Sedation for endoscopic procedures: not as simple as it seems

The Bispectral Index (BIS) is a processed electroencephalogram, which has been evaluated as an automated monitoring technique for patients receiving sedation for endoscopic procedures. BIS monitoring has not been shown to be of significant clinical benefit, but the need for an objective quantitative measure of the depth of sedation in patients undergoing endoscopy remains.     

Sedation with propofol for interventional endoscopic procedures: A risk factor analysis

Objective. Propofol sedation for mainly diagnostic endoscopic procedures has proved safe in recent trials, with no need for endotracheal intubation. However, there is evidence that cardiorespiratory side effects occur more frequently and that assisted ventilation may be necessary if propofol sedation is performed for interventional endoscopic procedures. Material and methods. Over a 6-year period, all adverse events (defined as premature termination of the procedure due to sedation-related events or either the need for assisted ventilation or admission to ICU) occurring during 9547 endoscopic interventions (UGI, n=5.374, ERCP, n=3.937, EUS, n=236) under propofol sedation were assessed. Results. A total of 135 adverse events (1.4%) were documented. Assisted ventilation was necessary in 40 patients (0.4%); 9 patients required endotracheal intubation (0.09%); 28 needed further monitoring on the ICU (0.3%); and 4 patients died, 3 potentially due to sedation-related side effects (mortality, 0.03%). Independent risk factors for sedation-related side effects were emergency endoscopic examinations and a total propofol dose >100 mg. Conclusions. Interventional endoscopy under propofol sedation is not risk-free. Increased attention must be focused on close monitoring of vital parameters, particularly when undertaking long-lasting interventions and emergency procedures.     

Conscious sedation for endoscopic procedures

Despite the fact that gastrointestinal endoscopy is a safe procedure, significant complications can occur. According to the literature most complications are related to sedation and compared with perioperative mortality under general anaesthesia, the mortality for this procedure appears high. Strict implementation of existing guidelines is warranted.     

Training for advanced endoscopic procedures

Advanced endoscopy has evolved from diagnostic ERCP to an ever-increasing array of therapeutic procedures including EUS with FNA, ablative therapies, deep enteroscopy, luminal stenting, endoscopic suturing and endoscopic mucosal resection among others. As these procedures have become increasingly more complex, the risk of potential complications has also risen. Training in advanced endoscopy involves more than obtaining a minimum number of therapeutic procedures. The means of assessing a trainee's competence level and ability to practice independently continues to be a matter of debate. The use of quality indicators to measure performance levels may be beneficial as more advanced techniques and procedures become available.     

Sedation of the pediatric and adolescent patient for GI procedures

Opinion statement There remains no ideal sedative for pediatric and adolescent patients undergoing gastrointestinal procedures. Instead, pediatric gastroenterologists must consider many factors, including patient age, medical history, clinical status, anxiety level, as well as targeted sedation level, to select the appropriate methods and agents to achieve optimal sedation for endoscopy. The two primary types of sedation are endoscopist-administered intravenous (IV) sedation and anesthesiologist-administered general anesthesia. If IV sedation is used, pediatric endoscopists must be prepared for children to become agitated, adding to stress for both patients and clinical staff. General anesthesia provides the advantage of complete patient immobility but also entails increased costs and utilization of hospital resources. Technical advances in electronic monitoring, both in the pediatric endoscopy suite and operating room settings, are contributing to increased patient safety. Nevertheless, sedation-related events, independent of type of sedation or regimen, represent the most common complications of pediatric endoscopy.     

Management of anticoagulation for gastrointestinal endoscopic procedures

Opinion statement  

Emergencies after endoscopic procedures

Endoscopy adverse events (AEs), or complications, are a rising concern on the quality of endoscopic care, given the technical advances and the crescent complexity of therapeutic procedures, over the entire gastrointestinal and bilio-pancreatic tract. In a small percentage, not established, there can be real emergency conditions, as perforation, severe bleeding, embolization or infection. Distinct variables interfere in its occurrence, although, the awareness of the operator for their potential, early recognition, and local organized facilities for immediate handling, makes all the difference in the subsequent outcome. This review outlines general AEs' frequencies, important predisposing factors and putative prophylactic measures for specific procedures (from conventional endoscopy to endoscopic cholangio-pancreatography and ultrasonography), with comprehensive approaches to the management of emergent bleeding and perforation.     

Percutaneous transhepatic biliary endoscopic procedures

Two cases are presented to demonstrate the acceptability of the percutaneous route for performing endoscopic procedures in the biliary tree. They involved debridement of an atypical villoglandular polyp and ultrasonic lithotripsy of intrahepatic stones. Both cases serve to introduce percutaneous biliary endoscopy as a viable alternative for diagnosis and therapy in selected cases.