Clinical Endoscopy

Review

Remimazolam, a novel drug, for safe and effective endoscopic sedation: Jae Min Lee, Yehyun Park, Dong Won Ahn, Jun Kyu Lee, Kwang Hyuck Lee; Received February 7, 2024 Accepted May 8, 2024 Published online January 14, 2025; DOI: https://doi.org/10.5946/ce.2024.026 [Epub ahead of print]

Abstract PDF PubReader ePub: Remimazolam is a novel benzodiazepine with unique pharmacokinetic and pharmacodynamic properties, making it an ideal candidate for sedation during endoscopic procedures. Distinguished by its rapid onset and short duration of action, remimazolam offers a safer and more efficient alternative to traditional sedatives, such as midazolam and propofol, with fewer side effects, such as hypotension, bradycardia, and respiratory depression. This article reviews the characteristics of remimazolam and its practical advantages, including ease of use, quick recovery time, and minimal residual sedation, emphasizing its potential to improve patient safety and procedural efficiency in clinical endoscopy settings.

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Original Articles

Comparison of bispectral index-guided endoscopic ultrasonography with continuous vs. intermittent infusion of propofol: a retrospective study in Japan: Ayana Okamoto, Ken Kamata, Tomohiro Yamazaki, Shunsuke Omoto, Kosuke Minaga, Mamoru Takenaka, Masatoshi Kudo; Clin Endosc 2024;57(6):814-820. Published online July 24, 2024; DOI: https://doi.org/10.5946/ce.2024.019

Graphical Abstract Abstract PDF PubReader ePub: Background
/Aims: This study aimed to evaluate the safety and efficacy of continuous propofol infusion for anesthesia during endoscopic ultrasonography (EUS).
Methods
A total of 427 consecutive patients who underwent EUS between May 2018 and February 2019 were enrolled in this study. The patients were divided into two propofol infusion groups: continuous (n=207) and intermittent (n=220). The following parameters were compared: (1) propofol dose, (2) respiratory and circulatory depression, (3) body movement requiring discontinuation of the examination, (4) awakening score, and (5) patient satisfaction.
Results
The median total maintenance dose of propofol was significantly higher in the continuous group than in the intermittent group (160.0 mg vs. 130.0 mg, respectively); however, the reduction in SpO2 was significantly lower in the continuous group (2.9% vs. 13.2%). Body movements occurred less frequently in the continuous group than in the intermittent group (40.1% vs. 49.5%, respectively). The rate of complete awakening was significantly higher in the continuous group than in the intermittent group. Finally, there was a significant difference in the percentage of patients who answered “absolutely yes” when asked about receiving EUS again: 52.7% in the continuous group vs. 34.3% in the intermittent group.
Conclusions
Continuous infusion resulted in stable sedation and reduced propofol-associated risks.

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Anesthesia care provider sedation versus conscious sedation for endoscopic ultrasound–guided tissue acquisition: a retrospective cohort study: Sneha Shaha, Yinglin Gao, Jiahao Peng, Kendrick Che, John J. Kim, Wasseem Skef; Clin Endosc 2023;56(5):658-665. Published online July 3, 2023; DOI: https://doi.org/10.5946/ce.2023.006

Graphical Abstract Abstract PDF PubReader ePub: Background
/Aims: We aimed to study the effects of sedation on endoscopic ultrasound–guided tissue acquisition.
Methods
We conducted a retrospective study evaluating the role of sedation in endoscopic ultrasound–guided tissue acquisition by comparing two groups: anesthesia care provider (ACP) sedation and endoscopist-directed conscious sedation (CS).
Results
Technical success was achieved in 219/233 (94.0%) in the ACP group and 114/136 (83.8%) in the CS group (p=0.0086). In multivariate analysis, the difference in technical success between the two groups was not significant (adjusted odds ratio [aOR], 0.5; 95% confidence interval [CI], 0.234–1.069; p=0.0738). A successful diagnostic yield was present in 146/196 (74.5%) in the ACP group and 66/106 (62.3%) in the CS group, respectively (p=0.0274). In multivariate analysis, the difference in diagnostic yield between the two groups was not significant (aOR, 0.643; 95% CI, 0.356–1.159; p=0.142). A total of 33 adverse events (AEs) were observed. The incidence of AEs was significantly lower in the CS group (5/33 CS vs. 28/33 ACP; OR, 0.281; 95% CI, 0.095–0.833; p=0.022).
Conclusions
CS provided equivalent technical success and diagnostic yield for malignancy in endoscopic ultrasound–guided tissue acquisition. Increased AEs were associated with anesthesia for the endoscopic ultrasound–guided tissue acquisition.

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Impact of a simple non-invasive nasal mask device on intraprocedural hypoxemia in overweight individuals undergoing upper gastrointestinal endoscopy with sedation provided by a non-anesthesiologist provider: Jan Drews, Jonas Harder, Hannah Kaiser, Miriam Soenarjo, Dorothee Spahlinger, Peter Wohlmuth, Sebastian Wirtz, Ralf Eberhardt, Florian Bornitz, Torsten Bunde, Thomas von Hahn; Clin Endosc 2024;57(2):196-202. Published online June 27, 2023; DOI: https://doi.org/10.5946/ce.2023.010

Graphical Abstract Abstract PDF PubReader ePub

Background
/Aims: Hypoxemia is a common side effect of propofol sedation during endoscopy. Applying mild positive airway pressure (PAP) using a nasal mask may offer a simple way to reduce such events and optimize the conditions for diagnostic and therapeutic upper gastrointestinal endoscopies.
Methods
We compared overweight patients (body mass index >25 kg/m2) with a nasal PAP mask or standard nasal cannula undergoing upper gastrointestinal endoscopies by non-anesthesiologists who provided propofol sedation. Outcome parameters included the frequency and severity of hypoxemic episodes.
Results
We analyzed 102 procedures in 51 patients with nasal PAP masks and 51 controls. Episodes of hypoxemia (oxygen saturation [SpO2] <90% at any time during sedation) occurred in 25 (49.0%) controls compared to 8 (15.7%) patients with nasal PAP masks (p<0.001). Severe hypoxemia (SpO2 <80%) occurred in three individuals (5.9%) in both groups. The mean delta between baseline SpO2 and the lowest SpO2 recorded was significantly decreased among patients with nasal PAP mask compared to controls (3.7 and 8.2 percentage points difference, respectively). There were significantly fewer airway interventions performed in the nasal PAP mask group (15.7% vs. 41.2%, p=0.008).
Conclusions
Using a nasal PAP mask may be a simple means of increasing patient safety and ease of examination.

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Sedation for GI Endoscopy in the Morbidly Obese: Challenges and Possible Solutions
Lalitha Sundararaman, Basavana Goudra
Journal of Clinical Medicine.2024; 13(16): 4635. CrossRef

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Respiratory complications during recovery from gastrointestinal endoscopies performed by gastroenterologists under moderate sedation: Inna Eidelman Pozin, Amir Zabida, Moshe Nadler, Guy Zahavi, Dina Orkin, Haim Berkenstadt; Clin Endosc 2023;56(2):188-193. Published online January 10, 2023; DOI: https://doi.org/10.5946/ce.2022.033

Abstract PDF PubReader ePub

Background
/Aims: Data on the incidence of adverse respiratory events during recovery from gastrointestinal endoscopy are limited. The aim of this study was to investigate the incidence of these complications.
Methods
In this retrospective cohort study, data were obtained from the electronic records of 657 consecutive patients, who underwent gastroenterological procedures under sedation.
Results
Pulse oximetry oxygen saturation (SpO2) <90% for <60 seconds occurred in 82 patients (12.5%) and in 11 patients (1.7%), SpO2 of <90% for >60 seconds occurred in 79 patients (12.0%) and in 11 patients (1.7%), and SpO2 <75% occurred in four patients (0.6%) and in no patients during the procedure and recovery period, respectively. No major complications were noted. The occurrence of desaturation during recovery was correlated with desaturation during the procedure (p<0.001). American Society of Anesthesiologists score (odds ratio [OR], 1.867; 95% confidence interval [CI], 1.008–3.458), ischemic heart disease (OR, 1.815; 95% CI, 0.649–5.080), hypertension (OR, 1.289; 95% CI, 0.472–3.516), and diabetes mellitus (OR, 2.406; 95% CI, 0.950–6.095) increased the occurrence of desaturation during recovery.
Conclusions
We found no major complications during recovery after balanced propofol-based sedation administered by a gastroenterologist-nurse team. Patients with the identified risk predictors must be monitored carefully.

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Development of a predictive model for hypoxia due to sedatives in gastrointestinal endoscopy: a prospective clinical study in Korea
Jung Wan Choe, Jong Jin Hyun, Seong-Jin Son, Seung-Hak Lee
Clinical Endoscopy.2024; 57(4): 476. CrossRef

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Reviews

New sedatives and analgesic drugs for gastrointestinal endoscopic procedures: Jae Min Lee, Yehyun Park, Jin Myung Park, Hong Jun Park, Jun Yong Bae, Seung Young Seo, Jee Hyun Lee, Hyung Ku Chon, Jun-Won Chung, Hyun Ho Choi, Jun Kyu Lee, Byung-Wook Kim, Endoscopic Sedation Committee of the Korean Society of Gastrointestinal Endoscopy; Clin Endosc 2022;55(5):581-587. Published online August 29, 2022; DOI: https://doi.org/10.5946/ce.2021.283

Abstract PDF PubReader ePub

Procedural sedation has become increasingly common in endoscopy. Sedatives and analgesics induce anxiolysis and amnesia. In addition, an appropriate level of sedation is necessary for safe procedures including therapeutic endoscopy. Midazolam and propofol are the most commonly used drugs in sedative endoscopy. In recent years, the need to ascertain the safety and effectiveness of sedation has increased in practice. Therefore, new sedatives and analgesic drugs for optimal sedative endoscopy, have recently emerged. This article reviews the characteristics of sedatives and analgesics, and describes their clinical use in gastrointestinal endoscopy.

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Characterization of Pediatric Rectal Absorption, Drug Disposition, and Sedation Level for Midazolam Gel Using Physiologically Based Pharmacokinetic/Pharmacodynamic Modeling
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Development of a predictive model for hypoxia due to sedatives in gastrointestinal endoscopy: a prospective clinical study in Korea
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Quality of recovery and pre-existing impaired cognition in patients undergoing advanced GI endoscopic procedures with patient-controlled sedation: a prospective observational cohort study
Sara Lyckner, Michelle S. Chew, Andreas Nilsson
iGIE.2023; 2(3): 292. CrossRef
Clinical Practice Guideline for Percutaneous Endoscopic Gastrostomy
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The Korean Journal of Gastroenterology.2023; 82(3): 107. CrossRef
Drugs used for sedation in gastrointestinal endoscopy
Jun Kyu Lee
Journal of the Korean Medical Association.2022; 65(11): 735. CrossRef

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2021 Korean Society of Gastrointestinal Endoscopy Clinical Practice Guidelines for Endoscopic Sedation: Hong Jun Park, Byung-Wook Kim, Jun Kyu Lee, Yehyun Park, Jin Myung Park, Jun Yong Bae, Seung Young Seo, Jae Min Lee, Jee Hyun Lee, Hyung Ku Chon, Jun-Won Chung, Hyun Ho Choi, Myung Ha Kim, Dong Ah Park, Jae Hung Jung, Joo Young Cho, Endoscopic Sedation Committee of Korean Society of Gastrointestinal Endoscopy; Clin Endosc 2022;55(2):167-182. Published online February 22, 2022; DOI: https://doi.org/10.5946/ce.2021.282

Abstract PDF Supplementary Material PubReader ePub

Sedation can resolve anxiety and fear in patients undergoing endoscopy. The use of sedatives has increased in Korea. Appropriate sedation is a state in which the patient feels subjectively comfortable while maintaining the airway reflex for stable spontaneous breathing. The patient should maintain a state of consciousness to the extent that he or she can cooperate with the needs of the medical staff. Despite its benefits, endoscopic sedation has been associated with cardiopulmonary complications. Cardiopulmonary complications are usually temporary. Most patients recover without sequelae. However, they may progress to serious complications, such as cardiovascular collapse. Therefore, it is essential to screen high-risk patients before sedation and reduce complications by meticulous monitoring. Additionally, physicians should be familiar with the management of emergencies. The first Korean clinical practice guideline for endoscopic sedation was developed based on previous worldwide guidelines for endoscopic sedation using an adaptation process. The guideline consists of nine recommendations based on a critical review of currently available data and expert consensus when the guideline was drafted. These guidelines should provide clinicians, nurses, medical school students, and policy makers with information on how to perform endoscopic sedation with minimal risk.

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Using Clinical-based Discharge Criteria to Discharge Patients After Endoscopy Procedures Under Drug-induced Intravenous Sedation in the Outpatient Care Unit: An Observational Study
Liangyu Fang, Lina Chen, Bingbing Wu, Yinchuan Xu, Laijuan Chen
Journal of PeriAnesthesia Nursing.2024; 39(5): 859. CrossRef
Development and Effectiveness Evaluation of 360-Degree Virtual Reality-Based Educational Intervention for Adult Patients Undergoing Colonoscopy
Minju Gwag, Jaeyong Yoo
Healthcare.2024; 12(14): 1448. CrossRef
Development of a predictive model for hypoxia due to sedatives in gastrointestinal endoscopy: a prospective clinical study in Korea
Jung Wan Choe, Jong Jin Hyun, Seong-Jin Son, Seung-Hak Lee
Clinical Endoscopy.2024; 57(4): 476. CrossRef
Comparison of Synergistic Sedation with Midazolam and Propofol Versus Midazolam and Pethidine in Colonoscopies: A Prospective, Randomized Controlled Study
Jae Woong Lim, Min Jae Kim, Gang Han Lee, Dae Sol Kim, Sang Hyuk Jung, Yu Yeon Kim, Jin Won Kim, Yohan Lee, Hyun Soo Kim, Seon Young Park, Dong Hyun Kim
Chonnam Medical Journal.2024; 60(3): 192. CrossRef
Nasal mask versus conventional oxygen supply for endoscopy under intravenous sedation: protocol for a systematic review and meta-analysis
Wentao Ji, Yu Deng, Min Zheng, Xiaoting Zhang, Jun Lu, Jinhai Liu, Bo Li, Lulong Bo
BMJ Open.2024; 14(12): e092868. CrossRef
Experience of organizing outpatient anesthetic care at Endoscopy centre of Multidisciplinary city clinic
O. V. Makarov, S. A. Osipov, E. P. Rodionov, A. A. Malyshev, I. Yu. Korzheva, L. M. Avramenko, Z. Z. Loseva, I. V. Balykov, L. A. Baichorova, E. I. Alikhanova, A. V. Vlasenko, E. A. Evdokimov, V. I. Makovey, V. V. Erofeev
Medical alphabet.2023; (6): 50. CrossRef
Anesthesia care provider sedation versus conscious sedation for endoscopic ultrasound–guided tissue acquisition: a retrospective cohort study
Sneha Shaha, Yinglin Gao, Jiahao Peng, Kendrick Che, John J. Kim, Wasseem Skef
Clinical Endoscopy.2023; 56(5): 658. CrossRef
Current status of the gastric cancer screening program in Korea
Young-Il Kim, Il Ju Choi
Journal of the Korean Medical Association.2022; 65(5): 250. CrossRef
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Upender Gowd, Sukhminder Jit Singh Bajwa, Madhuri Kurdi, Gaurav Sindwani
Indian Journal of Anaesthesia.2022; 66(10): 683. CrossRef
Drugs used for sedation in gastrointestinal endoscopy
Jun Kyu Lee
Journal of the Korean Medical Association.2022; 65(11): 735. CrossRef

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Original Article

Propofol Alone versus Propofol in Combination with Midazolam for Sedative Endoscopy in Patients with Paradoxical Reactions to Midazolam: Ji Hyung Nam, Dong Kee Jang, Jun Kyu Lee, Hyoun Woo Kang, Byung-Wook Kim, Byung Ik Jang, the Committees of Quality Management and Conscious Sedation of Korean Society of Gastrointestinal Endoscopy; Clin Endosc 2022;55(2):234-239. Published online October 12, 2021; DOI: https://doi.org/10.5946/ce.2021.126

Abstract PDF PubReader ePub

Background
/Aims: The efficacy of propofol in gastrointestinal endoscopy for patients with midazolam-induced paradoxical reactions remains unclarified. This study aimed to compare the efficacy and safety of propofol-based sedation in patients who previously experienced paradoxical reactions.
Methods
This was a prospective, single-blinded, randomized controlled pilot study. Participants with a history of paradoxical reactions to midazolam during a previous esophagogastroduodenoscopy were recruited and randomly assigned to group I (propofol monosedation) or group II (combination of propofol and midazolam). The primary endpoint was the occurrence of a paradoxical reaction.
Results
A total of 30 participants (mean age, 54.7±12.6 years; male, 19/30) were randomly assigned to group I (n=16) or group II (n=14). There were no paradoxical reactions in group I, but there were two in group II, without a significant difference (p=0.209). The mean dose of propofol was higher in group I than in group II (p=0.002). Meanwhile, the procedure and recovery times did not differ between groups.
Conclusions
Propofol-based sedation was safe and effective for patients who experienced paradoxical reactions to midazolam. However, caution is needed because few cases of paradoxical reaction again can happen in group II in which midazolam was readministered.

Citations

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Development of a predictive model for hypoxia due to sedatives in gastrointestinal endoscopy: a prospective clinical study in Korea
Jung Wan Choe, Jong Jin Hyun, Seong-Jin Son, Seung-Hak Lee
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The effective dose of butorphanol tartrate in patients of different ages undergoing painless gastroscopy
Yaorui Sun, Shujiao Liu, Wenli Si, Quanyi Zhang, Fei Yu, Ming Su, Chao Sun
Journal of International Medical Research.2024;[Epub] CrossRef
Efficacy and safety of remimazolam-based sedation for intensive care unit patients undergoing upper gastrointestinal endoscopy: a cohort study
Yuan-rui Zhao, Ke-sheng Huang, Guo Hou, Lan Yao, Li-ping Lu, Song Xu, Ying-tao Lian, Zhun Yao, Zhui Yu
World Journal of Emergency Medicine.2023; 14(1): 31. CrossRef
Effective dose of propofol combined with a low-dose esketamine for gastroscopy in elderly patients: A dose finding study using dixon’s up-and-down method
Yuling Zheng, Yafei Xu, Bixin Huang, Ying Mai, Yiwen Zhang, Zhongqi Zhang
Frontiers in Pharmacology.2022;[Epub] CrossRef
Drugs used for sedation in gastrointestinal endoscopy
Jun Kyu Lee
Journal of the Korean Medical Association.2022; 65(11): 735. CrossRef

5,042 View
283 Download
6 Web of Science
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Review

Recent Developments in Devices Used for Gastrointestinal Endoscopy Sedation: Basavana Goudra, Gowri Gouda, Preet Mohinder Singh; Clin Endosc 2021;54(2):182-192. Published online March 18, 2021; DOI: https://doi.org/10.5946/ce.2020.057

Abstract PDF PubReader ePub

Hypoxemia is a frequent and potentially fatal complication occurring in patients during gastrointestinal endoscopy. The administration of propofol sedation increases the risk of most complications, especially hypoxemia. Nevertheless, propofol has been increasingly used in the United States, and the trend is likely to increase in the years to come. Patient satisfaction and endoscopist satisfaction along with rapid turnover are some of the touted reasons for this trend. However, propofol sedation generally implies deep sedation or general anesthesia. As a result, hypopnea and apnea frequently occur. Inadequate sedation and presence of irritable airway often cause coughing and laryngospasm, both leading to hypoxemia and potential cardiac arrest. Hence, prevention of hypoxemia is of paramount importance. Traditionally, standard nasal cannula is used to administer supplement oxygen. However, it cannot sufficiently provide continuous positive airway pressure (CPAP) or positive pressure ventilation. Device manufacturers have stepped in to fill this void and created many types of cannulas that provide apneic insufflation of oxygen and CPAP and eliminate dead space. Such measures decrease the incidence of hypoxemia. This review aimed to provide essential information of some of these devices.

Citations

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Impact of a simple non-invasive nasal mask device on intraprocedural hypoxemia in overweight individuals undergoing upper gastrointestinal endoscopy with sedation provided by a non-anesthesiologist provider
Jan Drews, Jonas Harder, Hannah Kaiser, Miriam Soenarjo, Dorothee Spahlinger, Peter Wohlmuth, Sebastian Wirtz, Ralf Eberhardt, Florian Bornitz, Torsten Bunde, Thomas von Hahn
Clinical Endoscopy.2024; 57(2): 196. CrossRef
Noninvasive respiratory support with high-flow nasal cannula in endoscopic surgery in a patient with Legionella Pneumophila pneumonia: a case report
Vincenzo Pota, Francesco Coppolino, Annamaria Auricchio, Francesca Cardella, Maurizio Del Prete, Antonio Scalvenzi, Pasquale Sansone, Maria Beatrice Passavanti, Maria Caterina Pace
Perioperative Medicine.2024;[Epub] CrossRef
Sedation for GI Endoscopy in the Morbidly Obese: Challenges and Possible Solutions
Lalitha Sundararaman, Basavana Goudra
Journal of Clinical Medicine.2024; 13(16): 4635. CrossRef
Comprehensive review of perioperative factors influencing ferroptosis
Cheng-Hui Fan, Xiao-Qin Zeng, Rui-Min Feng, Hua-Wei Yi, Rui Xia
Biomedicine & Pharmacotherapy.2024; 179: 117375. CrossRef
Should We Use High-Flow Nasal Cannula in Patients Receiving Gastrointestinal Endoscopies? Critical Appraisals through Updated Meta-Analyses with Multiple Methodologies and Depiction of Certainty of Evidence
Chi Chan Lee, Teressa Reanne Ju, Pei Chun Lai, Hsin-Ti Lin, Yen Ta Huang
Journal of Clinical Medicine.2022; 11(13): 3860. CrossRef
An intravenous anesthetic drug-propofol, influences the biological characteristics of malignant tumors and reshapes the tumor microenvironment: A narrative literature review
Xueliang Zhou, Yanfei Shao, Shuchun Li, Sen Zhang, Chengsheng Ding, Lei Zhuang, Jing Sun
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Fateh Bazerbachi, Rodger M White, Nauzer Forbes, Basavana Goudra, Barham K Abu Dayyeh, Vinay Chandrasekhara, BobbieJean Sweitzer
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High-flow oxygen via oxygenating mouthguard in short upper gastrointestinal endoscopy: A randomised controlled trial
Kim Hay Be, Leonardo Zorron Cheng Tao Pu, Brett Pearce, Matthew Lee, Luke Fletcher, Rebecca Cogan, Philip Peyton, Rhys Vaughan, Marios Efthymiou, Sujievvan Chandran
World Journal of Gastrointestinal Endoscopy.2022; 14(12): 777. CrossRef

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Original Articles

Risk Factors for Prolonged Hospital Stay after Endoscopy: Toshihiro Nishizawa, Shuntaro Yoshida, Osamu Toyoshima, Tatsuya Matsuno, Masataka Irokawa, Toru Arano, Hirotoshi Ebinuma, Hidekazu Suzuki, Takanori Kanai, Kazuhiko Koike; Clin Endosc 2021;54(6):851-856. Published online March 16, 2021; DOI: https://doi.org/10.5946/ce.2020.292

Abstract PDF PubReader ePub

Background
/Aims: The recovery room used after endoscopy has limited capacity, and an efficient flow of the endoscopy unit is desired. We investigated the duration of hospital stay after endoscopy and the risk factors for prolonged hospital stay among outpatients.
Methods
We retrospectively studied consecutive patients who underwent esophagogastroduodenoscopy or colonoscopy at the Toyoshima Endoscopy Clinic. We collected data on age, sex, body weight, midazolam and pethidine dosage, respiratory depression during endoscopy, and duration of hospital stay after endoscopy (scope out to check out). Risk factors for prolonged hospital stay (>100 minutes) were identified using multiple logistic regression analysis.
Results
We enrolled 3,898 patients, including 3,517 (90.2%) patients tested under sedation and 381 (9.8%) patients tested without sedation. Overall, 442 (11.3%) patients had prolonged stay (>100 min). The mean time difference between sedation group and non-sedation group was 44.2 minutes for esophagogastroduodenoscopy and 39.1 minutes for colonoscopy. Age (odds ratio [OR], 1.025; 95% confidence interval [CI], 1.014−1.036), female sex (OR, 1.657; 95% CI, 1.220−2.249), and midazolam dose (OR, 1.019; 95% CI, 1.013−1.026) were independently associated with prolonged hospital stay after esophagogastroduodenoscopy, with similar results for colonoscopy.
Conclusions
Old age, female sex, and midazolam dose were independent risk factors for prolonged hospital stay after endoscopy.

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Comparison of sedation with pentazocine or pethidine hydrochloride for endoscopic ultrasonography in outpatients: A single‐center retrospective study
Makiko Urabe, Kenji Ikezawa, Yusuke Seiki, Ko Watsuji, Yasuharu Kawamoto, Takeru Hirao, Yugo Kai, Ryoji Takada, Takuo Yamai, Kaori Mukai, Tasuku Nakabori, Hiroyuki Uehara, Kazuyoshi Ohkawa
DEN Open.2025;[Epub] CrossRef
Timing of Endoscopic Intervention for Esophageal Food Impaction and Its Impact on Patient Outcomes
Mark S. Obri, Momin Samad, Suhib Alhaj, Ammad Chaudhary, Sheema Rehman, M. Ramzi Almajed, Courtney Rose, Lonni Schultz, Kevin Harris, Suraj Suresh
Digestive Diseases and Sciences.2024; 69(10): 3835. CrossRef
Drugs used for sedation in gastrointestinal endoscopy
Jun Kyu Lee
Journal of the Korean Medical Association.2022; 65(11): 735. CrossRef
TXI (Texture and Color Enhancement Imaging) for Serrated Colorectal Lesions
Toshihiro Nishizawa, Osamu Toyoshima, Shuntaro Yoshida, Chie Uekura, Ken Kurokawa, Munkhbayar Munkhjargal, Miho Obata, Tomoharu Yamada, Mitsuhiro Fujishiro, Hirotoshi Ebinuma, Hidekazu Suzuki
Journal of Clinical Medicine.2021; 11(1): 119. CrossRef

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Impact of Moderate versus Deep Sedation and Trainee Participation on Adenoma Detection Rate-Analysis of a Veteran Population: Hemnishil K. Marella, Nasir Saleem, Claudio Tombazzi; Clin Endosc 2021;54(2):250-255. Published online December 15, 2020; DOI: https://doi.org/10.5946/ce.2020.091

Abstract PDF PubReader ePub

Background
/Aims: The adenoma detection rate (ADR) is used as a quality indicator for screening and surveillance colonoscopy. The study aimed to determine if moderate versus deep sedation affects the outcomes of the ADR and other quality metrics in the veteran population.
Methods
A retrospective review of colonoscopies performed at Memphis Veterans Affairs Medical Center over a one-year period was conducted. A total of 900 colonoscopy reports were reviewed. After exclusion criteria, a total of 229 index, average-risk screening colonoscopies were identified. Data were collected to determine the impact of moderate (benzodiazepine plus opioids) versus deep (propofol) sedation on the ADR, polyp detection rate (PDR), and withdrawal time.
Results
Among 229 screening colonoscopies, 103 (44.9%) used moderate sedation while 126 (55%) were done under deep sedation. The ADR and PDR were not significantly different between moderate versus deep sedation at 35.9% vs. 37.3% (p=0.82) and 58.2% vs. 48.4% (p=0.13), respectively. Similarly, there was no significant difference in withdrawal time between moderate and deep sedation (13.4 min vs. 14 min, p=0.56) during screening colonoscopies.
Conclusions
In veterans undergoing index, average-risk screening colonoscopies, the quality metrics of the ADR, PDR, and withdrawal time are not influenced by deep sedation compared with moderate sedation.

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AI-powered medical devices for practical clinicians including the diagnosis of colorectal polyps
Donghwan Kim, Eunsun Kim
Journal of the Korean Medical Association.2023; 66(11): 658. CrossRef
Patient Satisfaction, at What Cost?
Byron P. Vaughn
Clinical Gastroenterology and Hepatology.2022; 20(4): e912. CrossRef
Impact of sedation type on adenoma detection rate by colonoscopy
Hawraa Tarhini, Ayman Alrazim, Wissam Ghusn, Mohammad Hosni, Anthony Kerbage, Assaad Soweid, Ala-I Sharara, Fadi Mourad, Fadi Francis, Yasser Shaib, Kassem Barada, Fady Daniel
Clinics and Research in Hepatology and Gastroenterology.2022; 46(7): 101981. CrossRef
Safety, Efficacy and High-Quality Standards of Gastrointestinal Endoscopy Procedures in Personalized Sedoanalgesia Managed by the Gastroenterologist: A Retrospective Study
Marina Rizzi, Francesco Panzera, Demetrio Panzera, Berardino D’Ascoli
Journal of Personalized Medicine.2022; 12(7): 1171. CrossRef

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Safety and Recipient Satisfaction of Propofol Sedation in Outpatient Endoscopy: A 24-Hour Prospective Investigation Using a Questionnaire Survey: Yoshihide Kanno, Tetsuya Ohira, Yoshihiro Harada, Shinsuke Koshita, Takahisa Ogawa, Hiroaki Kusunose, Yoshiki Koike, Taku Yamagata, Toshitaka Sakai, Kaori Masu, Keisuke Yonamine, Kazuaki Miyamoto, Megumi Tanaka, Tomohiro Shimada, Fumisato Kozakai, Kazuki Endo, Haruka Okano, Daichi Komabayashi, Takeshi Shimizu, Shohei Suzuki, Kei Ito; Clin Endosc 2021;54(3):340-347. Published online December 11, 2020; DOI: https://doi.org/10.5946/ce.2020.138

Abstract PDF PubReader ePub

Background
/Aims: The aim of this study was to evaluate the safety of sedation with propofol as an alternative to benzodiazepine drugs in outpatient endoscopy.
Methods
In this prospective study, examinees who underwent outpatient endoscopy under propofol sedation and submitted a nextday questionnaire with providing informed consent were evaluated. Periprocedural acute responses, late adverse events within 24 hours, and examinee satisfaction were evaluated.
Results
Among the 4,122 patients who received propofol in the 17,978 outpatient-based endoscopic examinations performed between November 2016 and March 2018, 2,305 eligible examinees (esophagogastroduodenoscopy for 1,340, endoscopic ultrasonography for 945, and total colonoscopy for 20) were enrolled, and their responses to a questionnaire were analyzed. The mean propofol dose was 69.6±24.4 mg (range, 20–200 mg). Diazepam, midazolam, and/or pentazocine in combination with propofol was administered to 146 examinees. Mild oxygen desaturation was observed in 59 examinees (2.6%); and mild bradycardia, in 2 (0.09%). Other severe reactions or late events did not occur. After eliminating 181 invalid responses, 97.7% (2,065/2,124) of the patients desired propofol sedation in future examinations.
Conclusions
Propofol sedation was found to be safe—without severe adverse events or accidents—for outpatient endoscopy on the basis of the patients’ next-day self-evaluation. Given the high satisfaction level, propofol sedation might be an ideal tool for painless endoscopic screening.

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Comparison of sedation with pentazocine or pethidine hydrochloride for endoscopic ultrasonography in outpatients: A single‐center retrospective study
Makiko Urabe, Kenji Ikezawa, Yusuke Seiki, Ko Watsuji, Yasuharu Kawamoto, Takeru Hirao, Yugo Kai, Ryoji Takada, Takuo Yamai, Kaori Mukai, Tasuku Nakabori, Hiroyuki Uehara, Kazuyoshi Ohkawa
DEN Open.2025;[Epub] CrossRef
Remimazolam and Its Place in the Current Landscape of Procedural Sedation and General Anesthesia
Matthew Brohan, Janette Brohan, Basavana Goudra
Journal of Clinical Medicine.2024; 13(15): 4362. CrossRef
How to implement adverse events as a quality indicator in gastrointestinal endoscopy
Tom G. Moreels
Digestive Endoscopy.2024; 36(1): 89. CrossRef
Propofol Alone versus Propofol in Combination with Midazolam for Sedative Endoscopy in Patients with Paradoxical Reactions to Midazolam
Ji Hyung Nam, Dong Kee Jang, Jun Kyu Lee, Hyoun Woo Kang, Byung-Wook Kim, Byung Ik Jang
Clinical Endoscopy.2022; 55(2): 234. CrossRef
Drugs used for sedation in gastrointestinal endoscopy
Jun Kyu Lee
Journal of the Korean Medical Association.2022; 65(11): 735. CrossRef

4,724 View
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Comparison of Fentanyl versus Meperidine in Combination with Midazolam for Sedative Colonoscopy in Korea: Gwan Woo Hong, Jun Kyu Lee, Jung Hyeon Lee, Ji Hun Bong, Sung Hun Choi, Hyeki Cho, Ji Hyung Nam, Dong Kee Jang, Hyoun Woo Kang, Jae Hak Kim, Yun Jeong Lim, Moon Soo Koh, Jin Ho Lee; Clin Endosc 2020;53(5):562-567. Published online July 3, 2020; DOI: https://doi.org/10.5946/ce.2020.022

Abstract PDF PubReader ePub

Background
/Aims: Combination of midazolam and opioids is used widely for endoscopic sedation. Compared with meperidine, fentanyl is reportedly associated with rapid recovery, turnover rate of endoscopy room, and quality of endoscopy. We compared fentanyl with meperidine when combined with midazolam for sedative colonoscopy.
Methods
A retrospective, cross-sectional, 1:2 matching study was conducted. Induction and recovery time were compared as the primary outcomes. Moreover, cecal intubation time, withdrawal time, total procedure time of colonoscopy, paradoxical reaction, adenoma detection rate, and adverse effect of midazolam or opioids were assessed as the secondary outcomes.
Results
A total of 129 subjects (43 fentanyl vs. 86 meperidine) were included in the analysis. The fentanyl group showed significantly more rapid induction time (4.5±2.7 min vs. 7.5±4.7 min, p<0.001), but longer recovery time (59.5±25.6 min vs. 50.3±10.9 min, p=0.030) than the meperidine group. In multivariate analysis, the induction time of the fentanyl group was 3.40 min faster (p<0.001), but the recovery time was 6.38 min longer (p=0.046) than that of the meperidine group. There was no difference in withdrawal time and adenoma detection rate between the two groups.
Conclusions
The fentanyl group had more rapid sedation induction time but longer recovery time than the meperidine group.

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Roberto Piro, Eleonora Casalini, Matteo Fontana, Carla Galeone, Patrizia Ruggiero, Sofia Taddei, Giulia Ghidoni, Giulia Patricelli, Nicola Facciolongo
Thoracic Cancer.2022; 13(4): 533. CrossRef
Propofol Alone versus Propofol in Combination with Midazolam for Sedative Endoscopy in Patients with Paradoxical Reactions to Midazolam
Ji Hyung Nam, Dong Kee Jang, Jun Kyu Lee, Hyoun Woo Kang, Byung-Wook Kim, Byung Ik Jang
Clinical Endoscopy.2022; 55(2): 234. CrossRef
[Retracted] Efficacy of Analgesic Propofol/Esketamine and Propofol/Fentanyl for Painless Induced Abortion: A Randomized Clinical Trial
Naixing Xin, Wei Yan, Shuangfen Jin, Min Tang
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Endoscopist-Driven Sedation Practices in South Korea: Re-evaluation Considering the Nationwide Survey in 2019
Seon-Young Park, Jun Kyu Lee, Chang-Hwan Park, Byung-Wook Kim, Chang Kyun Lee, Hong Jun Park, Byung Ik Jang, Dong Uk Kim, Jin Myung Park, Jae Min Lee, Young Sin Cho, Hyung Ku Chon, Seung Young Seo, Woo Hyun Paik
Gut and Liver.2022; 16(6): 899. CrossRef
Drugs used for sedation in gastrointestinal endoscopy
Jun Kyu Lee
Journal of the Korean Medical Association.2022; 65(11): 735. CrossRef
Risk Factors for Prolonged Hospital Stay after Endoscopy
Toshihiro Nishizawa, Shuntaro Yoshida, Osamu Toyoshima, Tatsuya Matsuno, Masataka Irokawa, Toru Arano, Hirotoshi Ebinuma, Hidekazu Suzuki, Takanori Kanai, Kazuhiko Koike
Clinical Endoscopy.2021; 54(6): 851. CrossRef

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Special Review: Korean Society of Gastrointestinal Endoscopy “Accreditation of Qualified Endoscopy Unit” Guideline: Update 2019

Updates on the Sedation for Gastrointestinal Endoscopy: Jun Kyu Lee, Yoo Jin Lee, Jun Hyung Cho, Jong Pil Im, Chang-Hwan Park, Jae-Young Jang, Byung Ik Jang, the Quality Management Committee and the Disinfection Management/Conscious Sedation Committee of Korean Society of Gastrointestinal Endoscopy (KSGE); Clin Endosc 2019;52(5):451-457. Published online September 30, 2019; DOI: https://doi.org/10.5946/ce.2019.172

Abstract PDF Supplementary Material PubReader ePub

Sedation, defined as the depressed level of consciousness, induced by drug administration, is widely used for gastrointestinal endoscopy to relieve a patient’s anxiety and discomfort. In addition, successful procedure is anticipated with control of unintended movements. Endoscopic sedation, however, cannot be free from the risk of serious adverse events, e.g., cardiopulmonary compromise. Therefore, principles on personnel, facility and equipment, as well as performance itself, should be followed to prevent unfavorable incidents. In this article, sedation guidelines for the Accreditation of Qualified Endoscopy Units, issued by the Korean Society of Gastrointestinal Endoscopy, are presented.

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Andrea Minciullo, Lucia Filomeno
Gastroenterology Nursing.2024; 47(1): 33. CrossRef
Sedation reversal trends at outpatient ambulatory endoscopic center vs in-hospital ambulatory procedure center using a triage protocol
Saqib Walayat, Peter Stadmeyer, Azfar Hameed, Minahil Sarfaraz, Paul Estrada, Mark Benson, Anurag Soni, Patrick Pfau, Paul Hayes, Brittney Kile, Toni Cruz, Deepak Gopal
World Journal of Gastrointestinal Endoscopy.2024; 16(7): 413. CrossRef
Propofol Alone versus Propofol in Combination with Midazolam for Sedative Endoscopy in Patients with Paradoxical Reactions to Midazolam
Ji Hyung Nam, Dong Kee Jang, Jun Kyu Lee, Hyoun Woo Kang, Byung-Wook Kim, Byung Ik Jang
Clinical Endoscopy.2022; 55(2): 234. CrossRef
Endoscopist-Driven Sedation Practices in South Korea: Re-evaluation Considering the Nationwide Survey in 2019
Seon-Young Park, Jun Kyu Lee, Chang-Hwan Park, Byung-Wook Kim, Chang Kyun Lee, Hong Jun Park, Byung Ik Jang, Dong Uk Kim, Jin Myung Park, Jae Min Lee, Young Sin Cho, Hyung Ku Chon, Seung Young Seo, Woo Hyun Paik
Gut and Liver.2022; 16(6): 899. CrossRef
Drugs used for sedation in gastrointestinal endoscopy
Jun Kyu Lee
Journal of the Korean Medical Association.2022; 65(11): 735. CrossRef
Pain Intensity at Injection Site during Esophagogastroduodenoscopy Using Long- and Medium-Chain versus Long-Chain Triglyceride Propofol: A Randomized Controlled Double-Blind Study
Joon Seop Lee, Eun Soo Kim, Kwang Bum Cho, Kyung Sik Park, Yoo Jin Lee, Ju Yup Lee
Gut and Liver.2021; 15(4): 562. CrossRef
A Nationwide Survey on the Facilities and Personnel for Endoscopic Sedation: Results from 50 Qualified Endoscopy Units of Teaching Hospitals Accredited by the Korean Society of Gastrointestinal Endoscopy (KSGE)
Seon-Young Park, Jun Kyu Lee, Jung-Wook Kim, Tae Hee Lee, Chang-Hwan Park, Jae-Yong Jang, Byung-Wook Kim, Byung Ik Jang
Clinical Endoscopy.2021; 54(6): 843. CrossRef
Risk Factors for Prolonged Hospital Stay after Endoscopy
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Clinical Endoscopy.2021; 54(6): 851. CrossRef

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Focused Review Series: Endoscopy in Children

Sedation in Pediatric Esophagogastroduodenoscopy: Seak Hee Oh; Clin Endosc 2018;51(2):120-128. Published online March 30, 2018; DOI: https://doi.org/10.5946/ce.2018.028

Abstract PDF PubReader ePub

Pediatric esophagogastroduodenoscopy (EGD) has become an established diagnostic and therapeutic modality in pediatric gastroenterology. Effective sedation strategies have been adopted to improve patient tolerance during pediatric EGD. For children, safety is a fundamental consideration during this procedure as they are at a higher risk of severe adverse events from procedural sedation compared to adults. Therefore, a detailed risk evaluation is required prior to the procedure, and practitioners should be aware of the benefits and risks associated with sedation regimens during pediatric EGD. In addition, pediatric advanced life support by endoscopists or immediate intervention by anesthesiologists should be available in the event that severe adverse events occur during pediatric EGD.

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Propofol Sedation in Pediatric Upper Endoscopy: A Study of Pharmacodynamics and the Effects of Gastroenterologists, Anesthesiologists, and Supervised Participants on the Procedure Time and Sedation Time
Ahila Manivannan, Shailender Madani, Michael Woodall, George McKelvey , Sharon Kemper
Cureus.2024;[Epub] CrossRef
Comparison of Ketamine and Propofol-Based Regimens for Deep Sedation in Children Undergoing Esophagogastroduodenoscopy
Olugbenga Akingbola, Sudesh K. Srivastav, Michelle Nguyen, Dinesh Singh, Edwin M. Frieberg, Amy Thibodeaux
Journal of Pediatric Intensive Care.2022; 11(01): 019. CrossRef
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Ankit Dalal, Nagesh Kamat, Gaurav Patil, Rajen Daftary, Amit Maydeo
Endoscopy International Open.2022; 10(02): E192. CrossRef
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Chi-Wen Hung, Solomon Chih-Chen Chen, Li-Jung Elizabeth Ku, Bor-Shyang Sheu, Yao-Jong Yang
Frontiers in Pediatrics.2022;[Epub] CrossRef
Low‐dose adjuvant dexmedetomidine did not decrease propofol sedation requirements in children undergoing gastrointestinal endoscopy
Eric G. Johnson, Sarah G. Weaver, Kelsey L. Batt, Robert H. Weaver, Aric Schadler, Sarah J. Hall
Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy.2022; 42(10): 792. CrossRef
Gastrointestinal endoscopy in children and adults: How do they differ?
Sara Isoldi, Salvatore Cucchiara, Alessandro Repici, Diana G. Lerner, Mike Thomson, Salvatore Oliva
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Safety and Competency are the Main Priorities in Pediatric Endoscopy
Byung-Ho Choe
Clinical Endoscopy.2020; 53(4): 379. CrossRef
Letter to the Editor: Is Propofol Good Choice for Procedural Sedation? Evaluation of Propofol in Comparison with Other General Anesthetics for Surgery in Children Younger than 3 Years
Soon Chul Kim
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Dexamethasone Reduces Postoperative Nausea in Pediatric Upper Endoscopy With Deep Sedation
Hamed Moheimani, Mehdi Yaseri
Journal of Pediatric Gastroenterology and Nutrition.2019; 69(3): 281. CrossRef

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Original Article

Considerable Variability of Procedural Sedation and Analgesia Practices for Gastrointestinal Endoscopic Procedures in Europe: Hermanus H. B. Vaessen, Johannes T. A. Knape; Clin Endosc 2016;49(1):47-55. Published online January 28, 2016; DOI: https://doi.org/10.5946/ce.2016.49.1.47

Abstract PDF PubReader ePub

Background
/Aims: The use of moderate to deep sedation for gastrointestinal endoscopic procedures has increased in Europe considerably. Because this level of sedation is a risky medical procedure, a number of international guidelines have been developed. This survey aims to review if, and if so which, quality aspects have been included in new sedation practices when compared to traditional uncontrolled sedation practices.
Methods
A questionnaire was sent to the National Associations of Nurse Anesthetists in Europe and the National Delegates of the European Section and Board of Anaesthesiology from January 2012 to August 2012.
Results
Huge variation in practices for moderate to deep sedation were identified between and within European countries in terms of safety, type of practitioners, responsibilities, monitoring, informed consent, patient satisfaction, complication registration, and training requirements. Seventy-five percent of respondents were not familiar with international sedation guidelines. Safe sedation practices (mainly propofol-based moderate to deep sedation) are rapidly gaining popularity.
Conclusions
The risky medical procedure of moderate to deep sedation has become common practice for gastrointestinal endoscopy. Safe sedation practices requiring adequate selection of patients, adequate monitoring, training of sedation practitioners, and adequate after-care, are gaining attention in a field that is in transition from uncontrolled sedation care to controlled sedation care.

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The effectiveness of esketamine and propofol versus dezocine and propofol sedation during gastroscopy: A randomized controlled study
Yafei Xu, Yuling Zheng, Tianying Tang, Lvlv Chen, Yiwen Zhang, Zhongqi Zhang
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Lili Tang, Chenxuan Ye, Nan Wang, Chen Chen, Sirui Chen, Shan Gao, Xuesheng Liu
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Review

Prerequisites of Colonoscopy: Kyong Hee Hong, Yun Jeong Lim; Clin Endosc 2014;47(4):324-329. Published online July 28, 2014; DOI: https://doi.org/10.5946/ce.2014.47.4.324

Abstract PDF PubReader ePub

Colonoscopy is a widely accepted method for the evaluation of the colon and terminal ileum. Its diagnostic accuracy and therapeutic safety are influenced by prerequisites, including modulation of medication and bowel cleansing. Appropriate choices of sedative medication and bowel-cleansing regimen, together with diet modification, should be made based on the patient's underlying disease, age, and medication intake. Moreover, effective methods for patient education regarding bowel preparation should be considered.

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Randomized Controlled Trial of Sodium Phosphate Tablets versus 2 L Polyethylene Glycol Solution for Bowel Cleansing prior to Colonoscopy
Yun Ho Lee, Seong Yeon Jeong, You Sun Kim, Hye Jin Jung, Min Jung Kwon, Cheol Hun Kwak, Song I Bae, Jeong Seop Moon, Ji Won Kim, Su Hwan Kim, Kook Lae Lee
The Korean Journal of Gastroenterology.2015; 65(1): 27. CrossRef
Highlights from the 50th Seminar of the Korean Society of Gastrointestinal Endoscopy
Eun Young Kim, Il Ju Choi, Kwang An Kwon, Ji Kon Ryu, Seok Ho Dong, Ki Baik Hahm
Clinical Endoscopy.2014; 47(4): 285. CrossRef

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Focused Review Series: Endoscopic Sedation Revisited: Principles and Practices

Endoscopic Sedation: Risk Assessment and Monitoring: Young Chul Yoo; Clin Endosc 2014;47(2):151-154. Published online March 31, 2014; DOI: https://doi.org/10.5946/ce.2014.47.2.151

Abstract PDF PubReader ePub

Sedation for endoscopic procedures is done to increase patient comfort and endoscopic performance. Drugs used for sedation suppress respiratory and cardiovascular function, and while the degree of suppression may vary, it may be fatal in certain patients. The aim of this article is to provide an overview and brief summary of presedation risk assessment and monitoring during and after sedation in order to maintain patient safety.

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Yahia Al-Hagawi, Nasser I Alqahtani, Saeed Nasser Alsharif, Rafaat Chakik, Dawlah Hadi Asiri, Salihah Y Al mani, Azizah Badawi, Haneen Ahmad Al-assiri, Hana Saeed Al Malih, Hend Alamri, Amjad Saad AlAli, Aisha A Ali Alqhtani, Asiah A Al-BinAbdullah, Moha
Cureus.2024;[Epub] CrossRef
Ciprofol versus propofol for adult sedation in gastrointestinal endoscopic procedures: a systematic review and meta-analysis
Guilherme H. ORTEGAL, Eduardo C. BARBOSA, Pedro C. FARIA, João V. COUTO, Guilherme C. SILVA, Márcio H. SOUZA, Lucas N. FERREIRA, Vitor R. MORAES, Maria C. CAMPOS, Luiza A. CAMPOS
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Colonoscopy: an evidence-based approach
Lucy Kelly
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Sung Hak Lee, Pyung Kang Park, Kyoung Young Lee, Woo-Cho Chung, Seung Goun Hong
Soonchunhyang Medical Science.2015; 21(2): 121. CrossRef

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Endoscopic Sedation: From Training to Performance: Tae Hoon Lee, Chang Kyun Lee; Clin Endosc 2014;47(2):141-150. Published online March 31, 2014; DOI: https://doi.org/10.5946/ce.2014.47.2.141

Abstract PDF PubReader ePub

Adequate sedation and analgesia are considered essential requirements to relieve patient discomfort and pain and ultimately to improve the outcomes of modern gastrointestinal endoscopic procedures. The willingness of patients to undergo sedation during endoscopy has increased steadily in recent years and standard sedation practices are needed for both patient safety and successful procedural outcomes. Therefore, regular training and education of healthcare providers is warranted. However, training curricula and guidelines for endoscopic sedation may have conflicts according to varying legal frameworks and/or social security systems of each country, and well-recognized endoscopic sedation training systems are not currently available in all endoscopy units. Although European and American curricula for endoscopic sedation have been extensively developed, general curricula and guidelines for each country and institution are also needed. In this review, an overview of recent curricula and guidelines for training and basic performance of endoscopic sedation is presented based on the current literature.

Citations

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Sedation Regimens for Gastrointestinal Endoscopy: Sung-Hoon Moon; Clin Endosc 2014;47(2):135-140. Published online March 31, 2014; DOI: https://doi.org/10.5946/ce.2014.47.2.135

Abstract PDF PubReader ePub

Sedation allows patients to tolerate unpleasant endoscopic procedures by relieving anxiety, discomfort, or pain. It also reduces a patient's risk of physical injury during endoscopic procedures, while providing the endoscopist with an adequate setting for a detailed examination. Sedation is therefore considered by many endoscopists to be an essential component of gastrointestinal endoscopy. Endoscopic sedation by nonanesthesiologists is a worldwide practice and has been proven effective and safe. Moderate sedation/analgesia is generally accepted as an appropriate target for sedation by nonanesthesiologists. This focused review describes the general principles of endoscopic sedation, the detailed pharmacology of sedatives and analgesics (focused on midazolam, propofol, meperidine, and fentanyl), and the multiple regimens available for use in actual practice.

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Endoscopist-Directed Propofol: Pros and Cons: Eun Hye Kim, Sang Kil Lee; Clin Endosc 2014;47(2):129-134. Published online March 31, 2014; DOI: https://doi.org/10.5946/ce.2014.47.2.129

Abstract PDF PubReader ePub

Concerns about the safety of endoscopist-directed propofol (EDP) have been voiced that propofol should be given only by healthcare professionals trained in the administration of general anesthesia. Here we discuss the safety and drawbacks of EDP for routine endoscopic procedures. Currently, both diagnostic and therapeutic endoscopy are well tolerated and accepted by both patients and endoscopists due to the application of sedation in most clinics worldwide. Accordingly, propofol use is increasing in many countries. It is crucial for endoscopists to be very familiar with the use of propofol or a combination of drugs. However, the controversy regarding the administration of sedation by an endoscopist or an anesthesiologist continues. Until now, there have been no randomized control trials comparing sedation induced by propofol administered by an endoscopist or by an anesthesiologist. It might be difficult to perform this kind of study. For the convenience and safety of sedative endoscopy, it would be important that EDP be generally applied to endoscopic procedures, and for more safety, an anesthesiologist may automatically take care of particular patients at high risk of suffering from propofol side effects.

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Original Articles

Comparison between Midazolam Used Alone and in Combination with Propofol for Sedation during Endoscopic Retrograde Cholangiopancreatography: Yu Seok Kim, Myung-Hwan Kim, Seung Uk Jeong, Byung Uk Lee, Sang Soo Lee, Do Hyun Park, Dong-Wan Seo, Sung Koo Lee; Clin Endosc 2014;47(1):94-100. Published online January 24, 2014; DOI: https://doi.org/10.5946/ce.2014.47.1.94

Abstract PDF PubReader ePub

Background/Aims

Endoscopic retrograde cholangiopancreatography (ERCP) is an uncomfortable procedure that requires adequate sedation for its successful conduction. We investigated the efficacy and safety of the combined use of intravenous midazolam and propofol for sedation during ERCP.

Methods

A retrospective review of patient records from a single tertiary care hospital was performed. Ninety-four patients undergoing ERCP received one of the two medication regimens, which was administered by a nurse under the supervision of a gastroenterologist. Patients in the midazolam (M) group (n=44) received only intravenous midazolam, which was titrated to achieve deep sedation. Patients in the midazolam pulse propofol (MP) group (n=50) initially received an intravenous combination of midazolam and propofol, and then propofol was titrated to achieve deep sedation.

Results

The time to the initial sedation was shorter in the MP group than in the M group (1.13 minutes vs. 1.84 minutes, respectively; p<0.001). The recovery time was faster in the MP group than in the M group (p=0.031). There were no significant differences between the two groups with respect to frequency of adverse events, pain experienced by the patient, patient discomfort, degree of amnesia, and gag reflex. Patient cooperation, rated by the endoscopist as excellent, was greater in the MP group than in the M group (p=0.046).

Conclusions

The combined use of intravenous midazolam and propofol for sedation during ERCP is more effective than midazolam alone. There is no difference in the safety of the procedure.

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Comparison of Midazolam Alone versus Midazolam Plus Propofol during Endoscopic Submucosal Dissection: Young Shim Cho, Euikeun Seo, Jung-Ho Han, Soon Man Yoon, Hee Bok Chae, Seon Mee Park, Sei Jin Youn; Clin Endosc 2011;44(1):22-26. Published online September 30, 2011; DOI: https://doi.org/10.5946/ce.2011.44.1.22; Retraction in: Clin Endosc 2012;45(1):108

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Conscious Sedation During Gastrointestinal Endoscopy: Midazolam vs Propofol: Ja Seol Koo, M.D. and Jai Hyun Choi, M.D.; Korean J Gastrointest Endosc 2011;42(2):67-73. Published online February 28, 2011

Abstract PDF: Endoscopy is increasingly performed with the patient under conscious sedation in many countries. The majority of patients can be adequately and safely sedated during routine upper endoscopy and colonoscopy with a combination of a benzodiazepine and opioid. Midazolam is a water-soluble benzodiazepine that is characterized by a rapid onset of action and a shorter duration compared with that of the other drugs of the same class. The major side effect of midazolam is respiratory depression, which can be reversed by flumazenil, a benzodiazepine-specific antagonist. Propofol is a lipid-soluble agent that has the advantages of a more rapid onset of action and a shorter recovery time compared to that of midazolam. However, it should be used with caution since it can lead to hypotension and respiratory depression. Propofol can be safely and effectively administered by nonanesthesiology physicians and nurses provided that they have received adequate training. Two models have been proposed for the administration of propofol by endoscopists: nurse-administered propofol sedation (NAPS) and combination propofol (propofol plus other agents) sedation. In order to modify the pharmacological disadvantages of propofol, fospropofol sodium, a water-soluble prodrug of propofol, has recently been developed. In addition, new delivery systems have been devised: patient-controlled sedation and computer-assisted personalized sedation, in which the computer continuously monitors the patient's condition and adjusts the dose of propofol accordingly. Endoscopists must have a thorough understanding of the medications used for endoscopic sedation and they must acquire the skills necessary for the treatment of cardiopulmonary complications. Therefore, it is necessary to develop a practice guideline pertaining to endoscopic sedation and also training programs for physicians and nurses in Korea. (Korean J Gastrointest Endosc 2011;42:67-73)

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Risk Factors for Delayed Bleeding after Colonoscopic Polypectomy: Woo Jin Han, M.D., Yoon Jae Kim, M.D., Jung Gon Kim, M.D., Tae Kyung Kim, M.D., Seo Young Lee, M.D., Moon Sook Cho, M.D., Jun Won Chung, M.D., Dong Kyun Park, M.D., Ki Baik Hahm, M.D., Yun Soo Kim, M.D. and Ju Hyun Kim, M.D.; Korean J Gastrointest Endosc 2010;40(3):164-169. Published online March 30, 2010

Abstract PDF: Background
/Aims: The aim of this study was to identify risk factors for delayed bleeding after colonoscopic polypectomy.
Methods
3,530 polypectomies in 1,542 patients were evaluated. Risk factors were identified among patient-related factors (age, sex, comorbidity, anticoagulants, antiplatelets), polyp-related factors (size, shape, location, histology), and procedure-related factors (experience of the endoscopist, sedation, resection method).
Results
Delayed bleeding occurred in 26 lesions (0.7%) of 24 patients (1.6%). Polyp-based multivariate analysis revealed that polyp size greater than 15 mm (OR, 2.882; 95% CI, 1.106 to 7.506; p=0.030) and sedation-free colonoscopy (OR, 2.606; 95% CI, 1.116 to 6.084; p=0.027) were significant risk factors for delayed bleeding after polypectomy. In colonoscopy-based analysis, hypertension increased the risk of delayed bleeding after polypectomy (OR, 2.938; 95% CI, 1.009 to 8.557; p=0.048).
Conclusions
Large polyp size, sedation-free colonoscopy, and hypertension are associated with delayed bleeding after colonoscopic polypectomy. (Korean J Gastrointest Endosc 2010;40:164-169)

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A Gigantic Gastric Mucosal Rupture When Performing Endoscopy under Conscious Sedation in a Patient with Hiatal Hernia: Pyoung Rak Choi, M.D., Won Moon, M.D., Chan Bok Park, M.D., Eun Ho Park, M.D., Ji Suk Lee, M.D., Kyu Jong Kim, M.D., Moo In Park, M.D. and Seun Ja Park, M.D.; Korean J Gastrointest Endosc 2009;38(3):137-141. Published online March 30, 2009

Abstract PDF: Mallory-Weiss syndrome is a tear in the gastro-esophageal junction or its adjacent mucosa, and this occurs due to nausea or vomiting that is caused by various etiologic factors. It may occur in patients with excessive retching and struggling when undergoing upper gastrointestinal endoscopy, and its underlying factors are esophageal hiatal hernia, atrophic gastritis and old age. There are currently only rare reports about gigantic gastric mucosal rupture during performance of upper gastrointestinal endoscopy in patients with esophageal hiatal hernia. We recently experienced a 76-year-old woman who developed a gigantic gastric mucosal rupture that ranged from the gastro-esophageal junction to the gastric angle. This occurred during performance of standard upper gastrointestinal endoscopy with the patient under sedation and the patient had a concurrent esophageal hiatal hernia. The patient was treated conservatively for the rupture. Herein we report on our case along with a review of the relevant literature. (Korean J Gastrointest Endosc 2009;38:137-141)

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A Case of Esophageal Submucosal Dissection that Developed during Conscious Sedation Endoscopy: Hong Jun You, M.D., Moo In Park, M.D., Kyu Jong Kim, M.D., Won Moon, M.D., Sun Jung Kim, M.D., Sung Woo Yang, M.D., Se Young Park, M.D., Woo Seong Jeon, M.D., Dong Yang Park, M.D., Jun Young Song, M.D. and Seun Ja Park, M.D.; Korean J Gastrointest Endosc 2007;35(5):328-331. Published online November 30, 2007

Abstract PDF: Esophageal submucosal dissection is a rare condition, resulting in the separation of the submucosa and muscle layer by mucosal laceration and bleeding. Possible causes are external trauma, foreign body entrapment, endoscopic instrumentation and even spontaneous dissection. Typical endoscopic findings show a false lumen from the torn mucosa and a muscle layer in the false lumen. Esophagography shows a "double barrelled" appearance. A dissection can be resolved with conservative management. We experienced a case of a submucosal dissection of the esophagus with perforation, an unusual complication of conscious sedation endoscopy. (Korean J Gastrointest Endosc 2007;35:328-331)

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Conscious Sedation with Midazolam Combined with Propofol for Colonoscopy: Ja Seol Koo, M.D., Jai Hyun Choi, M.D., Sung Woo Jung, M.D., Woo Sik Han, M.D., Jong Sup Lee, M.D., Hyung Joon Yim, M.D., Yoon Tae Jeen, M.D., Hoon Jai Chun, M.D., Hong Sik Lee, M.D., Sang Woo Lee, M.D., Chang Duck Kim, M.D. and Ho Sang Ryu, M.D.; Korean J Gastrointest Endosc 2007;34(6):298-303. Published online June 30, 2007

Abstract PDF: Background/Aims: There is increasing interest in the use of propofol as a sedative agent for colonoscopy. We evaluated the safety and efficacy of the synergistic sedation with midazolam combined with low-dose propofol versus that of midazolam alone. Methods: A total of 56 patients from among those who underwent total colonoscopy between August 2004 and October 2004 were randomly assigned to one of three medication treatment groups. Group A (n=18) received low-dose midazolam (0.03 mg/kg IV) plus propofol, group B (n=19) received high-dose midazolam (0.07 mg/kg IV) plus propofol, and group C (n=19) received high-dose midazolam alone. The patients' vital signs were monitored throughout the course of the study. The recovery time and quality as well as the patients' comfort level were also assessed. Results: There were no significant differences in baseline characteristics among the treatment groups. There were also no differences in the duration and insertion time of the colonoscopy among the three groups. The patients' comfort level and cardiorespiratory parameters during colonoscopy were similar among the three groups. The sedation efficacy and recovery times were also similar among the three groups. Conclusions: Midazolam combined with low-dose propofol as a sedative for colonoscopy exhibits similar effects on safety, patient' comfort level and recovery time to those of midazolam alone.

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The Evalution of Patient Anxiety Associated with Upper Gastrointestinal Endoscopy: Jin Su Jang, M.D., Moon Kyung Joo, M.D., Jin Nam Kim, M.D., Yong Sik Kim, M.D., Yoon Tae Jeen, M.D., Hoon Jai Chun, M.D., Hong Sik Lee, M.D., Sang Woo Lee, M.D., Jai Hyun Choi, M.D., Chang Duck Kim, M.D. and Ho Sang Ryu, M.D.; Korean J Gastrointest Endosc 2007;34(2):65-70. Published online March 2, 2007

Abstract PDF: Background
/Aims: Upper gastrointestinal (UGI) endoscopy is a necessary procedure for making the diagnosis of UGI diseases. However, it may evoke anxiety due to the procedural discomfort before endoscopy. There have been few detailed studies that have evaluated the anxiety of patients who undergo UGI endoscopy in Korea. The aim of this study is to evaluate the patient's anxiety associated with UGI endoscopy and to determine the methods to improve the tolerance of patients to UGI endoscopy. Methods: From May to September 2004, we assessed 38 patients who received UGI endoscopy for the first time as outpatients at Korea University, Anam Hospital. One group was examined with UGI endoscopy after being sedated. The patient's anxiety was rated at baseline and immediately before the procedure. Results: Endoscopy was associated with a significant increase in anxiety (prior to procedure, 48.53 vs. baseline, 43.58, p＜0.001) but not trait anxiety (43.92 vs. 43.63, p=0.70). The procedural anxiety was not influenced by gender, age or the education level, but it was correlated with conscious sedation (without CS, 5.67±0.23 vs. with CS, 4.06±0.16, p＜0.05). Conclusions: Sedating the patient during UGI endoscopy is an effective method to lower procedural anxiety.

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An Evaluation of Websites about Endoscopy under Conscious Sedation: Hyun Jeong Lee, M.D., Young Jae Oh, M.D., Il Chol Hong, M.D., Jun Haeng Lee, M.D., Poong-Lyul Rhee, M.D., Jae J. Kim, M.D. and Jong Chul Rhee, M.D.; Korean J Gastrointest Endosc 2006;32(5):307-312. Published online May 30, 2006

Abstract PDF: Background
/Aims: The internet has become an important source of medical information not only for doctors but also for patients. Therefore, this study evaluated the quality of medical information on endoscopy under conscious sedation on the internet in Korea. Methods: 147 patients (mean age: 51 years, male：female 76：71) who visited the gastroenterology clinic were surveyed using a questionnaire about use of medical information on the Internet. The first 20 Internet sites using the key word 'endoscopy under sedation' were retrieved from the 5 most frequently used Internet search engines. The quality of information from a total of 63 websites was evaluated using a checklist. Results: Among a total 63 sites about endoscopy under sedation, 46 sites (73.0%) were made by private hospitals or private clinics and 60 sites (95%) were made for patients. The definition of endoscopy under conscious sedation was accurately mentioned in only 7 sites (11%). The complications and risk factors were mentioned in 29 sites (46%). Conclusions: Most websites made by private hospitals or private clinics overemphasized the merits of sedation. Websites with a more balanced point of view by official organizations may help improve the quality of medical information on the Internet. (Korean J Gastrointest Endosc 2006;32:307⁣312)

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