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Alternatives and adjuncts to moderate procedural sedation for gastrointestinal endoscopy

Jonathan Cohen, MD
Section Editors
John R Saltzman, MD, FACP, FACG, FASGE, AGAF
Girish P Joshi, MB, BS, MD, FFARCSI
Deputy Editor
Kristen M Robson, MD, MBA, FACG


The development of gastrointestinal endoscopy has greatly expanded the diagnostic and therapeutic capabilities of gastroenterologists. Adequate patient tolerance is essential for successful completion of a safe examination and compliance with subsequent follow-up. As a result, endoscopists have developed skills in administering a variety of sedative and analgesic agents to facilitate procedures and enhance patient comfort.

Most of the attention has been placed on selecting the optimal regimen for producing procedural sedation and monitoring patients adequately during the procedures. Many procedures are performed using intravenous benzodiazepines and opiates (previously referred to as intravenous conscious sedation), which typically result in moderate degrees of sedation. More recently, there have been attempts to determine which patients and procedures require deeper sedation. In addition, there has been an effort to make some diagnostic procedures more tolerable to avoid the cost and risk of procedural sedation altogether.

Endoscopists occasionally encounter individuals who are difficult or impossible to adequately sedate for endoscopy using standard agents. In addition, certain therapeutic endoscopic procedures require deeper levels of sedation. There are multiple options in these settings:

Addition of diphenhydramine or, rarely, droperidol to standard procedural sedation

Administration of propofol

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Literature review current through: Oct 2017. | This topic last updated: Feb 14, 2017.
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  1. Cook PJ, Flanagan R, James IM. Diazepam tolerance: effect of age, regular sedation, and alcohol. Br Med J (Clin Res Ed) 1984; 289:351.
  2. Peña LR, Mardini HE, Nickl NJ. Development of an instrument to assess and predict satisfaction and poor tolerance among patients undergoing endoscopic procedures. Dig Dis Sci 2005; 50:1860.
  3. Schutz SM, Lee JG, Schmitt CM, et al. Clues to patient dissatisfaction with conscious sedation for colonoscopy. Am J Gastroenterol 1994; 89:1476.
  4. Mahajan RJ, Johnson JC, Marshall JB. Predictors of patient cooperation during gastrointestinal endoscopy. J Clin Gastroenterol 1997; 24:220.
  5. Bal BS, Crowell MD, Kohli DR, et al. What factors are associated with the difficult-to-sedate endoscopy patient? Dig Dis Sci 2012; 57:2527.
  6. Lee SY, Son HJ, Lee JM, et al. Identification of factors that influence conscious sedation in gastrointestinal endoscopy. J Korean Med Sci 2004; 19:536.
  7. Tu RH, Grewall P, Leung JW, et al. Diphenhydramine as an adjunct to sedation for colonoscopy: a double-blind randomized, placebo-controlled study. Gastrointest Endosc 2006; 63:87.
  8. Wilcox CM, Forsmark CE, Cello JP. Utility of droperidol for conscious sedation in gastrointestinal endoscopic procedures. Gastrointest Endosc 1990; 36:112.
  9. Rozen P, Ratan J, Gilat T. Fentanyl-droperidol neuroleptanalgesia in gastrointestinal endoscopy. Gastrointest Endosc 1977; 23:142.
  10. Le Brun HI. Neuroleptanalgesia in upper alimentary endoscopy. Gut 1976; 17:655.
  11. Rubin J, Bryer JV, Brock-Utne JG, Moshal MG. The use of neurolept analgesia for gastro-intestinal endoscopy. S Afr Med J 1977; 52:835.
  12. Moshal MG, Rubin J, Greenberg MJ, et al. Variable premedication for upper gastrointestinal endoscopy. Am J Gastroenterol 1979; 71:158.
  13. Reed WD, Hopkins BE, Joske RA, Laurence BH. A comparative study of conventional premedication (pethidine, promethazine, and atropine) and neuroleptanalgesia (droperidol and phenoperidine) for peroral endoscopy. Gut 1971; 12:736.
  14. Barthel JS, Marshall JB, King PD, et al. The effect of droperidol on objective markers of patient cooperation and vital signs during esophagogastroduodenoscopy: a randomized, double-blind, placebo-controlled, prospective investigation. Gastrointest Endosc 1995; 42:45.
  15. Claussen D. Droperidol (Inapsine). Gastroenterol Nurs 1992; 15:81.
  16. US Food and Drug Administration. Inapsine (droperidol) Dear Healthcare Professional Letter Dec 2001. http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm173778.htm (Accessed on June 24, 2011).
  17. Faigel DO, Baron TH, Goldstein JL, et al. Guidelines for the use of deep sedation and anesthesia for GI endoscopy. Gastrointest Endosc 2002; 56:613.
  18. al-Atrakchi HA. Upper gastrointestinal endoscopy without sedation: a prospective study of 2000 examinations. Gastrointest Endosc 1989; 35:79.
  19. De Gregorio BT, Poorman JC, Katon RM. Peroral ultrathin endoscopy in adult patients. Gastrointest Endosc 1997; 45:303.
  20. Tan CC, Freeman JG. Throat spray for upper gastrointestinal endoscopy is quite acceptable to patients. Endoscopy 1996; 28:277.
  21. Solomon SA, Kajla VK, Banerjee AK. Can the elderly tolerate endoscopy without sedation? J R Coll Physicians Lond 1994; 28:407.
  22. Dhir V, Swaroop VS, Vazifdar KF, Wagle SD. Topical pharyngeal anesthesia without intravenous sedation during upper gastrointestinal endoscopy. Indian J Gastroenterol 1997; 16:10.
  23. Schutz SM, Lee JG, Schmitt CM, Baillie J. Patient satisfaction with conscious sedation for endoscopy. Gastrointest Endosc 1994; 40:119.
  24. Cohen J, Haber GB, Dorais JA, 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.
  25. Wille RT, Barnett JL, Chey WD, et al. Routine droperidol pre-medication improves sedation for ERCP. Gastrointest Endosc 2000; 52:362.
  26. Wilcox CM, Linder J. Prospective evaluation of droperidol on sphincter of Oddi motility. Gastrointest Endosc 2003; 58:483.
  27. Fogel EL, Sherman S, Bucksot L, et al. Effects of droperidol on the pancreatic and biliary sphincters. Gastrointest Endosc 2003; 58:488.
  28. Yimcharoen P, Fogel EL, Kovacs RJ, et al. Droperidol, when used for sedation during ERCP, may prolong the QT interval. Gastrointest Endosc 2006; 63:979.
  29. Dumonceau JM, Riphaus A, Aparicio JR, et al. European Society of Gastrointestinal Endoscopy, European Society of Gastroenterology and Endoscopy Nurses and Associates, and the European Society of Anaesthesiology Guideline: Non-anesthesiologist administration of propofol for GI endoscopy. Endoscopy 2010; 42:960.
  30. Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy, Lichtenstein DR, Jagannath S, et al. Sedation and anesthesia in GI endoscopy. Gastrointest Endosc 2008; 68:815.
  31. Deitch K, Miner J, Chudnofsky CR, et al. Does end tidal CO2 monitoring during emergency department procedural sedation and analgesia with propofol decrease the incidence of hypoxic events? A randomized, controlled trial. Ann Emerg Med 2010; 55:258.
  32. https://www.asahq.org/For-Members/~/media/For%20Members/Standards%20and%20Guidelines/STATEMENT%20ON%20GRANTING%20PRIVILEGES%20FOR%20ADMINISTRATION.pdf (Accessed on July 09, 2014).
  33. Bower AL, Ripepi A, Dilger J, et al. Bispectral index monitoring of sedation during endoscopy. Gastrointest Endosc 2000; 52:192.
  34. Wehrmann T, Grotkamp J, Stergiou N, et al. Electroencephalogram monitoring facilitates sedation with propofol for routine ERCP: a randomized, controlled trial. Gastrointest Endosc 2002; 56:817.
  35. Graber RG. Propofol in the endoscopy suite: an anesthesiologist's perspective. Gastrointest Endosc 1999; 49:803.
  36. Goff JS. Effect of propofol on human sphincter of Oddi. Dig Dis Sci 1995; 40:2364.
  37. Carlsson U, Grattidge P. Sedation for upper gastrointestinal endoscopy: a comparative study of propofol and midazolam. Endoscopy 1995; 27:240.
  38. Wehrmann 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.
  39. Jung M, Hofmann C, Kiesslich R, Brackertz A. Improved sedation in diagnostic and therapeutic ERCP: propofol is an alternative to midazolam. Endoscopy 2000; 32:233.
  40. Kim LS, Cammarano WB, Querimit LA, et al. Randomized controlled trial of propofol for patient sedation during endoscopic retrograde cholangiopancreatography (ERCP) (abstract). Gastrointest Endosc 1998; 47:AB53.
  41. Vargo JJ, Zuccaro G Jr, Dumot JA, et al. Gastroenterologist-administered propofol versus meperidine and midazolam for advanced upper endoscopy: a prospective, randomized trial. Gastroenterology 2002; 123:8.
  42. Ulmer BJ, Hansen JJ, Overley CA, et al. Propofol versus midazolam/fentanyl for outpatient colonoscopy: administration by nurses supervised by endoscopists. Clin Gastroenterol Hepatol 2003; 1:425.
  43. Yusoff IF, Raymond G, Sahai AV. Endoscopist administered propofol for upper-GI EUS is safe and effective: a prospective study in 500 patients. Gastrointest Endosc 2004; 60:356.
  44. Fanti L, Agostoni M, Casati A, et al. Target-controlled propofol infusion during monitored anesthesia in patients undergoing ERCP. Gastrointest Endosc 2004; 60:361.
  45. Sipe BW, Scheidler M, Baluyut A, Wright B. A prospective safety study of a low-dose propofol sedation protocol for colonoscopy. Clin Gastroenterol Hepatol 2007; 5:563.
  46. Horiuchi A, Nakayama Y, Hidaka N, et al. Low-dose propofol sedation for diagnostic esophagogastroduodenoscopy: results in 10,662 adults. Am J Gastroenterol 2009; 104:1650.
  47. Singh H, Poluha W, Cheung M, et al. Propofol for sedation during colonoscopy. Cochrane Database Syst Rev 2008; :CD006268.
  48. Gepts E, Claeys MA, Camu F, Smekens L. Infusion of propofol ('Diprivan') as sedative technique for colonoscopies. Postgrad Med J 1985; 61 Suppl 3:120.
  49. Pohlmann S, Herden HN, Hagenmüller F. [Propofol narcosis for endoscopy--more dangerous than midazolam?]. Bildgebung 1993; 60 Suppl 1:61.
  50. Sipe BW, Rex DK, Latinovich D, et al. Propofol versus midazolam/meperidine for outpatient colonoscopy: administration by nurses supervised by endoscopists. Gastrointest Endosc 2002; 55:815.
  51. Heuss LT, Schnieper P, Drewe J, et al. Risk stratification and safe administration of propofol by registered nurses supervised by the gastroenterologist: a prospective observational study of more than 2000 cases. Gastrointest Endosc 2003; 57:664.
  52. Walker JA, McIntyre RD, Schleinitz PF, et al. Nurse-administered propofol sedation without anesthesia specialists in 9152 endoscopic cases in an ambulatory surgery center. Am J Gastroenterol 2003; 98:1744.
  53. Riphaus A, Stergiou N, Wehrmann T. Sedation with propofol for routine ERCP in high-risk octogenarians: a randomized, controlled study. Am J Gastroenterol 2005; 100:1957.
  54. Cooper GS, Kou TD, Rex DK. Complications following colonoscopy with anesthesia assistance: a population-based analysis. JAMA Intern Med 2013; 173:551.
  55. Wernli KJ, Inadomi JM. Anesthesia for colonoscopy: too much of a good thing? JAMA Intern Med 2013; 173:556.
  56. Wadhwa V, Issa D, Garg S, et al. Similar Risk of Cardiopulmonary Adverse Events Between Propofol and Traditional Anesthesia for Gastrointestinal Endoscopy: A Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2017; 15:194.
  57. Dikman AE, Sanyal S, Aisenberg J, et al. Gastroenterologist-Directed, Balanced Propofol Sedation for EGD and Colonoscopy: An Analysis of Safety in 15,286 Patients. Gastrointest Endosc 2008; 67:AB84.
  58. Lee CK, Lee SH, Chung IK, et al. Balanced propofol sedation for therapeutic GI endoscopic procedures: a prospective, randomized study. Gastrointest Endosc 2011; 73:206.
  59. Levitzky BE, Lopez R, Dumot JA, Vargo JJ. Moderate sedation for elective upper endoscopy with balanced propofol versus fentanyl and midazolam alone: a randomized clinical trial. Endoscopy 2012; 44:13.
  60. ASGE Technology Committee, Banerjee S, Desilets D, et al. Computer-assisted personalized sedation. Gastrointest Endosc 2011; 73:423.
  61. Pambianco DJ, Whitten CJ, Moerman A, et al. An assessment of computer-assisted personalized sedation: a sedation delivery system to administer propofol for gastrointestinal endoscopy. Gastrointest Endosc 2008; 68:542.
  62. Pambianco DJ, Vargo JJ, Pruitt RE, et al. Computer-assisted personalized sedation for upper endoscopy and colonoscopy: a comparative, multicenter randomized study. Gastrointest Endosc 2011; 73:765.
  63. Külling D, Fantin AC, Biro P, et al. Safer colonoscopy with patient-controlled analgesia and sedation with propofol and alfentanil. Gastrointest Endosc 2001; 54:1.
  64. Ng JM, Kong CF, Nyam D. Patient-controlled sedation with propofol for colonoscopy. Gastrointest Endosc 2001; 54:8.
  65. Gillham MJ, Hutchinson RC, Carter R, Kenny GN. Patient-maintained sedation for ERCP with a target-controlled infusion of propofol: a pilot study. Gastrointest Endosc 2001; 54:14.
  66. Mazanikov M, Udd M, Kylänpää L, et al. Patient-controlled sedation with propofol and remifentanil for ERCP: a randomized, controlled study. Gastrointest Endosc 2011; 73:260.
  67. Yimcharoen P, Fogel EL, McHenry L, et al. Use of Droperidol at ERCP and QTc Prolongation: Do We Need to Follow the Black Box Warning? Gastrointest Endosc 2005; 61:AB125.
  68. Rex DK, Deenadayalu V, Eid E. Gastroenterologist-directed propofol: an update. Gastrointest Endosc Clin N Am 2008; 18:717.
  69. Külling D, Orlandi M, Inauen W. Propofol sedation during endoscopic procedures: how much staff and monitoring are necessary? Gastrointest Endosc 2007; 66:443.
  70. Cohen LB, Delegge MH, Aisenberg J, et al. AGA Institute review of endoscopic sedation. Gastroenterology 2007; 133:675.
  71. Rex DK, Deenadayalu VP, Eid E, et al. Endoscopist-directed administration of propofol: a worldwide safety experience. Gastroenterology 2009; 137:1229.
  72. Vargo JJ, Cohen LB, Rex DK, et al. Position statement: Nonanesthesiologist administration of propofol for GI endoscopy. Gastroenterology 2009; 137:2161.
  73. Balsells F, Wyllie R, Kay M, Steffen R. Use of conscious sedation for lower and upper gastrointestinal endoscopic examinations in children, adolescents, and young adults: a twelve-year review. Gastrointest Endosc 1997; 45:375.
  74. Etzkorn KP, Diab F, Brown RD, et al. Endoscopic retrograde cholangiopancreatography under general anesthesia: indications and results. Gastrointest Endosc 1998; 47:363.
  75. Osborn IP, Cohen J, Soper RJ, Roth LA. Laryngeal mask airway--a novel method of airway protection during ERCP: comparison with endotracheal intubation. Gastrointest Endosc 2002; 56:122.