The room where endoscopic procedures are carried out should be large enough to accommodate appropriate endoscopic and monitoring equipment, and to allow the easy movement of attending health

care workers within the endoscopy suite. Infection control measures, in particular disposal of blood contaminated equipment (‘sharps’) should be in conformity with the guidelines enunciated by the US Center for Disease Control. Facilities to house a variety of syringes, needles of different sizes, tapes, dressings, topical antiseptic agents, intravenous cannulas, intravenous tubing, giving sets and disposable gloves of various sizes should be present. Suction and oxygen outlets with appropriate tubing and accessories should be present. Patients should be positioned on trolleys of appropriate check details width with functioning side rails. Although MS-275 endoscopy suites are often free standing, particularly in private practice, there is merit in having endoscopy suites either co-located or within easy access time to operating theaters, intensive care units and cardiac resuscitation teams. Careful monitoring of patients is essential for the safe practice of endoscopy in sedated patients. Patients should be under constant clinical surveillance with particular attention to respiratory movement and response to verbal and tactile

stimuli. At least one of the endoscopy suite personnel should be exclusively attending to the sedation and monitoring of the patient. This can either be a medical practitioner trained in sedation and monitoring, or a nurse working under the supervision of the medical or surgical endoscopist. In addition, continuous pulse oximetry and regular blood pressure and pulse measurements before, during and after the procedure(s) should be carried out, and the results recorded contemporaneously. Other monitoring techniques, such as capnography may be appropriate particularly in higher risk patients—this has been shown to be a more sensitive indicator of hypoventilation than either oximetry or visual inspection38,39 and to reduce the risk

of desaturation if used during ERCP and endoscopic ultrasound (EUS).40 Electroencephalographic monitoring has not been shown to offer MCE benefit in the context of endoscopic sedation; its use remains experimental.41 A double-blind randomized study from Hong Kong showed that oral administration of 7.5 mg midazolam 20 min before upper gastrointestinal endoscopy reduced patient anxiety and increased patient satisfaction.42 Similar results were reported with premedication before sigmoidoscopy.43 On the other hand, a German study failed to show any benefit from oral administration of 1 mg lorazepam before ERCP, and premedicated patients actually required higher doses of propofol in the early stages of the procedures and higher overall doses of ketamine compared with controls.44 In general, for endoscopic practice it is unlikely that oral premedication adds substantially to smoother or safer sedation.