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Official reprint from UpToDate®

www.uptodate.com ©2018 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Adverse events related to procedural sedation for gastrointestinal endoscopy

Author: Jonathan Cohen, MD

Section Editors: John R Saltzman, MD, FACP, FACG, FASGE, AGAF, Girish P Joshi, MB, BS, MD, FFARCSI
Deputy Editor: Kristen M Robson, MD, MBA, FACG

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Sep 2018. | This topic last updated: Jun 15, 2018.

INTRODUCTION — The development of gastrointestinal (GI) endoscopy has greatly expanded the diagnostic
and therapeutic capabilities of gastroenterologists. Adequate patient tolerance is essential for successful
completion of a safe examination and compliance with subsequent follow-up. As a result, endoscopists have
developed skills in administering a variety of sedative and analgesic agents to facilitate procedures and
enhance patient comfort. However, a number of adverse events related to procedural sedation have been
described.

This topic review will focus on the adverse events related to procedural sedation for GI endoscopy. An
overview of procedural sedation for endoscopic procedures, issues related to endoscopic procedures without
sedation, and the management of patients who are difficult to sedate are discussed elsewhere. (See
"Overview of procedural sedation for gastrointestinal endoscopy" and "Sedation-free gastrointestinal
endoscopy" and "Alternatives and adjuncts to moderate procedural sedation for gastrointestinal endoscopy".)

ADVERSE EVENTS RELATED TO PHARYNGEAL ANESTHESIA

Aspiration — The main concern related to topical pharyngeal anesthesia is inhibition of the gag reflex and
the risk of aspiration. Oversedation may exacerbate this risk. This is particularly important in the management
of patients with acute upper gastrointestinal (GI) bleeding. Endotracheal intubation for airway protection
should be considered to prevent life-threatening aspiration in patients with active hematemesis. It may also be
advisable to avoid topical inhibition of the gag reflex in such patients and in other individuals at high risk for
aspiration (table 1). (See "Aspiration pneumonia in adults", section on 'Predisposing conditions'.)

Local anesthetic toxicity — Systemic effects such as arrhythmias and seizures due to absorption of the
topical local anesthetic have been observed, although they are uncommon [1]. These drugs have also rarely
been associated with the development of methemoglobinemia (benzocaine more than lidocaine) [1-3]. (See
"Clinical features, diagnosis, and treatment of methemoglobinemia".)

Methemoglobinemia — Significant methemoglobinemia may be clinically suspected by the presence of

clinical "cyanosis" and an oxygen saturation (SaO2) of approximately 85 percent in the face of a normal
arterial PO2 (PaO2). The blood in methemoglobinemia has been variously described as dark-red, chocolate,
or brownish to blue in color, and unlike deoxyhemoglobin, the color does not change with the addition of
oxygen. Pulse oximetry is inaccurate in monitoring oxygen saturation in the presence of methemoglobinemia.
(See "Clinical features, diagnosis, and treatment of methemoglobinemia".)

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ADVERSE EVENTS RELATED TO MEDICATIONS USED FOR SEDATION

Pulmonary and cardiovascular adverse events — The most frequent and serious adverse events of
procedural sedation are cardiopulmonary. Risk factors for the development of cardiopulmonary adverse
events include advanced age, underlying comorbid illness (especially pulmonary disease), dementia, anemia,
obesity, significant cardiovascular disease (eg, heart failure or severe valvular disease), and endoscopy
performed for emergent indications [4]. Adverse events resulting from oversedation include hypoventilation,
airway obstruction, hypoxemia, hypercarbia, hypotension, vasovagal episodes, arrhythmias, and aspiration.
The frequency of such unplanned cardiopulmonary events has been shown to be associated with increasing
American Society of Anesthesiologists scores [4].

The overall incidence of cardiopulmonary adverse events is low, but important. In a prospective survey of
14,149 upper endoscopies and a retrospective study of 21,011 procedures, the rate of early cardiopulmonary
events was 2 to 5.4 per 1000 cases, and the mortality rate, which included cases of aspiration pneumonia,
pulmonary embolism, and myocardial infarction, was 0.3 to 0.5 per 1000 cases [5,6].

Hypoxemia — One of the potential causes of cardiopulmonary adverse events is arterial oxygen
desaturation, which can result from oversedation. (See 'Use of reversal agents' below.)

Hypoxemia is common during endoscopic procedures. As patients reach deeper levels of sedation,
hypoxemia may result from either decreased respiratory drive or from loss of protective airway reflexes. This
was illustrated in a study in which arterial oxygen saturation was measured in 236 consecutive patients
undergoing elective endoscopy [7]. A drop in the oxygen saturation to below 90 percent was observed in 40
percent of individuals having an upper endoscopy and 54 percent of those having a colonoscopy. A similar
incidence of oxygen desaturation (41 percent) was observed in another report of 103 consecutive
colonoscopies [8]. In the case of upper endoscopy, oxygen desaturation is largely related to the use of
sedation rather than the passage of an endoscope along the airway [9]. (See "Procedural sedation in adults
outside the operating room", section on 'Complications' and "Anesthesia for gastrointestinal endoscopy in
adults", section on 'Propofol'.)

Some degree of hypoxemia can be noted during endoscopy, even in patients who do not receive procedural
sedation [10-12]. In one study, for example, 9 percent of individuals undergoing unsedated flexible
sigmoidoscopy had an episode of hypoxemia [12]. Causes of hypoxemia in this setting may include
breathholding or comorbid illnesses.

Other risk factors for hypoxemia include:

● The combination of a benzodiazepine and opioid, which significantly increases the risk of hypoxemia
compared with midazolam alone [13].

● A high frequency of oxygen desaturation (up to 50 percent) is seen with procedures of longer duration,
such as endoscopic retrograde cholangiopancreatography, providing a rationale for the routine use of
supplemental oxygen [12,14,15].

● Active bleeding [10].

Other patient characteristics that may increase the risk of sedation-induced hypoxemia during endoscopy
include baseline oxygen saturation less than 95 percent, emergent indication for endoscopic procedure, long
duration of procedure, and comorbid illness [16]. In contrast, patients with cirrhosis do not appear to be at
increased risk [17]. In addition, most studies suggest patients with obstructive sleep apnea are not at
increased risk [18-22].

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Routine pulse oximetry is suggested in all patients undergoing endoscopy since the variables discussed
above are not sufficiently precise to predict which patients are at risk for becoming hypoxic [7-9,12,23]. (See
"Overview of procedural sedation for gastrointestinal endoscopy", section on 'Monitoring'.)

A potentially important limitation of pulse oximetry is that it is a delayed indicator of airway obstruction and
hypoventilation due to respiratory depression, particularly in patients receiving supplemental oxygen. Thus,
hypercapnia and respiratory acidosis resulting from airway obstruction and respiratory depression occur prior
to desaturation. (See "Overview of procedural sedation for gastrointestinal endoscopy", section on
'Monitoring' and "The evaluation, diagnosis, and treatment of the adult patient with acute hypercapnic
respiratory failure".)

The risk of hypoventilation is increased with obstructive pulmonary disease, dementia, and the use of high
doses of opioids or benzodiazepines [14]. In addition to their sedative effects, opioids and benzodiazepines
inhibit the central responsiveness to carbon dioxide, leading to decreased respiratory drive.

The degree to which different benzodiazepines inhibit the respiratory drive is variable. In a comparison of
midazolam and diazepam for procedural sedation, the rate of respiratory depression, as indicated by elevated
end-tidal CO2 pressure, was slightly higher with midazolam during the first 45 minutes after drug
administration, but higher with diazepam during the recovery period [24].

Cardiac arrhythmias — The risk of cardiac arrhythmias during endoscopy depends upon the patient's
age, underlying medical conditions, the incidence of significant arterial oxygen desaturation (see 'Hypoxemia'
above), and the type of procedure. Some of these issues were illustrated in a study in which Holter monitoring
was used to detect cardiac arrhythmias in 164 patients undergoing elective upper endoscopy who were
randomly assigned to one of three groups that differed in either endoscope diameter or use of sedation [9].

The overall incidence of arrhythmias was higher among individuals with prior cardiovascular disease
compared with those without cardiovascular disease (30 versus 6 percent). The most common arrhythmia
was sinus tachycardia, which correlated with patient tolerance of the procedure. Among patients receiving
sedation, arrhythmias were more common in patients who experienced oxygen desaturations compared with
patients who did not experience oxygen desaturations (75 versus 46 percent). There were also more
electrocardiographic abnormalities during examinations with larger endoscopes. Vasovagal reactions are
another frequent adverse event, occurring in up to 16 percent of colonoscopies [25].

Hypotension — Hypotension is a potential complication of procedural sedation. In one study of the effects
of midazolam in patients undergoing colonoscopy, hypotension developed in 19 percent (compared with 3 to
7 percent of patients in the control groups) [26]. Consequences of hypotension can include ischemia and
infarction in susceptible organs (eg, the brain and heart in patients with vascular disease).

The risk of developing hypotension varies depending on the patient’s underlying risk factors for hypotension
(eg, use of antihypertensive medications) and on the medication given for sedation. These issues are
discussed in greater detail separately. (See "Procedural sedation in adults outside the operating room" and
"Anesthesia for gastrointestinal endoscopy in adults", section on 'Choice of drugs for sedation/analgesia'.)

Other events — Aspiration pneumonia is a rare complication of upper endoscopy, and the preprocedure
assessment includes identifying risk factors for aspiration (table 2). Conditions that increase the risk of
aspiration and management of patients at risk are discussed separately. (See "Anesthesia for gastrointestinal
endoscopy in adults", section on 'Airway management' and "Overview of procedural sedation for
gastrointestinal endoscopy", section on 'Pre-procedure preparation and assessment'.)

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Phlebitis — Intravenous administration of sedatives and analgesics is associated with a small risk of
phlebitis. The risk appears to be higher with diazepam compared with midazolam [27]. The risk of phlebitis
from diazepam is increased with injection into a small caliber vein and increasing duration of infusion [28].
Administration of medications through a running intravenous line may reduce pain at the infusion site.

Propofol, which is used for deeper sedation, can cause pain on injection, particularly when administered
through a small vein, but does not cause phlebitis. This may be averted by the pre-administration of a small
amount of lidocaine (10 to 20 mg).

USE OF REVERSAL AGENTS — Agents to treat oversedation may be needed if patients exhibit signs of
respiratory depression, such as hypoxemia or decreased ventilation, despite supplemental oxygen or gentle
stimulation. Naloxone is given to reverse the effects of opioids, and flumazenil is given to reverse the effects
of benzodiazepines. These agents have also been looked at to reduce recovery times [29,30]. However, it is
not our practice to use them to speed recovery due to, at best, marginal benefits, added cost, and risk of
resedation when the reversal agents wear off.

There is no reversal agent for oversedation due to propofol, an agent used to achieve deeper levels of
sedation. Oversedation due to propofol must be managed by supportive measures, including proper airway
management, until the drug rapidly wears off. (See "Alternatives and adjuncts to moderate procedural
sedation for gastrointestinal endoscopy", section on 'Propofol'.)

With both naloxone and flumazenil, patients are at risk of resedation since the half-lives of these medications
can be shorter than the medications that they antagonize (table 3). This requires postprocedure monitoring if
one of these agents is used. We recommend that patients be monitored for a prolonged observation period
(at least 90 minutes) after receiving one of these medications for the treatment of oversedation.

Naloxone — Naloxone is an opioid antagonist that is used to reverse the respiratory depression and sedation
caused by opioid agents (usually fentanyl or meperidine). Appropriate additional supportive measures such
as fluid resuscitation and even vasopressor agents may be required to manage cardiovascular compromise
resulting from opioid overdose. (See "Acute opioid intoxication in adults", section on 'Basic measures and
antidotal therapy'.)

Administration of naloxone causes the release of catecholamines and thus should be used with caution in
older adults and those with cardiac disease to avoid cardiovascular adverse events. In addition,
administration to patients who regularly take opioid agents, prescribed or otherwise, may result in
considerable pain and precipitate an acute withdrawal syndrome.

The usual dose of naloxone given to reverse an oversedated patient with respiratory depression is 0.2 to 0.4
mg given intravenously (table 3). Smaller doses may be used for older adults. (See "Acute opioid intoxication
in adults", section on 'Basic measures and antidotal therapy'.)

Because naloxone may be cleared faster than fentanyl and meperidine, individuals who require naloxone
reversal must be observed carefully for a prolonged observation period (at least one hour) to detect the
development of resedation. Recovery room personnel should be alerted when naloxone has been given so
that resedation will be detected quickly.

Flumazenil — The benzodiazepine antagonist flumazenil is used to reverse sedation induced by

benzodiazepines, but it has limited efficacy in reversing respiratory depression. As a result, patients who
develop severe respiratory depression after being given an opioid agent and a benzodiazepine should
generally receive the opioid antagonist naloxone before being given flumazenil. In addition, flumazenil should

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be used cautiously in patients who chronically use benzodiazepines, chloral hydrate, carbamazepine, or high-
dose tricyclic antidepressants, because it may induce seizures or withdrawal.

An initial dose of 0.1 to 0.3 mg is given as an intravenous bolus (table 3). This can be followed with additional
boluses or an infusion (0.3 to 0.5 mg per hour) to prevent resedation. (See "Benzodiazepine poisoning and
withdrawal", section on 'Antidote (flumazenil)'.)

The average duration of antagonism is one hour. However, the effects of midazolam may persist for 80
minutes or longer, so, as is the case with naloxone, patients receiving flumazenil must be observed carefully
for signs of resedation.

SUMMARY AND RECOMMENDATIONS

● Adverse events related to procedural sedation for gastrointestinal endoscopy include hypoxia,
hypotension, and cardiac arrhythmias. (See 'Adverse events related to medications used for sedation'
above.)

● Naloxone is an opioid antagonist that can be used for opioid-induced respiratory depression. (See
'Naloxone' above.)

● Flumazenil is a benzodiazepine antagonist. It can be used to reverse the sedative effects of

benzodiazepines, but it has limited efficacy for reversing respiratory depression. (See 'Flumazenil'
above.)

● We suggest that patients who have received reversal agents be observed for a minimum of 90 minutes to
monitor for signs of resedation (Grade 2B). (See 'Use of reversal agents' above.)

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REFERENCES

1. Patel D, Chopra S, Berman MD. Serious systemic toxicity resulting from use of tetracaine for pharyngeal
anesthesia in upper endoscopic procedures. Dig Dis Sci 1989; 34:882.
2. Khan NA, Kruse JA. Methemoglobinemia induced by topical anesthesia: a case report and review. Am J
Med Sci 1999; 318:415.
3. Collins JF. Methemoglobinemia as a complication of 20% benzocaine spray for endoscopy.
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4. Sharma VK, Nguyen CC, Crowell MD, et al. A national study of cardiopulmonary unplanned events after
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5. Quine MA, Bell GD, McCloy RF, et al. Prospective audit of upper gastrointestinal endoscopy in two
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7. O'Connor KW, Jones S. Oxygen desaturation is common and clinically underappreciated during elective
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8. Bilotta JJ, Floyd JL, Waye JD. Arterial oxygen desaturation during ambulatory colonoscopy:

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predictability, incidence, and clinical insignificance. Gastrointest Endosc 1990; 36:S5.

9. Lieberman DA, Wuerker CK, Katon RM. Cardiopulmonary risk of esophagogastroduodenoscopy. Role of
endoscope diameter and systemic sedation. Gastroenterology 1985; 88:468.
10. Yen D, Hu SC, Chen LS, et al. Arterial oxygen desaturation during emergent nonsedated upper
gastrointestinal endoscopy in the emergency department. Am J Emerg Med 1997; 15:644.
11. Barkin JS, Krieger B, Blinder M, et al. Oxygen desaturation and changes in breathing pattern in patients
undergoing colonoscopy and gastroscopy. Gastrointest Endosc 1989; 35:526.
12. Reshef R, Shiller M, Kinberg R, et al. A prospective study evaluating the usefulness of continuous
supplemental oxygen in various endoscopic procedures. Isr J Med Sci 1996; 32:736.
13. Jurell KR, O'Connor KW, Slack J, et al. Effect of supplemental oxygen on cardiopulmonary changes
during gastrointestinal endoscopy. Gastrointest Endosc 1994; 40:665.
14. Freeman ML, Hennessy JT, Cass OW, Pheley AM. Carbon dioxide retention and oxygen desaturation
during gastrointestinal endoscopy. Gastroenterology 1993; 105:331.
15. Freeman ML. Sedation and monitoring for gastrointestinal endoscopy. Gastrointest Endosc Clin N Am
1994; 4:475.
16. ASGE Standards of Practice Committee, Early DS, Lightdale JR, et al. Guidelines for sedation and
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17. Iwao T, Toyonaga A, Harada H, et al. Arterial oxygen desaturation during non-sedated diagnostic upper
gastrointestinal endoscopy in patients with cirrhosis. Gastrointest Endosc 1994; 40:281.
18. Khiani VS, Salah W, Maimone S, et al. Sedation during endoscopy for patients at risk of obstructive
sleep apnea. Gastrointest Endosc 2009; 70:1116.
19. Coté GA, Hovis CE, Hovis RM, et al. A screening instrument for sleep apnea predicts airway maneuvers
in patients undergoing advanced endoscopic procedures. Clin Gastroenterol Hepatol 2010; 8:660.
20. Mador MJ, Nadler J, Mreyoud A, et al. Do patients at risk of sleep apnea have an increased risk of
cardio-respiratory complications during endoscopy procedures? Sleep Breath 2012; 16:609.
21. Cha JM, Jeun JW, Pack KM, et al. Risk of sedation for diagnostic esophagogastroduodenoscopy in
obstructive sleep apnea patients. World J Gastroenterol 2013; 19:4745.
22. Mehta PP, Kochhar G, Kalra S, et al. Can a validated sleep apnea scoring system predict
cardiopulmonary events using propofol sedation for routine EGD or colonoscopy? A prospective cohort
study. Gastrointest Endosc 2014; 79:436.
23. Bell GD, Reeve PA, Moshiri M, et al. Intravenous midazolam: a study of the degree of oxygen
desaturation occurring during upper gastrointestinal endoscopy. Br J Clin Pharmacol 1987; 23:703.
24. Zakko SF, Seifert HA, Gross JB. A comparison of midazolam and diazepam for conscious sedation
during colonoscopy in a prospective double-blind study. Gastrointest Endosc 1999; 49:684.
25. Herman LL, Kurtz RC, McKee KJ, et al. Risk factors associated with vasovagal reactions during
colonoscopy. Gastrointest Endosc 1993; 39:388.
26. Ristikankare M, Julkunen R, Mattila M, et al. Conscious sedation and cardiorespiratory safety during
colonoscopy. Gastrointest Endosc 2000; 52:48.
27. Kawar P, Dundee JW. Frequency of pain on injection and venous sequelae following the I.V.
administration of certain anaesthetics and sedatives. Br J Anaesth 1982; 54:935.
28. Morgan M, Thrash WJ, Blanton PL, Glaser JJ. Incidence and extent of venous sequelae with

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intravenous diazepam utilizing a standardized conscious sedation technique. Part II: Effects of injection
site. J Periodontol 1983; 54:680.
29. Bartelsman JF, Sars PR, Tytgat GN. Flumazenil used for reversal of midazolam-induced sedation in
endoscopy outpatients. Gastrointest Endosc 1990; 36:S9.
30. Wille RT, Chaffee BW, Ryan ML, et al. Pharmacoeconomic evaluation of flumazenil for routine outpatient
EGD. Gastrointest Endosc 2000; 51:282.

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GRAPHICS

Conditions that predispose to aspiration

Altered consciousness
Alcoholism, seizures, head trauma, general anesthesia, drug overdose

Dysphagia
Esophageal disorders including stricture, neoplasm, diverticula, tracheoesophageal fistula, incompetent cardiac
sphincter, achalasia, oropharyngeal obstruc on, xerostomia
Neurologic disorder
Cerebrovascular accident, mul ple sclerosis, Parkinson disease, myasthenia gravis, pseudobulbar palsy,
amyotrophic lateral sclerosis
Mechanical disruption of the usual defense barriers
Nasogastric tube, endotracheal intubation, tracheostomy, upper gastrointestinal endoscopy, bronchoscopy

Other
Protracted vomiting, gastric outlet obstruction, large-volume nasogastric tube feedings, pharyngeal anesthesia,
general debility, recumbent position, ascites, gastroparesis, ileus, glo c insufficiency (eg, vocal cord paralysis)

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Conditions that increase risk of aspiration during induction of anesthesia

Full stomach – nonfasted, emergency surgery or trauma

Pregnancy after 12 to 20 weeks gestation (gestational age for increased risk is controversial)

Symptomatic gastroesophageal reflux

Diabetic or other gastroparesis

Hiatal hernia

Gastric outlet obstruction

Esophageal pathology

Bowel obstruction

Increased intra-abdominal pressure – ascites, abdominal mass

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Intravenous medications used for sedation and analgesia in endoscopy

Initial Repeat
Onset Duration
Agent dose dose ¶ Effects
(minutes) (minutes)
(adult)* (minutes)

Benzodiazepines

Midazolam 0.02 to 0.03 1 to 2 15 to 80 2 to 5 Sedative, amnestic, anxiolytic.

mg/kg (1 to 2 Nonanalgesic. Delayed
mg) over 2 to recovery in older adults, with
3 minutes obesity or impaired hepatic
function. Reduce dose in
combination with opiate
analgesic.

Lorazepam 0.044 mg/kg 15 to 20 360 to 480 15 to 20 Sedative, amnestic, anxiolytic.

(2 to 4 mg) Prolonged onset, slow recovery,
over 1 to 2 variable response.
minutes

Diazepam Δ 0.03 to 0.1 2 to 3 360 2 to 5 Sedative, amnestic, anxiolytic.

mg/kg (5 to 10 Phlebitis, IV incompatibility,
mg) over 2 to prolonged onset, slow recovery.
3 minutes

Opiate analgesics

Fentanyl 0.5 to 1 2 to 3 30 to 60 2 Sedative, analgesic.

micrograms/kg Nonamnestic. Minimal
over 3 or more hypotension and histamine
minutes release. Reduce dose in
combination with
benzodiazepine.

Morphine 2.5 to 5 mg 5 to 10 120 to 240 5 to 10 Sedative, analgesic. Histamine

over 3 to 5 release, hypotension.
minutes Prolonged duration and
recovery.

Meperidine 25 to 50 mg 5 60 to 180 5 to 10 Sedative, analgesic. Histamine

over 3 to 5 release, hypotension, nausea.
minutes Prolonged duration and
recovery. Interaction with MAO
inhibitors.

Sedative-hypnotic anesthetic

Propofol Initiate <1 Approximately Continuous Sedative, amnestic.

continuous infusion at 25 3 to 10 upon infusion Nonanalgesic. Rapid onset and
infusion ◊ micrograms/kg discontinuation neurologic recovery upon
per minute; discontinuation. Respiratory
titrate depression, O 2 desaturation,
gradually to apnea, hypotension with overly
response rapid administration. Injection
(consult site pain. Older adults: Reduce
detailed dose by 20%. Contains egg
reference) ◊ lecithin, soybean oil (potential
allergens).

Antagonist agents for reversal of overdose

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Naloxone 0.1 to 0.2 mg 2 to 3 45 to 120 2 to 3 Overcomes respiratory

depression, sedation and
hypotension of opiates.
Reverses analgesia. Acute
narcotic withdrawal if tolerant.

Flumazenil 0.2 mg over 1 to 3 (peak Approximately 1 Overcomes sedation and

30 seconds 6 to 10) 60 partially reverses respiratory
depression of benzodiazepines.
Agitation, acute withdrawal and
risk of withdrawal seizures if
benzodiazepine tolerant.

IV: intravenous; MAO: monoamine oxidase.

* Initial dose for healthy adults <60 years of age. Older, debilitated persons and/or those with compromised
cardiorespiratory function or hepatic or renal insufficiency are at increased risk of adverse events with these agents, and
dosing should be adjusted accordingly. See text for details.
¶ Sedatives and analgesics: Repeat one-half initial dose at interval noted if needed to achieve desired depth and duration
of sedation. Additional titration may be needed.
Δ Dose for conventional (nonemulsion) diazepam injection. Diazepam emulsion is not available in United States.
◊ Bolus injection of propofol alone or in combination with small doses of an opiate and/or benzodiazepine is commonly
practiced as an alternative to administration by IV infusion. When given as a bolus, it should be administered by an
anesthesiologist or certified registered nurse anesthetist.

Data from:
1. Cohen LB, DeLegge MH, Aisenberg J, et al. AGA institute review of endoscopic sedation. Gastroenterology 2007;
133:675.
2. Gahart BL, Nazareno AR. Intravenous medications 27th ed, Mosby Elsevier, St. Louis, MO 2011.

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Contributor Disclosures
Jonathan Cohen, MD Speaker's Bureau: Otsuka Pharmaceuticals [Helicobacter pylori breath testing];
Ferring Pharmaceuticals [Gastrointestinal endoscopy (bowel preparation)]. Consultant/Advisory Boards:
Boston Scientific [ERCP]; Olympus [Gastrointestinal endoscopy (narrow band imaging)]. Equity
Ownership/Stock Options: GI Windows [magnetic anastomosis (stock)]; Virtual Health Partners
[obesity]. John R Saltzman, MD, FACP, FACG, FASGE, AGAF Consultant/Advisory Boards: Iterative scopes
[Artificial intelligence (AI) applied to polyp detection during colonoscopy]. Girish P Joshi, MB, BS, MD,
FFARCSI Speaker's Bureau: Mallinckrodt Pharmaceuticals [pain management (intravenous acetaminophen)];
Baxter [anesthesia (desflurane)]. Consultant/Advisory Boards: Pacira Pharmaceuticals [pain management
(bupivacaine); Merck [anesthesia (sugammadex)]. Kristen M Robson, MD, MBA, FACG Nothing to disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must conform
to UpToDate standards of evidence.

Conflict of interest policy

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