Procedural sedation: not to be routine

KEYWORDS:

• Sedation
• procedural sedation
• conscious sedation
• procedural safety
• decisional capacity
• analgesia

Procedural sedation

Sedation with analgesia is an accepted, pharmaceutical pre-treatment approach to facilitate endoscopies [1]. Commonly utilized, procedural sedation diminishes discomfort during medical procedures, like colonoscopies. It safely blocks anxiety, pain, and memory of the event. Some people ask their doctors to ‘put me out during this test.’ Many physicians and patients prefer utilizing sedation and/or analgesia before such assessments.

However, many endoscopies are nevertheless safely, more quickly, and comfortably performed without sedatives or analgesics [2–10]. This type of pre-treatment is not always required nor so desirable; there are fewer cardiopulmonary complications and less cognitive or sedation concerns when omitting these pharmaceuticals [11]. Ironically, some doctors prefer to be drug-free when they, themselves, or their colleagues undergo such procedures [12]. Most people are unaware that sedation-free endoscopy is possible.

Procedures

Procedural sedation is clearly warranted for some patients, like those with cognitive impairment, children, less well-controlled persons, and/or whenever discomfort levels are high, as in complicated biopsy cases. Yet, administering sedative and/or analgesic drugs increase the risks and types of side effects [1–10]. These medications also add to the duration of the endoscopy, recovery time, physician presence, recovery room utilization, and cost [13,14].

The USA is an exception to the elsewhere frequent absence of such pharmacotherapy before endoscopies [5–9]. Despite the majority of cases currently performed under pre-procedure medication, there is support for appropriate individuals to undergo examinations like these without sedation or analgesia [2–10].

Physicians should at least consider offering ‘sedation-free’ endoscopy, ‘sedation-on-demand’ as an option, and/or utilizing calmative pharmaceuticals whenever specifically indicated [9,15]. Some patients would be able to select the degree of sedation they wish to experience.

Considerations

During informed consent sessions, doctors are encouraged to offer the option of drug-free endoscopy when indicated. The risks and benefits of both potential alternatives are reviewed; this includes the medical, safety, and financial aspects. That adds to patient autonomy, making the procedure more patient-centered. Whenever pre-procedure pharmaceuticals are initially not provided, these medicines can be added later, upon patient request and/or at physician discretion.

Topical, pharyngeal anesthesia is routine during upper endoscopies, since it diminishes the gag reflex; it also yields no sedation, nor compromises cognition. Without pre-treatment, however, higher doses of the topical anesthesia are frequently required, which incurs additional risks, like lidocaine toxicity.

Advantages

Sedation-free endoscopy is well-tolerated. It may not be worth the increased risk involved, especially since endoscopy discomfort is usually brief. It also reduces cost [13,14]. Non-sedated individuals are more able to follow physician instructions at facilitating the endoscopy. Some patients like being awake and knowing their test results immediately [6,9,10].

Disadvantages

A disadvantage of endoscopies without premedication can include patient discomfort. That makes the procedure more difficult. When a patient is troubled, this might lead to a more rushed, incomplete examination – even missing some pathology. That may discourage some people from further screenings. Procedural discomfort also requires greater physician expertise. Additionally, when an endoscopists is uncomfortable to proceed without pre-treatments, it would be unwise to omit pharmacotherapy.

Decisional capacity

Beyond avoiding potential adversities, sedation-free procedures potentially allow patients to be of decisional capacity throughout and afterward. A non-medicated person is attentive and in a cognitive state appropriate for discussion with the physician during and immediately following the procedure. Alert, they are able to drive and return to their routine activities, without assistance. They are also able to discuss findings, plans, and follow-up with the doctor. The same applies to topical-only pharyngeal analgesia.

Comment

Patients should have the option of selectively skipping these medications or receiving them later, if needed. The patient should help in deciding how much or how little sedation is utilized for the given procedure. Prescribing procedural sedation only when indicated can benefit patients and endoscopists.