Quality in Endoscopic Sedation

In developed countries, the vast majority of gastrointestinal endoscopic procedures are performed with sedation. Midazolam and fentanyl continue to be the most widely used agents, but propofol is becoming steadily more popular because its unique pharmacokinetic properties allow potent sedation followed by rapid recovery. Moderate sedation through the use of nurse-administered propofol sedation is the standard in some European countries, while deep sedation by monitored anesthesia care is commonly used in the USA. In certain high-risk patients, general anesthesia with endotracheal intubation may be required. High-quality sedation is a prerequisite of high-quality endoscopy; thus it is important to define, measure, and improve endoscopic sedation quality. This chapter discusses the main features of high-quality endoscopic sedation, including (1) pre-procedural issues, such as sedation training and certification of endoscopic personnel, accurate assessment of patient risk and sedation requirements, and formulation of a suitable sedation plan (moderate sedation versus monitored anesthesia care); (2) intra-procedural issues, such as informed consent, the procedural pause, comprehensive procedural monitoring and effective management of complications, and an efficient and safe recovery and discharge process; and (3) post-procedural issues, such as treatment of delayed sedation-related complications, systematic adverse event tracking, and quality improvement measures on a unit and individual level (including regular morbidity and mortality conferences and, if needed, personal improvement plans, equipment upgrades, and protocol changes).