Anxiolytics: Benzodiazepines (Midazolam remains the preferred one for its desirable pharmacokinetics “short acting “. Temazepam can also be given orally but has limitation for its narrow window of action )
Opiates: Fentanyl to provide additional synergy to pain control by Local Anaesthetics.
Propofol: please see below.
Ketamine: Some anaesthetists use it. (Due to its undesirable side effects it is less than ideal for use in my own practice.)
The use of Propofol for sedation requires specific training and skills because It has potential to cause rapid and profound changes in sedative/anaesthetic depth.
No specific antagonists.
Marked synergy with other sedative drugs.
As a consequence its use for sedation results in significantly different challenges from the use of intravenous benzodiazepines and/or opioids; further, Propofol’s general anaesthetic properties reduce its margin of safety for sedation purposes. These challenges must not be underestimated, particularly in this group of patients who often present with significant co-morbidities.
Widespread experience indicates that Propofol alone provides excellent sedation for the majority of patients; if opioids are also required, only small doses are needed and are best administered first, with sufficient time allowed for their peak effect to be reached. The synergistic effects of benzodiazepines in combination with Propofol and opioids greatly increase the risk of the onset of general anaesthesia.
Previous British Society of Gastroenterology (BSG) guidance1 has indicated that there is ‘No room for complacency’ with regard to sedation and the American Society of Anesthesiologists (ASA) have stated that, ‘the use of Propofol for sedation requires special attention’; these views are supported by the Working Party in UK.
In the USA and several European Union (EU) countries, the use of Propofol by non-anaesthetists is described in the literature, although this practice still remains controversial. European guidelines on the non-anaesthetist administration of Propofol (NAAP) for endoscopy were published in December 2010.3 They stipulated stringent regulations and demonstration of clearly defined competencies. A formal mentored training program and achieving an appropriate qualification in the practice were strongly advised and self-training discouraged. Nevertheless, these guidelines have been rejected by many EU national societies of anaesthesia who remain clear that only anaesthetists should administer Propofol. In the UK at present there is no provision for nationally recognized formal training programs or qualification in NAAP.
The opinion of the working party is that, at the present time in the UK, the administration and monitoring of Propofol sedation for such potentially complex endoscopic procedures should be the responsibility of a dedicated and appropriately trained anaesthetist (with the minimum competencies identified as those for ‘Intermediate Level’ sedation training identified in the relevant section of the CCT in Anaesthetics, 2010, or an appropriately trained Physicians’ Assistant (Anaesthesia) working under the direct supervision of a consultant anaesthetist at all times;4 this will ensure that the potential complications of sedation and anaesthesia in such patients are appropriately managed.
A review of this guidance and the use of NAAP may occur in the future when the wider topic of sedation practice has been revisited and reviewed by a Joint Working Party of the Academy of Medical Royal Colleges.
The use of sedation in clinical practice, particularly in non-theatre areas, is increasing and anaesthetists are frequently asked to provide/oversee its administration. It is essential that CT 1/2 anaesthetic trainees understand what is meant by conscious sedation [‘A technique in which the use of a drug or drugs produces a state of depression of the central nervous system enabling treatment to be carried out, but during which verbal contact with the patient is maintained throughout the period of sedation’] and how it is administered safely.