Preparation, premedication and surveillance

The main end points for sedation during endoscopy are patients' satisfaction, short duration of the procedure, and safety. During the last year, attention has focused on attempting to identify the "ideal" candidate for moderate sedation/analgesia and on the importance of providing the patient with appropriate information before the procedure. The increasing pressure to perform more procedures, reduce costs, and achieve shorter patient turnaround times has affected recent approaches to sedation during endoscopy, focusing attention on alternatives to pharmacological sedation such as providing relaxing music, using small-caliber endoscopes for unsedated peroral gastroscopy, and using magnetic endoscopic imaging to increase tolerance and reduce discomfort during colonoscopy. The results, however, have not been convincing. The role of benzodiazepines was discussed in some studies, highlighting the well-known effect of midazolam on postprocedural amnesia, its pharmacological profile and tolerability after intranasal spraying in healthy volunteers, and the efficacy and safety of this route of administration as an alternative to intravenous administration in diagnostic upper gastrointestinal endoscopy. The form of sedation for gastrointestinal endoscopy that has attracted great interest over the last year is the use of intravenous propofol, either alone or with concomitant benzodiazepines or opioids. As expected in view of the drug's known pharmacological properties, the quality of sedation was better and recovery time was shorter in patients treated with propofol. However, important questions involving the narrow therapeutic range and the mode of administration of propofol (by endoscopists or nurses, or by anesthesiologists) remain open. One important aspect of sedation procedures is prevention of cardiopulmonary complications. The use of electronic monitoring techniques, with a pulse oximeter, has been recommended as a standard procedure during digestive endoscopy; however, pulse oximetry no longer reflects the normal ventilatory functions and does not detect episodes of severe CO2 retention. CO2 monitoring by transcutaneous measurement - or better, by capnography - appears to be useful, as an alternative to pulse oximetry, as a measure of hypoventilation, and for detecting potentially important abnormalities in respiratory activity in patients undergoing sedation for gastrointestinal endoscopy. With regard to preparation for endoscopic procedures, several "ideal" formulas for bowel preparation have been presented. These include the use of sodium phosphate compounds as an alternative to polyethylene glycol electrolyte lavage solutions (PEG-ELS); however, the results so far have been conflicting. The best and most cost-effective bowel cleansing procedure for colonoscopy and sigmoidoscopy has yet to be established.