Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

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. 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 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 to standard procedural sedation

Administration of propofol

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Dec 04, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  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. 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.
  19. 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.
  20. 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.
  21. https://www.asahq.org/For-Members/~/media/For%20Members/Standards%20and%20Guidelines/STATEMENT%20ON%20GRANTING%20PRIVILEGES%20FOR%20ADMINISTRATION.pdf (Accessed on July 09, 2014).
  22. Bower AL, Ripepi A, Dilger J, et al. Bispectral index monitoring of sedation during endoscopy. Gastrointest Endosc 2000; 52:192.
  23. 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.
  24. Graber RG. Propofol in the endoscopy suite: an anesthesiologist's perspective. Gastrointest Endosc 1999; 49:803.
  25. Carlsson U, Grattidge P. Sedation for upper gastrointestinal endoscopy: a comparative study of propofol and midazolam. Endoscopy 1995; 27:240.
  26. 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.
  27. 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.
  28. 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.
  29. Singh H, Poluha W, Cheung M, et al. Propofol for sedation during colonoscopy. Cochrane Database Syst Rev 2008; :CD006268.
  30. 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.
  31. 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.
  32. Wang D, Chen C, Chen J, et al. The use of propofol as a sedative agent in gastrointestinal endoscopy: a meta-analysis. PLoS One 2013; 8:e53311.
  33. Padmanabhan A, Frangopoulos C, Shaffer LET. Patient Satisfaction With Propofol for Outpatient Colonoscopy: A Prospective, Randomized, Double-Blind Study. Dis Colon Rectum 2017; 60:1102.
  34. 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.
  35. 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.
  36. 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.
  37. 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.
  38. Fanti L, Agostoni M, Casati A, et al. Target-controlled propofol infusion during monitored anesthesia in patients undergoing ERCP. Gastrointest Endosc 2004; 60:361.
  39. Goff JS. Effect of propofol on human sphincter of Oddi. Dig Dis Sci 1995; 40:2364.
  40. Cooper GS, Kou TD, Rex DK. Complications following colonoscopy with anesthesia assistance: a population-based analysis. JAMA Intern Med 2013; 173:551.
  41. Wernli KJ, Inadomi JM. Anesthesia for colonoscopy: too much of a good thing? JAMA Intern Med 2013; 173:556.
  42. 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.
  43. 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.
  44. 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.
  45. 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.
  46. 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.
  47. Ng JM, Kong CF, Nyam D. Patient-controlled sedation with propofol for colonoscopy. Gastrointest Endosc 2001; 54:8.
  48. 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.
  49. 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.
  50. 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.
  51. Rex DK, Deenadayalu V, Eid E. Gastroenterologist-directed propofol: an update. Gastrointest Endosc Clin N Am 2008; 18:717.
  52. Külling D, Orlandi M, Inauen W. Propofol sedation during endoscopic procedures: how much staff and monitoring are necessary? Gastrointest Endosc 2007; 66:443.
  53. Cohen LB, Delegge MH, Aisenberg J, et al. AGA Institute review of endoscopic sedation. Gastroenterology 2007; 133:675.
  54. Rex DK, Deenadayalu VP, Eid E, et al. Endoscopist-directed administration of propofol: a worldwide safety experience. Gastroenterology 2009; 137:1229.
  55. Vargo JJ, Cohen LB, Rex DK, et al. Position statement: Nonanesthesiologist administration of propofol for GI endoscopy. Gastroenterology 2009; 137:2161.
  56. 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.
  57. Etzkorn KP, Diab F, Brown RD, et al. Endoscopic retrograde cholangiopancreatography under general anesthesia: indications and results. Gastrointest Endosc 1998; 47:363.
  58. 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.