Sedation in endoscopy: Current practices and future innovations

Abstract

Sedation practices in gastrointestinal endoscopy have evolved considerably, driven by patient demand for comfort and the need to minimize cardiopulmonary complications. Recent guidelines emphasize personalized sedation strategies, risk assessment, and vigilant hemodynamic monitoring to ensure that sedation depth aligns with each patient’s comorbidities and procedural requirements. Within this landscape, the trial by Luo et al highlights the value of adding etomidate to propofol target-controlled infusion, demonstrating significantly reduced hypotension, faster induction, and fewer respiratory complications in typical American Society of Anesthesiologists I-III candidates. These findings align with broader recommendations from both European and American societies advocating sedation regimens that preserve stable circulation. Etomidate’s favorable hemodynamic profile, coupled with propofol’s reliability, suggests potential applications in advanced endoscopic interventions such as endoscopic retrograde cholangiopancreatography, interventional endoscopic ultrasound, and endoscopic submucosal dissection, where deeper or more sustained sedation is often required. Remimazolam, a novel short-acting benzodiazepine, has similarly been associated with reduced cardiovascular depression and faster recovery, particularly in high-risk populations, although direct comparisons between etomidate-propofol and remimazolam-based regimens remain limited. Further investigations into these sedation strategies in higher-risk cohorts, as well as complex therapeutic endoscopy, will likely inform more nuanced, patient-specific protocols aimed at maximizing both safety and procedural efficiency.

Keywords: Etomidate; Propofol; Remimazolam; Endoscopy sedation; Gastrointestinal endoscopy; Sedation monitoring; Target-controlled infusion

Core Tip: In light of the increasing complexity of endoscopic procedures such as endoscopic retrograde cholangiopancreatography, interventional endoscopic ultrasound, and endoscopic submucosal dissection, stable and reversible sedation regimens, exemplified by etomidate-propofol or emerging agents like remimazolam, hold promise for balancing patient comfort, procedural efficacy, and minimal hemodynamic compromise. The study by Luo et al demonstrates that combining etomidate with propofol target-controlled infusion can reduce sedation-related hypotension, speed induction, and improve safety in routine bidirectional endoscopy.