New ASGE Guidelines on Sedation and Anesthesia Differ From ASA's Over Capnography Use

The American Society for Gastrointestinal Endoscopy (ASGE) has released updated guidelines on the use of sedation and anesthesia during GI endoscopic procedures.

There are similarities to the guidelines of the American Society of Anesthesiologists (ASA), particularly when it comes to timing of sedation. However, the new ASGE guidelines offer a different approach for capnography during endoscopic procedures under moderate sedation.

Although previously there was no universal practice standard, both the ASGE and ASA are in agreement that patients should fast for a minimum of two hours after ingestion of clear liquids and six hours after ingestion of light meals before sedation can be administered. The new guidelines note it is typical to use the ASA physical status classification system to risk-stratify patients for sedation prior to a procedure, and emphasizes the importance of carefully classifying patients in order to accurately understand their risk for adverse events during GI procedures.

Based on data from the Clinical Outcomes Research Initiative database, increasing ASA physical status has been linked to increasing risk for unplanned cardiopulmonary events during endoscopy. 

The new guidelines recommend the use of pulse oximetry during all sedated endoscopic surgeries. Additionally, blood pressure, oxygen saturation and heart rate should be monitored routinely, and clinical observation for changes in cardiopulmonary status during all endoscopic procedures using sedation should be done. 

In contrast to the ASA, the ASGE maintains that the use of capnography to monitor patients during endoscopic procedures using moderate sedation has not yielded improvements in patient safety. Despite this, capnography was recommended in procedures using deep sedation.

The ASGE guidelines suggest that capnography monitoring be considered in complex endoscopic procedures, for patients with multiple medical comorbidities, or for those at risk for airway compromise. Anesthesia providers should administer sedation in these cases.

Among the recommendations for minimal to moderate sedation, the document notes that benzodiazepines and opioids are safe for use in low-risk upper endoscopy and colonoscopy patients.