AGA InstituteAGA Institute Review of Endoscopic Sedation
Section snippets
Preprocedure Assessment
An evaluation of the patient should precede the administration of intravenous sedation. This assessment is designed to identify those aspects of a patient’s medical history and physical examination that could adversely affect the outcome of endoscopic sedation. Essential elements of the medical history include the following: (1) significant cardiac or pulmonary disease; (2) neurologic or seizure disorder; (3) stridor, snoring, or sleep apnea; (4) adverse reaction to sedation or anesthesia; (5)
Pharmacology of Sedation
The goal of endoscopic sedation is to maximize patient comfort while minimizing the risk of drug-related side effects. Achieving optimal sedation requires careful consideration of patient and procedure-related variables. Patient factors include age, health status, concurrent medications, preprocedural anxiety, and pain tolerance. The procedural variables include the degree of invasiveness, level of procedure-related discomfort, and the duration of examination. The drugs most widely used for
Patient Monitoring
Patient monitoring is an essential element of endoscopic sedation. The term monitoring includes both visual assessment as well as the use of devices to measure physiologic parameters. A trained observer may recognize subtle alterations in the patient’s condition before objective changes are detected in vital signs and other parameters.
Guidelines for patient monitoring during endoscopic procedures have been developed by several professional medical societies.5, 45, 116 The American Society of
Training Guidelines
The training process should provide the skills necessary to administer endoscopic sedation safely and effectively. This requires the following: (1) an understanding of the pharmacologic principles of the drugs used for sedation and analgesia, (2) an ability to monitor sedated patients, and (3) the resources to manage complications that may occur. In addition to the skill sets listed earlier, the endoscopist should possess a thorough understanding of the preprocedural assessment and be able to
Medicolegal Considerations
Endoscopic sedation is associated with unavoidable clinical risk, separate and apart from that associated with manipulation of the endoscope and auxiliary devices. Data for malpractice claims arising from complications of endoscopic sedation are difficult to find.139 The Physician Insurers’ Association of America database, a large malpractice claims database, does not breakdown endoscopy-related claims into those that are procedure-related and those that are sedation-related.140 However,
Future Directions in Endoscopic Sedation
The benzodiazepines and opioid narcotics are the drug classes most widely used for endoscopic sedation within the United States.1 Although these agents produce effective sedation and analgesia for most patients, they lack the pharmacologic properties necessary to achieve optimal sedation during an endoscopic procedure. For example, the opioid analgesics are associated with troublesome side effects such as respiratory depression, bradycardia, nausea, and vomiting. Further, both fentanyl and
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This literature review and the recommendations therein were prepared for the AGA Institute Clinical Practice and Economics Committee by the AGA Institute Sedation Subcommittee. The paper was approved by the Committee on April 26, 2007, and by the AGA Institute Governing Board on May 19, 2007.