Comparison of ASGE guidelines2 and consensus-based practice recommendations
| Category | ASGE guidelines | Consensus-based practice recommendations |
| Preprocedure risk assessment | ‘We recommend that all patients undergoing endoscopic procedures be evaluated to assess their risk of sedation related to pre-existing medical conditions’. | No recommendations provided. |
| Preferred sedative agent | ‘We recommend that the combination of an opioid and benzodiazepine is a safe and effective regimen for achieving minimal to moderate sedation for upper endoscopy and colonoscopy in patients without risk factors for sedation-related adverse events’. ‘Minimal and/or moderate sedation can be delivered safely by endoscopists to patients who are ASA Class I, II, or III. Other candidates for minimal or moderate sedation include those with a history of previously successful procedures with moderate sedation and an expectation for moderate sedation as well as those undergoing a procedure that is expected to be uncomplicated or routine’. ‘We suggest using an appropriate adjunctive agent (e.g., diphenhydramine, promethazine, or droperidol) in combination with conventional sedative drugs in select clinical circumstances’. | All endoscopists performing colonoscopy should be able to complete colonoscopy safely and effectively (per accepted benchmarks) using moderate sedation or less. Deep sedation/propofol only in select circumstances (see below). |
| Personnel capable of administering moderate sedation | ‘Minimal and/or moderate sedation can be delivered safely by endoscopists to patients who are ASA Class I, II, or III. Other candidates for minimal or moderate sedation include those with a history of previously successful procedures with moderate sedation and an expectation for moderate sedation as well as those undergoing a procedure that is expected to be uncomplicated or routine’. ‘Medications targeting minimal and moderate sedation generally can be administered in an incremental fashion by an appropriately trained registered nurse (RN) under the supervision of an endoscopist’. | For patients undergoing routine colonoscopy, endoscopists can safely administer moderate sedation with the assistance of a trained nurse. |
| Skills and training required of endoscopists | ‘We recommend that providers undergo specific training in the administration of endoscopic sedation and possess the skills necessary for the diagnosis and management of sedation-related adverse events, including rescue from a level of sedation deep than that intended’. | All endoscopists performing colonoscopy should be able to complete colonoscopy safely and effectively (per accepted benchmarks) using moderate sedation or less. Endoscopists unable to complete colonoscopy safely and effectively (per accepted benchmarks) using moderate sedation should undergo additional training. |
| Personnel responsible for monitoring moderately sedated patients | ‘For moderate sedation, the personnel assigned to monitoring the patient can be assigned brief and interruptible tasks (such as mucosal biopsy), provided that the patient has not reached a state of deep sedation’. | For routine in-hospital colonoscopy under moderate sedation, a single RN can both monitor the patient and perform brief interruptible tasks. |
| Equipment required for monitoring sedated patients | ‘We recommend that routine monitoring of blood pressure, oxygen saturation, and heart rate in addition to clinical observation for changes in cardiopulmonary status during all endoscopic procedures using sedation. Supplemental oxygen administration should be considered for moderate sedation and should be administered during deep sedation. Supplemental oxygen should be administered if hypoxemia is anticipated or develops’. ‘We suggest that capnography monitoring be considered for patients undergoing endoscopy targeting deep sedation’. | No recommendations provided. |
| Techniques to enhance patient experience under moderate sedation | No recommendations provided. | Preprocedure,intraproceduraland postprocedure techniques provided (table 1). |
| Reasons to consider use of deep sedation/propofol | ‘We suggest that endoscopists use propofol-based sedation (endoscopist-directed or anesthesia-provider administered) when it is expected to improve patient safety, comfort, procedural efficiency, and/or successful procedure completion’. | Select patients undergoing routine colonoscopy may benefit from deep sedation. Numerouspatientand context factors to consider identified (table 1). Institutions will not mandate the use of deep sedation for routine colonoscopy. |
| Reasons to involve an anaesthesia provider | ‘We recommend anesthesia provider-administered sedation be considered for complex endoscopic procedures or patients with multiple medical comorbidities or at risk for airway compromise’. ‘Patient risk factors include significant medical conditions such as extremes of age; severe pulmonary, cardiac, renal, or hepatic disease; pregnancy; the abuse of drugs or alcohol; uncooperative patients; a potentially difficult airway for positive-pressure ventilation; and individuals with anatomy that is associated with more difficult intubation. Additionally, an anesthesia provider may be used to provide propofol-based sedation for settings in which regulations or policies do not allow endoscopist-administered propofol, but the treating physicians judge the benefits of a propofol regimen to outweigh the risks and costs’. | Select patients undergoing colonoscopy, such as those with severe comorbidities, may benefit from having sedation administered and monitored by an anaesthesia provider, irrespective of level of sedation (see table 1). |
| Personnel capable of administering deep sedation/propofol | ‘We suggest that endoscopists use propofol-based sedation (endoscopist-directed or anesthesia-provider administered)…’. ‘Extensive data have demonstrated the safety and efficacy of non-anesthesiologist-administered propofol sedation (NAAP)…NAAP requires specialized training, patient selection, and personnel dedicated to continuous physiologic monitoring. Regulations regarding administration of propofol are determined at the state, regional, and local levels regardless of targeted level of sedation. As a result, the practice of NAAP is quite limited nationally. Hence, propofol-based sedation for low-risk patients undergoing routine procedures often is administered by anesthesia personnel’. | Deep sedation for colonoscopy should only be administered by an anaesthesia provider. |
| Personnel responsible for monitoring deeply sedated patients | ‘For deep sedation, personnel assigned to monitoring the patient must do so in a continuous and uninterrupted fashion’. | For routine colonoscopy under deep sedation, an anaesthesia provider will be responsible for monitoring the patient and should not be responsible for additional tasks. |
ASA, American Society of Anesthesiologists; ASGE, American Society for Gastrointestinal Endoscopy.