[Apologies for the poor formatting of this article]
GUIDELINE
Guidelines for sedation and anesthesia in GI endoscopy
Prepared by: ASGE STANDARDS OF PRACTICE COMMITTEE
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
Endoscopy.
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).
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
guidelines.
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
ASGE.
2-4
A sedation continuum has been described,
ranging from minimal sedation or anxiolysis to general
anesthesia (Table 2). During endoscopic procedures
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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.
2,5
In
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.
5
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.
3,6,7
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.
5
PRE-PROCEDURAL PREPARATION AND
ASSESSMENT
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.
8
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
effectively.
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.
9
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.
10
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
1
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.
1
TABLE 2. Levels of sedation and anesthesia
Minimal sedation
(anxiolysis)
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.
11
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.
12
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).
5
In addition, pregnancy testing should be obtained from all
women of childbearing age in the appropriate clinical
setting, because some sedatives may be teratogenic.
13,14
Table 3 shows the ASA classification used to risk-stratify
patients for sedation.
15
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.
giejournal.org Volume 87, No. 2 : 2018 GASTROINTESTINAL ENDOSCOPY 329
Sedation and anesthesia in GI endoscopy
may be useful in stratification of risk for GI endoscopy.
16
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.
16,17
Documentation and sedation planning in accordance
with the ASA and the ASGE recommendations are important
quality metrics.
5
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.
18
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.
19
The Mallampati Classification identifies potential
obstructive sleep apnea and predicts difficulty with any
endotracheal intubation.
20
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.
5
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.
2
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).
INTRA-PROCEDURAL PATIENT MONITORING
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.
20
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
endoscopy
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.
2,5
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.
20
ASA guidelines recommend continuous
electrocardiogram (ECG) monitoring of patients with
significant cardiovascular disease or dysrhythmia during
moderate sedation.
2
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.
2,6
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.
21
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.
2,5
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.
22
Capnography has been demonstrated to detect depressed respiratory
activity before transient hypoxemia,
23,24
but a clear link between transient hypoxemia and serious cardiopulmonary
unplanned events during sedated endoscopy has not been established.
25
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
monitoring.
26
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.
27
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
guideline.
20
UNSEDATED ENDOSCOPY
Select patients may be able to undergo endoscopic procedures
without sedation,
28,29
and provider education may
increase patient willingness to consider this option.
30
Small-diameter endoscopes (<6 mm) can improve the
tolerability of upper endoscopy when sedation is not
used.
31
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.
32,33
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.
34-36
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.
37,38
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.
39-41
MINIMAL AND MODERATE SEDATION FOR
ENDOSCOPY
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.
42
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.
5,6,22
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.
42
However,
most endoscopists favor midazolam for its fast onset
of action, short duration of action, lower risk of
thrombophlebitis, and high amnestic properties.
5,43
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
document.
5
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.
5
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.
44,45
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
sedation.
46
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.
47,48
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
benzodiazepine.
49
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.
4,50
BPS will be discussed
further in the section on propofol-mediated sedation.
PROPOFOL-MEDIATED SEDATION
Non-anesthesiologist–administered propofol
sedation
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.
50
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
51-53
report various dosing
schedules of administered propofol. Propofol dosing and
the depth of sedation should be individualized to the
needs of each patient.
7
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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.
5
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.
54
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%.
55
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.
56
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
57
and midazolam plus
meperidine.
58
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.
4,50
BPS provides the benefits of
propofol-mediated sedation, such as shorter recovery
times and enhanced patient satisfaction, while reducing
the risk of over-sedation.
50,59-61
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,
55
for which there is no
specific reversal agent.
62
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.
5,50,51,63
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).
64
Potential
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.
65,66
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 ventila
