Sedation practices for routine gastrointestinal endoscopy: a systematic review of recommendations

Abstract

Background Sedation is commonly used in gastrointestinal endoscopy; however, considerable variability in sedation practices has been reported. The objective of this review was to identify and synthesize existing recommendations on sedation practices for routine gastrointestinal endoscopy procedures. Methods We systematically reviewed guidelines and position statements identified through a search of PubMed, guidelines databases, and websites of relevant professional associations from January 1, 2005 to May 10, 2019. We included English-language guidelines/position statements with recommendations relating to sedation for adults undergoing routine gastrointestinal endoscopy. Documents with guidance only for complex endoscopic procedures were excluded. We extracted and synthesized recommendations relating to: 1) choice of sedatives, 2) sedation administration, 3) personnel responsible for monitoring sedated patients, 4) skills and training of individuals involved in sedation, and 5) equipment required for monitoring sedated patients. We assessed the quality of included documents using the Appraisal of Guidelines for Research & Evaluation (AGREE) II tool. Results We identified 19 guidelines and 7 position statements meeting inclusion criteria. Documents generally agreed that a single, trained registered nurse can administer moderate sedation, monitor the patient, and assist with brief, interruptible tasks. Documents also agreed on the routine use of pulse oximetry and blood pressure monitoring during endoscopy. However, recommendations relating to the drugs to be used for sedation, the healthcare personnel capable of administering propofol and monitoring patients sedated with propofol, and the need for capnography when monitoring sedated patients varied. Only 9 documents provided a grade or level of evidence in support of their recommendations. Conclusions Recommendations for sedation practices in routine gastrointestinal endoscopy differ across guidelines/position statements and often lack supporting evidence with potential implications for patient safety and procedural efficiency.

The Efficacy and Safety of Remimazolam Tosilate versus Etomidate-Propofol in Elderly Outpatients Undergoing Colonoscopy: A Prospective, Randomized, Single-Blind, Non-Inferiority Trial

“…36 In our study, we adopted a 1:1 EP mixture to allow longer examination time and stimulation needed for colonoscopy compared with gastroscopy. 6 A previous study reported that 70% of the usual dose could be administered to complete endoscopy in elderly patients, although the number of remediations was…”

“…5 Propofol, etomidate, and midazolam combined with opioids are the most commonly used drugs globally for sedation during endoscopic procedures. 6 However, each drug has both advantages and disadvantages. The disadvantage of propofol is injection pain, aspiration pneumonia due to loss of protective reflexes, lack of an analgesic effect and specific antagonists, risk of developing propofol infusion syndrome and bacterial contamination, metabolic acidosis, a narrow therapeutic index (which increase the risk of hypoxia), and cardiovascular and respiratory depression, especially when combined with opioids.…”

Remimazolam: Non-Clinical and Clinical Profile of a New Sedative/Anesthetic Agent

“…The sedation of patients to reduce pain, reduce anxiety and provide amnesia facilitates uncomfortable diagnostic procedures such as endoscopy ( Dossa et al, 2021 ) and interventional procedures such as those employed in cardiology ( Makkad, 2013 ). Several clinical trials of remimazolam as a sedative agent for procedural sedation have been conducted.…”

Autonomous Nervous Response During Sedation in Colonoscopy and the Relationship With Clinician Satisfaction

“…Single propofol boluses were administered in order to reach the desired sedation level. Following the German and ESGE guidelines for sedation in gastrointestinal endoscopy, a moderate sedation level was targeted for colonoscopy procedures ( 26 , 27 ). The additional administration of midazolam was allowed in accordance with national sedation guidelines ( 4 ).…”