The study flow diagram is presented in Fig. 1. We identified 1,350 citations through database and targeted searching. Following title and abstract screening, the full-text records of 82 documents were assessed for eligibility. Thirty-two documents met all inclusion criteria (Appendix 2).16–47 Five of these documents were updates of previously published guidelines16,21,32 or position statements41,43 – only the most recent versions were included18,22,25,42,44; 2 citations were considered companion documents for each other and treated as a single result.36,37 Therefore, 26 documents were included in the final synthesis, including 19 guidelines17–20,22−31,33–35,37,38 and 7 position statements.39,40,42,44−47
Characteristics of Included Documents
A summary of the characteristics of the included documents is provided in Supplemental Table 1. Though most documents addressed GI endoscopy procedures in general, four documents specifically addressed colonoscopy.31,33,37,38 Some organizations developed more than one document addressing different topics related to GI endoscopy practice, including 7 documents from the American Society of Gastrointestinal Endoscopy (ASGE),19, 24–26,30,40,47 2 documents from the Spanish Society of Gastrointestinal Endoscopy (SSGE),29, 31 and 2 documents from the Society of Gastroenterology Nurses and Associates (SGNA)39,44
Quality Assessment
Scores on the AGREE II domains were generally low (Table 1). Among guidelines, the highest scoring domains were scope and purpose (average score = 53%) and clarity of presentation (average score = 47%); the lowest scoring domain was applicability (average score = 9%). Position statements had similar scores for the clarity of presentation domain (average score = 45%) but lower scores in the scope and purpose domain (average score = 27%). The majority (n = 22) of included documents scored < 60% in the rigor of development domain. Of these, 15 were guidelines17–20,23−31,33,35 and 7 were position statements.39,40,42,44−47 Only 9 documents22,24,25,27,29,31,34,38,47 provided a grade or level of evidence in support of their recommendations, making it difficult to assess the evidentiary base for the reported recommendations. When used, recommendation and evidence grading systems varied across documents, making cross-document comparisons challenging.
Table 1
Quality assessment of included documents using the AGREE II tool
Document Developer | Scope and purpose | Stakeholder involvement | Rigor of development | Clarity of presentation | Applicability | Editorial independence |
Guidelines (n = 19) |
ASGE (2006)26 | 61% | 47% | 1% | 14% | 2% | 0% |
BSG (2006)27 | 58% | 44% | 21% | 22% | 2% | 0% |
FSDE (2006)33 | 6% | 14% | 15% | 22% | 6% | 0% |
AGA (2007)20 | 36% | 36% | 10% | 64% | 4% | 0% |
ASGH (2007)35 | 11% | 0% | 7% | 17% | 0% | 42% |
SAGES (2009)28 | 42% | 22% | 4% | 11% | 4% | 0% |
ASGE (2010)30 | 53% | 39% | 27% | 61% | 0% | 0% |
GSA (2014)18 | 53% | 25% | 1% | 33% | 0% | 0% |
DSRPGSA (2011)17 | 69% | 28% | 2% | 28% | 10% | 0% |
SSGE (2012)31 | 58% | 28% | 43% | 61% | 10% | 0% |
EC (2012)38 | 67% | 58% | 82% | 78% | 44% | 100% |
ASGE (2013)24 | 64% | 50% | 30% | 36% | 0% | 42% |
ASGE (2014)19 | 56% | 31% | 11% | 58% | 2% | 33% |
CCO (2013, 2014)36,37 | 94% | 78% | 76% | 69% | 38% | 100% |
SSGE (2014)29 | 36% | 33% | 20% | 64% | 15% | 0% |
ESGE & ESGENA (2015)22 | 58% | 42% | 66% | 75% | 10% | 38% |
GSGDMD (2014)34 | 69% | 56% | 73% | 72% | 6% | 83% |
ASGE (2018)25 | 36% | 36% | 30% | 61% | 15% | 0% |
JAG (2019)23 | 78% | 61% | 42% | 56% | 8% | 100% |
Position Statements (n = 7) |
CAG (2008)45 | 39% | 3% | 9% | 53% | 2% | 0% |
SGNA (2008)39 | 17% | 11% | 4% | 19% | 0% | 0% |
ASGE (2009)47 | 28% | 44% | 48% | 50% | 2% | 58% |
ASGE, ACG, & AGA (2012)40 | 11% | 14% | 13% | 28% | 13% | 0% |
CSGNA (2015)42 | 19% | 17% | 2% | 44% | 0% | 0% |
SGNA (2016)44 | 33% | 25% | 6% | 36% | 13% | 0% |
ISDE (2017)46 | 44% | 11% | 31% | 83% | 25% | 50% |
ACG = American College of Gastroenterology; AGA = American Gastroenterological Association; ASGE = American Society for Gastrointestinal Endoscopy; ASGH = Austrian Society of Gastroenterology and Hepatology; BSG = British Society of Gastroenterology; CAG = Canadian Association of Gastroenterology; CCO = Cancer Care Ontario; CSGNA = Canadian Society of Gastroenterology Nurses and Associations; DSRPGSA = Danish Secretariat for Reference Programmes for Gastroenterology, Surgery and Anaesthetics; EC = European Commission; ESGE = European Society of Gastrointestinal Endoscopy; ESGENA = European Society of Gastrointestinal Endoscopy Nurses and Associates; FSDE = French Society of Digestive Endoscopy; GSA = Gastroenterological Society of Australia; GSGDMD = German Society for Gastroenterology, Digestive and Metabolic Diseases; ISDE = Italian Society of Digestive Endoscopy; JAG = Joint Advisory Group; SAGES = Society of American Gastrointestinal and Endoscopic Surgeons; SGNA = Society of Gastroenterology Nurses and Associates; SSGE = Spanish Society of Gastrointestinal Endoscopy |
Recommended Agents for Sedation
Twelve documents provided guidance on the choice of sedatives for GI endoscopy (Table 2).17,19,20,22,24,25,29,31,33,34,38,45
Table 2
Summary of recommendations for sedative agents
Subject | Document | Recommendation or Statement (Quote) | Strength | Level of Evidence |
Moderate sedation |
| Use midazolam over other benzodiazepines | GSGMD34 | If benzodiazepines are used for sedation because of their stronger amnestic effect, we suggest that midazolam be preferred to diazepam because of its shorter half-life | B | 2a |
SSGE29 | When benzodiazepines are used, midazolam is recommended | B | 2++ |
| Moderate sedation provides high satisfaction for patients and physicians | SSGE29 | Moderate sedation using currently available drugs for routine endoscopic procedures (colonoscopies and gastroscopies) is highly satisfactory for patients and physicians alike given their low risk for adverse events | A | 1- |
Depth of sedation/choice of agent |
| Moderate sedation/benzodiazepines adequate | SSGE29 | Moderate sedation using currently available drugs for routine endoscopic procedures (colonoscopies and gastroscopies) is highly satisfactory for patients and physicians alike given their low risk for adverse events | A | 1- |
For non-complex diagnostic or therapeutic gastroscopy and colonoscopy superficial sedation suffices | A | 1+ |
ESGE22 | Simple endoscopic procedures can be performed with moderate sedation, maintaining a high degree of patient satisfaction. Prolonged or complex procedures (e.g. EUS, ERCP) are frequently performed under deep sedation | Strong | High |
CAG45 | It should be recognized that adequate sedation can usually be achieved with a combination of opioids and benzodiazepines. As such, there is no mandate for endoscopists to switch to propofol, particularly because most operators have considerable experience administering standard agents | - | - |
ASGE25 | We recommend that the combination of an opioid and benzodiazepine is a safe and effective regimen for achieving minimal to moderate sedation for upper endoscopy and colonoscopy in patients without risk factors for sedation-related adverse events | - | High |
| Deep sedation/propofol preferred | GSGMD34 | Because of data on efficacy, recovery, and complications, we suggest that propofol should be preferred to midazolam | B | 2b |
SSGE31 | Literature data available on effectiveness, recovery issues, and complications seem to favor the use of propofol over benzodiazepines | B | 2b |
SSGE29 | Propofol is an ideal drug to provide sedation for endoscopic examinations For complex or prolonged procedures (ERCP, EUS, etc.) deep sedation is to be preferred | A | 1+ |
FSDE33 | All patients undergoing a colonoscopy must be offered a general anesthesia. However, an examination without general anesthesia is conceivable for patients who have been told about the potential plan. | - | - |
| Individualize | GSGMD34 | We recommend that the type and intensity of the sedation and the drug used should be selected according to the type of intervention and the patient’s ASA grade and individual risk profile | A | 5 |
ASGE19 | The choice of specific sedation agents and the level of sedation targeted should be determined on a case-by-case basis by the endoscopist in consultation with the patient | - | - |
EC38 | Because there is no clear benefit from a particular approach and for practical reasons, it is recommended that policies on the use of sedation should be adopted according to protocols based on national or pan-European guidelines, and must take into account historical context, the impact on the patient experience, and cost | B | I |
ASGE25 | We suggest that endoscopists use propofol-based sedation (endoscopist-directed or anesthesia-provider administered) when it is expected to improve patient safety, comfort, procedural efficiency, and/or successful procedure completion | - | Low |
SSGE29 | Sedation level and drug type depend on procedure characteristics, individual patient-related factors, patient preferences, and need for patient cooperation | D | 4 |
Propofol sedation |
| Delivery | GSGMD34 | We suggest that propofol should be administered by intermittent bolus administration | B | 1b |
ESGE22 | We recommend administering propofol through intermittent bolus infusion or perfusor system, including target-controlled infusion (TCI), and consideration of patient-controlled sedation (PCS) in particular settings | Strong | High |
| Avoid concomitant use of pharyngeal anesthesia | ESGE22 | We do not suggest using pharyngeal anesthesia during propofol sedation for upper GI endoscopy | Weak | Moderate |
| Use propofol monotherapy | ESGE22 | We suggest propofol monotherapy except in particular situations. In some situations, low dose midazolam premedication might be beneficial to facilitate intravenous line placement and to reduce the need for propofol. Such situations include patients with high anxiety potential, long-lasting procedures in patients with a known important need for sedatives, and patients with limited left ventricular function or with previous pronounced hypotension following propofol administration | Weak | High |
GSGMD34 | We suggest that a combination of propofol and midazolam should not be used | B | 1b |
DSRPGSA17 | Propofol is administered intravenously and should be used only as monotherapy | - | - |
| Consider use of balanced propofol administration | SSGE29 | Midazolam administration before propofol allows to reduce dosage and adverse effects, particularly hypotension in cardiac patients or in hypovolemia, but recovery is delayed | B | 1+ |
| Special populations | GSGDM34 | Propofol may be considered for sedation in elderly populations | Statement | 1b |
GSGMD34 | We recommend that propofol should be used for sedation of patients with hepatic encephalopathy. Benzodiazepines should not be used in patients with hepatic encephalopathy | A | 1b |
Sedation practice in general |
| Offering sedation | GSGMD34 | We recommend that sedation should be offered to every patient before endoscopy. The advantages and disadvantages should be discussed in detail | A | 5 |
GSGMD34 | We suggest that, on principle, simple endoscopic examinations can be performed without sedation | Statement | 2b |
| Use of adjunctive agents | GSGMD34 | We suggest that opioids, ketamines, inhalational anesthetics, and neuroleptics should not be used as monotherapeutics for sedation in endoscopy | B | 5 |
GSGMD34 | Nitrous oxide (laughing gas) may be considered for analgesia and sedation during colonoscopy; appropriate structural requirements must be met | Statement | 1b |
AGA20 | The majority of patients can be adequately sedated by using a combination of an opioid and benzodiazepine. The addition of an adjunctive agent in combination with conventional sedation drugs may be useful for the difficult-to-sedate patient | - | - |
| Titrating sedative doses in special populations | ASGE24 | We recommend that lower initial doses of sedatives than standard adult dosing should be considered in the elderly and that titration should be more gradual to allow assessment of the full dose effect at each dose level | - | Moderate |
GSGMD34 | Patients with higher ASA grade and/or older patients are at higher risk of sedation-related side effects (cardiorespiratory depression). We suggest that the dose of the sedative/analgesic used should be adjusted/reduced accordingly | B | 2b |
AGA = American Gastroenterological Association; ASGE = American Society for Gastrointestinal Endoscopy; CAG = Canadian Association of Gastroenterology; DSRPGSA = Danish Secretariat for Reference Programmes for Gastroenterology, Surgery and Anaesthetics; EC = European Commission; ESGE = European Society of Gastrointestinal Endoscopy; FSDE = French Society of Digestive Endoscopy; GSGDMD = German Society for Gastroenterology, Digestive and Metabolic Diseases; SSGE = Spanish Society of Gastrointestinal Endoscopy |
Two documents made recommendations about specific agents for moderate sedation. Both the German Society for Gastroenterology, Digestive and Metabolic Diseases (GSGMD)34 and the SSGE29 stated that midazolam is the preferred benzodiazepine for moderate sedation based on systematic reviews of cohort studies.
With respect to the administration of propofol, documents were not consistent in their recommendations. Documents from the GSGMD,34 European Society of Gastrointestinal Endoscopy (ESGE) & European Society of Gastrointestinal Endoscopy Nurses and Associates (ESGENA),22 and the Danish Secretariat for Reference Programmes for Gastroenterology, Surgery, and Anaesthetics (DSRPGSA)17 recommended propofol monotherapy. In contrast, a guideline from the SSGE29 recommended that patients receiving propofol be pre-medicated with midazolam to reduce the total dose of and adverse events associated with propofol; the ESGE/ESGENA22 guideline recommended pre-medication with midazolam only in select cases (Table 2). The GSGMD34 recommended administration by intermittent boluses, whereas the ESGE/ESGENA22 recommended intermittent bolus or perfusor systems, such as target-controlled or patient-controlled infusion systems. The ESGE/ESGENA guideline22 also suggested against the use of pharyngeal anesthesia for patients undergoing upper GI endoscopy under propofol sedation.
There was no consensus across documents on the optimal sedating agents (i.e. benzodiazepine +/- opioid vs. propofol) or targeted depth of sedation (i.e. moderate vs. deep) (Table 2). Based on high-quality evidence, documents from the SSGE29 and ESGE/ESGENA22 stated that moderate sedation provides high patient satisfaction for GI endoscopy but that deep sedation is preferred for complex procedures (e.g. EUS, ERCP). Although propofol can be targeted to moderate sedation (e.g. with use of balanced propofol sedation, which combines propofol with a benzodiazepine and opioid20,25,48), documents from the ASGE25 and the Canadian Association of Gastroenterology (CAG)45 specifically stated that the combination of an opioid and benzodiazepine is adequate for routine endoscopy. In contrast, documents from the GSGMD34 and SSGE29,31 expressed a preference for propofol over benzodiazepines. However, several documents, including guidelines from the GSGMD,34 ASGE,19,25 SSGE,29 and European Commission (EC),38 made recommendations for tailoring the agent and depth of sedation to the patient, generally based on low-quality evidence (Table 2). A document from the French Society of Digestive Endoscopy (FSDE)33 stated that general anesthesia should be used for all patients undergoing colonoscopy; however, this document did not define general anesthesia, nor did it specify which agents were recommended for use.
Personnel Capable of Administering Sedation
Nineteen documents (14 guidelines17–20,22,25,27–31,33−35 and 5 position statements39,42,45−47) provided recommendations regarding the types of healthcare professionals capable of administering sedation for routine GI endoscopy. These recommendations are summarized in Table 3. Few documents detailed the level of evidence or the strength of the recommendations (n = 6)22,25,29,31,34,47 (Supplemental Table 2).
Table 3
Summary of recommendations for individuals capable of administering sedation
Subject | Number of documents | Document developers | Comments |
Moderate sedation |
| Can be administered by a nurse who is directed by a physician | 4 | ASGE,19,25,30 SGNA39 | - |
| Should be administered by a practitioner other than the endoscopist | 1 | GSA18 | Trained medical/dental practitioner (with advanced life support skills) |
Deep sedation |
| Should be administered by an anesthesia professional | 3 | ASGE19 | Anesthesiologist, Certified Registered Nurse Anesthetist (CRNA), or Anesthesiologist Assistant (as determined by institutional policies) |
GSA18 | Anesthetist or other appropriately trained and credentialed medical specialist within his/her scope of practice |
SGNA39 | Anesthesiologist |
Propofol |
| Should not be administered by nurses | 3 | CSGNA42 | Not within scope of practice |
GSA18 | Intravenous anesthetics should be administered by a second medical or dental practitioner |
BSG27 | - |
| Non-anesthesiologist propofol administration can be considered | 8 | GSGMD34 | Administered by a non-physician, who has sedation as their sole task, under the instruction of a physician can be considered |
DSRPGSA17 | Can be administered by a nurse under direction of a non-anesthetist physician |
AGA20 | Gastroenterologist-directed administration is safe |
SSGE31 | Administration by non-anesthesiologist is safe |
SSGE29 | Administration by endoscopist/trained nurse safe and may improve efficiency |
CAG45 | Administration by endoscopists and/or trained endoscopy nurses is safe; anesthesiologist not required for low-risk patients |
ASGE47 | Administration by non-anesthesiologists improves practice efficiency for healthy, low-risk patients undergoing routine GI endoscopy |
ISDE46 | Administration by trained non-anesthesiologists is safe |
| An anesthesiologist should be readily available when non-anesthesiologist propofol sedation is used | 2 | DSRPGSA17 | Must be in immediate vicinity |
SSGE29 | Available within 5 minutes |
| Patient and procedure factors to consider when determining whether an anesthesiologist is required |
| | ASA class | 7 | ESGE,22 DSRPGSA,17 SSGE,29,31 CAG,45 ISDE46 | ASA ≥ III |
GSGMD34 | ASA IV-V |
| | Mallampati class or facial features | 1 | ESGE22 | Mallampati class ≥ 3 Dysmorphic facial features or oral abnormalities (mouth opening < 3 cm, high arched palate, macroglossia, micrognathia) |
| | Other factors suggestive of difficult intubation or ventilation | 5 | SSGE29 | Short neck, sleep apnea |
ESGE22 | Pharyngolaryngeal tumors, history of stridor, snoring, obstructive sleep apnea, neck or cervical spine abnormalities, tracheal deviation, advanced rheumatoid arthritis |
DSRPGSA17 | BMI ≥ 35, non-compliance with fasting guidelines, respiratory assessment score ≥ 4 |
CAG45 | Difficulty anatomy for ventilation (obesity, thick neck) |
ISDE46 | Difficult anatomy for ventilation (obesity, thick neck) |
| | Patients with other high risk conditions | 2 | DSRPGSA17 | Acute upper GI hemorrhage, sub-acute bowel obstruction/ileus, achalasia, sleep apnea, SpO2 < 95% with supplemental oxygen |
SSGE29 | Chronic decompensated serious diseases |
| | Long or complex procedures | 5 | DSRPGSA17 | > 1 hour |
SSGE29 | Complex therapeutic procedures |
CAG45 | Prolonged or high-risk interventional procedures |
ESGE22 | Long-lasting procedures |
ISDE46 | Long-lasting or high-risk interventional procedures |
| | Other risk factors | 3 | ESGE22 | Chronic narcotic use, intolerant to sedatives, difficult to sedate |
DSRPGSA17 | Previous problems with anesthesia |
ISDE46 | Uncooperative patients |
Sedation practice in general |
| The role of nurses in the administration of sedation | 5 | CSGNA42 | Competent Registered Nurses can administer sedation when directed by a physician |
ASGH35 | An individual must be present who is responsible for sedation administration (can be a trained assistant, nurse, member of the general medical staff, or anesthesiologist) |
ASGE19 | Licensed practical nurses and unlicensed assistive personnel not qualified to administer sedation |
GSA18 | Appropriately trained nurse may administer sedatives under direction of the physician |
SAGES28 | Nurses administering sedation must work within their scope of practice |
| Intravenous sedation should be administered by an anesthesiologist | 1 | FSDE33 | Non-anesthesiologist IV sedation should only be used in clinical trials |
| Patients and procedure factors to consider when determining whether an anesthesiologist is required |
| | ASA class | 5 | GSGMD34 | ≥III |
AGA,20 GSA,18 ASGE,25 SSGE29 | IV-V |
| | Mallampati class or facial features | 2 | GSGMD34 | Mallampati grade 3 or 4, mouth opening < 2 cm, hyoid-to-chin distance < 4 cm |
SSGE29 | Mallampati grade 4, mouth opening < 3 cm, decreased hyoid-chin distance, protruding incisors, macroglossia, gothic plate, tonsillar hypertrophy, retrognathia, micrognathia, trismus, severe dental malocclusion, dysmorphic face (Trisomy 21, Pierre-Robin sequence) |
| | Other factors suggestive of difficult intubation or ventilation | 5 | GSGMD34 | Craniofacial malformation; lingual, laryngeal, or hypopharyngeal tumor; severely restricted mobility of the cervical spine |
GSA18 | Morbid obesity, significant obstructive sleep apnea, known or suspected difficult endotracheal intubation, potential for aspiration |
ASGE25 | Anatomical variants portending increased risk for airway obstruction |
SSGE29 | History of laryngeal stridor, sleep apnea, short thick neck, limited cervical extension, cervical spine conditions, trauma, severe tracheal deviation |
AGA20 | Morbid obesity |
| | Patients with other high risk conditions | 3 | GSA18 | Elderly; severely limiting heart, cerebrovascular, lung, liver, or renal disease; acute GI bleeding; severe anemia |
ASGE25 | Multiple medical comorbidities or at risk for airway compromise |
BSG27 | Outflow obstruction or any serious form of cardiac or pulmonary compromise |
| | Long or complex procedures | 4 | GSGMD34 | Difficult endoscopic intervention |
AGA20 | ERCP, stent placement in upper GI tract, EUS, complex therapeutic procedures (e.g. ESD, plication of the cardioesophageal junction, EGD with drainage of pseudocyst) |
ASGE25 | Complex endoscopic procedures |
SSGE29 | Urgent, prolonged, or therapeutically complex procedures |
| | Other risk factors | 5 | AGA20 | History of alcohol or substance abuse, pregnancy, neurological/neuromuscular disorders, uncooperative or delirious patients |
GSA18 | Previous sedation-related adverse events |
ASGE25 | Anticipated intolerance to sedatives |
SSGE29 | Intolerance or allergy to standard sedatives |
BSG27 | Severe learning difficulties, patients who have previously failed or are likely to fail sedation including alcoholic or drug addicted patients, poor venous access; uncooperative or phobic patients |
AGA = American Gastroenterological Association; ASGE = American Society for Gastrointestinal Endoscopy; ASGH = Austrian Society of Gastroenterology and Hepatology; BSG = British Society of Gastroenterology; CAG = Canadian Association of Gastroenterology; CSGNA = Canadian Society of Gastroenterology Nurses and Associations; DSRPGSA = Danish Secretariat for Reference Programmes for Gastroenterology, Surgery and Anaesthetics; ESGE = European Society of Gastrointestinal Endoscopy; FSDE = French Society of Digestive Endoscopy; GSA = Gastroenterological Society of Australia; GSGDMD = German Society for Gastroenterology, Digestive and Metabolic Diseases; ISDE = Italian Society of Digestive Endoscopy; SAGES = Society of American Gastrointestinal and Endoscopic Surgeons; SGNA = Society of Gastroenterology Nurses and Associates; SSGE = Spanish Society of Gastrointestinal Endoscopy |
Five documents, from 3 organizations, provided recommendations relevant to the administration of moderate sedation.18,19,25,30,39 Documents from the ASGE19,25,30 and SGNA39 supported nurse-administered moderate sedation with supervision from a physician. A guideline from the GSA,18 however, stated that an “appropriately trained medical practitioner,” who is not the endoscopist, is required to administer intravenous sedation.
Recommendations for administration of deep sedation were provided in documents from the ASGE,19 Gastroenterological Society of Australia (GSA),18 and SGNA.39 Although all three documents recommended that an anesthesia professional be involved in the administration of deep sedation, documents varied in the strength of their recommendations and the suggested personnel – the SGNA recommended that involvement of an anesthesiologist be considered for patients undergoing deep sedation39; the ASGE suggested that anesthesia professionals could include an anesthesiologist, a certified registered nurse anesthetist, or an anesthesiology assistant, depending on institutional policies19; and the GSA stated that an anesthesiologist or other appropriately trained and credential medical specialist must be present when deep sedation is used.18
Recommendations specific to the administration of propofol were provided in 13 documents17,18,20,22,25,27,29,31,34,42,45−47 and varied considerably. Documents from the CSGNA,42 GSA,18 and British Society of Gastroenterology (BSG)27 did not support nurse-administered propofol sedation; the GSA18 and BSG27 further recommended that propofol be administered by an anesthesiologist or a second, appropriately trained, medical practitioner who is not the endoscopist.18 In contrast, documents from the ESGE,22 DSRPGSA,17 ASGE,47 and Italian Society of Digestive Endoscopy (ISDE)46 specifically focused on non-anesthesiologist administered propofol (NAAP) sedation and 5 additional documents made recommendations regarding cases in which NAAP sedation would be appropriate.20,29,31,34,45 These documents generally stated that NAAP sedation is safe in appropriately selected patients20,29,31,45,46 and may improve efficiency of the endoscopy unit.29,47 The GSGMD,34 DSRPGSA,17 SSGE,29 and CAG45 specifically stated that propofol administration by nurses, under the direction of physicians, is safe for low-risk patients and documents from the SSGE,29,31 ASGE,47 and ISDE46 stated that involvement of an anesthesiologist for low-risk patients undergoing propofol sedation is not cost-effective. To ensure safety, two documents recommended that an anesthesiologist be readily available when NAAP sedation is used.17,29 Furthermore, most documents discussing propofol sedation provided recommendations for circumstances that would necessitate administration of propofol by an anesthesiologist. Important factors in the decision of whether to involve an anesthesiologist included the patient’s American Society of Anesthesiologists (ASA) class17,22,29,31,34,45,46; Mallampati class, presence of facial abnormalities, or other factors suggestive of difficult intubation or ventilation17,22,29,45,46; patients with other high risk medical conditions17,29; long and complex procedures17,22,29,45,46; and other risk factors, including individuals with previous problems with sedation, uncooperative patients, and chronic narcotic users (Table 3).17,22,46
Similar recommendations were made for the involvement of an anesthesiologist for sedation practice in general (Table 3). Unique recommendations relating to sedation practice in general included a recommendation from the ASGE19 that licensed practical nurses and unlicensed assistive personnel are not qualified to administer sedation and a recommendation from the FSDE33 that non-anesthesiologist intravenous sedation (not otherwise specified) not be used outside of clinical trials.
Personnel Responsible for Monitoring Sedated Patients
Recommendations for the healthcare personnel required for monitoring sedated patients were discussed in 17 documents (12 guidelines17–20, 22,23,25, 28–30,34, 35 and 5 position statements39,42,44−46); few documents detailed the level of evidence or the strength of these recommendations (n = 3)22,29,34 (Supplemental Table 3).
For moderately sedated patients, there was consensus among documents from the American Gastroenterological Association (AGA),20 ASGE,19,25,30 SGNA,39 and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES)28 that a single nurse is capable of both monitoring a moderately sedated patient and performing brief, interruptible tasks. A position statement from the Canadian Society of Gastroenterology Nurses and Associates (CSGNA)42 recommended that two health professionals be present in the endoscopy suite when moderate sedation is being used but did not define who these health professionals could be. There was also consensus among documents from the ASGE19,30 and SGNA39 that a second assistant be available to assist the endoscopist in complex procedures (e.g. difficult polypectomy)19,30,39 or severely ill patients,39 allowing the nurse administering sedation to focus on monitoring the patient. Guidelines from the ASGE19,30 stated that these second assistants could be registered nurses, licensed practical nurses, or unlicensed assistive personnel.
Five documents provided recommendations for patients undergoing deep sedation. Documents from the AGA,20 ASGE,19,30 and SGNA39 consistently recommended that when deep sedation is used, the individual monitoring the sedated patient should not have any other responsibilities. This necessitates an additional individual to assist the endoscopist with technical aspects of the procedure. Two guidelines suggested that an anesthesia professional be present to monitor the deeply sedated patient.19,35 A guideline from the Austrian Society of Gastroenterology and Hepatology (ASGH)35 suggested involving an anesthesiologist for patients who may require endotracheal intubation. The ASGE19 recognized that many institutions require an anesthesia professional for administration of deep sedation and recommended that this individual also monitor the patient during the procedure.
Two documents18,23 made recommendations for monitoring patients under general anesthesia; however, recommendations in these documents differed. A guideline from Joint Advisory Group on Gastrointestinal Endoscopy (JAG)23 recommended that an anesthesiologist be present to monitor patients under general anesthesia, whereas a guideline from GSA18 recommended that both an anesthesiologist and an individual dedicated to assisting the anesthesiologist be present.
Documents providing recommendations for monitoring patients sedated with propofol were generally in agreement that use of propofol sedation requires an individual dedicated to monitoring the patient who has no other responsibilities, necessitating a second individual to assist the endoscopist with the procedure.17,22,25,34,45,46 However, a document from the SSGE29 recommended that patient and procedure complexity be considered when determining whether an individual dedicated to monitoring sedation is needed. This document stated that basic endoscopic procedures on ASA class I-II patients do not require dedicated sedation staff but that complex therapeutic procedures or procedures performed on higher risk individuals (ASA > III) be staffed by individuals solely dedicated to monitoring the sedated patient. Two documents further recommended that a physician be present and available from the time of propofol administration to when the patient wakes up17 or is ready for discharge,25 but were not specific as to who this physician could be.
Documents providing guidance for sedation practices in general made a range of recommendations (Supplemental Table 3), including that a minimum of one nurse is required for endoscopy with sedation20,44; nurses are capable of monitoring sedating patients and performing brief, interruptible tasks44; sedated endoscopy requires an individual solely dedicated to monitoring the sedated patient18,34; additional staff are required for complex procedures or endoscopy performed on high-risk patients28,34,35,42,44; and when sedation is provided by anesthesia personnel, an individual responsible for assisting the endoscopist, and possibly the anesthesia professional, is needed.18,19,30,42,44 Uniquely, the CSGNA42 stated that a second Registered Nurse, Licensed Practical Nurse, or Registered Practical Nurse is required for “therapeutic” procedures; however, this document did not define the procedures considered to be therapeutic.
Skills and Training Required to Administer Sedation and Monitor Sedated Patients
Seventeen documents (12 guidelines17–20, 22,25,26,28,29,31,34, 35 and 5 position statements39,42,45−47) provided varying recommendations regarding the skills and training required for individuals involved in procedural sedation for endoscopy, often without a grade or level of evidence stated (Supplemental Table 4). Most recommendations for moderate sedation referred specifically to nurses. Recommendations included formal training in procedural sedation,42 knowledge of the sedatives used and their reversal agents,39,42 an understanding of airway management,42 skills to rescue patients who enter deeper levels of sedation than intended,42 and the ability to manage other complications.39,42 Guidelines from the AGA20 and ASGE26 also recommended that physicians involved in these procedures be able to rescue patients from deeper levels of sedation than intended. The CSGNA42 further recommended that endoscopy nurses working in hospitals have at least basic cardiac life support training and those working in private endoscopy clinics have advanced cardiac life support (ACLS) training; this document did not require ACLS training for nurses working within institutions with code response teams.
Documents addressing deep sedation similarly recommended knowledge of the medications used,39 the ability to rescue patients from a deeper level of sedation than intended (i.e. general anesthesia),26 and skills in advanced airway management and the management of cardiorespiratory complications.20,26,39 The SGNA specifically recommended that both nurses and physicians involved in deep sedation have skills in ACLS.39
Prior to involvement in non-anesthesiologist administered propofol sedation, documents recommended formal training in propofol administration.17,20,22,25,45−47 The ESGE22 further stated that intensive care or anesthesia experience for the physician directing propofol sedation is desirable. Additional recommendations for propofol administration included basic resuscitation skills,17,47 skills in managing complications,17,25,45 and skills in airway management.17,25,26,45−47 Documents from CAG,45 ASGE,25,47 and ISDE46 recommended ACLS training and the ESGE22 recommended that if the individual administering propofol has ACLS training a life support team does not need to be rapidly available.
Recommendations for sedation practice not tied to a specific level of sedation were similar, including recommendations for formal training in sedation,18,25,28,29,34 knowledge of the agents being used,19,20,26,29,34,35 the ability to recognize and manage complications and rescue patients from deeper than intended levels of sedation,18–20, 25,26,29,35 skills in basic resuscitation19,20,28,29,34 and airway management,18,20,29,34 and ACLS training.18–20, 28,31 Uniquely, the GSGMD recommended that the physician responsible for sedation generally have intensive care medicine experience.34
Equipment Required to Monitor Sedated Patients
Equipment recommendations are summarized in Table 4. The equipment most consistently recommended for monitoring all sedated patients (regardless of level targeted or use of propofol) included non-invasive blood pressure monitoring and pulse oximetry.17–20, 22,25,28,29,31,34,35,37,42,45,46 Documents referring to moderate sedation and documents that did not specify the level of sedation generally recommended electrocardiography only for select cases. These cases included patients with cardiac or pulmonary disease,20,28,31,34,37,42 elderly patients,37 or prolonged procedures.37 A guideline from Cancer Care Ontario (CCO)37 also recommended the same factors to be considered when determining whether electrocardiography is needed for patients undergoing deep sedation. Five documents suggested routine use of electrocardiography for patients undergoing propofol sedation,17,25,27,35,45 whereas two documents recommended selective use, in particular for patients with cardiac22,46 and/or pulmonary disease.22 Recommendations for capnography varied. For patients undergoing moderate sedation, a guideline from the ASGE19 and a joint statement from the ASGE, American College of Gastroenterology (ACG), and AGA40 both stated that there was insufficient data to recommend routine use of capnography. For patients undergoing deep sedation, two documents from the ASGE19,25 stated that capnography may be considered. For patients specifically undergoing sedation with propofol, there was no consensus on the use of capnography – use was recommended for all patients by the BSG,27 recommended to be considered by the ASGE,25 and recommended only in select cases by the ESGE22; statements that routine use is not supported were made by CAG45 and ASGE.47 Similarly, documents that did not specify the level of sedation also differed in recommendations for capnography, which was recommended for use by the CSGNA42 and SSGE,29 while the GSGMD34 and GSA18 stated capnography may be considered. The AGA20 and ESGE22 did not recommend routine use of the bispectral index (BIS)/electroencephalography (EEG) during moderate sedation or NAAP, respectively; the GSGMD34 stated that a benefit to EEG monitoring has not been demonstrated for sedated patients (no specific level of sedation identified).
Table 4
Summary of recommendations for equipment required to monitor sedated patients
| Moderate Sedation | Deep Sedation | Propofol | Sedation Practices in General |
Non-Invasive Blood Pressure Monitoring | ASGE19 CCO36,37 | CCO36,37 | ESGE22 DSRPGSA17 ASGH35 CAG45 ASGE25 ISDE | GSGMD34 CSGNA42 AGA20 GSA18 ASGE25 SAGES28 |
Pulse Oximetry | ASGE19 CCO36,37 | CCO36,37 | ESGE22 DSRPGSA17 CAG45 ASGE25 ISDE46 | GSGMD34 CSGNA42 AGA20 ASGH35 SSGE29,31 GSA18 SAGES28 |
Capnography | Insufficient evidence: ASGE19 ASGE,ACG,AGA40 | Can be considered: ASGE19,25 | Recommended: BSG27 Consider: ASGE25 Select cases: ESGE22[b] Routine use not supported: CAG45 ASGE47 | Recommended: CSGNA42 SSGE29 Consider GSGMD34 GSA18 Insufficient evidence: AGA20 |
Electrocardiography | For select patients: CCO36,37[a] | For select patients: CCO36,37[a] | BSG27 DSRPGSA17 ASGH35 CAG45 ASGE25 Select patients only: ESGE22[c] ISDE46[d] | For select patients: GSGMD34[e] CSGNA42[f] AGA20[g] SSGE31[h] GSA18[i] SAGES28[j] |
Bispectral index monitoring | Not recommended: AGA20 | - | Not recommended: ESGE22 | Not recommended: GSGMD34 |
aReasonable for high-risk populations: history of cardiac or pulmonary disease, elderly patients, long procedures |
bHigh-risk patients, intended deep sedation, long procedures |
cHistory of cardiac and/or pulmonary disease |
dPatients with specific cardiovascular risk |
ePatients who have severe heart disease or expected arrhythmic problems |
fIf cardiac history may negatively impact outcomes |
gHigh-risk patients (including those with a history of dysrhythmias) |
hIn patients with heart diseases |
iAccording to the clinical status of the patient |
jPatients with a history of cardiac disease |
ACG = American College of Gastroenterology; AGA = American Gastroenterological Association; ASGE = American Society for Gastrointestinal Endoscopy; ASGH = Austrian Society of Gastroenterology and Hepatology; BSG = British Society of Gastroenterology; CAG = Canadian Association of Gastroenterology; CCO = Cancer Care Ontario; CSGNA = Canadian Society of Gastroenterology Nurses and Associations; DSRPGSA = Danish Secretariat for Reference Programmes for Gastroenterology, Surgery and Anaesthetics; ESGE = European Society of Gastrointestinal Endoscopy; GSA = Gastroenterological Society of Australia; GSGMD = German Society for Gastroenterology, Digestive and Metabolic Diseases; ISDE = Italian Society of Digestive Endoscopy; SAGES = Society of American Gastrointestinal and Endoscopic Surgeons; SSGE = Spanish Society of Gastrointestinal Endoscopy |