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 May be defined as a drug-induced depression  Purpose to relieve patient anxiety and discomfort to improve the outcome of the examination to diminish the patient’s memory of the event  Preparation and assessment Informed agreement No absolute guidelines as to timing of cessation of oral intake ASA guidelines American College of Emergency Physicians

A history and physical examination

Consideration Patient-age, health status, concurrent medications, preprocedural anxiety, pain tolerance Procedure-degree of invasiveness, the level of procedure-related discomfort, the need for the patient to lie relatively motionless (eg, EUS-FNA), duration of examination Choice of sedative Is largely operator dependent Is based on maximizing patient comfort while minimizing patient risks Benzodiazepines used either alone or in combination with an opiate Am J Gastroenterology 1993;88:

Benzodiazepine  relieve of anxiety, sedation, loss of memory, anti-convulsion  increase activation of GABA  Midazolam vs Diazepam The efficacy of sedation is comparable Gastrointest Endosc Jun;49(6):684-9 Most endoscopists favor midazolam for its fast onset of action, short duration of action, and high amnestic properties. Standard sedation –combination with opiates Category D

Midazolam ◦ Water-soluble benzodiazepine ◦ Rapid onset of action and shorter duration ◦ Major side effect  Respiratory depression – reversed by flumazenil combined with opiate rapid infusion dose dependent peak time: 3~5minute after infusion  Paradoxical reaction – reported about 5% of sedative patients - anxiety, agitation, clamping

Propofol ◦ Lipid-soluble agent ◦ More rapid onset of action and a shorter recovery time compared to that of midazolam ◦ No analgesic properties ◦ Major side effect  Hypotension  Respiratory depression  Chemical phlebitis – about 30%

 Nurse-administered propofol sedation (NAPS) ◦ Administered by a well-trained nurse ◦ Initial infusion of 10~60mg and additional does of 10~20mg after 20~30sec. (20/20 rule) ◦ Deep sedation ◦ Propofol alone  Balanced propofol sedation (BPS) ◦ Combination propofol sedation ◦ Multi-drugs sedation ◦ Moderate sedation  Upper GI endoscopy vs Lower GI endoscopy ◦ More risk in upper GI endoscopy

1. Jeong Eun Shin, Review sedative and reversal agents, The korean journal of Gastrointestinal Endoscopy, 2010; Ja Seol Koo, Jai Hyun choi, Conscious sedation during Gastrointestinal Endoscopy; Midazolam vs propofol, The Korean journal of gastrointestinal endoscopy ;Feb. 2011; Sedation and anesthesia in GI endoscopy, American Society for Gastrointestinal Endoscopy, Chang Kyun lee, Non-Anesthesiologist-administered propofol, The korean journal of Gastrointestinal Endoscopy, 2010; Propofol using in Endoscopy, American Society for Gastrointestinal Endoscopy, 2010