Sedationless upper endoscopy

The use of sedation with peroral passage of conventionally sized endoscopes for upper endoscopy is the standard practice for most endoscopists in the United States. The administration of sedatives requires time-consuming and resource-intensive patient monitoring, has substantial cost, and can produce side effects and rare complications. Ultra-thin videoendoscopes (outer diameter less than 6 mm) have been developed, can easily be passed transorally or transnasally without sedation, and have been shown to be well tolerated and accurate. Unsedated upper endoscopy can provide an efficient, cost-effective alternative to standard endoscopy, should be useful for endoscopic screening, and can be offered as an option to conventional sedated examination.     

Use of anesthesia on the rise in gastrointestinal endoscopy

Conscious sedation has been the standard of care for many years for gastrointestinal endoscopic procedures. As procedures have become more complex and lengthy, additional medications became essential for adequate sedation. Often time’s deep sedation is required for procedures such as endoscopic retrograde cholangiography which necessitates higher doses of narcotics and benzodiazepines or even use of other medications such as ketamine. Given its pharmacologic properties, pro-pofol was rapidly adopted worldwide to gastrointestinal endoscopy for complex procedures and more recently to routine upper and lower endoscopy. Many studies have shown superiority for both the physician and patient compared to standard sedation. Nevertheless, its use remains highly controversial. A number of studies worldwide show that propofol can be given safely by endoscopists or nurses when well trained. Despite this wealth of data, at many centers its use has been pro-hibited unless administered by anesthesiology. In this commentary, we review the use of anesthesia support for endoscopy in the United States based on recent data and its implications for gastroenterologists world-wide.     

A synopsis of patient-controlled analgesia and sedation for endoscopic procedures

Patient-controlled analgesia and sedation (PCAS) has the potential advantage over standard sedation of tailoring the level of sedation to individual patients and procedures. Ultra-short acting agents such as propofol and the newer opioids, with their fast onset and short duration of action, are ideal agents for use in PCAS for endoscopy. The majority of trials using PCAS have been performed in colonoscopy and demonstrated PCAS is effective, safe, and yields high patient satisfaction. Target controlled infusion of propofol has shown encouraging results for prolonged upper endoscopy procedures like endoscopic retrograde cholangiopancreatography.     

Techniques in unsedated endoscopy

The evolution of gastrointestinal endoscopy in the United States has led to the near-universal practice of performing all endoscopic procedures under conscious sedation. Performing endoscopy without sedation has intuitive benefits and may play a larger role in the future of endoscopic practice. Esophagogastroduodenoscopy (EGD) or esophagoscopy using small caliber endoscopes may be the most promising application of unsedated endoscopy. Most upper endoscopies are done for diagnostic purposes and such unsedated procedures may be completed in less than ten minutes. Unsedated EGD has been shown to be tolerable, feasible, and safe. Despite such reports, unsedated endoscopy has not gained widespread use in the United States. The goals of this chapter are to review the technical aspects of unsedated upper endoscopy in an attempt to promote its more widespread practice.     

Upper gastrointestinal endoscopy without sedation: a prospective study of 2000 examinations

Various drugs are used for sedation prior to upper gastrointestinal endoscopy, some with undesirable side effects. In an attempt to avoid these side effects, 2000 upper diagnostic gastrointestinal endoscopies were performed in a period of 4 years between 1982 and 1986, without any sedation, using Olympus GIF-Q and GIF-P3 gastroscopes. Anxiety, ease of introduction of gastroscope, tolerance of the procedure, and the overall success of the procedure were assessed. Most patients were calm (81.2%); 94.4% had an easy introduction of the gastroscope, 80.3% tolerated the procedure well; and 94.2% of the endoscopies were completely successful. There were no complications, and only four examinations failed (0.2%). Sedation had to be used (intravenous diazepam) in 32 patients due to excessive anxiety and an inability to introduce the gastroscope and in three children under 10 years (1.6%). The average time needed to complete an endoscopy without sedation was found to be 9.5 min, nearly half of the average time needed before this study when sedation was routinely given. It is concluded that upper gastrointestinal endoscopy without sedation can be a safe, quick, well-tolerated procedure.     

Sedation with intranasal midazolam in adults undergoing upper gastrointestinal endoscopy

The use of intranasal (IN) midazolam in adults for sedation in upper gastrointestinal endoscopy has been evaluated in a controlled clinical study. Eighty-one patients with a mean age of 37.02 +/- 12.50 years who underwent upper gastrointestinal endoscopy for various reasons were included in the study. Three groups were formed according to the sedation regimen. In the first group (n = 30), patients received IN midazolam. In the second group (n = 28) intravenous (IV) midazolam was given for sedation, and the third group of patients (n = 23) received placebo before the procedures. Patients were monitored (using a pulse oximeter with an interval of 5 minutes until the 45th minute after the procedure) for arterial oxygen saturation, heart rate, systolic and diastolic arterial blood pressure, and respiratory rate. Efficacy of sedation, amnesia, side effects, and patients' preferences were evaluated. Superior results regarding the efficacy of sedation has been documented with the use of IV midazolam (p < 0.001), and this was the preferred route for drug application according to the patients' answers (p < 0.01). However, regarding amnesia, IN midazolam was found to be almost equally effective as IV midazolam (p < 0.05); moreover, IN route of drug application caused significantly fewer side effects than did the IV form (p < 0.001 ). Intranasal application of midazolam for gastrointestinal endoscopy appeared to be an interesting alternative to the IV route, the usage of which might be limited because of its potentially serious side effects. In contrast to the IV application of midazolam, the IN route may not even necessitate the monitoring of the patient during upper gastrointestinal endoscopy.     

Sedation and analgesia in gastrointestinal endoscopy: What’s new?

Various types of sedation and analgesia technique have been used during gastrointestinal endoscopy procedures.The best methods for analgesia and sedation during gastrointestinal endoscopy are still debated.Providing an adequate regimen of sedation/analgesia might be considered an art,influencing several aspects of endoscopic procedures: the quality of the examination,the patient’s cooperation and the patient’s and physician’s satisfaction with the sedation.The properties of a model sedative agent for endosc...     

Predicting which patients can undergo upper endoscopy comfortably without conscious sedation

BACKGROUND: Eliminating conscious sedation for diagnostic endoscopy may be advantageous for patient safety and cost containment. The aim of this study was to identify and validate independent predictors of a comfortable, technically adequate, unsedated diagnostic upper endoscopy in Canadian patients. METHODS: Patients were consecutively enrolled in a prospective fashion. Data collected on an initial cohort of 268 patients included demographics, a validated anxiety questionnaire, use of sedatives/analgesics, upper endoscopy experience, pharyngeal sensitivity, technical adequacy, and patient assessment of comfort after the procedure. The main outcome measure was "satisfactory upper endoscopy," a composite of optimal scores for patient comfort and technical adequacy. Univariate and multivariate analyses were performed to identify the optimal predictive model of a satisfactory unsedated diagnostic upper endoscopy. Once identified, 68 additional patients were enrolled in a similar fashion from an independent prospective sample for purposes of outcome validation. Multivariate analysis was then repeated with the total cohort (N = 336). These results were then compared for concordance with those obtained from the initial cohort. RESULTS: Among the initial 268 patients (54.3% women; mean age 51 +/- 17 years), 49% were anxious, 15% regularly used sedatives and analgesics, 28% experienced increased pharyngeal sensitivity, and 41% had previously undergone upper endoscopy. Endoscopy was completed in 94.7% of patients without sedation and was technically adequate in 97%, and 80.1% were willing to repeat the procedure under similar conditions. Satisfactory upper endoscopy was achieved in only 59% of the initial cohort. The only independent and significant predictors of a satisfactory upper endoscopy were advancing age (OR 1.2: 95% CI [1.1, 1.4]) and decreased pharyngeal sensitivity (OR 0.5: 95% CI [0.27, 0.93]). Concordance of results were noted after validation with the second cohort. Satisfactory endoscopy was achieved in only 59.5% of the total cohort (n = 336); only 61% reported a comfortable procedural experience. CONCLUSIONS: The proportion of patients who can comfortably undergo technically adequate unsedated upper endoscopy is modest. Unsedated upper endoscopy is most likely to be successful under these procedural conditions in patients of advancing age with decreased pharyngeal sensitivity. The generalizability of these findings to an American population requires further study and may assist in identifying a subgroup of patients in whom it is cost-effective to perform upper endoscopy comfortably without sedation.     

Review on sedation for gastrointestinal tract endoscopy in children by non-anesthesiologists

AIM: To present evidence and formulate recommendations for sedation in pediatric gastrointestinal(GI) endoscopy by non-anesthesiologists.METHODS: The databases MEDLINE, Cochrane and EMBASE were searched for the following keywords "endoscopy, GI", "endoscopy, digestive system" AND "sedation", "conscious sedation", "moderate sedation", "deep sedation" and "hypnotics and sedatives" for publications in English restricted to the pediatric age. We searched additional information published between January 2011 and January 2014. Searches for(upper) GI endoscopy sedation in pediatrics and sedation guidelines by non-anesthesiologists for the adult population were performed. RESULTS: From the available studies three sedation protocols are highlighted. Propofol, which seems to offer the best balance between efficacy and safety is rarely used by non-anesthesiologists mainly because of legal restrictions. Ketamine and a combination of a benzodiazepine and an opioid are more frequently used. Data regarding other sedatives, anesthetics and adjuvant medications used for pediatric GI endoscopy are also presented.CONCLUSION: General anesthesia by a multidisciplinary team led by an anesthesiologist is preferred. The creation of sedation teams led by non-anesthesiologists and a careful selection of anesthetic drugs may offer an alternative, but should be in line with national legislation and institutional regulations.     

Sedation and analgesia in gastrointestinal endoscopy: What’s new?

Various types of sedation and analgesia technique have been used during gastrointestinal endoscopy procedures. The best methods for analgesia and sedation during gastrointestinal endoscopy are still debated. Providing an adequate regimen of sedation/analgesia might be considered an art, influencing several aspects of endoscopic procedures: the quality of the examination, the patient’s cooperation and the patient’s and physician’s satisfaction with the sedation. The properties of a model sedative agent for endoscopy would include rapid onset and offset of action, analgesic and anxiolytic effects, ease of titration to desired level of sedation, rapid recovery and an excellent safety profile. Therefore there is an impulse for development of new approaches to endoscopic sedation. This article provides an update on the methods of sedation today available and future directions in endoscopic sedation.     

Sedation in endoscopy: when and how

Sedation for endoscopy provides comfort for the patient and better examination conditions for the endoscopist. The high costs of providing anaesthesia by specialists and the relative lack of specialist personnel in many countries have led to the wider introduction of sedation delivered by non-anaesthesiologists. Such sedation should be targeted for moderate levels of sedation; however, personnel should be able to avoid - and rescue patients from - deeper sedation levels. Several conditions have to be fulfilled to provide proper and safe non-anaesthesiologist sedation for endoscopy, especially when propofol is to be used. These conditions include formal training, supervision by anaesthesiology staff, and definition of standard operating procedures on the national as well as local levels.     

Endoscopy: Can computer-aided personalized sedation bridge troubled waters?

The issue of propofol administration by nonanesthesiologists for upper endoscopy and colonoscopy remains controversial. A recent study investigated the efficacy and safety of a novel computer-assisted personalized sedation device. Patients sedated using the device experienced fewer serious cardiorespiratory events than patients undergoing standard sedation by bolus administration using a hand-held syringe.     

Unsedated transnasal endoscopy: A safe and less costly alternative

Upper endoscopy is an integral component in the management of upper gastrointestinal disorders, but it is underutilized because of its high cost and potential complications. Unsedated transnasal endoscopy (T-EGD) is a relatively new technique using an ultrathin endoscope. Because it is better tolerated than standard upper endoscopy, it is performed with the patient unsedated, thus avoiding the associated costs and complications of conscious sedation. In this review, the technique of T-EGD and its current experience are discussed. In addition, potential future applications, special considerations, and potential pitfalls are reviewed.     

Is routine sedation or topical pharyngeal anesthesia beneficial during upper endoscopy?

BACKGROUND: Upper endoscopy is an invasive procedure. However, the benefits of routinely administered sedative medication or topical pharyngeal anesthesic are controversial. The aim of this study was to clarify their effects on patient tolerance and difficulty of upper endoscopy. METHODS: A total of 252 patients scheduled for diagnostic upper endoscopy were randomly assigned to 4 groups: (1) sedation with midazolam and placebo pharyngeal spray (midazolam group), (2) placebo sedation and lidocaine pharyngeal spray (lidocaine group), (3) placebo sedation and placebo pharyngeal spray (placebo group), and (4) no intravenous cannula/pharyngeal spray (control group). The endoscopist and the patient assessed the procedure immediately after the examination. Another questionnaire was sent to the patients 2 weeks later. RESULTS: Patients in the midazolam group rated the examination easier and less uncomfortable compared with those in the other groups. The differences were especially evident in the questionnaires completed 2 weeks after the examination ( p < 0.001). Lidocaine did not significantly improve patient tolerance. However, endoscopists found the procedure easier in patients in the lidocaine group compared with the midazolam ( p < 0.01) and control groups ( p < 0.01) but not the placebo group. CONCLUSIONS: Routine administration of midazolam for sedation increased patient tolerance for upper endoscopy. However, endoscopists found intubation to be more difficult in sedated vs. non-sedated patients. Topical pharyngeal anesthesia did not enhance patient tolerance, but it did make upper endoscopy technically easier compared with endoscopy in patients sedated with midazolam without topical pharyngeal anesthesia, and in patients who had no sedation or pharyngeal anesthesia, but not in patients who received placebo sedation and placebo pharyngeal anesthesia.     

Transnasal endoscopy: Technical considerations,advantages and limitations

Transnasal endoscopy(TNE) is an upper endoscopy method which is performed by the nasal route using a thin endoscope less than 6 mm in diameter. The primary goal of this method is to improve patient tolerance and convenience of the procedure. TNE can be performed without sedation and thus eliminates the risks associated with general anesthesia. In this way,TNE decreases the cost and total duration of endoscopic procedures, while maintaining the image quality of standard caliber endoscopes, providing good results for diagnostic purposes. However, the small working channel of the ultra-thin endoscope used for TNE makes it difficult to use for therapeutic procedures except in certain conditions which require a thinner endoscope.Biopsy is possible with special forceps less than 2 mm in diameter. Recently, TNE has been used for screening endoscopy in Far East Asia, including Japan. In most controlled studies, TNE was found to have better patient tolerance when compared to unsedated endoscopy. Nasal pain is the most significant symptom associated with endoscopic procedures but can be reduced with nasal pretreatment. Despite the potential advantage of TNE, it is not common in Western countries, usually due to a lack of training in the technique and a lack of awareness of its potential advantages. This paper briefly reviews the technical considerations as well as the potential advantages and limitations of TNE with ultra-thin scopes.     

Transnasal endoscopy: Technical considerations,advantages and limitations简

Transnasal endoscopy (TNE) is an upper endoscopy method which is performed by the nasal route using a thin endoscope less than 6 mm in diameter. The primary goal of this method is to improve patient tolerance and convenience of the procedure. TNE can be performed without sedation and thus eliminates the risks associated with general anesthesia. In this way, TNE decreases the cost and total duration of endoscopic procedures, while maintaining the image quality of standard caliber endoscopes, providing good results for diagnostic purposes. However, the small working channel of the ultra-thin endoscope used for TNE makes it difficult to use for therapeutic procedures except in certain conditions which require a thinner endoscope. Biopsy is possible with special forceps less than 2 mm in diameter. Recently, TNE has been used for screening endoscopy in Far East Asia, including Japan. In most controlled studies, TNE was found to have better patient tolerance when compared to unsedated endoscopy. Nasal pain is the most significant symptom associated with endoscopic procedures but can be reduced with nasal pretreatment. Despite the potential advantage of TNE, it is not common in Western countries, usually due to a lack of training in the technique and a lack of awareness of its potential advantages. This paper briefly reviews the technical considerations as well as the potential advantages and limitations of TNE with ultra-thin scopes.     

Assessment of Competence in Pediatric Gastrointestinal Endoscopy

Gastrointestinal endoscopy is an invaluable tool for the diagnosis and treatment of upper and lower gastrointestinal diseases in children. Pediatric and adult endoscopy differ in several respects including differences in procedural indications, sedation practices, pre-procedure preparation, equipment, and the importance of routine tissue sampling and terminal ileum intubation. In the same way that performance of endoscopy in children requires pediatric-specific training, assessment of pediatric endoscopists requires an approach that is tailored to pediatric practice and the use of assessment methods and measures that have been developed and validated specifically within the pediatric context.     

Premedication with meperidine and diazepam for upper gastrointestinal endoscopy precludes the need for topical anesthesia

The authors conducted a prospective study in 90 patients undergoing upper endoscopic examination under sedation to determine whether there was any beneficial effect in anesthetizing the pharynx with topical anesthesia. These patients were divided into three groups of 30 patients. Group A received 39 ml of viscous lidocaine gargle (2%) diluted with 15 ml of tap water. Group B received the placebo. Group C received neither viscous lidocaine nor placebo. All patients received intravenous meperidine and diazepam titrated to produce adequate sedation for upper endoscopy. It was demonstrated that the undesirable effects of upper endoscopy, that is, gagging, sore throat, and dysphagia, did not differ significantly in any of the three study groups as evaluated by either the patients or the endoscopist. Only two patients complained that the procedure was mildly unpleasant. The authors conclude that the practice of anesthetizing the pharynx in patients receiving sedation for upper endoscopy should be abandoned since anesthesia of the pharynx is not exempt from morbidity and mortality as well as being time-consuming and expensive.     

Arterial blood oxygen desaturation in infants and children during upper gastrointestinal endoscopy

Arterial blood oxygen desaturation and abnormal electrocardiographic changes have been reported in adults undergoing upper gastrointestinal endoscopy. We studied 32 infants and children less than 12 years of age using pulse oximetry and continuous electrocardiography before, during, and after upper gastrointestinal endoscopy performed under intravenous sedation. Sinus tachycardia was the most common electrocardiographic change, and no clinically significant electrocardiographic abnormalities were induced by the procedure. Desaturation to less than or equal to 90% was found in 37.5% of the patients and was most commonly noted during the endoscopy procedure and in patients with cardiopulmonary disease. The desaturation was unpredictable because there was no correlation between desaturation and medication, tolerance to the procedure, weight, or age of the child. Some patients who subjectively appeared to tolerate the procedure well had significant desaturation. The use of pulse oximetry should be considered for all children undergoing upper gastrointestinal endoscopy.