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Guidelines for sedation and anesthesia in GI endoscopy


Dayna S. Early, MD, FASGE, Jenifer R. Lightdale, MD, MPH, FASGE,

John J. Vargo, II, MD, MPH, FASGE (invited content expert, ad hoc member), Ruben D. Acosta, MD,

Vinay Chandrasekhara, MD, Krishnavel V. Chathadi, MD, John A. Evans, MD,

Deborah A. Fisher, MD, MHS, FASGE, Lisa Fonkalsrud, BSN, RN, CGRN, Joo Ha Hwang, MD, PhD, FASGE,

Mouen A. Khashab, MD, V. Raman Muthusamy, MD, FASGE, Shabana F. Pasha, MD, FASGE,

John R. Saltzman, MD, FASGE, Amandeep K. Shergill, MD, Brooks D. Cash, MD, FASGE,

Previous Committee Chair, John M. DeWitt, MD, FASGE, Committee Chair

The ASGE guidelines for sedation and anesthesia in GI endoscopy were reviewed and endorsed by the American

Association for the Study of Liver Diseases, the American College of Gastroenterology, and the American

Gastroenterological Association.

This document was reviewed and approved by the Governing Board of the American Society for Gastrointestinal


This document is an update of guidelines for sedation

and anesthesia in endoscopy prepared by the Standards

of Practice Committee of the American Society for Gastrointestinal

Endoscopy (ASGE). In preparing this guideline,

a search of the medical literature was performed by using

PubMed from January 1980 through August 2017 that

related to the topic of “sedation and anesthesia for gastrointestinal

endoscopy” by using the keyword(s) “sedation,”

“anesthesia,” “gastrointestinal endoscopy,” “endoscopy,”

“endoscopic procedures,” and “procedures.” The search

was supplemented by accessing the “related articles”

feature of PubMed, with articles identified on PubMed

as the references. Pertinent studies published in English

were reviewed. Additional references were obtained

from the bibliographies of the identified articles and

from recommendations of expert consultants. When little

or no data existed from well-designed prospective trials,

emphasis was given to results from large series and

reports from recognized experts. Guidelines for appropriate

use of endoscopy are based on a critical review

of the available data and expert consensus at the time

the guidelines were drafted. Further controlled clinical

studies may be needed to clarify aspects of this guideline.

This guideline may be revised as necessary to account for

changes in technology, new data, or other aspects of

clinical practice. The recommendations were based on

reviewed studies and were graded on the strength of the

supporting evidence by using the GRADE criteria

(Table 1).


This guideline is intended to be an educational device

to provide information that may assist endoscopists in

providing care to patients. This guideline is not a rule

and should not be construed as establishing a legal standard

of care or as encouraging, advocating, requiring,

or discouraging any particular treatment. Clinical decisions

in any particular case involve a complex analysis

of the patient’s condition and available courses of action.

Therefore, clinical considerations may lead an endoscopist

to take a course of action that varies from these


Sedation is a drug-induced depression in the level of

consciousness. The clinical objectives of administering

sedation for GI endoscopy are to relieve patient anxiety

and discomfort, improve the outcome of the examination,

and diminish the patient’s memory of the event. A number

of different sedatives and analgesics can be used to achieve

appropriate levels of sedation for GI endoscopic procedures.

The targeted level of sedation may vary depending

on patient and procedural variables, and doses of sedatives

should be titrated accordingly to achieve a safe, comfortable,

and technically successful endoscopic procedure.

Knowledge of the pharmacologic profiles of sedation

agents is necessary to maximize the likelihood that the

desired level of sedation is achieved.

Practice guidelines for non-anesthesiologists providing

sedation have been put forth by the American Society of

Anesthesiologists (ASA) Committee for Sedation and Analgesia

by Non-Anesthesiologists and were approved by the



A sedation continuum has been described,

ranging from minimal sedation or anxiolysis to general

anesthesia (Table 2). During endoscopic procedures

Copyright ª 2018 by the American Society for Gastrointestinal Endoscopy



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performed with moderate sedation (formerly referred to as

conscious sedation), the patient maintains ventilatory and

cardiovascular function and is able to make purposeful

responses to verbal or light tactile stimulation.



contrast, a patient undergoing deep sedation cannot be

aroused easily but may respond purposefully to repeated

or painful stimulation. Airway support maneuvers, such

as performance of chin lifts or jaw thrusts as well as insertion

of oral or nasal airways, may be required during deep

sedation. At the level of general anesthesia, the patient

cannot be aroused by painful stimuli, and cardiovascular

function may be impaired. Individuals differ in their responses

to sedation and may require different levels of

sedation for the same procedure. In addition, patients

may attain varying levels of sedation during a single procedure.

Therefore, practitioners should possess the skills

necessary to resuscitate or rescue a patient whose level

of sedation is deeper than initially intended.


This article evaluates the strength of evidence in the

medical literature to provide guidelines for the use of sedation

and anesthesia across all levels of sedation during GI

endoscopic procedures and is an update of 3 previous

ASGE documents.


Providers of GI endoscopy should be trained specifically

to provide procedural sedation across the sedation continuum,

from minimal through moderate sedation. This

training should include skills in recognizing when the level

of sedation is deeper than planned as well as in the ability

to rescue patients when this occurs. The multi-society

sedation curriculum for GI endoscopy should serve as a

guide to train providers in procedural sedation.




Patients should provide informed consent for administration

of sedation through a process that involves a discussion

of benefits, risks, and limitations as well as possible

alternatives to the sedation plan.


As much as possible,the level of sedation targeted should be commensurate

with the patient’s expectation of sedation depth as well

as that necessary to perform the procedure safely and


Because of risks of aspiration with blunting of airwayprotective

reflexes, patients undergoing sedation should

be asked to fast for a specific time period. There are no

data to support a direct relationship between duration of

fasting and the risk of pulmonary aspiration, and the literature

contains varying recommendations for oral intake

before procedural sedation.


There is no practicestandard for pre-procedural fasting that has been universally

accepted. The ASA guidelines indicate that patients

should not drink fluids or eat solid foods for a sufficient

period of time to allow for gastric emptying before the procedure.


Specifically, these guidelines state that patients

should fast a minimum of 2 hours after ingestion of clear

liquids and 6 hours after ingestion of light meals before

sedation is administered. In situations where gastric

emptying is impaired or in emergent situations, the

potential for pulmonary aspiration of gastric contents

must be considered in determining (1) the target level of

sedation, (2) whether the procedure should be delayed,

or (3) whether the airway should be protected by

TABLE 1. System for rating the quality of evidence for guidelines


Quality of evidence Definition Symbol

High quality Further research is very unlikely to change our confidence in the estimate of effect. 4444

Moderate quality Further research is likely to have an important impact on our confidence in the estimate of effect

and may change the estimate.

444 B

Low quality Further research is very likely to have an important impact on our confidence in the estimate of effect

and is likely to change the estimate.

44 BB

Very-low quality Any estimate of effect is very uncertain. 4 BBB

Adapted from Guyatt et al.


TABLE 2. Levels of sedation and anesthesia

Minimal sedation


Moderate sedation

(conscious sedation) Deep sedation General anesthesia

Responsiveness Normal response to

verbal stimulation

Purposeful response to

verbal or tactile stimulation

Purposeful response after

repeated or painful stimulation

Unarousable even

with painful stimulus

Airway Unaffected No intervention required Intervention may

be required

Intervention often required

Spontaneous ventilation Unaffected Adequate May be inadequate Frequently inadequate

Cardiovascular function Unaffected Usually maintained Usually maintained May be impaired

Sedation and anesthesia in GI endoscopy

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endotracheal intubation.


In these instances, a team

approach to minimize the patient’s aspiration risk should

be used.

All patients undergoing endoscopic procedures require

pre-procedural evaluation to assess their risk for sedation

and to manage potential problems related to pre-existing

medical conditions. A history and focused physical examination

at the time of the procedure are necessary.

Elements of the history that may impact sedation include

(1) a history of snoring, stridor, or sleep apnea; (2) a

history of drug allergies, use of current medications, and

potential for drug interactions; (3) a history of an adverse

reaction to sedation or anesthesia; (4) time and contents

of the last oral intake; and (5) a history of tobacco, alcohol,

or substance use.


A focused physical examination

includes vital sign measurements, auscultation of the

heart and lungs, and assessment of the patient’s baseline

level of consciousness and airway anatomy (Fig. 1).


In addition, pregnancy testing should be obtained from all

women of childbearing age in the appropriate clinical

setting, because some sedatives may be teratogenic.


Table 3 shows the ASA classification used to risk-stratify

patients for sedation.


One recent retrospective study of

more than 1 million patients undergoing endoscopy and

colonoscopy confirmed that the ASA class is associated

with a risk of adverse events during GI procedures and

Figure 1. The Mallampati Classification. Class I: soft palate, fauces, uvula, pillars. Class II: soft palate, fauces, portion of uvula. Class III: soft palate, base of

uvula. Class IV: hard palate only. The original figure was first published in the article “Multisociety sedation curriculum for gastrointestinal endoscopy”

Gastrointest Endosc 2012;76:el-25 and is reused with permission.

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Sedation and anesthesia in GI endoscopy

may be useful in stratification of risk for GI endoscopy.


Analysis of the Clinical Outcomes Research Initiative

database has demonstrated that increasing ASA

class is associated with increased risk of unplanned

cardiopulmonary events during endoscopy.


Documentation and sedation planning in accordance

with the ASA and the ASGE recommendations are important

quality metrics.


In addition, regulatory frameworks,

including those of the Joint Commission, mandate that

pre-procedural assessment should be documented and a

procedural pause (“time out”) should be performed before

initiation of sedation.


During the time out, the patient

and all members of the procedure team stop other

activities to perform a final verification of patient

identification and the planned outcome, including the

sedation plan, before the procedure is begun.


The Mallampati Classification identifies potential

obstructive sleep apnea and predicts difficulty with any

endotracheal intubation.


This classification is based onthe structures visualized with maximal mouth opening

and tongue protrusion in the sitting position (Fig. 1). In

addition, airway management may be difficult in patients

with the following situations: (1) previous problems with

anesthesia or sedation; (2) a history of stridor, snoring,

or sleep apnea; (3) dysmorphic facial features, such as

Pierre-Robin syndrome or trisomy 21; (4) oral abnormalities,

such as a small opening (<3 cm in an adult), edentulous

dentition, protruding incisors, loose or capped teeth,

high arched palate, macroglossia, tonsillar hypertrophy, or

a nonvisible uvula; (5) neck abnormalities, such as obesity

involving the neck and facial structures, short neck, limited

neck extension, decreased hyoid-mental distance (<3 cm

in an adult), a neck mass, cervical spine disease or trauma,

tracheal deviation, or advanced rheumatoid arthritis; and

(6) jaw abnormalities such as micrognathia, retrognathia,

trismus, or significant malocclusion.


An ASA task force that devised guidelines for sedation

and analgesia administered by non-anesthesiologists states

that the presence of 1 or more sedation-related risk factors

coupled with the potential for deep sedation will increase

the likelihood of sedation-related adverse events.


According to the ASA, if the practitioner confronted with

these situations is not trained in the rescue of patients

from general anesthesia, an anesthesia professional

should be consulted to provide sedation (Table 4).


Recommendations for various staff roles and responsibilities

for patient monitoring as well as minimum

staffing numbers during sedated procedures, were

addressed in a recent ASGE guideline on safety in the

endoscopy unit.


Patient monitoring during sedated GI

endoscopy may detect changes in pulse, blood pressure,

ventilatory status, cardiac electrical activity, and level of

sedation before clinically significant events occur. For

both moderate and deep sedation, patient level of

consciousness and vital signs must be periodically

assessed and documented at a frequency that depends

on the type and amount of medication administered, the

length of the procedure, and the general condition of

the patient. At a minimum, the assessment of the

patient’s level of consciousness and vital signs should be

done (1) before the procedure is begun; (2) after

administration of sedative-analgesic agents; (3) at least

every 5 minutes during the procedure; (4) during initial

recovery; and (5) just before discharge. If recording is

performed automatically, device alarms should be set to

alert the care team to critical changes in patient status.

Equipment and medications for emergent resuscitation

should be immediately available. For moderate sedation,

TABLE 3. ASA classification

Class Description

I The patient is normal and healthy.

II The patient has mild systemic disease that does not limit activities (eg, controlled hypertension or controlled diabetes without

systemic sequelae).

III The patient has moderate or severe systemic disease that does not limit activities (eg, stable angina or diabetes with systemic sequelae).

IV The patient has severe systemic disease that is a constant threat to life (eg, severe congestive heart failure, end stage renal failure).

V The patient is morbid and is at a substantial risk of death within 24 hours (with or without a procedure).

E Emergency status: in addition to indicating the underlying ASA status (I-V), any patient undergoing an emergency procedure

is indicated by suffix “E.”

ASA, American Society of Anesthesiologists.

TABLE 4. Guideline for anesthesia provider assistance during GI


Anesthesia provider assistance should be considered in the

following situations:

Prolonged or therapeutic endoscopic procedures requiring

deep sedation

Anticipated intolerance to standard sedatives

Increased risk for adverse event because of severe comorbidity

(ASA class IV or V)

Increased risk for airway obstruction because of anatomic variant

ASA, American Society of Anesthesiologists.

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Sedation and anesthesia in GI endoscopy

the personnel assigned to monitoring the patient can be

assigned brief and interruptible tasks (such as mucosal

biopsy), provided that the patient has not reached a state

of deep sedation. For deep sedation, personnel assigned

to monitoring the patient must do so in a continuous

and uninterrupted fashion.


Minimal patient monitoring requirements for sedated

GI procedures include electronic assessment of blood

pressure, heart rate, and pulse oximetry and the visual

assessment of ventilatory activity, level of consciousness,

and discomfort.


ASA guidelines recommend continuous

electrocardiogram (ECG) monitoring of patients with

significant cardiovascular disease or dysrhythmia during

moderate sedation.


Other patients who may benefitfrom ECG monitoring include those with a history of

significant pulmonary disease, the elderly, and those in

whom prolonged procedures are anticipated. All patients

receiving intravenous sedation should be monitored with

non-invasive blood pressure devices.

Pulse oximetry effectively detects oxygen desaturation

in patients undergoing sedation and analgesia, and both

the ASA and the ASGE recommend that pulse oximetry

be used during all sedated endoscopic procedures.


Risk factors for hypoxemia include a baseline oxygen saturation

of less than 95%, emergent indication for the endoscopic

procedure, a procedure of long duration, difficulty

with esophageal intubation, and the presence of comorbid

illness. The routine administration of supplemental oxygen

has been shown to reduce the magnitude of oxygen

desaturation during sedated endoscopic procedures.


The ASA and the ASGE recommend that supplemental

oxygen be considered for moderate sedation, and it is

required for all procedures with intended deep sedation.

Supplemental oxygen should be administered if

hypoxemia is anticipated or develops.


Capnography is a noninvasive technology that detects

disordered or depressed respiratory activity by graphic

assessment of the partial pressure of carbon dioxide

throughout the respiratory cycle.


Capnography has been demonstrated to detect depressed respiratory

activity before transient hypoxemia,


but a clear link between transient hypoxemia and serious cardiopulmonary

unplanned events during sedated endoscopy has not been established.


Integrating capnography into patient monitoring protocols for endoscopic procedures with moderate sedation has not been shown to improve

patient safety; however, there is evidence supporting its

use in procedures targeting deep sedation. A randomized

study of more than 500 patients undergoing colonoscopy

with deep sedation found a significantly lower incidence

of transient hypoxemia in patients with capnography

monitoring compared with those receiving standard



Independent risk factors for hypoxemia in

this study were age, high body mass index, history of

sleep apnea, and increased doses of sedatives. A recent

randomized controlled trial in healthy ASA Class I and II

patients undergoing elective outpatient upper endoscopy

and colonoscopy targeting moderate sedation with a

combination of benzodiazepines and opioids found that

capnography did not reduce the incidence of hypoxemia

in either procedure type.


After the completion of endoscopic procedures,

patients should be monitored for adverse effects from

either instrumentation or sedation. Standardized discharge

criteria should be used to assess recovery from sedation.

Post-procedural monitoring after sedated endoscopy

has been discussed in a previously published ASGE




Select patients may be able to undergo endoscopic procedures

without sedation,


and provider education may

increase patient willingness to consider this option.


Small-diameter endoscopes (<6 mm) can improve the

tolerability of upper endoscopy when sedation is not



In general, topical anesthesia is used during

unsedated upper endoscopy. Successful colonoscopy also

is possible in selected patients who receive no sedation

or sedation only if needed.


Older patients, men, patients

who are not anxious, and patients without a history

of abdominal pain may be more willing to undergo upper

endoscopy or colonoscopy with little or no sedation.


Standard pre-procedural preparation for sedation and

monitoring, including intravenous insertion, should be

followed, in the event that the patient does not tolerate

the procedure or develops a cardiopulmonary unplanned

event, and sedation is ultimately required. In addition,

the use of water-assisted or carbon dioxide insufflation

may reduce pain during and after the procedure in

both unsedated and sedated colonoscopy.


The use of topical anesthesia may decrease patient discomfort in

those receiving unsedated procedures or non-propofol

mediated sedation. In randomized controlled trials that

used propofol mediated sedation for EGD, topical

anesthesia did not affect endoscopist satisfaction, the total

propofol dose, or patient responsiveness.




Minimal and moderate sedation are defined in Table 2

and are routinely used to improve patient tolerance of

upper endoscopy and colonoscopy. Endoscopy is

generally well tolerated but may be associated with pain

or discomfort during the procedure as well as anxiety

about the procedure and possible findings. The decision

to use minimal or moderate sedation should be shared

between the provider and patient. There is an

expectation in the United States that endoscopic

procedures will be performed by using at least minimal

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Sedation and anesthesia in GI endoscopy

sedation, although patient wishes and medical conditions

must be considered when determining whether sedation

is necessary and safe.

Minimal and/or moderate sedation can be delivered

safely by endoscopists to patients who are ASA Class I, II,

or III. Other candidates for minimal or moderate sedation

include those with a history of previously successful

procedures with moderate sedation and an expectation

for moderate sedation as well as those undergoing a procedure

that is expected to be uncomplicated or routine.


Medications targeting minimal and moderate sedation

generally can be administered in an incremental fashion

by an appropriately trained registered nurse (RN) under

the supervision of an endoscopist. Patient response to

administered sedatives and analgesics should be monitored

by a nurse (generally an RN), whose primary responsibility

is patient monitoring.


In this setting, the RN

can perform short, interruptible tasks in addition to monitoring

the patient.

Moderate sedation with benzodiazepines

and opioids

Minimal and moderate sedation regimens typically

consist of a benzodiazepine to minimize anxiety and a

narcotic analgesic to minimize pain and discomfort. Benzodiazepines

have been used either alone or in combination

with an opiate to achieve minimal to moderate sedation for

endoscopy. The most commonly used benzodiazepines

are midazolam and diazepam. The efficacy of sedation

with these 2 benzodiazepines is comparable.



most endoscopists favor midazolam for its fast onset

of action, short duration of action, lower risk of

thrombophlebitis, and high amnestic properties.


Opiates, such as meperidine and fentanyl administered

intravenously, provide both analgesia and sedation. Fentanyl

has a more rapid onset of action and clearance and has

a lower incidence of nausea compared with meperidine.

The pharmacologic profiles of the benzodiazepines and

opiates are discussed in a previously published ASGE



Specific antagonists of opiates (naloxone)

and benzodiazepines (flumazenil) should be readily

available in every endoscopy unit. The effects of reversal

agents may be shorter than the effects of the

benzodiazepines and opioids themselves. Therefore, a

policy of extended recovery room monitoring may be

necessary to avoid post-discharge sedation-related issues.


Pharmacologic adjuncts to a typical benzodiazepinenarcotic

combination may include diphenhydramine,

promethazine, and droperidol. These medications potentiate

the action of the benzodiazepine-narcotic regimen

and can result in deeper levels of sedation and potentially

a prolonged recovery. Droperidol is a neuroleptic agent in

the same class as haloperidol and has sedative effects.

Randomized trials have demonstrated the efficacy of droperidol

in patients undergoing therapeutic endoscopy,

particularly those who are difficult to sedate.


A black

box warning on the U.S. Food and Drug Administration

product label indicates that droperidol should be used

only when first-line agents have not provided adequate



Droperidol use is contraindicated in patients

with a prolonged QTc interval (>440 ms in men,

>450 ms in women), and should be used with extreme

caution in patients at increased risk of developing QT

interval prolongation (eg, patients receiving other

medications known to increase the QT interval; patients

with a history of congestive heart failure, bradycardia,

diuretic use, cardiac hypertrophy, alcohol abuse,

hypokalemia, hypomagnesemia; aged >65 years) because

of the risk of ventricular tachyarrhthmias.


In addition,

the use of diphenhydramine has been shown to improve

sedation and decrease pain in patients undergoing

colonoscopy with a combination of an opioid and



Balanced propofol for moderate sedation

The use of propofol in addition to an opioid and benzodiazepine

is referred to as balanced propofol sedation

(BPS). BPS can be effective in achieving moderate sedation

for endoscopic procedures.


BPS will be discussed

further in the section on propofol-mediated sedation.


Non-anesthesiologist–administered propofol


Extensive data have demonstrated the safety and efficacy

of non-anesthesiologist–administered propofol sedation

(NAAP). NAAP can be divided further into nurseadministered

propofol sedation (NAPS), in which propofol

is administered as a single agent to target deep sedation

under the direction of the endoscopist, and BPS, which

involves the administration of a single dose of an opioid

and benzodiazepine followed by intermittent bolus administration

with propofol to target moderate sedation.

NAAP has been associated universally with shorter sedation

times and shorter recovery times, when compared with the

combination of an opioid and benzodiazepine targeting

moderate sedation thus supporting its use in routine

sedation regimens.


NAAP requires specialized training,

patient selection, and personnel dedicated to continuous

physiologic monitoring (Table 4). Regulations regarding

administration of propofol are determined at the state,

regional, and local levels regardless of the targeted level

of sedation. As a result, the practice of NAAP is quite

limited nationally. Hence, propofol-based sedation for

low-risk patients undergoing routine procedures often is

administered by anesthesia personnel.

Published protocols for NAPS


report various dosing

schedules of administered propofol. Propofol dosing and

the depth of sedation should be individualized to the

needs of each patient.


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Sedation and anesthesia in GI endoscopy

NAPS should be administered by personnel specifically

trained in its administration who should have expertise

in emergency airway management and must be present

continuously during its use.


In addition, the patient’s

physiologic parameters and level of sedation must be

continuously monitored. Multiple studies have shown a

high level of safety and have confirmed that it compares

favorably with lighter levels of sedation by using a

combination of an opioid and benzodiazepine. The

appropriate personnel and equipment for deep sedation

propofol administration are listed in Table 5.

In centers in the United States and worldwide where it

is permitted, NAPS is typically performed by trained

RNs whose sole responsibilities are patient monitoring

and administration of propofol.


In a multicenter

retrospective review of more than 36,000 endoscopies

performed with NAPS, the rate of clinically important

events, defined as an episode of apnea or other airway

compromise requiring assisted ventilation, was <0.2%.


Endotracheal intubation was not required, and no patient

had permanent injury or died.

A prospective study of more than 24,000 patients

receiving NAPS found a major adverse event rate of

0.016%, involving 2 patients who received bag-mask ventilation

and 1 who experienced largyngospasm.


The minor

adverse event rate in this same series, which included

patients who received monopropofol infusions or propofol

plus midazolam, was 0.46% and was mostly characterized

by transient and reversible hypoxemia. Several studies

have compared NAAP sedation to standard moderate

sedation (ie, a benzodiazepine plus narcotic), with respect

to safety, patient and provider satisfaction, and induction

and recovery times. Two randomized controlled trials

compared NAPS for colonoscopy with a combination

regimen of midazolam and fentanyl


and midazolam plus



All studies found that NAPS exhibited

significantly shorter recovery times. There were no

significant differences across sedation regimens in the

incidence of bradycardia, hypotension, hypoxemia,

physician satisfaction, or in the number of patients

reporting pain or discomfort. Patient satisfaction across all

controlled trials was lower with midazolam plus narcotic,

when compared with monopropofol sedation.

BPS is effective at achieving moderate sedation for

endoscopic procedures.


BPS provides the benefits of

propofol-mediated sedation, such as shorter recovery

times and enhanced patient satisfaction, while reducing

the risk of over-sedation.


Typically, loading doses

of an opioid and benzodiazepine are given, followed by

intermittent bolus dosing of propofol to target moderate

sedation. When propofol is used alone for endoscopy, its

lack of analgesic properties may require larger doses and

therefore result in deep sedation,


for which there is no

specific reversal agent.


In contrast, when BPS is used,

analgesia and amnesia can be achieved with less than

hypnotic doses, mitigating the potential for deep

sedation. Furthermore, more precise dose titration is

possible with smaller bolus doses of propofol (5-15 mg),

and the potential for partial pharmacologic reversibility is

retained by using naloxone or flumazenil.


Anesthesia provider–administered sedation

Anesthesia provider–administered sedation comprises a

sizeable proportion of procedural sedation for outpatient

endoscopic procedures in the United States. It is estimated

that over half of colonoscopies currently are performed

with monitored anesthesia care (MAC).



advantages to the use of anesthesia provider–administered

sedation for routine colonoscopy and upper endoscopy

may include improved patient satisfaction, decreased

distractions for the endoscopist, and increased throughput

through the endoscopy unit because of shorter sedation

and recovery times, although there are no published

studies confirming these. In addition, patients with

medical comorbidities may require MAC that typically

involves administration of propofol with or without

adjunctive sedatives to achieve moderate sedation, deep

sedation, or general anesthesia.


Governance to determine

who can administer MAC is dictated by state and institutional

regulations. In some instances, anesthesiologists

TABLE 5. Recommendations for propofol use during endoscopy

A sedation team with appropriate education and training.

At least 1 person who is qualified in advanced life support skills (ie, airway management, defibrillation, and the use of resuscitative medications).

Trained personnel dedicated to the uninterrupted monitoring of the patient’s clinical and physiologic parameters throughout the procedure should

be available.

Physiologic monitoring must include pulse oximetry, electrocardiography, and intermittent blood pressure measurement.

Monitoring oxygenation by pulse oximetry is not a substitute for monitoring ventilatory function.

Capnography should be considered because it may decrease the risks during deep sedation.

Continuous monitoring will allow recognition of patients who have progressed to a deeper level of sedation.

Personnel should have the ability to rescue a patient who becomes unresponsive or unable to protect his or her airway or who loses spontaneous

respiratory or cardiovascular function.

Age-appropriate equipment for airway management and resuscitation must be immediately available.

A physician should be present throughout propofol sedation and must remain immediately available until the patient meets discharge criteria.

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Sedation and anesthesia in GI endoscopy

directly administer MAC or supervise certified registered

nurse anesthetists. In other states, certified registered nurse

anesthetists may administer MAC independently or under

the direction of an endoscopist.

Several factors that may determine whether the assistance

of anesthesia providers is needed include patientspecific

risk factors for sedation, the planned depth of

sedation, and the urgency and type of endoscopic procedure

performed (Table 5).


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 that is associated

with more difficult intubation.


Additionally, an anesthesia

provider may be used to provide propofol-based

sedation for settings in which regulations or policies do

not allow endoscopist-administered propofol, but the

treating physicians judge the benefits of a propofol

regimen to outweigh the risks and costs.

Studies have demonstrated that anesthesia provider–

administered sedation for EUS-guided FNA of pancreatic

masses and overtube-assisted enteroscopy is associated

with improved outcomes.


Anesthesia provider–administered

sedation is advantageous during ERCP, which often

involves placing a patient in a prone position. The prone

position may be associated with altered cardiovascular

and pulmonary physiology and may involve limited airway



However, for lower-risk patients (ASA I-III) undergoing

non-advanced endoscopic procedures such as elective colonoscopy

and EGD, recent large population–based studies

found a higher risk of aspiration and other unplanned cardiopulmonary

events in patients receiving deep sedation

with propofol as administered by anesthesiologists, when

compared with patients who received lighter sedation as

administered by endoscopists.


Additionally, a recent

study using claims data found a higher perforation rate in

colonoscopies with anesthesia services.


Currently, the cost of anesthesia-delivered propofol

sedation is a separate charge from the endoscopy procedure

and can range from $150 to $1500 per case. Despite

the demonstration of no safety benefit, utilization of anesthesia

services for low-risk endoscopic procedures such as

EGD and colonoscopy continues to increase.


In a costeffectiveness

model, Hassan et al


showed that

endoscopist-directed propofol sedation was more cost

effective than anesthesia-administered propofol sedation.

Dominitz et al


demonstrated in a large cohort study of

Medicare beneficiaries that anesthesia-administered sedation

for colonoscopy varies widely across regions and

appears to be more associated with reimbursement practices

(ie, Medicare contractors), rather than assessment

of patient risk. This study also found no significant

difference in the adenoma detection rate between

endoscopist-directed or anesthetist-directed sedation.


In summary, anesthesia provider–administered sedation

most likely improves throughput, patient and/or endoscopist

satisfaction, and endoscopist focus. In the setting of

advanced endoscopic procedures such as EUS-guided

FNA, it may also improve efficacy. Anesthesia provider–

administered sedation is more expensive and does not

appear to result in improved safety as compared with

endoscopist-directed sedation for ambulatory endoscopic

procedures such as upper endoscopy and colonoscopy.


Patient-controlled sedation and analgesia with propofol

and other agents is a method of sedation in which patients

deliver their own drug via an infusion pump. Patientcontrolled

sedation has been studied in several randomized

trials. Külling et al


showed that patients receiving

patient-controlled sedation with propofol and/or alfentanil

exhibited a high degree of patient satisfaction and more

complete recovery at 45 minutes when compared with

conventional sedation and analgesia. Ng et al



that patients undergoing colonoscopy with propofol

patient-controlled sedation exhibited significantly shorter

mean recovery times (43 vs 61 minutes; P Z .001) and

improved comfort compared with midazolam alone. Heuss

et al


reported that younger and more anxious patients

are less likely to agree to patient-controlled sedation.

Currently, this method of procedural sedation remains

under the purview of anesthesia providers.


1. We recommend that all patients undergoing endoscopic

procedures be evaluated to assess their risk of sedation

related to pre-existing medical conditions. 4444

2. We recommend that the combination of an opioid and

benzodiazepine is a safe and effective regimen for

achieving minimal to moderate sedation for upper

endoscopy and colonoscopy in patients without risk

factors for sedation-related adverse events. 4444

3. We suggest using an appropriate adjunctive agent

(eg, diphenhydramine, promethazine, or droperidol)

in combination with conventional sedative drugs in

select clinical circumstances. 44 BB

4. We recommend that providers undergo specific training

in the administration of endoscopic sedation and

possess the skills necessary for the diagnosis and

management of sedation-related adverse events,

including rescue from a level of sedation deeper than

that intended. 4444

5. We recommend the routine monitoring of blood

pressure, oxygen saturation, and heart rate in addition

to clinical observation for changes in cardiopulmonary

status during all endoscopic procedures using

sedation. Supplemental oxygen administration should

334 GASTROINTESTINAL ENDOSCOPY Volume 87, No. 2 : 2018 giejournal.org

Sedation and anesthesia in GI endoscopy

be considered for moderate sedation and should be

administered during deep sedation. Supplemental

oxygen should be administered if hypoxemia is anticipated

or develops. 4444

6. We suggest that capnography monitoring be considered

for patients undergoing endoscopy targeting deep sedation. 44 BB

7. We recommend anesthesia provider–administered sedation

be considered for complex endoscopic procedures

or patients with multiple medical comorbidities or at

risk for airway compromise. 444 B

8. We suggest that endoscopists use propofol-based

sedation (endoscopist-directed or anesthesia-provider

administered) when it is expected to improve patient

safety, comfort, procedural efficiency, and/or successful

procedure completion. 44 BB


Dr Muthusamy is a consultant for Boston Scientific

and received honoraria from Covidien GI Solutions. Dr

Chathadi is a consultant for Boston Scientific. Dr Khashab

is a consultant for Boston Scientific. He is on their advisory

board and has received grants from them. He is a

consultant for Olympus America and has received grants

from Cook Medical. All other authors disclosed no financial

relationships relevant to this publication.

Abbreviations: ASA, American Society of Anesthesiologists; ASGE,

American Society for Gastrointestinal Endoscopy; BPS, balanced

propofol sedation; ECG, electrocardiogram; MAC, monitored

anesthesia care; NAAP, non-anesthesiologist–administered propofol

sedation; NAPS, nurse-administered propofol sedation; RN, registered



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