Sedation-free gastrointestinal endoscopy

INTRODUCTION

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. More recently, there has been some attempt to determine which patients and which procedures require deeper sedation to achieve optimal conditions. Finally, there has been an effort to make some of the diagnostic procedures more tolerable to avoid the cost and risk of procedural sedation altogether.

This topic review will focus on sedation-free endoscopy. Standard methods of procedural sedation and their complications, recommendations for procedural sedation, and the management of patients who are difficult to sedate are discussed separately. (See "Overview of procedural sedation for gastrointestinal endoscopy" and "Complications of procedural sedation for gastrointestinal endoscopy" and "Alternatives and adjuncts to moderate procedural sedation for gastrointestinal endoscopy".)

RATIONALE

Unsedated endoscopy may be advantageous for several reasons. First, it significantly decreases the risk of hypoxemia and respiratory depression. Second, it reduces the procedure and recovery room time, and the associated costs. Third, it allows patients to leave the endoscopy unit after the procedure without delay and return to work if they so choose, which may produce economic benefit by reducing the indirect costs of endoscopy. Furthermore, a number of studies have demonstrated satisfactory outcomes when focusing on parameters such as successful completion of examinations, patient satisfaction with their comfort level, and their willingness to undergo future examinations without sedation (see below). As a result, in many countries, upper endoscopy, and to a lesser extent, colonoscopy, are commonly performed without routine procedural sedation [1-3]. By contrast, sedation-free endoscopy is not widely accepted in the United States [4].

The use of procedural sedation varies considerably among different countries, reflecting different practice standards and social customs. As an example, in a survey of International Editors for the journal Gastrointestinal Endoscopy, sedation was always or usually administered in 44 percent of procedures in Asia, 56 percent in Europe, and 72 percent in the Americas (Canada, Central and South America) [5]. In the United States, only flexible sigmoidoscopy is typically performed without sedation.