“Wake Me Up before You Go-Go”. Drug, ‘Wham’, Scope, then Snooze. Can’t We do Better with Conscious Sedation for Endoscopy?

Abstract

The words of British singer George Michael, in the title of the present editorial, might make some of us think back to our halcyon days when we were young, or at least younger; however, I very much doubt he was highlighting the issues surrounding conscious sedation for endoscopy, although I have not actually asked him about this. Nevertheless, the song title perfectly encapsulates a fairly common situation in endoscopy units where patients are either ‘oversedated’, with a significant recovery period, or do not even feel the ‘sedative’ benefits properly until the procedure is actually completed. I am sure endoscopists are all familiar with the situation in which a patient is somewhat combative during an endoscopic procedure but sleeps like a baby for what seems like ages after the procedure has been completed. Despite undoubted advances in this whole sphere, it is glaringly obvious that there is significant room for improvement in how patients are sedated. Dr Michael F Byrne Gastrointestinal (GI) endoscopy is generally performed under conscious sedation. The most common practice, certainly in North America and much of Europe, is to use intravenous doses of benzodiazepines, usually midazolam, and opiates such as meperidine (Demerol, sanofiaventis Canada Inc) or fentanyl with the level of sedation depending to some degree on the type of procedure and the patient. Diazepam is also used quite commonly, either alone or in conjunction with midazolam. Although we generally think of these agents as ‘safe’, morbidity rates of one in 200 to one in 2000, and occasional mortality, usually due to cardiorespiratory complications, have been reported. To address these concerns, organizations such as the American Society of Anesthesiologists and the American Society for Gastrointestinal Endoscopy devised more formal practice guidelines for conscious sedation that included the use of supplemental oxygen and revised dosing guidelines recommending titration of sedative medications rather than bolus doses. The issue of bolus versus titrated sedation would need to be addressed in its own article to do it justice, but it is my impression that most of my colleagues in units across Canada and the United Kingdom use bolus sedation. Having previously worked in the Duke Medical Center in the United States, I shudder at the thought of returning to nurse-directed titration. I recall many instances in Duke where it could take up to 30 min for the patient to be deemed ‘ready’ for endoscopy, particularly for procedures such as endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasonography. Clearly, this would have a huge negative impact on our already suboptimal situation where we are trying to meet an ever increasing demand for endoscopy. It is debatable if titration improves safety or patient satisfaction. Assuming we are stuck with bolus administration, how are we doing with standard sedation using midazolam and fentanyl? My own routine practice is to use 2 mg to 3 mg of midazolam along with 50 μg to 100 μg of fentanyl for colonoscopy, to which I often add 5 mg to 10 mg of diazepam for ERCP. If I do actually sedate patients for upper GI endoscopy, I use 1 mg to 3 mg of midazolam on average. Many of our patients do well with such drug regimens, but we do see a number of patients for whom endoscopy was not a comfortable experience, and we struggle with the amount of time it takes to safely recover the patient before he or she leaves our unit.