Which agent and how to deliver it? A review of benzodiazepine sedation and its reversal in endoscopy.

Amnesia, relaxation, and cooperation, not anaesthesia, should be the clinical end points when using intravenous sedative drugs for endoscopic procedures. Diazepam has now been replaced by midazolam as the first-choice sedative agent to achieve these effects. Midazolam, when used in correct doses, is more suited to endoscopy than diazepam because of its shorter elimination half-life, larger volume of distribution, and faster total body clearance. Midazolam is also clinically superior, as it achieves amnesia in twice as many patients and at lighter levels of sedation than with diazepam. The routine use of opioids in combination with benzodiazepines is to be avoided, as it increases the likelihood of adverse cardiopulmonary events. The availability of the specific benzodiazepine antagonist, flumazenil, is not an excuse for the administration of excessive doses of benzodiazepines. Flumazenil is an essential emergency drug when benzodiazepine-induced sedation is used. Reversing single-dose benzodiazepine-induced sedation after outpatient endoscopy enables earlier accurate retention of information and earlier discharge and may have significant cost-benefit implications.