Endoscopy 2005; 37(2): 101-109
DOI: 10.1055/s-2004-826149
State of the Art Review
© Georg Thieme Verlag KG Stuttgart · New York

Preparation, Premedication, and Surveillance

M.  Lazzaroni1 , G.  Bianchi Porro1
  • 1Gastrointestinal Unit, L. Sacco University Hospital, Milan, Italy
Further Information

Publication History

Publication Date:
03 February 2005 (online)

In the year since the last review, continuing pressure on endoscopy suites to improve efficiency and reduce costs without compromising patient care has led to growing interest in alternatives to pharmacological sedation and in the use of short-acting sedatives. Relaxation music, acupuncture, and the use of small-caliber endoscopes for unsedated peroral gastroscopy have therefore been suggested as ways of increasing tolerance and reducing discomfort. With regard to ultrathin and superthin endoscopes, the results are interesting, but further data from controlled trials and in studies including larger numbers of patients are still needed.
The form of sedation for gastrointestinal endoscopy that has attracted greatest interest over the last year is the use by nonanesthetists of intravenous propofol, administered either alone at standard doses to achieve deep sedation, or at lower doses combined with benzodiazepines and opioids to achieve moderate sedation/analgesia. In comparison with benzodiazepines/opioids, the results were in favor of propofol: the mean time to sedation was shorter and the depth of sedation was greater. In addition, patients receiving propofol reached full recovery earlier and were discharged sooner. However, in the survey of patient satisfaction at discharge, it was found that the sedation methods did not have a significant impact on overall patient satisfaction. Some important issues concerning the narrow therapeutic range of propofol and the need for adequate training of endoscopists to deal with any problems related to deep sedation are still open - despite the growing amount of data suggesting that the drug is safe even when administered by registered nurses, an approach that is possibly more cost-effective than delivery by gastroenterologists or anesthetists.
The morbidity and mortality associated with cardiopulmonary complications continue to be a significant concern during gastrointestinal endoscopy. Professional societies and national expert peer groups have issued practice guidelines for sedation and analgesia that call for continuous monitoring of the patient’s hemodynamic and ventilatory status and consciousness. Direct observation is facilitated by electronic devices (pulse oximetry, capnography), directly indicating the patient’s ventilatory status and the depth of sedation. Recently, it has been proposed that the bispectral index (BIS), an electroencephalography-based technique, can be used to monitor the depth of sedation during gastrointestinal endoscopy. However, the results of a recent study cast some doubt on the usefulness of the BIS, in its current version, for titrating boluses of propofol to an adequate level of sedation. Further data therefore appear to be needed to assess whether or not BIS values can help avoid unnecessary propofol dosage and can replace continuous assessment of the ventilatory effort.

References

  • 1 Bell G D. Preparation, premedication, and surveillance.  Endoscopy. 2004;  36 23-31
  • 2 Lazzaroni M, Bianchi Porro  G. Preparation, premedication, and surveillance.  Endoscopy. 2003;  35 103-111
  • 3 Sorbi D, Chak A. Unsedated EGD.  Gastrointest Endosc. 2003;  58 102-110
  • 4 American Society for Gastrointestinal Endoscopy. Guidelines for conscious sedation and monitoring during gastrointestinal endoscopy.  Gastrointest Endosc. 2003;  58 317-322
  • 5 Abraham N S, Wieczorek P, Huang J. et al . Assessing clinical generalizability in sedation studies of upper GI endoscopy.  Gastrointest Endosc. 2004;  60 28-33
  • 6 Smale S, Bjarnason I, Forgacs I. et al . Upper gastrointestinal endoscopy performed by nurses: scope for the future?.  Gut. 2003;  52 1090-1094
  • 7 Levine D F, Teague R H. A UK training programme for nurse practitioner flexible sigmoidoscopy.  Gut. 1999;  44 897
  • 8 Carey E, Sorbi D. Unsedated endoscopy.  Gastrointest Endosc Clin N Am. 2004;  14 369-383
  • 9 Bell G D. Premedication, preparation, and surveillance.  Endoscopy. 2002;  34 2-12
  • 10 Wong R CK. The menu of endoscopic sedation: all you can eat, combination set; à la carte, alternative cuisine, or go hungry.  Gastrointest Endosc. 2001;  54 123-126
  • 11 Yoruk G, Aksok K, Unsal B. et al . Colonoscopy without sedation.  Turk J Gastroenterol. 2003;  14 59-63
  • 12 Hacket M L, Lane M R, McCarthy D C. Upper gastrointestinal endoscopy: are preparatory interventions effective?.  Gastrointest Endosc. 1998;  48 341-347
  • 13 Luck A, Pearson S, Maddern G. et al . Effect of video information on precolonoscopy anxiety and knowledge: a randomized trial.  Lancet. 1999;  354 2032-2035
  • 14 Bonta P, Fok M F, Bergman J J. et al . Conscious sedation for EUS of the esophagus and stomach: a double blind, randomized, controlled trial comparing midazolam and placebo.  Gastrointest Endosc. 2003;  57 842-847
  • 15 Jones M P, Ebert C C, Sloan T. et al . Patient anxiety and elective gastrointestinal endoscopy.  J Clin Gastroenterol. 2004;  38 35-40
  • 16 Thanvi B R, Munshi S K, Vijayakumar N. et al . Acceptability of oesophagogastroduodenoscopy without intravenous sedation: patients’ versus endoscopist’s perception with special reference to older patients.  Postgrad Med J. 2003;  79 650-651
  • 17 Mulcahy H E, Greaves R RSH, Ballinger A. et al . A double blind randomized trial of a low-dose versus high-dose topical anaesthesia in unsedated upper gastrointestinal endoscopy.  Aliment Pharmacol Ther. 1996;  10 975-979
  • 18 Soda K, Shimanuki K, Yoshida Y. et al . Serum lidocaine and MEGX concentrations after pharyngeal anesthesia for gastroscopy.  Endoscopy. 1994;  26 347-351
  • 19 Byrne M F, Mitchell R M, Gerke H. et al . The need for caution with topical anesthesia during endoscopic procedures, as liberal use may result in methemoglobinemia.  J Clin Gastroenterol. 2004;  38 225-229
  • 20 Fanti L, Gemma M, Passaretti S. et al . Electroacupuncture analgesia for colonoscopy: a prospective, randomized, placebo-controlled study.  Am J Gastroenterol. 2003;  98 312-316
  • 21 Lee D W, Chan A CW, Wong S KH. et al . Can visual distraction decrease the dose of patient-controlled sedation required during colonoscopy? A prospective randomized controlled trial.  Endoscopy. 2004;  36 197-201
  • 22 Lee D WH, Chan K W, Poon C M. et al . Relaxation music decreases the dose of patient-controlled sedation during colonoscopy: a prospective randomized controlled trial.  Gastrointest Endosc. 2002;  55 33-36
  • 23 Garcia R T, Cello J P, Nguyen M H. Unsedated ultrathin EGD is well accepted when compared with conventional sedated EGD: a multicenter randomized trial.  Gastroenterology. 2003;  125 1606-1612
  • 24 Mokhashi M, Wildi S M, Glenn T. A prospective, blinded study of diagnostic esophagoscopy with a superthin, stand-alone, battery powered esophagoscope.  Am J Gastroenterol. 2003;  98 2383-2389
  • 25 Devault K R. Ultrathin endoscopy without sedation: is this the future of esophagology?.  Am J Gastroenterol. 2003;  98 2342-2344
  • 26 Bhasin D K, Siyad I. Variceal bleeding and portal hypertension: new lights on old horizon.  Endoscopy. 2004;  36 120-129
  • 27 Dumortier J, Lapalus M G, Pereira A. Unsedated transnasal PEG placement.  Gastrointest Endosc. 2004;  59 54-57
  • 28 Saruc M, Sertdemir A, Turkel N. et al . Midazolam-induced sedation for upper gastrointestinal endoscopy: assessment of endoscopist and patient satisfaction.  Gastroenterol Nurs. 2003;  26 164-167
  • 29 Rodriguez-Gonzales F J, Naranjio-Rodriguez A, Mata-Tapia I. ERCP in patients 90 years of age or older.  Gastrointest Endosc. 2003;  58 220-225
  • 30 Gasparovic S, Rustemovic N, Opacic M. et al . Comparison of colonoscopies performed under sedation with propofol or with midazolam or without sedation.  Acta Med Austriaca. 2003;  30 13-16
  • 31 Ulmer B J, Hansen J J, Overley C A. et al . Propofol versus midazolam/fentanyl for outpatient colonoscopy: administration by nurses supervised by endoscopists.  Clin Gastroenterol Hepatol. 2003;  1 425-432
  • 32 Rudner R, Jalowiecki P, Kawecki P. et al . Conscious analgesia/sedation with remifentanil and propofol versus total intravenous anesthesia with fentanyl, midazolam, and propofol for outpatient colonoscopy.  Gastrointest Endosc. 2003;  57 657-663
  • 33 Hansen J J, Ulmer B J, Rex D. Technical performance of colonoscopy in patents sedated with nurse-administered propofol.  Am J Gastroenterol. 2003;  98 52-55
  • 34 Weston B R, Chadalawada V, Chalasani N. et al . Nurse-administered propofol versus midazolam and meperidine for upper endoscopy in cirrhotic patients.  Am J Gastroenterol. 2003;  98 2440-2447
  • 35 Cohen L, Bubovsky A, Aisenberg J, Miller K. Propofol for endoscopic sedation: a protocol for safe and effective administration by the gastroenterologist.  Gastrointest Endosc. 2003;  58 725-732
  • 36 Bright E, Rosevare C, Dalgleish D. et al . Patient-controlled sedation for colonoscopy: a randomized trial comparing patient-controlled administration of propofol and alfentanil with physician-administered midazolam and pethidine.  Endoscopy. 2003;  35 683-687
  • 37 Heuss L T, Drewe J, Schnieper P. et al . Patient-controlled versus nurse-administered sedation with propofol during colonoscopy: a prospective randomized trial.  Am J Gastroenterol. 2004;  99 511-518
  • 38 Cohen L B, Hightower C D, Wood D A. et al . Moderate level sedation during endoscopy: a prospective study using low-dose propofol, meperidine/fentanyl, and midazolam.  Gastrointest Endosc. 2004;  59 795-803
  • 39 Wurz S M, Bernstein B. Propofol or process: what really affects efficiency?.  Gastroenterol Nurs. 2004;  27 69-73
  • 40 Chan S C, Rex D K. Registered nurse-administered propofol sedation for endoscopy.  Aliment Pharmacol Ther. 2004;  19 147-155
  • 41 Walker J A, McIntyre R D, Schleinitz P F. et al . Nurse-administered propofol sedation without anesthesia specialists in 9152 endoscopic cases in ambulatory surgery center.  Am J Gastroenterol. 2003;  98 1744-1750
  • 42 Heuss L T, Schnieper P, Drewe J. et al . Safety of propofol for conscious sedation during endoscopic procedures in high-risk patients: a prospective, controlled study.  Am J Gastroenterol. 2003;  98 1751-1757
  • 43 Heuss L T, Schnieper P, Drewe J. et al . Conscious sedation with propofol in elderly patients: a prospective evaluation.  Aliment Pharmacol Ther. 2003;  17 1493-1501
  • 44 Vargo J J. Propofol: a gastroenterologist’s perspective.  Gastrointest Endosc Clin N Am. 2004;  14 313-323
  • 45 American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice guidelines for sedation and analgesia by non-anesthesiologists.  Anesthesiology. 2002;  96 1004-1017
  • 46 Karan S B, Bailey P L. Update and review of moderate and deep sedation.  Gastrointest Endosc Clin N Am. 2004;  14 289-312
  • 47 Meltzer B. RNs pushing propofol.  Outpatient Surg Mag. 2003;  7 24-37
  • 48 Redaelli F, Terruzzi V, Minoli G. Extended/advanced monitoring techniques in gastrointestinal endoscopy.  Gastrointest Endosc N Am. 2004;  14 335-352
  • 49 Ross R, Newton J L. Heart rate and blood pressure changes during gastroscopy in healthy older subjects.  Gerontology. 2004;  50 182-186
  • 50 Yazawa K, Adachi M, Owa N. et al . Can sedation reduce the cardiac stress during gastrointestinal endoscopy? A study with non-invasive automated cardiac flow measurement by color Doppler echocardiography.  Scand J Gastroenterol. 2002;  37 602-607
  • 51 Koniaris L G, Wilson S, Drugas G, Simmons W. Capnographic monitoring of ventilatory status during moderate (conscious) sedation.  Surg Endosc. 2003;  17 1261-1265
  • 52 Bower A L, Ripepi A, Diger J. et al . Bispectral index monitoring of sedation during endoscopy.  Gastrointest Endosc. 2000;  52 192-196
  • 53 Moses P L, Mitty R D, Pleskow D K. et al . BIS monitoring for sedation management during endoscopy: initial experience and correlation with a refined algorithm.  Am J Gastroenterol. 2003;  98 S279
  • 54 Leslie K, Absalom A, Kenny G N. Closed loop control of sedation for colonoscopy using the bispectral index.  Anaesthesia. 2002;  57 693-697
  • 55 Chen S C, Rex D K. An initial investigation of bispectral monitoring as an adjunct to nurse-administered propofol sedation for colonoscopy.  Am J Gastroenterol. 2004;  99 1081-1086
  • 56 Bowles C JA, Leicester R, Romaya C. et al . A prospective study of colonoscopy practice in the UK today: are we adequately prepared for national colorectal cancer screening tomorrow?.  Gut. 2004;  53 277-283
  • 57 Mullen J P. Poor bowel preparation: a poor excuse [letter].  Gut. 2004;  53 1056
  • 58 Faigel D O, Eisen G M, Baron T H. et al . Preparation of patients for GI endoscopy.  Gastrointest Endosc. 2003;  57 446-450
  • 59 Aronchick C A, Lipshutz W H, Wright S H. et al . A novel tableted purgative for colonoscopic preparation: efficacy and safety comparisons with Colyte and Fleet Phospho-Soda.  Gastrointest Endosc. 2000;  52 346-352
  • 60 Roston A, Jolicoeur E. Validation of a new scale for the assessment of bowel preparation quality.  Gastrointest Endosc. 2004;  59 482-486
  • 61 Harewood G, Wright C A, Baron T H. Assessment of patients’ perceptions of bowel preparation quality of colonoscopy.  Am J Gastroenterol. 2004;  99 839-843
  • 62 Mann N S, Conton D S, Leung J W. Colonic preparation correlates with fasting breath hydrogen in patients undergoing colonoscopy.  Hepatogastroenterology. 2003;  50 85-86
  • 63 Urita Y, Hike K, Torii N. et al . Hydrogen breath test as an indicator of the quality of colonic preparation for colonoscopy.  Gastrointest Endosc. 2003;  57 174-177
  • 64 Hayes A, Buffum M, Fuller D. Bowel preparation comparison: flavored versus unflavored Colyte.  Gastroenterol Nurs. 2003;  26 106-109
  • 65 Ell C, Fischbach W, Keller R. et al . A randomized, blinded, prospective trial to compare the safety and efficacy of three bowel-cleansing solutions for colonoscopy (HSG-01).  Endoscopy. 2003;  35 300-304
  • 66 Balaban D H, Leavell B S, Oblinger M J. et al . Low dose bowel preparation for colonoscopy: randomized, endoscopist-blinded trial of liquid sodium phosphate versus tablet sodium phosphate.  Am J Gastroenterol. 2003;  98 827-832
  • 67 Curran M P, Plosker G L. Oral sodium phosphate solution: a review of its use as a colorectal cleanser.  Drugs. 2004;  64 1697-1714
  • 68 Rasmussen M, Bohlbro K, Qvist N. Oral sodium phosphate compared with water enemas combined with bisacodyl as bowel preparation for elective colonoscopy.  Scand J Gastroenterol. 2003;  38 1090-1094
  • 69 DiPalma J A, Wolff B G, Meagher A, Cleveland M. Comparison of reduced volume versus four liter sulfate-free electrolyte lavage solutions for colonoscopy colon cleansing.  Am J Gastroenterol. 2003;  98 2187-2191
  • 70 El Sayed A MA, Kanafani Z A, Mourad F H. et al . A randomized single-blind trial of whole versus split-dose polyethylene glycol-electrolyte solution for colonoscopy preparation.  Gastrointest Endosc. 2003;  58 36-40
  • 71 Hsu C W, Imperiale T F. Meta-analysis and cost comparison of polyethylene glycol lavage versus sodium phosphate for colonoscopy preparation.  Gastrointest Endosc. 1998;  48 276-282
  • 72 Seinela L, Pehkonen E, Laasanen T, Ahvenainen J. Bowel preparation for colonoscopy in very old patients.  Scand J Gastroenterol. 2003;  38 216-220
  • 73 Ma K K, Ng C S, Mui L M. et al . Severe hyperphosphatemia and hypocalcemia following sodium phosphate bowel preparation: a forgotten menace.  Endoscopy. 2003;  35 717
  • 74 Gumurdulu Y, Serin E, Ozer B. et al . Age as a predictor of hyperphosphatemia after oral phosphosoda administration for colon preparation.  J Gastroenterol Hepatol. 2004;  19 68-72

G. Bianchi Porro, M. D.

Chair of Gastroenterology, L Sacco University Hospital

Via GB Grassi, 74 · 20157 Milan · Italy

Fax: + 39-2-39042232

Email: gabriele.bianchiporro@unimi.it

    >