Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Review Article
  • Published:

How best to approach endoscopic sedation?

Nature Reviews Gastroenterology & Hepatology volume 8, pages 481–490 (2011)Cite this article

Subjects

Abstract

Sedation is the drug-induced reduction of a patient's consciousness. The aim of sedation in endoscopic procedures is to increase the patient's comfort and to improve endoscopic performance, especially in therapeutic procedures. The most commonly used sedation regimen for conscious sedation in gastrointestinal endoscopy is still the combination of benzodiazepines with opioids. However, the use of propofol has increased enormously in the past decade and several studies show advantages of propofol over the traditional regimes in terms of faster recovery time. It is important to be aware that the complication rate of endoscopies increases when sedation is used; therefore, a thorough risk evaluation before the procedure and monitoring during the procedure must be performed. In addition, properly trained staff and emergency equipment should be available. The best approach to sedation in endoscopy is to choose a sedation regimen for the individual patient, tailored according to the clinical risk assessment and the anxiety level of the patient, as well as to the type of planned endoscopic procedure.

Key Points

  • Sedation can make endoscopic procedures more comfortable and successful; however, about half of the serious complications in gastrointestinal endoscopy are due to procedural sedation

  • Risk estimation for each individual is essential before choosing the best sedation strategy and appropriate monitoring for the patient

  • Routine monitoring of patients should include heart rate, blood pressure and oxygen saturation

  • Dedicated emergency equipment as well as a properly trained staff must be available in case of cardiorespiratory depression during the procedure and during post-procedure care

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Figure 1: Sedation levels occur along a continuum.
Figure 2: Pulse oximetric and capnographic monitoring during an apnea episode.
Figure 3: How best to approach endoscopic sedation.

Similar content being viewed by others

References

  1. Cohen, L. B. et al. Sedation in digestive endoscopy: the Athens international position statements. Aliment. Pharmacol. Ther. 32, 425–442 (2010).

    CAS  PubMed  Google Scholar 

  2. Abraham, N. S. et al. Sedation versus no sedation in the performance of diagnostic upper gastrointestinal endoscopy: a Canadian randomized controlled cost-outcome study. Am. J. Gastroenterol. 99, 1692–1699 (2004).

    PubMed  Google Scholar 

  3. Lee, M. G., Hanna, W. & Harding, H. Sedation for upper gastrointestinal endoscopy: a comparative study of midazolam and diazepam. Gastrointest. Endosc. 35, 82–84 (1984).

    Google Scholar 

  4. Riphaus, A. et al. S3 Guideline: sedation for gastrointestinal endoscopy. Endoscopy 41, 1137–1143 (2009).

    Google Scholar 

  5. Meining, A. et al. The effect of sedation on the quality of upper gastrointestinal endoscopy: an investigator-blinded, randomized study comparing propofol with midazolam. Endoscopy 39, 345–349 (2007).

    CAS  PubMed  Google Scholar 

  6. Crispin, A., Birkner, B., Munte, A., Nusko, G. & Mansmann, U. Process, quality and incidence of acute complications in a series of more than 230,000 outpatient colonoscopies. Endoscopy 41, 1018–1025 (2009).

    CAS  PubMed  Google Scholar 

  7. MCQuaid, K. R. & Laine, L. A systematic review and meta-analysis of randomized, controlled trials of moderate sedation for routine endoscopic procedures. Gastrointest. Endosc. 67, 910–923 (2008).

    PubMed  Google Scholar 

  8. Lichtenstein, D. R. et al. Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy. Sedation and anesthesia in GI endoscopy. Gastrointest. Endosc. 68, 815–826 (2008).

    PubMed  Google Scholar 

  9. Ladas, S. D. et al. Use of sedation for routine diagnostic upper gastrointestinal endoscopy: a European Society of Gastrointestinal Endoscopy Survey of National Endoscopy Society Members. Digestion 74, 69–77 (2006).

    CAS  PubMed  Google Scholar 

  10. Baudet, J. S. et al. Use of sedation in gastrointestinal endoscopy: a nationwide survey in Spain. Eur. J. Gastroenterol. Hepatol. 21, 882–888 (2009).

    PubMed  Google Scholar 

  11. Miller, M. A., Levy, P. & Patel, M. M. Procedural sedation and anesthesia in the emergency department: what are the risks? Emerg. Med. Clin. North Am. 23, 551–572 (2005).

    PubMed  Google Scholar 

  12. Mallampati, S. R. et al. A clinical sign to predict difficult tracheal intubation: a prospective study. Can. Anaesth. Soc. J. 32, 429–434 (1985).

    CAS  PubMed  Google Scholar 

  13. Qureshi, W. A. et al. American Society for Gastrointestinal Endoscopy. ASGE Guideline: Guidelines for endoscopy in pregnant and lactating women. Gastrointest. Endosc. 61, 357–362 (2005).

    PubMed  Google Scholar 

  14. American Society of Anesthesiologists Committee. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters. Anesthesiology 114, 495–511 (2011).

  15. Cohen, L. B. et al. AGA Institute review of endoscopic sedation. Gastroenterology 133, 675–701 (2007).

    CAS  PubMed  Google Scholar 

  16. Gross, J. B. et al. American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology 96, 1004–1017 (2002).

    Google Scholar 

  17. Waring, J. P. et al. American Society for Gastrointestinal Endoscopy.Guidelines for conscious sedation and monitoring during gastrointestinal endoscopy. Gastrointest. Endosc. 58, 317–322 (2003).

    PubMed  Google Scholar 

  18. Quadeer, M. A., Lopez, A. R., Dumot, J. A. & Vargo, J. J. Hypoxemia during moderate sedation for gastrointestinal endoscopy: causes and associations. Digestion 84, 37–45 (2011).

    Google Scholar 

  19. Alcain, G., Gullén, P., Escolar, A., Moreno, M. & Martin, L. Predictive factors of oxygen desaturation during upper gastrointestinal endoscopy in nonsedated patients. Gastrointest. Endosc. 48, 143–147 (1998).

    CAS  PubMed  Google Scholar 

  20. Müller, S., Prolla, J. C., Maguilnik, I. & Breyer, H. P. Predictive factors of oxygen desaturation of patients submitted to endoscopic retrograde cholangiopancreatography under conscious sedation. Arq. Gastroenterol. 41, 162–166 (2004).

    PubMed  Google Scholar 

  21. Lightdale, J. R. et al. Microstream capnography improves patient monitoring during moderate sedation: a randomized, controlled trial. Pediatrics 117, 1170–1178 (2006).

    Google Scholar 

  22. Qadeer, M. A. et al. Capnographic monitoring of respiratory activity improves safety of sedation for ERCP and EUS. Gastroenterology 136, 1568–1576 (2009).

    PubMed  Google Scholar 

  23. Vargo, J. J. et al. Automated graphic assessment of respiratory activity is superior to pulse oximetry and visual assessment for the detection of early respiratory depression during therapeutic upper endoscopy. Gastrointest. Endosc. 55, 826–831 (2002).

    PubMed  Google Scholar 

  24. Johansen, J. W. Update on bi-spectral index monitoring. Best Pract. Res. Clin. Anaesthesiol. 20, 81–96 (2006).

    PubMed  Google Scholar 

  25. Krugliak, P. et al. Propofol versus midazolam for conscious sedation guided by processed EEG during endoscopic retrograde cholangiopancreatography: a prospective, randomized, double-blind trial. Endoscopy 32, 677–682 (2000).

    CAS  PubMed  Google Scholar 

  26. Doenicke, A. W. et al. The Narcotrend monitor and the electroencephalogram in propofol-induced sedation. Anesth. Analg. 105, 982–992 (2007).

    PubMed  Google Scholar 

  27. Bailey, P. L. & Zuccaro, G. Jr Sedation for endoscopic procedures:not as simple as it seems. Am. J. Gastroenterol. 101, 2008–2010 (2006).

    PubMed  Google Scholar 

  28. Al-Sammak, Z., Al-Falaki, M. M. & Gamal, H. M. Predictor of sedation during endoscopic retrograde cholangiopancreatography—bispectral index vs clinical assessment. Middle East J. Anesthesiol. 18, 141–148 (2005).

    CAS  PubMed  Google Scholar 

  29. Wehrmann, T. et al. Electroencephalogram monitoring facilitates sedation with propofol for routine ERCP: a randomized, controlled trial. Gastrointest. Endosc. 56, 817–824 (2002).

    PubMed  Google Scholar 

  30. Paspatis, G. A. et al. Efficacy of bispectral index monitoring as an adjunct to propofol deep sedation for ERCP: a randomized controlled trial. Endoscopy 41, 1046–1051 (2009).

    CAS  PubMed  Google Scholar 

  31. Dumonceau, J. M. et al. European Society of Gastrointestinal Endoscopy, European Society of Gastroenterology and Endoscopy Nurses and Associates, and the European Society of Anaesthesiology Guideline: Non-anesthesiologist administration of propofol for GI endoscopy. Endoscopy 42, 960–974 (2010).

    CAS  PubMed  Google Scholar 

  32. Wang, C. Y., Ling, L. C., Cardosa, M. S., Wong, A. K. & Wong, N. W. Hypoxia during upper gastrointestinal endoscopy with and without sedation and the effect of pre-oxygenation on oxygen saturation. Anaesthesia 55, 654–658 (2000).

    CAS  PubMed  Google Scholar 

  33. Bell, G. D., Bown, S., Morden, A., Coady, T. & Logan, R. F. Prevention of hypoxaemia during upper-gastrointestinal endoscopy by means of oxygen via nasal cannulae. Lancet 1, 1022–1024 (1987).

    CAS  PubMed  Google Scholar 

  34. Miner, J. R., Heegaard, W. & Plummer, D. End-tidal carbon dioxide monitoring during procedural sedation. Acad. Emerg. Med. 9, 275–280 (2002).

    PubMed  Google Scholar 

  35. Fu, E. S., Downs, J. B., Schweiger, J. W., Miguel, R. V. & Smith, R. A. Supplement oxygen impairs detection of hypoventilation by pulse oximetry. Chest 126, 1552–1558 (2004).

    PubMed  Google Scholar 

  36. Faulx, A. l. et al. The changing landscape of practice patterns regarding unsedated endoscopy and propofol use: a national web survey. Gastrointest. Endosc. 62, 9–15 (2005).

    PubMed  Google Scholar 

  37. Koshy, G., Nair, S., Norkus, E. P., Hertan, H. I. & Pitchumoni, C. S. Propofol versus midazolam and meperidine for conscious sedation in GI endoscopy. Am. J. Gastroenterol. 95, 1476–1479 (2000).

    CAS  PubMed  Google Scholar 

  38. Wehrmann, T., Kokabpick, S., Lembcke, B., Caspary, W. F. & Seifert, H. Efficacy and safety of intravenous propofol sedation during routine ERCP: a prospective, controlled study. Gastrointest. Endosc. 49, 677–683 (1999).

    CAS  PubMed  Google Scholar 

  39. Horn, E. & Nesbit, S. A. Pharmacology and pharmacokinetics of sedatives and analgesics. Gastrointest. Endosc. Clin. N. Am. 14, 247–268 (2004).

    PubMed  Google Scholar 

  40. Zakko, S. F., Seifert, H. A. & Gross, J. B. A comparison of midazolam and diazepam for conscious sedation during colonoscopy in a prospective double-blind study. Gastrointest. Endosc. 49, 684–689 (1999).

    CAS  PubMed  Google Scholar 

  41. Cole, S. G., Brozinsky, S. & Isenberg, J. I. Midazolam, a new more potent benzodiazepine, compared with diazepam: a randomized, double-blind study of preendoscopic sedatives. Gastrointest. Endosc. 29, 219–222 (1983).

    CAS  PubMed  Google Scholar 

  42. Bell, G. D., Spickett, G. P., Reeve, P. A., Morden, A. & Logan, R. F. Intravenous midazolam for upper gastrointestinal endoscopy: a study of 800 consecutive cases relating dose to age and sex of patient. Br. J. Clin. Pharmacol. 23, 241–243 (1987).

    CAS  PubMed  PubMed Central  Google Scholar 

  43. Christe, C., Janssens, J. P., Armenian, B., Herrmann, F. & Vogt, N. Midazolam sedation for upper gastrointestinal endoscopy in older persons: a randomized, double-blind, placebo-controlled study. J. Am. Geriatr. Soc. 48, 1398–1403 (2000).

    CAS  PubMed  Google Scholar 

  44. Bailey, P. L. et al. Frequent hypoxemia and apnea after sedation with midazolam and fentanyl. Anesthesiology 73, 826–830 (1990).

    CAS  PubMed  Google Scholar 

  45. Mather, L. E., Tucker, G. T., Pflug, A. E., Lindop, M. J. & Wilkerson, C. Meperidine kinetics in man. Intravenous injection in surgical patients and volunteers. Clin. Pharmacol. Ther. 17, 21–30 (1975).

    CAS  PubMed  Google Scholar 

  46. Stack, C. G., Rogers, P. & Linter, S. P. Monoamine oxidase inhibitors and anaesthesia. A review. Br. J. Anaesth. 60, 222–227 (1988).

    CAS  PubMed  Google Scholar 

  47. Trescot, A. M., Datta, S., Lee, M. & Hansen, H. Opioid pharmacology. Pain Physician 11, 133–153 (2008).

    Google Scholar 

  48. Bowdle, T. A. Adverse effects of opioid agonists and antagonists in anaesthesia. Drug Saf. 19, 173–189 (1998).

    CAS  PubMed  Google Scholar 

  49. Robertson, D. J., Jacobs, D. P., Mackenzei, T. A., Oringer, J. A. & Rothstein, R. I. Clinical trial: a randomized, study comparing meperidine (pethidine) and fentanyl in adult gastrointestinal endoscopy. Aliment. Pharmacol. Ther. 29, 817–823 (2009).

    CAS  PubMed  Google Scholar 

  50. Scholz, J., Steinfath, M. & Schulz, M. Clinical pharmacokinetics of alfentanil, fentanyl and sufentanil. An update. Clin. Pharmacokinet. 31, 275–292 (1996).

    CAS  PubMed  Google Scholar 

  51. Fanti, L. et al. Remifentanil vs. meperidine for patient-controlled analgesia during colonoscopy: a randomized double-blind trial. Am. J. Gastroenterol. 104, 1119–1124 (2009).

    CAS  PubMed  Google Scholar 

  52. Manolaraki, M. M. et al. Remifentanil compared with midazolam and pethidine sedation during colonoscopy: a prospective, randomized study. Dig. Dis. Sci. 53, 34–40 (2008).

    CAS  PubMed  Google Scholar 

  53. Brown, T. B., Lovato, L. M. & Parker, D. Procedural sedation in the acute care setting. Am. Fam. Physician 71, 85–90 (2005).

    PubMed  Google Scholar 

  54. Gilger, M. A., Spearman, R. S., Dietrich, C. L., Spearman, G. & Wilsey, M. J. Jr . Safety and effectiveness of ketamine as a sedative agent for pediatric GI endoscopy. Gastrointest. Endosc. 59, 659–663 (2004).

    PubMed  Google Scholar 

  55. Sipe, B. W. et al. Propofol versus midazolam/meperidine for outpatient colonoscopy: administration by nurses supervised by endoscopists. Gastrointest. Endosc. 55, 815–825 (2002).

    PubMed  Google Scholar 

  56. Singh, H. et al. Propofol for sedation during colonoscopy. Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD006268 doi:10.1002/14651858.CD006268.pub2 (2008).

  57. Riphaus, A., Stergiou, N. & Wehrmann, T. Sedation with propofol for routine ERCP in high-risk octogenarians: a randomized, controlled study. Am. J. Gastroenterol. 100, 1957–1963 (2005).

    CAS  PubMed  Google Scholar 

  58. Jung, M., Hofmann, C., Kiesslich, R. & Brackertz, A. Improved sedation in diagnostic and therapeutic ERCP: propofol is an alternative to midazolam. Endoscopy 32, 233–238 (2000).

    CAS  PubMed  Google Scholar 

  59. Morcos, W. E. & Payne, J. P. The induction of anaesthesia with propofol ('Disoprivan') compared in normal and renal failure patients. Postgrad. Med. J. 61, 62–63 (1985).

    PubMed  Google Scholar 

  60. Heuss, L. T., Schnieper, P., Drewe, J., Pflimlin, E. & Beglinger, C. Safety of propofol for conscious sedation during endoscopic procedures in high-risk patients-a prospective, controlled study. Am. J. Gastroenterol. 98, 1751–1757 (2003).

    CAS  PubMed  Google Scholar 

  61. Amoros, A. et al. Deep sedation with propofol does not precipitate hepatic encephalopathy during elective upper endoscopy. Gastrointest. Endosc. 70, 262–268 (2009).

    PubMed  Google Scholar 

  62. Riphaus, A., Lechowicz, I., Frenz, M. B. & Wehrmann, T. Propofol sedation for upper gastrointestinal endoscopy in patients with liver cirrhosis as an alternative to midazolam to avoid acute deterioration of minimal encephalopathy: a randomized, controlled study. Scand. J. Gastroenterol. 44, 1244–1251 (2009).

    CAS  PubMed  Google Scholar 

  63. Bamji, N. & Cohen, L. B. Endoscopic sedation of patients with chronic liver disease. Clin. Liver Dis. 14, 185–194 (2010).

    PubMed  Google Scholar 

  64. Sharma, V. K. et al. International study of cardiopulmonary unplanned events after GI endoscopy. Gastrointest. Endosc. 66, 27–34 (2007).

    PubMed  Google Scholar 

  65. Daneshmend, T. K., Bell, G. D. & Logan, R. F. Sedation for upper gastrointestinal endoscopy: results of a nationwide survey. Gut 32, 12–15 (1991).

    CAS  PubMed  PubMed Central  Google Scholar 

  66. Thompson, A. M. et al. Analysis of 153 deaths after upper gastrointestinal endoscopy: room for improvement? Surg. Endosc. 18, 22–25 (2004).

    CAS  PubMed  Google Scholar 

  67. Rex, D. K. et al. Endoscopist-directed administration of propofol: a worldwide safety experience. Gastroenterology 137, 1229–1237 (2009).

    PubMed  Google Scholar 

  68. Lagasse, R. S. Anesthesia safety: model or myth? A review of the published literature and analysis of current original data. Anesthesiology 97, 1609–1617 (2002).

    PubMed  Google Scholar 

  69. Heuss, L. T. & Inauen, W. The dawning of a new sedative: propofol in gastrointestinal endoscopy. Digestion 69, 20–26 (2004).

    CAS  PubMed  Google Scholar 

  70. Chutkan, R. et al. Training guideline for use of propofol in gastrointestinal endoscopy. Gastrointest. Endosc. 50, 167–172 (2004).

    Google Scholar 

  71. Vargo, J. J., Cohen, L. B., Rex, D. K. & Kwo, P. J. Position statement: nonanesthesiologist administration of propofol for GI endoscopy. Gastrointest. Endosc. 70, 1053–1059 (2009).

    PubMed  Google Scholar 

  72. Lee, C. K. et al. Balanced propofol sedation for therapeutic GI endoscopic procedures: a prospective, randomized study. Gastrointest. Endosc. 73, 206–214 (2011).

    PubMed  Google Scholar 

  73. Leslie, K. L., Clavisi, O. & Hargrove, J. Target-controlled infusion versus manually-controlled infusion of propofol for general anesthesia or sedation in adults. Cochrane Database of Systematic Reviews Issue 3. Art. No.: CD006059 doi: 10.1002/14651858.CD006059.pub2 (2008).

  74. Pambianco, D. J. et al. An assessment of computer-assisted personalized sedation: a sedation delivery system to administer propofol for gastrointestinal endoscopy. Gastrointest. Endosc. 68, 542–547 (2008).

    PubMed  Google Scholar 

  75. Rex, D. K., Heuss, L. T., Walker, J. A. & Qi, R. Trained registered nurses/endoscopy teams can administer propofol safely for endoscopy. Gastroenterology 129, 1384–1391 (2005).

    PubMed  Google Scholar 

  76. Vargo, J. J. Procedural sedation. Curr. Opin. Gastroenterol. 26, 421–424 (2010).

    PubMed  Google Scholar 

  77. Cohen, L. B., Dubovsky, A. N., Aisenberg, J. & Miller, K. M. Propofol for endoscopic sedation: A protocol for safe and effective administration by the gastroenterologist. Gastrointest. Endosc. 58, 725–732 (2003).

    PubMed  Google Scholar 

  78. Külling, D., Orlandi, M. & Inauen, W. Propofol sedation during endoscopic procedures: how much staff and monitoring are necessary? Gastrointest. Endosc. 66, 443–449 (2007).

    PubMed  Google Scholar 

  79. Heneghan, S., Myers, J., Fanelli, R., Richardson, W. & Society of American Gastrointestinal Endoscopic Surgeons. Society of American Gastrointestinal Endoscopic Surgeons (SAGES) guidelines for office endoscopic services. Surg. Endosc. 23, 1125–1129 (2009).

    PubMed  Google Scholar 

  80. Byrne, M. F., Chiba, N., Singh, H., Sadowski, D. C. & Clinical Affairs Committee of the Canadian Association of Gastroenterology. Propofol use for sedation during endoscopy in adults: a Canadian Association of Gastroenterology position statement. Can. J. Gastroenterol. 22, 457–459 (2008).

    PubMed  PubMed Central  Google Scholar 

  81. López Rosés, L. & Subcomité de Protocolos Of The Spanish Society Of Gastrointestinal Endoscopy Seed. Sedation/analgesia guidelines for endoscopy. Rev. Esp. Enferm. Dig. 98, 685–692 (2006).

    PubMed  Google Scholar 

  82. Newman, D. H., Azer, M. M., Pitettio, R. D. & Singh, S. When is a patient safe for discharge after procedural sedation? The timing of adverse effect events in 1367 pediatric procedural sedations. Ann. Emerg. Med. 42, 627–635 (2003).

    PubMed  Google Scholar 

  83. Gross, J. B. et al. Practice guidelines for the perioperative management of patients with obstructive sleep apnea: a report by the American society of anesthesiologists task force on perioperative management of patients with obstructive sleep apnea. Anesthesiology 104, 1082–1093 (2006).

    Google Scholar 

  84. Dahan, A., Aarts, L. & Smith, T. W. Incidence, Reversal, and Prevention of Opioid-induced Respiratory Depression. Anesthesiology 112, 226–238 (2010).

    PubMed  Google Scholar 

  85. Aldrete, J. A. Modification to the postanesthesia score for use in ambulatory surgery. J. Perianesth. Nurs. 13, 148–155 (1998).

    CAS  PubMed  Google Scholar 

  86. Ead, H. From Aldrete to PADSS: Reviewing discharge criteria after ambulatory surgery. J. Perianesth. Nurs. 21, 259–267 (2006).

    PubMed  Google Scholar 

  87. Ulmer, B. J. et al. Propofol vs. midazolam/fentanyl for outpatient colonoscopy: administration by nurse supervised by endoscopists. Clin. Gastroenterol. Hepatol. 1, 425–432 (2003).

    CAS  PubMed  Google Scholar 

  88. Horiuchi, A. et al. Safety and driving ability following low-dose propofol sedation. Digestion 78, 190–194 (2008).

    CAS  PubMed  Google Scholar 

  89. Riphaus, A., Gstettenbauer, T., Frenz, M. B. & Wehrmann, T. Quality of psychomotor recovery after propofol sedation for routine endoscopy: a randomized and controlled study. Endoscopy 38, 677–683 (2006).

    CAS  PubMed  Google Scholar 

  90. Vargo, J. J. Doc, can I drive home? Am. J. Gastroenterol. 104, 1656–1657 (2009).

    PubMed  Google Scholar 

  91. Lazzaroni, M. & Porro, G. B. Preparation, premedication, and surveillance. Endoscopy 37, 101–109 (2005).

    CAS  PubMed  Google Scholar 

  92. Trevisani, L. et al. Unsedated ultrathin upper endoscopy is better than conventional endoscopy in routine outpatient gastroenterology practice: a randomized trial. World J. Gastroenterol. 14, 906–911 (2007).

    Google Scholar 

  93. Bretthauer, M. et al. Carbon dioxide insufflation for more comfortable endoscopic retrograde cholangiopancreatography: a randomized, controlled, double-blind trial. Endoscopy 39, 58–64 (2007).

    CAS  PubMed  Google Scholar 

  94. Radaelli, F., Paggi, S., Amato, A. & Terruzi, V. Warm water infusion versus air insufflation for unsedated colonoscopy: a randomized, controlled trial. Gastrointest. Endosc. 72, 701–709 (2010).

    PubMed  Google Scholar 

  95. Leung, F. W. et al. A proof-of-principle, prospective, randomized, controlled trial demonstrating improved outcomes in scheduled unsedated colonoscopy by the water method. Gastrointest. Endosc. 72, 693–700 (2010).

    PubMed  Google Scholar 

  96. Eisen, G. M. et al. Complications of upper GI endoscopy. Gastrointest. Endosc. 55, 784–793 (2002).

    PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Gastroenterology, Deutsche Klinik für Diagnostik, Aukammallee 33, Wiesbaden, 65191, Germany

    Michaela Müller & Till Wehrmann

Authors
  1. Michaela Müller
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Till Wehrmann
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Both authors contributed equally to all aspects of this manuscript.

Corresponding author

Correspondence to Till Wehrmann.

Ethics declarations

Competing interests

M. Müller and T. Wehrmann are on the speakers bureau for B. Braun Melsungen and Fresenius Medical.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Müller, M., Wehrmann, T. How best to approach endoscopic sedation?. Nat Rev Gastroenterol Hepatol 8, 481–490 (2011). https://doi.org/10.1038/nrgastro.2011.122

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/nrgastro.2011.122

This article is cited by

Search

Advanced search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing