterol Hepatol

    (2003)
  • J.J. Vargo et al.

    Gastroenterologist-administered propofol versus meperidine and midazolam for advanced upper endoscopy: a prospective, randomized trial

    Gastroenterology

    (2002)
  • G. Koshy et al.

    Propofol versus midazolam and meperidine for conscious sedation in GI endoscopy

    Am J Gastroenterol

    (2000)
  • B.W. Sipe et al.

    Propofol versus midazolam/meperidine for outpatient colonoscopy administration by nurses supervised by endoscopists

    Gastrointest Endosc

    (2002)
  • G.A. Paspatis et al.

    Synergistic sedation with midazolam and propofol versus midazolam and pethidine in colonoscopies: a prospective, randomized study

    Am J Gastroenterol

    (2002)
  • M.A. Qadeer et al.

    Propofol versus traditional sedative agents for gastrointestinal endoscopy: a meta-analysis

    Clin Gastroenterol Hepatol

    (2005)
  • D. Kulling et al.

    Propofol sedation during endoscopic procedures: how much staff and monitoring are necessary?

    Gastrointest Endosc

    (2007)
  • T. Wehrmann et al.

    Efficacy and safety of intravenous propofol sedation during routine ERCP: a prospective, controlled study

    Gastrointest Endosc

    (1999)
  • Walker et al.

    Nurse-administered propofol sedation without anesthesia specialists in 9152 endoscopic cases in an ambulatory surgery center

    Am J Gastroenterol

    (2003)
  • Cited by (349)

    View all citing articles on Scopus

    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.

    View full text