Sedation in digestive endoscopy: innovations for an old technique

Patient complexity, along with duration, number and invasiveness of procedures, increase every year in digestive endoscopy; so deep sedation, analgesia or general anesthesia requests are rising. The need for a safe, flexible, low cost and high-profile service play a central role in drugs, devices and monitoring development. The patient's degree of comfort and anxiety are also critical. On the other hand, the role of the anesthesiologist is still debated, and many European countries are promoting non-anesthesiologist administration of propofol (NAAP). For high risk patients, anesthesiologists play an important role in choosing sedative drugs, kind of anesthesia/analgesia and devices for airway control. New drugs with safe profile, low costs, and favorable pharmacokinetics are now available for digestive endoscopy. Among these, fospropofol, a water-soluble prodrug of Propofol, is a very promising compound. Moreover, new devices and different modalities of ventilation can help anesthesiologists in management of high-risk patients, like obese patients and others patients at risk of hypopnea/apnea. The main challenges for anesthesiologists in this setting are endoscopic retrograde cholangiopancreatography, management of obese patients and recovery time after procedure, since digestive endoscopies are frequently performed as outpatient procedures. Nevertheless, these short and at low risk procedures can induce cognitive impairment. Currently, only anesthesiologists seem to have the competences to maintain high levels of safety by an appropriate evaluation and sedatives' choice, and a detailed protocol should be present in each gastrointestinal endoscopy department. In conclusion, the role of the anesthetist should be to supervise endoscopy activities at every level.