GI Unit Leadership: Shaping a High-Performing Endoscopy Unit (On-Demand)

ASGE guideline_sedation

Pdf Summary

The American Society for Gastrointestinal Endoscopy (ASGE) updated guidelines provide comprehensive recommendations on sedation and anesthesia use during gastrointestinal (GI) endoscopy to maximize patient comfort, safety, and procedural efficacy. Sedation levels range from minimal (anxiolysis) to general anesthesia, with moderate and deep sedation frequently utilized in GI endoscopy. Sedation aims to relieve anxiety, improve procedure tolerance, and minimize memory of the event.<br /><br />Pre-procedural patient evaluation is essential, including assessment of medical history, airway anatomy (e.g., Mallampati classification), fasting status, and American Society of Anesthesiologists (ASA) classification to stratify anesthesia risk. Informed consent and a "time out" procedure to confirm sedation plans are recommended.<br /><br />During sedation, continuous monitoring of cardiopulmonary status—including blood pressure, heart rate, oxygen saturation, and level of consciousness—is necessary. Supplemental oxygen is advised for moderate sedation and required for deep sedation. Capnography can be considered for deep sedation to detect respiratory depression early.<br /><br />Sedation regimens include benzodiazepines plus opioids for minimal to moderate sedation, with adjunctive agents like diphenhydramine or droperidol in selected cases. Propofol-based sedation—either balanced propofol sedation (BPS) combined with opioids/benzodiazepines or non-anesthesiologist-administered propofol sedation (NAAP)—provides quicker recovery and high patient satisfaction. NAAP requires specialized training and continuous monitoring but has demonstrated safety comparable to traditional sedation. Anesthesia providers may administer sedation, especially for complex procedures or patients with comorbidities, although this increases cost and may not improve safety in low-risk cases.<br /><br />Unsedated endoscopy is feasible for select patients, often improving tolerability with small-diameter scopes and topical anesthesia. Patient-controlled sedation with propofol is another option, though typically under anesthesiology supervision.<br /><br />Key recommendations include thorough pre-procedure risk assessment, provider training in sedation and rescue techniques, routine vital sign monitoring, selective use of adjunctive agents, consideration of capnography in deep sedation, and anesthesia involvement for high-risk patients or complex procedures. Endoscopist-directed propofol sedation is cost-effective and safe for many patients, while anesthesia services are reserved for higher-risk scenarios.

Keywords

ASGE guidelines

gastrointestinal endoscopy

sedation levels

anesthesia risk assessment

patient monitoring

propofol sedation

non-anesthesiologist-administered propofol

capnography

pre-procedural evaluation

anesthesia involvement