The endoscopic literature published during the past year has once again confirmed that there is significant variation from country to country regarding whether or not patients wish to receive conscious sedation during endoscopy (and particularly colonoscopy) - and there may even be variation from one endoscopic unit to another within the same country. Particular attention has been given to attempts to identify „ideal” candidates for conscious sedation, and to the importance of providing patients with information before the procedure. It has been shown that patients who receive detailed information about a medical procedure beforehand are able to benefit from this. The role of benzodiazepines, particularly midazolam, was investigated in studies emphasizing that the dosage should be kept to the minimum that is compatible with patient comfort and successful performance of the procedure. There have been few publications comparing propofol with midazolam. As expected, in view of the known pharmacological properties of the two drugs, the quality of sedation was better and the recovery time was shorter in patients who were treated with propofol. However, important questions are still open regarding the narrow therapeutic range of propofol and the methods by which it is administered (by endoscopists or by anesthesiologists). An important aspect of sedation procedures is the prevention of hypoxia and cardiopulmonary complications. Recent endoscopic reports have added little further information concerning the well-known risk of oxygen desaturation during conscious sedation. Performing endoscopy in unsedated patients reduces, but does not eliminate, the risk of hypoxia. Among the various risk factors, it has been found that chronic respiratory failure and coronary heart disease are factors predictive of severe desaturation and relevant electrocardiographic changes. The use of electronic monitoring techniques with pulse oximetry is recommended as a standard procedure during digestive endoscopy; however, it has been observed that when supplemental oxygen is administered, pulse oximetry no longer reflects normal ventilatory function and does not detect episodes of severe CO2 retention. Transcutaneous measurement of PCO2 therefore seems more reliable as a means of assessing hypoventilation. Several papers have proposed “ideal formulas” for bowel preparation for endoscopic procedures. Various regimens have been proposed as alternatives to polyethylene glycol electrolyte lavage solution (PEG-ELS) and sodium phosphate compounds, with different results. On the whole, there is still little information regarding the best and most cost-effective method of bowel cleansing for colonoscopy and flexible sigmoidoscopy.
References
-
1
Quine M A, Colin-Jones D G.
Gastrointestinal endoscopy: to sedate or not to sedate?.
Endoscopy.
1996;
28
306-307
-
2
Rey J F.
Sedation for upper gastrointestinal endoscopy: as much as possible, or without?.
Endoscopy.
1996;
28
308-309
-
3
Vallot T, Servin F.
Endoscopie haute, sédation et anesthésie: quels besoins? Quelles conditions?.
Gastroenterol Clin Biol.
1996;
20
561-563
-
4
Daneshmend T K, Bell G D, Logan R FA.
Sedation for upper gastrointestinal endoscopy: results of a nationwide survey.
Gut.
1991;
32
12-15
-
5
Eckardt V F, Kanzler G, Schmitt T, et al.
Complications and adverse effects of colonoscopy with selective sedation.
Gastrointest Endosc.
1999;
49
560-565
-
6
Froehlich F, Gonvers J J, Fried M.
Conscious sedation, clinically relevant complications and monitoring of endoscopy: results of a nationwide survey in Switzerland.
Endoscopy.
1994;
26
231-234
-
7
Ristikankare M K O, Julkunen R JK.
Premedication for gastrointestinal endoscopy is a rare practice in Finland: a nationwide survey.
Gastrointest Endosc.
1998;
47
204- 207
-
8
Ristinkankare M, Hartikainen J, Heikkinen M, et al.
Is routinely given conscious sedation of benefit during colonoscopy?.
Gastrointest Endosc.
1999;
49
566-572
-
9
Fisher N C, Bailey S, Gibson J A.
A prospective, randomized controlled trial of sedation vs. no sedation in outpatient diagnostic upper gastrointestinal endoscopy.
Endoscopy.
1998;
30
21-24
-
10
Early D S, Saiffuddin T, Johnson J C, et al.
Patients' attitudes toward undergoing colonoscopy without sedation.
Am J Gastroenterol.
1999;
94
1862-1865
-
11
Rex D K, Imperiale T F, Portish V.
Patients willing to try colonoscopy without sedation: associated clinical factors and results of a randomized controlled trial.
Gastrointest Endosc.
1999;
49
554-559
-
12
Luck A, Pearson S, Maddern G, Hewett P.
Effects of video information on precolonoscopy anxiety and knowledge: a randomised trial.
Lancet.
1999;
354
2032-2035
-
13
Morgan J, Roufeil L, Kaushik S, Basset M.
Influence of coping style and precolonoscopy information on pain and anxiety of colonoscopy.
Gastrointest Endosc.
1998;
48
119-127
-
14
Martin J P, Arlett P A, Holdstock G.
Development of a sedation policy for upper GI endoscopy based on an audit of patients' perception of the procedure.
Eur J Gastroenterol Hepatol.
1996;
8
355-357
-
15
McCloy R, Nagengast F, Fried M, et al.
Conscious sedation for endoscopy.
Eur J Gastroenterol Hepatol.
1996;
8
1233-40
-
16
Bell G D.
Premedication, preparation, and surveillance.
Endoscopy.
2000;
32
92-100
-
17
VanHouten J S, Crane S A, Janardan S K, Well K.
A randomized, prospective, double blind comparison of midazolam (Versed) and emulsified diazepam (Dizac) for opioid-based, conscious sedation in endoscopic procedures.
Am J Gastroenterol.
1998;
93
170-174
-
18
Macken E, Gevers A M, Hendrickx A, Rutgeerts P.
Midazolam versus diazepam in lipid emulsion as conscious sedation for colonoscopy with or without reversal of sedation with flumazenil.
Gastrointest Endosc.
1998;
47
57-61
-
19
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.
1999;
49
684-689
-
20
Campo R, Brullet R, Montserrat A, et al.
Efficacy of low and standard midazolam doses for gastroscopy: a randomised double blind study.
Eur J Gastroenterol Hepatol.
2000;
12
187-190
-
21
Stermer E, Gaitini L, Yudashkin M, et al.
Patient-controlled analgesia for conscious sedation during colonoscopy: a randomized controlled study.
Gastrointest Endosc.
2000;
51
278-281
-
22
Chang A C, Solinger M A, Yang D T, Chen Y K.
Impact of flumazenil on recovery after outpatient endoscopy: a placebo controlled trial.
Gastrointest Endosc.
1999;
49
573-579
-
23
Wille R T, Chaffee B W, Ryan M L, et al.
Pharmacoeconomic evaluation of flumazenil for routine outpatient EGD.
Gastrointest Endosc.
2000;
51
282-287
-
24
Peters J M, Tolia V, Simpson P, et al.
Flumazenil in children after esophagogastroduodenoscopy.
Am J Gastroenterol.
1999;
94
1857-1861
-
25
Bertelsman J FWM, Sars P RA, Tytgat G NJ.
Flumazenil used for reversal of midazolam-induced sedation in endoscopy outpatients.
Gastrointest Endosc.
1990;
36
9-12
-
26
Kankaria A, Lewis J H, Ginsberg G, et al.
Flumazenil reversal of psychomotor impairment due to midazolam or diazepam for conscious sedation for upper endoscopy.
Gastrointest Endosc.
1996;
44
416-421
-
27
Fulton S A, Mullen K D.
Completion of upper endoscopic procedures despite paradoxical reaction to midazolam: a role for flumazenil?.
Am J Gastroenterol.
2000;
95
809-811
-
28
Koshy G, Nair S, Norkus E P, et al.
Propofol versus midazolam and meperidine for conscious sedation in GI endoscopy.
Am J Gastroenterol.
2000;
95
1476-1479
-
29
Jung M, Hofman C, Kiesdslich R, Brackertz A.
Improved sedation in diagnostic and therapeutic ERCP: propofol is an alternative to midazolam.
Endoscopy.
2000;
32
233-238
-
30
Wehrman T, Kokabpick S, Lembcke B, et al.
Efficacy and safety of intravenous propofol sedation during routine ERCP: a prospective, controlled study.
Gastrointest Endosc.
1999;
49
677-683
-
31
Graber R G.
Propofol in the endoscopy suite: an anesthesiologist's perspective.
Gastrointest Endosc.
1999;
49
803-806
-
32
Rizzo J, Bernstein D, Gress F.
A randomized double-blind placebo-controlled trial evaluating the cost-effectiveness of droperidol as a sedative premedication for EUS.
Gastrointest Endosc.
1999;
49
178-182
-
33
Cohen J, Haber G B, Dorais J A, et al.
A randomized, double blind study of the use of droperidol for conscious sedation during therapeutic endoscopy in difficult to sedate patients.
Gastrointest Endosc.
2000;
51
546-551
-
34
Saunders B P, Williams C B.
Premedication with intravenous antispasmodic speeds colonoscope insertion.
Gastrointest Endosc.
1996;
43
209-211
-
35
Marshall J B, Patel M, Mahajan R J, et al.
Benefit of intravenous antispasmodic (hyoscyamine sulfate) as premedication for colonoscopy.
Gastrointest Endosc.
1999;
49
720-726
-
36
Shaheen N J, Robertson D J, Crosby M A, et al.
Hyoscyamine as a pharmacological adjunct in colonoscopy: a randomized, double blinded, placebo controlled trial.
Am J Gastroenterol.
1999;
94
2905-2908
-
37
Martin J P, Sexton B F, Tech B, et al.
Inhaled patient-administered nitrous oxide/oxygen mixture does not impair driving ability when used as analgesia during screening flexible sigmoidoscopy.
Gastrointest Endosc.
2000;
51
701-703
-
38
Lindblom A, Jansson O, Jepsson B, et al.
Nitrous oxide for colonoscopy discomfort: a randomized double blind study.
Endoscopy.
1994;
4
418-421
-
39
Ristikankare M, Julkunen R, Mattila M, et al.
Conscious sedation and cardiorespiratory safety during colonoscopy.
Gastrointest Endosc.
2000;
52
48-54
-
40
Fujimura M, Ishiura Y, Myou S, et al.
Cardiopulmonary complications during gastroscopy in patients with chronic respiratory failure undergoing long-term home oxygen therapy.
Endoscopy.
2000;
32
33-36
-
41
Yazawa K, Adachi W, Koide N, et al.
Changes in cardiopulmonary parameters during upper gastrointestinal endoscopy in patients with heart disease: towards safer endoscopy.
Endoscopy.
2000;
32
287-293
-
42
Schenk J, Muller C H, Lubbers H, et al.
Does gastroscopy induce myocardial ischemia in patients with coronary heart disease?.
Endoscopy.
2000;
32
373-376
-
43
American Medical Association Council of Scientific Affairs.
The use of pulse oximetry during conscious sedation.
JAMA.
1993;
270
1463-1468
-
44
Nelson D B, Freeman M L, Silvis S E, et al.
A randomized, controlled trial of transcutaneous carbon dioxide monitoring during ERCP.
Gastrointest Endosc.
2000;
51
288-295
-
45
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
-
46
Chen C C, Ng W W, Chang F Y, Lee S D.
Magnesium citrate-bisacodyl regimen proves better than castor oil for colonoscopic preparation.
J Gastroenterol Hepatol.
1999;
14
1219-1222
-
47
Chilton A P, O'Sullivan M, Cox M A, et al.
A blinded, randomized comparison of a novel, low dose, triple regimen with Fleet Phospho-Soda: a study of colon cleanliness, speed and success of colonoscopy.
Endoscopy.
2000;
32
37-41
-
48
Dashan A, Lin C H, Peters J, et al.
A randomized, prospective study to evaluate their efficacy and acceptance of three bowel preparations for colonoscopy in children.
Am J Gastroenterol.
1999;
94
3497-3501
-
49
Fincher H K, Osgard E M, Jackson J L, et al.
A comparison of bowel preparations for flexible sigmoidoscopy: oral magnesium citrate combined with oral bisacodyl, one hypertonic phosphate enema, or two hypertonic phosphate enema.
Am J Gastroenterol.
1999;
94
2122-2127
-
50
Bini E J, Unger J S, Rieber J M, et al.
Prospective, randomized, single-blind comparison of two preparations for screening flexible sigmoidoscopy.
Gastrointest Endosc.
2000;
52
218-222
G. Bianchi Porro
L. Sacco University Hospital
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