Lazzaroni M, Bianchi Porro G
Department of Gastroenterology, L. Sacco University Hospital, Milan, Italy.
Endoscopy. 2003 Feb;35(2):103-11. doi: 10.1055/s-2003-37012.
The main end points for sedation during endoscopy are patients' satisfaction, short duration of the procedure, and safety. During the last year, attention has focused on attempting to identify the "ideal" candidate for moderate sedation/analgesia and on the importance of providing the patient with appropriate information before the procedure. The increasing pressure to perform more procedures, reduce costs, and achieve shorter patient turnaround times has affected recent approaches to sedation during endoscopy, focusing attention on alternatives to pharmacological sedation such as providing relaxing music, using small-caliber endoscopes for unsedated peroral gastroscopy, and using magnetic endoscopic imaging to increase tolerance and reduce discomfort during colonoscopy. The results, however, have not been convincing. The role of benzodiazepines was discussed in some studies, highlighting the well-known effect of midazolam on postprocedural amnesia, its pharmacological profile and tolerability after intranasal spraying in healthy volunteers, and the efficacy and safety of this route of administration as an alternative to intravenous administration in diagnostic upper gastrointestinal endoscopy. The form of sedation for gastrointestinal endoscopy that has attracted great interest over the last year is the use of intravenous propofol, either alone or with concomitant benzodiazepines or opioids. As expected in view of the drug's known pharmacological properties, the quality of sedation was better and recovery time was shorter in patients treated with propofol. However, important questions involving the narrow therapeutic range and the mode of administration of propofol (by endoscopists or nurses, or by anesthesiologists) remain open. One important aspect of sedation procedures is prevention of cardiopulmonary complications. The use of electronic monitoring techniques, with a pulse oximeter, has been recommended as a standard procedure during digestive endoscopy; however, pulse oximetry no longer reflects the normal ventilatory functions and does not detect episodes of severe CO2 retention. CO2 monitoring by transcutaneous measurement - or better, by capnography - appears to be useful, as an alternative to pulse oximetry, as a measure of hypoventilation, and for detecting potentially important abnormalities in respiratory activity in patients undergoing sedation for gastrointestinal endoscopy. With regard to preparation for endoscopic procedures, several "ideal" formulas for bowel preparation have been presented. These include the use of sodium phosphate compounds as an alternative to polyethylene glycol electrolyte lavage solutions (PEG-ELS); however, the results so far have been conflicting. The best and most cost-effective bowel cleansing procedure for colonoscopy and sigmoidoscopy has yet to be established.
内镜检查期间镇静的主要终点是患者满意度、检查时间短和安全性。在过去一年中，注意力集中在试图确定中度镇静/镇痛的“理想”候选人以及在检查前向患者提供适当信息的重要性上。进行更多检查、降低成本和缩短患者周转时间的压力不断增加，影响了近期内镜检查期间的镇静方法，将注意力集中在药物镇静的替代方法上，如提供舒缓音乐、使用小口径内镜进行无镇静的经口胃镜检查以及使用磁内镜成像来提高结肠镜检查期间的耐受性并减轻不适。然而，结果并不令人信服。一些研究讨论了苯二氮䓬类药物的作用，强调了咪达唑仑对检查后遗忘的众所周知的作用、其药理学特性以及在健康志愿者中鼻内喷雾后的耐受性，以及这种给药途径作为诊断性上消化道内镜检查中静脉给药替代方法的有效性和安全性。过去一年中引起极大兴趣的胃肠道内镜检查镇静形式是单独使用静脉丙泊酚或与苯二氮䓬类药物或阿片类药物联合使用。鉴于该药物已知的药理学特性，丙泊酚治疗的患者镇静质量更好且恢复时间更短，这是意料之中的。然而，涉及丙泊酚狭窄治疗范围和给药方式（由内镜医师或护士，或由麻醉医师给药）的重要问题仍然悬而未决。镇静程序的一个重要方面是预防心肺并发症。推荐使用带有脉搏血氧仪的电子监测技术作为消化内镜检查期间的标准程序；然而，脉搏血氧测定不再反映正常的通气功能，也无法检测到严重二氧化碳潴留的发作。经皮测量——或者更好的是，通过二氧化碳监测——似乎是有用的，作为脉搏血氧测定的替代方法，作为通气不足的一种测量方法，以及用于检测接受胃肠道内镜检查镇静的患者呼吸活动中潜在的重要异常情况。关于内镜检查的准备工作，已经提出了几种“理想”的肠道准备方案。这些方案包括使用磷酸钠化合物替代聚乙二醇电解质灌洗液（PEG-ELS）；然而，迄今为止结果相互矛盾。结肠镜检查和乙状结肠镜检查的最佳且最具成本效益的肠道清洁程序尚未确定。
