Charles J. Lightdale, MD, Consulting Editor

For as long as we have performed endoscopy, we have always needed sedation for most cases in order to provide patient comfort and a quiet field to carry out successful examination or therapy. Historically, our first regimens relied on opioids and barbiturates, which were clunky to use and variably effective. The benzodiazepines then became the norm, and combinations of midazolam and fentanyl became popular. Many of us may still remember in the 1990s when the virtues of this regimen were extolled. As endoscopists, we marveled at its ability to work within 5 to 10 minutes, while being admonished to administer each drug in small increments. Alas, while benzodiazepines and opioids remain sufficient for most patients, it is also clear that they don’t work for a significant minority, including some who experience agitation, insufficient sedation, or excessive sedation. Recovery times can be very long and can be associated with long hangover symptoms.

The not-so-newest agent on the block, propofol, offers some definite benefits. When we all first starting using it about 20 years ago, the opaque white liquid was jokingly dubbed “the milk of amnesia.” It is extremely rapid-acting and puts practically everybody to sleep within a minute. Propofol is also cleared relatively quickly and has a fast recovery, helping unit efficiency and easing pressure on recovery space. However, its therapeutic window is narrow. Respiratory depression can occur with remarkable speed, and there are no agents to reverse its effects, unlike the case for opioids and benzodiazepines. Patients with obesity and sleep apnea syndromes receiving propofol are particularly prone to developing obstructive airway problems.

Still, as we have worked with it, large amounts of data have accumulated, which have indicated that gastrointestinal endoscopists can use propofol as safely as combinations of opioids and benzodiazepines. However, in the United States, endoscopist-administered propofol has been forced to cease under unwavering pressure from anesthesiology societies, who have convinced numerous federal and state regulatory agencies to restrict the use of propofol to certified anesthesia specialists.

Therefore, the current use of sedation and monitoring for gastrointestinal endoscopy in the United States involves either endoscopist-administered sedation using opioids and benzodiazepines, or anesthesiologist-administered sedation using propofol. Many high-throughput endoscopy centers are using anesthesiologist-administered propofol exclusively for sedation. Hospital-based endoscopists doing complex, lengthy, therapeutic procedures also have become high users of anesthesiologist-administered propofol.

There is no doubt that considerable authority and control in many gastrointestinal endoscopy units have been ceded to anesthesiology. Many endoscopists currently start a procedure day knowing it will be dictated by their assigned anesthesiologist or supervised nurse-anesthetist. Yet, while anesthesia specialists generally speaking have more experience rescuing patients from sedation-related respiratory depression than endoscopists, anesthesiologists and nurse anesthetists are certainly not always perfect or free from complications. Instead, there are remarkably different ways that propofol is administered by anesthesia specialists, often with mixed results. In the absence of fixed protocols for propofol administration for gastrointestinal procedures, it has become evident that some anesthesia specialists are more skilled at it than others. Costs for anesthesiology services for gastrointestinal endoscopy have escalated, while reimbursements for gastrointestinal endoscopists have been reduced. How this will all play out in the long transition from fee-for-service to global value-based reimbursement for our procedures remains an open question.

It seemed clear to me that we needed an issue of the Gastrointestinal Endoscopy Clinics of North America that would help us navigate this new and uneasy state-of-the-art of sedation and monitoring in our specialty. I am extremely pleased that Dr John Vargo agreed to be the guest editor for this issue. Dr Vargo, Chief of Gastroenterology and Hepatology at the Cleveland Clinic, has shown outstanding leadership in this field. His choice of topics and author-experts covers it all: preprocedural assessment, training and competency, legal issues, monitoring during endoscopy, special populations (including children, obesity, and sleep apnea), quality assurance, sedation in the Ambulatory Endoscopy Center, and computer-assisted and patient-controlled sedation. Finally, there is a topic looking into the future, which suggests the possibility of new drugs and methods that will bring improved safety and comfort at lower cost. This would be a dream come true. In the meantime, all gastrointestinal endoscopists should read this issue. It’s a wake-up call.