Table 2.
Summary of recommendations for sedative agents
| Subject | Document | Recommendation or Statement (Quote) | Strength | Level of evidence |
|---|---|---|---|---|
| Moderate sedation | ||||
| Use midazolam over other benzodiazepines | GSGMD [36] | If benzodiazepines are used for sedation because of their stronger amnestic effect, we suggest that midazolam be preferred to diazepam because of its shorter half-life | B | 2a |
| SSGE [31] | When benzodiazepines are used, midazolam is recommended | B | 2++ | |
| Moderate sedation provides high satisfaction for patients and physicians | SSGE [31] | Moderate sedation using currently available drugs for routine endoscopic procedures (colonoscopies and gastroscopies) is highly satisfactory for patients and physicians alike given their low risk for adverse events | A | 1- |
| Depth of sedation/choice of agent | ||||
| Moderate sedation/benzodiazepines adequate | SSGE [31] | Moderate sedation using currently available drugs for routine endoscopic procedures (colonoscopies and gastroscopies) is highly satisfactory for patients and physicians alike given their low risk for adverse events | A | 1- |
| For non-complex diagnostic or therapeutic gastroscopy and colonoscopy superficial sedation suffices | A | 1+ | ||
| ESGE [24] | Simple endoscopic procedures can be performed with moderate sedation, maintaining a high degree of patient satisfaction. Prolonged or complex procedures (e.g. EUS, ERCP) are frequently performed under deep sedation | Strong | High | |
| CAG [47] | It should be recognized that adequate sedation can usually be achieved with a combination of opioids and benzodiazepines. As such, there is no mandate for endoscopists to switch to propofol, particularly because most operators have considerable experience administering standard agents | – | – | |
| ASGE [27] | 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 | – | High | |
| Deep sedation/propofol preferred | GSGMD [36] | Because of data on efficacy, recovery, and complications, we suggest that propofol should be preferred to midazolam | B | 2b |
| SSGE [33] | Literature data available on effectiveness, recovery issues, and complications seem to favor the use of propofol over benzodiazepines | B | 2b | |
| SSGE [31] |
Propofol is an ideal drug to provide sedation for endoscopic examinations For complex or prolonged procedures (ERCP, EUS, etc.) deep sedation is to be preferred |
A | 1+ | |
| FSDE [35] | All patients undergoing a colonoscopy must be offered a general anesthesia. However, an examination without general anesthesia is conceivable for patients who have been told about the potential plan. | – | – | |
| Individualize | GSGMD [36] | We recommend that the type and intensity of the sedation and the drug used should be selected according to the type of intervention and the patient’s ASA grade and individual risk profile | A | 5 |
| ASGE [21] | The choice of specific sedation agents and the level of sedation targeted should be determined on a case-by-case basis by the endoscopist in consultation with the patient | – | – | |
| EC [40] | Because there is no clear benefit from a particular approach and for practical reasons, it is recommended that policies on the use of sedation should be adopted according to protocols based on national or pan-European guidelines, and must take into account historical context, the impact on the patient experience, and cost | B | I | |
| ASGE [27] | 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 | – | Low | |
| SSGE [31] | Sedation level and drug type depend on procedure characteristics, individual patient-related factors, patient preferences, and need for patient cooperation | D | 4 | |
| Propofol sedation | ||||
| Delivery | GSGMD [36] | We suggest that propofol should be administered by intermittent bolus administration | B | 1b |
| ESGE [24] | We recommend administering propofol through intermittent bolus infusion or perfusor system, including target-controlled infusion (TCI), and consideration of patient-controlled sedation (PCS) in particular settings | Strong | High | |
| Avoid concomitant use of pharyngeal anesthesia | ESGE [24] | We do not suggest using pharyngeal anesthesia during propofol sedation for upper GI endoscopy | Weak | Moderate |
| Use propofol monotherapy | ESGE [24] |
We suggest propofol monotherapy except in particular situations. In some situations, low dose midazolam premedication might be beneficial to facilitate intravenous line placement and to reduce the need for propofol. Such situations include patients with high anxiety potential, long-lasting procedures in patients with a known important need for sedatives, and patients with limited left ventricular function or with previous pronounced hypotension following propofol administration |
Weak | High |
| GSGMD [36] | We suggest that a combination of propofol and midazolam should not be used | B | 1b | |
| DSRPGSA [19] | Propofol is administered intravenously and should be used only as monotherapy | – | – | |
| Consider use of balanced propofol administration | SSGE [31] | Midazolam administration before propofol allows to reduce dosage and adverse effects, particularly hypotension in cardiac patients or in hypovolemia, but recovery is delayed | B | 1+ |
| Special populations | GSGDM [36] | Propofol may be considered for sedation in elderly populations | Statement | 1b |
| GSGMD [36] | We recommend that propofol should be used for sedation of patients with hepatic encephalopathy. Benzodiazepines should not be used in patients with hepatic encephalopathy | A | 1b | |
| Sedation practice in general | ||||
| Offering sedation | GSGMD [36] | We recommend that sedation should be offered to every patient before endoscopy. The advantages and disadvantages should be discussed in detail | A | 5 |
| GSGMD [36] | We suggest that, on principle, simple endoscopic examinations can be performed without sedation | Statement | 2b | |
| Use of adjunctive agents | GSGMD [36] | We suggest that opioids, ketamines, inhalational anesthetics, and neuroleptics should not be used as monotherapeutics for sedation in endoscopy | B | 5 |
| GSGMD [36] | Nitrous oxide (laughing gas) may be considered for analgesia and sedation during colonoscopy; appropriate structural requirements must be met | Statement | 1b | |
| AGA [22] | The majority of patients can be adequately sedated by using a combination of an opioid and benzodiazepine. The addition of an adjunctive agent in combination with conventional sedation drugs may be useful for the difficult-to-sedate patient | – | – | |
| Titrating sedative doses in special populations | ASGE [26] | We recommend that lower initial doses of sedatives than standard adult dosing should be considered in the elderly and that titration should be more gradual to allow assessment of the full dose effect at each dose level | – | Moderate |
| GSGMD [36] | Patients with higher ASA grade and/or older patients are at higher risk of sedation-related side effects (cardiorespiratory depression). We suggest that the dose of the sedative/analgesic used should be adjusted/reduced accordingly | B | 2b | |
AGA American Gastroenterological Association, ASGE American Society for Gastrointestinal Endoscopy, CAG Canadian Association of Gastroenterology, DSRPGSA Danish Secretariat for Reference Programmes for Gastroenterology, Surgery and Anaesthetics, EC European Commission, ESGE European Society of Gastrointestinal Endoscopy, FSDE French Society of Digestive Endoscopy, GSGDMD German Society for Gastroenterology, Digestive and Metabolic Diseases, SSGE Spanish Society of Gastrointestinal Endoscopy