Endoscopy 2003; 35(2): 103-111
DOI: 10.1055/s-2003-37012
State of the Art Review

© Georg Thieme Verlag Stuttgart · New York

Preparation, Premedication and Surveillance

M.  Lazzaroni1 , G.  Bianchi Porro1
  • 1Department of Gastroenterology, L. Sacco University Hospital, Milan, Italy
Further Information

Publication History

Publication Date:
30 January 2003 (online)

The main end points for sedation during endoscopy are patients' satisfaction, short duration of the procedure, and safety. During the last year, attention has focused on attempting to identify the “ideal” candidate for moderate sedation/analgesia and on the importance of providing the patient with appropriate information before the procedure. The increasing pressure to perform more procedures, reduce costs, and achieve shorter patient turnaround times has affected recent approaches to sedation during endoscopy, focusing attention on alternatives to pharmacological sedation such as providing relaxing music, using small-caliber endoscopes for unsedated peroral gastroscopy, and using magnetic endoscopic imaging to increase tolerance and reduce discomfort during colonoscopy. The results, however, have not been convincing. The role of benzodiazepines was discussed in some studies, highlighting the well-known effect of midazolam on postprocedural amnesia, its pharmacological profile and tolerability after intranasal spraying in healthy volunteers, and the efficacy and safety of this route of administration as an alternative to intravenous administration in diagnostic upper gastrointestinal endoscopy.
The form of sedation for gastrointestinal endoscopy that has attracted great interest over the last year is the use of intravenous propofol, either alone or with concomitant benzodiazepines or opioids. As expected in view of the drug's known pharmacological properties, the quality of sedation was better and recovery time was shorter in patients treated with propofol. However, important questions involving the narrow therapeutic range and the mode of administration of propofol (by endoscopists or nurses, or by anesthesiologists) remain open. One important aspect of sedation procedures is prevention of cardiopulmonary complications. The use of electronic monitoring techniques, with a pulse oximeter, has been recommended as a standard procedure during digestive endoscopy; however, pulse oximetry no longer reflects the normal ventilatory functions and does not detect episodes of severe CO2 retention. CO2 monitoring by transcutaneous measurement - or better, by capnography - appears to be useful, as an alternative to pulse oximetry, as a measure of hypoventilation, and for detecting potentially important abnormalities in respiratory activity in patients undergoing sedation for gastrointestinal endoscopy.
With regard to preparation for endoscopic procedures, several “ideal” formulas for bowel preparation have been presented. These include the use of sodium phosphate compounds as an alternative to polyethylene glycol electrolyte lavage solutions (PEG-ELS); however, the results so far have been conflicting. The best and most cost-effective bowel cleansing procedure for colonoscopy and sigmoidoscopy has yet to be established.

References

  • 1 Bell G D. Premedication, preparation, and surveillance.  Endoscopy. 2002;  34 2-12
  • 2 Lazzaroni M, Bianchi Porro G. Premedication, preparation, and surveillance.  Endoscopy. 1999;  31 2-8
  • 3 Lazzaroni M, Bianchi Porro G. Premedication, preparation, and surveillance.  Endoscopy. 2001;  33 103-108
  • 4 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
  • 5 Joint Commission Resources .Standard, intent, statements, and examples for sedation and anesthesia care. Joint Commission Resources, Inc. Comprehensive accreditation manual for hospitals: the official handbook (CAMH). Update 3. Oakbrook Terrace, IL; Joint Commission Resources, Inc. 2000: 15-17
  • 6 American Society of Anesthesiologists .Practice guidelines for sedation and analgesia by non-anesthesiologists. http: //www.asahq.org/practice/sedation/sedation1017.pdf 2001
  • 7 Academy of Medical Royal Colleges and their Faculties in the United Kingdom and Ireland .Implementing and ensuring safe sedation practice for healthcare procedures in adults: report of a Working Party set up by the Royal College of Anaesthetists, chaired by Professor J.A.W. Wildsmith. London; Academy of Medical Royal Colleges 2001
  • 8 Mayberry M K, Mayberry J F. Towards better informed consent in endoscopy: a study of information and consent processes in gastroscopy and flexible sigmoidoscopy.  Eur J Gastroenterol Hepatol. 2001;  13 1467-1476
  • 9 Mulcahy H E, Hennessy E, Connor P. et al . Changing patterns of sedation use for routine outpatient diagnostic gastroscopy between 1989 and 1998.  Aliment Pharmacol Ther. 2001;  15 217-220
  • 10 Abraham N, Barkun A, Larocque M. et al . Predicting which patients can undergo upper endoscopy comfortably without conscious sedation.  Gastrointest Endosc. 2002;  56 180-189
  • 11 Ringel Y, Dalton C B, Brandt L J. et al . Flexible sigmoidoscopy: the patient perception.  Gastrointest Endosc. 2002;  55 315-320
  • 12 Drossman D A, Brandt L J, Sears C. et al . A preliminary study of patients' concerns related to GI endoscopy.  Am J Gastroenterol. 1996;  91 287-291
  • 13 Early D S, Saiffuddin T, Johnson J C. et al . Patients attitudes toward undergoing colonoscopy without sedation.  Am J Gastroenterol. 1999;  94 1862-1865
  • 14 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
  • 15 Brandt L J. Patients' attitudes and apprehensions about endoscopy: how to calm troubled waters.  Am J Gastroenterol. 2001;  96 280-284
  • 16 Terruzzi V, Meucci G, Radaelli F. et al . Routine versus “on demand” sedation and analgesia for colonoscopy: a prospective randomized controlled trial.  Gastrointest Endosc. 2001;  54 169-174
  • 17 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
  • 18 Schiemann U, Gross M, Reuter R, Kellner H. Improved procedure of colonoscopy under accompanying music therapy.  Eur J Med Res. 2002;  7 131-134
  • 19 Shaker R, Saeian K. Unsedated transnasal laryngo-esophagogastroduodenoscopy: an alternative to conventional endoscopy.  Am J Med. 2001;  11 153-156
  • 20 Saeian K. Unsedated transnasal endoscopy: a safe and less costly alternative.  Curr Gastroenterol Rep. 2002;  4 213-217
  • 21 Mulcahy H E, Riches A, Kiely M. et al . A prospective controlled trial of an ultrathin versus a conventional endoscope in unsedated upper gastrointestinal endoscopy.  Endoscopy. 2001;  33 311-316
  • 22 Catanzaro A, Faulx A, Pfau P. et al . Accuracy of a narrow-diameter battery-powered endoscope in sedated and unsedated patients.  Gastrointest Endosc. 2002;  55 484-487
  • 23 Shah S G, Brooker J C, Thapar C. et al . Patient pain during colonoscopy: an analysis using real-time magnetic endoscope imaging.  Endoscopy. 2002;  34 435-440
  • 24 Shah S G, Brooker J C, Thapar C. et al . Effect of magnetic endoscope imaging on patient tolerance and sedation requirements during colonoscopy: a randomized controlled trial.  Gastrointest Endosc. 2002;  55 832-837
  • 25 Shah S G, Brooker J C, Williams C B. et al . Effect of magnetic endoscope imaging on colonoscopy performance: a randomised controlled trial.  Lancet. 2000;  356 1718-1722
  • 26 McGuire B M. Safety of endoscopy in patients with end-stage liver disease.  Gastrointest Endosc Clin N Am. 2001;  11 111-130
  • 27 Vasudevan A E, Goh K L, Bulgiba A M. Impairment of psychomotor responses after conscious sedation in cirrhotic patients undergoing therapeutic upper GI endoscopy.  Am J Gastroenterol. 2002;  97 1717-1721
  • 28 Darwin P, Zangara J, Heller T. et al . Unsedated esophagoscopy for the diagnosis of esophageal varices in patients with cirrhosis.  Endoscopy. 2000;  32 971-973
  • 29 Ishiguro T, Ishiguro C, Ishiguro G. et al . Midazolam sedation for upper gastrointestinal endoscopy: comparison between the states of patients in partial and complete amnesia.  Hepatogastroenterology. 2002;  49 438-440
  • 30 Veselis R Z, Reinsel R A, Feshcenko V A. Drug-induced amnesia is a separate phenomenon from sedation: electrophysiological evidence.  Anesthesiology. 2001;  95 896-897
  • 31 Knoester P D, Jonker D M, van der Hoeven R T. et al . Pharmacokinetics and pharmacodynamics of midazolam administered as a concentrated intranasal spray: a study in healthy volunteers.  Br J Clin Pharmacol. 2002;  53 501-507
  • 32 Uygur-Bayramicli O, Dabak R, Kuzucuoglu T. et al . Sedation with intranasal midazolam in adults undergoing upper gastrointestinal endoscopy.  J Clin Gastroenterol. 2002;  35 133-137
  • 33 Fazel A, Burton F R. A controlled study of the effect of midazolam on abnormal sphincter of Oddi motility.  Gastrointest Endosc. 2002;  55 637-640
  • 34 Fazel A, Burton F R. The effect of midazolam on the normal sphincter of Oddi: a controlled study.  Endoscopy. 2002;  34 78-81
  • 35 Hayes A, Buffum M. Educating patients after conscious sedation for gastrointestinal procedures.  Gastrointest Nurs. 2001;  24 54-57
  • 36 Sipe B W, Rex D K, Latinovich D. et al . Propofol versus midazolam/meperidine for outpatients colonoscopy: administration by nurses supervised by endoscopists.  Gastrointest Endosc. 2002;  55 815-25
  • 37 Theodorou T, Hales P, Gillespie P. et al . Total intravenous versus inhalation anaesthesia for colonoscopy: a prospective study of clinical recovery and psychomotor function.  Anaesth Intensive Care. 2001;  29 124-136
  • 38 Hashimoto T, Adachi K, Ishimura N. et al . Safety and efficacy of glucagon as a premedication for upper gastrointestinal endoscopy: a comparative study with butylscopolamine bromide.  Aliment Pharmacol Ther. 2002;  16 111-118
  • 39 Hadachi W, Yazawa K, Owa M. et al . Quantification of cardiac stress during EGD without sedation.  Gastrointest Endosc. 2002;  55 58-64
  • 40 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
  • 41 Vargo J J, Zuccaro G, Dumot J A. 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. 2002;  55 826-831
  • 42 Toledo T K, di Palma J A. Colon cleansing preparation for gastrointestinal procedures.  Aliment Pharmacol Ther. 2001;  15 605-611
  • 43 Rex D K, Imperiale T F, Latinovich D R. et al . Impact of bowel preparation on efficiency and cost of colonoscopy.  Am J Gastroenterol. 2002;  97 1696-1700
  • 44 Ness R M, Manam R, Hoen H. et al . Predictors of inadequate bowel preparation for colonoscopy.  Am J Gastroenterol. 2001;  96 1797-1802
  • 45 Poon C M, Lee D WH, Mak S K. et al . Two liters of polyethylene glycol lavage solution versus sodium phosphate as bowel cleansing regimen for colonoscopy: a prospective randomized controlled trial.  Endoscopy. 2002;  34 560-563
  • 46 Kastenberg D, Chasen R, Choudhary C. et al . Efficacy and safety of sodium phosphate tablets compared with PEG solution in colon cleansing: two identically designed, randomized, controlled, parallel group, multicenter phase III trials.  Gastrointest Endosc. 2001;  54 705-713
  • 47 Rex D K, Chasen R, Pochapin M B. Safety and efficacy of two reduced dosing regimens of sodium phosphate tablets for preparation prior to colonoscopy.  Aliment Pharmacol Ther. 2002;  16 937-944
  • 48 Berkelhammer C, Ekambaram A, Silva R G. Low-volume oral colonoscopy bowel preparation: sodium phosphate and magnesium citrate.  Gastrointest Endosc. 2002;  56 89-94
  • 49 Herman M, Shaw M, Loewen B. Comparison of three forms of bowel preparations for screening flexible sigmoidoscopy.  Gastroenterol Nurs. 2001;  24 178-181
  • 50 Kuo C H, Sheu B S, Kao A W. et al . A defoaming agent should be used with Pronase premedication to improve visibility in upper gastrointestinal endoscopy.  Endoscopy. 2002;  35 531-534

G. Bianchi Porro, M.D.

Chair of Gastroenterology · L. Sacco University Hospital

Via G.B. Grassi, 74 · 20157 Milan · Italy

Fax: + 39-2-39042232

Email: gabriele.bianchiporro@unimi.it