Advancements in Colonoscopy Sedation: Current and Emerging Practices

Building on ASGE/ASA sedation guidance, the field is balancing comfort, safety, and efficiency: new pharmacological approaches are enhancing colonoscopy experiences while keeping patient safety and procedural efficacy in clear view.

For moderate sedation, midazolam with an opioid (e.g., fentanyl) remains common, whereas propofol is widely used as the primary agent for deep sedation with rapid recovery when administered by trained providers. Evidence syntheses indicate that sedative selection shapes the balance between efficacy, recovery, and safety, as discussed in an analysis of sedation agents.

This approach can alleviate patient anxiety and may shorten recovery in some studies. Against that balance, emerging agents such as remimazolam and dexmedetomidine offer distinct pharmacokinetics and cardiorespiratory profiles relevant to endoscopy.

Remimazolam is associated with rapid recovery and favorable hemodynamics, whereas dexmedetomidine offers minimal respiratory depression but can cause bradycardia or hypotension and may be linked to longer recovery in some settings, as explored in a recent comparison of remimazolam and dexmedetomidine. Availability, evidence maturity, credentialing requirements, and cost considerations vary across settings, so adoption relative to propofol-centric practice depends on local resources and training.

On the patient safety side of the triad, for high-risk populations, such as the elderly or those with comorbidities, personalized sedation strategies are essential (guided by ASA physical status and airway risk tools such as STOP-Bang).

Propofol or newer agents like remimazolam, alongside enhanced monitoring (e.g., capnography), can reduce procedural risks for select patients, as discussed in propofol and monitoring in high-risk sedation.

On the efficiency side, workflow and staffing models matter: deep sedation with propofol often requires trained providers and clear rescue pathways, while introducing newer agents may necessitate updated credentialing and education for nursing and anesthesia teams.

Monitoring technologies continue to evolve. Beyond standard pulse oximetry and noninvasive blood pressure, many units incorporate capnography to detect early hypoventilation, aligning monitoring intensity with patient risk and the planned level of sedation.

Patient-reported outcomes complement traditional metrics. Comfort scores, satisfaction, time-to-discharge, and willingness to repeat the procedure help teams assess whether changes in sedative choice or monitoring truly improve the experience without compromising safety.

Implementation is iterative. Piloting protocol changes, auditing adverse events, and tracking recovery-room throughput allow teams to balance the comfort–safety–efficiency triad in their local context.

From data to practice, integration is reshaping protocols through selective, protocolized adoption where benefits outweigh trade-offs based on patient and procedural factors.

Key Takeaways:

• New pharmacological agents may improve both patient safety and procedural outcomes.
• Emerging sedatives like remimazolam have been associated with shorter recovery times versus midazolam in some trials.
• Risk-stratified protocols pair sedative choice with enhanced monitoring to balance airway safety and recovery.