The vigorous debate over whom to sedate, when to sedate, and how to sedate shows no sign of running out of steam. There is a general consensus that patients should be more involved in the decision-making process for the sedation “menu”. A move away from the take-it-or-leave-it attitude of all or nothing to an “à la carte” choice is to be encouraged. A new textbook and several further guidelines have appeared. The particular problems associated with sedating the elderly are briefly presented. The pros and cons of using local pharyngeal anaesthesia are discussed. Enthusiasm for the use of intravenous propofol is gathering momentum, despite continuing worries about its safety in the hands of the nonanaesthetist. For many endoscopists, the combination of a benzodiazepine plus (or minus) an opioid with which they are most familiar is still the best compromise in terms of efficacy, cost, and safety. Fatal drug-induced cardiopulmonary complications continue to occur, despite a general trend toward using smaller doses of sedation than we did 5 - 10 years ago. Monitoring techniques that are at present considered as research tools may one day become commonplace. These include: the use of an electroencephalography parameter known as bispectral analysis; transcutaneous CO2 measurement; and a modified continuous capnographic waveform trace to monitor ventilatory effort. Bispectral analysis may be of use in monitoring central nervous system depression and helping to distinguish between conscious sedation and deep sedation. If the measurement of CO2 levels, either transcutaneously or in breath samples, was as easy and inexpensive as measuring SpO2 with a pulse oximeter, then undoubtedly such technology would enhance the early detection of sedative-induced hypoventilation and apnoea. Further evidence regarding droperidol's possible role in conscious sedation is presented. Pain during colonoscopy remains a problem, and the possible role for intraluminal injection of peppermint oil, as well as the value of variable-stiffness colonoscopes, in reducing the need for intravenous sedation is discussed. Case reports of hyponatraemic encephalopathy and hypocalcaemic tetany as complications of oral bowel preparation are presented, as is the challenge associated with adequate bowel preparation in diabetic patients.
References
1
Lazzaroni M, Bianco-Porro G.
Review: premedication, preparation and surveillance.
Endoscopy.
1999;
31
2-8
5
American Society for Gastrointestinal Endoscopy .
ASGE guidelines: modification in endoscopic practice for pediatric patients.
Gastrointest Endosc.
2000;
52
838-842
6
American Society for Gastrointestinal Endoscopy .
ASGE guidelines: modification in endoscopic practice for the elderly.
Gastrointest Endosc.
2000;
52
849-851
7
Clarke G A, Jacobson B C, Hammett R J, Carr-Locke D L.
The indications, utilization and safety of gastrointestinal endoscopy in an extremely elderly patient cohort.
Endoscopy.
2001;
33
580-584
8
Wong R CK.
The menu of endoscopic sedation: all-you-can-eat, combination set, à la carte, alternative cuisine, or go hungry [editorial].
Gastrointest Endosc.
2001;
54
122-126
14
Soma Y, Saito H, Kishibe T. et al .
Evaluation of topical pharyngeal anesthesia for upper endoscopy, including factors associated with patient tolerance.
Gastrointest Endosc.
2001;
53
14-18
15
LaLuna L, Allen M L, DiMarino, Jr A J.
The comparison of midazolam and topical lidocaine spray versus the combination of midazolam, meperidine and topical lidocaine spray to sedate patients for upper endoscopy.
Gastrointest Endosc.
2001;
53
289-293
16
Gunaratnam N T, Vazquez-Sequeiros E, Gostout C J, Alexander G L.
Methemoglobinemia related to topical benzocaine use: is it time to reconsider the empiric use of topical anesthesia before sedated EGD?.
Gastrointest Endosc.
2000;
52
692-693
17 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; AOMRC 2001
19
American Society for Gastrointestinal Endoscopy .
ASGE technology status evaluation report: propofol use during gastrointestinal endoscopy.
Gastrointest Endosc.
2001;
53
876-879
21
Seifert H, Schnitt T H, Gultekin W F. et al .
Sedation with propofol plus midazolam versus propofol alone for interventional endoscopic procedures: a prospective, randomized study.
Aliment Pharmacol Ther.
2000;
14
1207-1214
22
Krugliak P, Ziff B, Rusabrov Y. et al .
Propofol versus midazolam for conscious sedation guided by processed EEG during endoscopic retrograde cholangiopancreatography: a prospective, randomised, double-blind study.
Endoscopy.
2000;
32
677-682
23
Vargo J J, Zuccaro G, Dumot J A. et al .
Gastroenterologist-administered propofol for therapeutic upper endoscopy with graphic assessment of respiratory activity: a case series.
Gastrointest Endosc.
2000;
52
250-255
24
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
25
Kulling D, Fantin A C, Biro P. et al .
Safer colonoscopy with patient-controlled analgesia and sedation with propofol and alfentanil.
Gastrointest Endosc.
2001;
54
1-7
27
Gilham M J, Hutchinson R C, Carter R, Kenny G NC.
Patient-maintained sedation for ERCP with a target-controlled infusion of propofol: a pilot study.
Gastrointest Endosc.
2001;
54
14-17
30
Farrell R J, Noonan N, Mahmud N. et al .
Potential impact of magnetic resonance cholangiopancreatography on endoscopic retrograde cholangiopancreatography workload and complication rate in patients referred because of abdominal pain.
Endoscopy.
2001;
33
668-675
31
Asao T, Mochiki E, Suzuki H. et al .
An easy method for the intraluminal administration of peppermint oil before colonoscopy and its effectiveness in reducing colonic spasm.
Gastrointest Endosc.
2001;
53
172-177
32
Somerville K W, Richmond C R, Bell G D.
Delayed release peppermint oil capsules (Colpermin) for the spastic colon syndrome: a pharmacokinetic study.
Br J Clin Pharmacol.
1984;
18
638-640
33
Wehrmann T, Schmitt T, Stergiou N. et al .
Topical application of nitrates onto the papilla of Vater: manometric and clinical studies.
Endoscopy.
2001;
33
323-328
34
Martin J P, Sexton B F, Saunders B P, Atkin W S.
Inhaled patient-administered nitrous oxide mixture does not impair driving ability when used as analgesia during screening flexible sigmoidoscopy.
Gastrointest Endosc.
2000;
51
701-703
35
Shah S G, Saunders B P, Brooker J C, Williams C B.
Magnetic imaging of colonoscopy: an audit of looping, accuracy and ancillary maneuvers.
Gastrointest Endosc.
2000;
52
1-8
37
Brooker J C, Saunders B P, Shan S G, Williams C B.
A new variable stiffness colonoscope makes colonoscopy easier: a randomised controlled trial.
Gut.
2000;
46
801-805
38
Sorbi D, Schleck C D, Zinsmeister A R, Gostout C J.
Clinical application of a new colonoscope with variable insertion tube rigidity: a pilot study.
Gastrointest Endosc.
2001;
53
638-642
39
Rex D K.
Effect of variable stiffness colonoscopes on cecal intubation times for routine colonoscopy by an experienced examiner in sedated patients.
Endoscopy.
2001;
33
60-64
42
Kim W H, Cho Y J, Park J Y. et al .
Factors affecting insertion time and patient discomfort during colonoscopy.
Gastrointest Endosc.
2000;
52
600-605
43
Thiis-Evensen E, Hoff G S, Sauar J, Vatn M H.
Patient tolerance of colonoscopy without sedation during screening examination for colorectal polyps.
Gastrointest Endosc.
2000;
52
606-610
45
Nelson D B, Freeman M L, Silvis S E. et al .
A randomised controlled trial of transcutaneous carbon dioxide monitoring during ERCP.
Gastrointest Endosc.
2000;
51
288-295
46
Ristikankare M, Julkunen R, Laitinen T. et al .
Effect of conscious sedation on cardiac autonomic regulation during colonoscopy.
Scand J Gastroenterol.
2000;
35
990-996
47
Petelenz M, Musialik J, Besser P. et al .
Cardiac sympathovagal balance during endoscopic retrograde cholangiopancreatography.
Endoscopy.
2000;
32
683-687
48
Shaoul R, Wolff R, Seligmann H. et al .
Symptoms of hyperphosphatemia, hypocalcaemia, and hypomagnesemia in an adolescent after oral administration of sodium phosphate in preparation for a colonoscopy.
Gastrointest Endosc.
2001;
53
650-652
50
Taylor C, Schubert M L.
Decreased efficacy of polyethylene glycol lavage solution (GoLytely) in the preparation of diabetic patients for outpatient colonoscopy: a prospective and blinded study.
Am J Gastroenterol.
2001;
96
710-714
