The vigorous debate over whom to sedate, when to sedate, and how to sedate shows no
sign of running out of steam. There is a general consensus that patients should be
more involved in the decision-making process for the sedation “menu”. A move away
from the take-it-or-leave-it attitude of all or nothing to an “à la carte” choice
is to be encouraged. A new textbook and several further guidelines have appeared.
The particular problems associated with sedating the elderly are briefly presented.
The pros and cons of using local pharyngeal anaesthesia are discussed. Enthusiasm
for the use of intravenous propofol is gathering momentum, despite continuing worries
about its safety in the hands of the nonanaesthetist. For many endoscopists, the combination
of a benzodiazepine plus (or minus) an opioid with which they are most familiar is
still the best compromise in terms of efficacy, cost, and safety. Fatal drug-induced
cardiopulmonary complications continue to occur, despite a general trend toward using
smaller doses of sedation than we did 5 - 10 years ago. Monitoring techniques that
are at present considered as research tools may one day become commonplace. These
include: the use of an electroencephalography parameter known as bispectral analysis;
transcutaneous CO2 measurement; and a modified continuous capnographic waveform trace to monitor ventilatory
effort. Bispectral analysis may be of use in monitoring central nervous system depression
and helping to distinguish between conscious sedation and deep sedation. If the measurement
of CO2 levels, either transcutaneously or in breath samples, was as easy and inexpensive
as measuring SpO2 with a pulse oximeter, then undoubtedly such technology would enhance the early detection
of sedative-induced hypoventilation and apnoea. Further evidence regarding droperidol's
possible role in conscious sedation is presented. Pain during colonoscopy remains
a problem, and the possible role for intraluminal injection of peppermint oil, as
well as the value of variable-stiffness colonoscopes, in reducing the need for intravenous
sedation is discussed. Case reports of hyponatraemic encephalopathy and hypocalcaemic
tetany as complications of oral bowel preparation are presented, as is the challenge
associated with adequate bowel preparation in diabetic patients.
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G. D. Bell
Faculty of Medical Sciences · University of Sunderland
The Grange · Chilton Moor · Durham DH4 6QB · United Kingdom
eMail: duncan_bell@compuserve.com
