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Sedation for gastrointestinal endoscopy: European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) Guideline.

From GI Signals issue №3: what this paper found, what it changes, and where it sits against the current standard of care, reviewed by Simon Mathews, MD.

Endoscopy guideline · Jul 21, 2026 · Endoscopy · IF 11.8

Sedation for gastrointestinal endoscopy: European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) Guideline.

Guideline / reviewguidelinesedationhealth services
Clinical takeawayIn your endoscopy practice: (1) adopt propofol as your first-line procedural sedation unless contraindicated or unavailable; (2) use midazolam with opiates as alternative if propofol not accessible; (3) consider remimazolam specifically for elderly patients or those with significant cardiac or pulmonary disease, but exercise caution when combining with other sedatives or analgesics; if analgesia is required, carefully coordinate drug selection with your sedation team; (4) ensure a dedicated, specifically trained staff member (not dual-tasking) administers all sedation; (5) perform pre-procedure risk assessment for each patient and calibrate your sedation regimen and monitoring based on both procedure complexity and patient risk factors; include capnography monitoring for high-risk patients; (6) individualize sedation decisions for patients taking GLP-1 receptor agonists rather than using a standard approach; (7) routinely offer unsedated diagnostic colonoscopy and gastroscopy as a patient option.
What it foundESGE/ESGENA guideline specifies propofol as first-line procedural sedation (where permissible), midazolam with opiates as alternative, and remimazolam for elderly patients or those with cardiovascular/respiratory comorbidities; mandates sedation delivery by dedicated trained professionals and tailors pre-assessment and periprocedural monitoring to both procedure complexity and patient risk profile.
ContextThis European guideline formalizes and standardizes endoscopy sedation practice. Propofol is already used first-line in many centers but is now officially endorsed across Europe where resources and law permit. Remimazolam is newly highlighted as a dedicated option for high-risk patients (elderly, cardiovascular/pulmonary comorbidities), reflecting evidence on ultrashort-acting agents in medically complex populations. The emphasis on dedicated trained sedation staff and explicit risk stratification strengthens safety protocols.
Reinforcessuggested applicable standard· ESGE/ESGENA 2026 (PMID 42480549); ESGE/ESGENA/ESA NAAP 2015; ASGE 2018; ASA 2018 moderate sedation; multisociety GLP-1 perioperative guidance 2024

Decision at stakesedation regimen and monitoring should be scaled to patient risk and procedure complexity, using propofol first-line or midazolam with opiates, with dedicated staffing and trained recovery

Scale pre-sedation assessment, regimen and monitoring to patient risk and procedure complexity. … Propofol AND midazolam-with-opiate are both strongly recommended; propofol as first line is conditioned on national legislation and staffing, not on demonstrated superiority. …

From our summary of this standard, unedited — the part the paper bears on. … marks omitted text. Our wording, not the guideline's; read the source for its own text.

Our full summary of this standard

Scale pre-sedation assessment, regimen and monitoring to patient risk and procedure complexity. Assess ASA class, Mallampati, BMI, OSA risk and fasting status before every sedated procedure. Propofol AND midazolam-with-opiate are both strongly recommended; propofol as first line is conditioned on national legislation and staffing, not on demonstrated superiority. Consider remimazolam in the elderly and in cardiorespiratory comorbidity. Whoever administers sedation must be able to rescue a patient one level deeper than intended. Involve an anesthesiology specialist for emergency endoscopy with increased aspiration risk, hemodynamic instability, OR significant comorbidities, and electively for ASA >=3, Mallampati >=3, severe OSA or anticipated difficult airway. Individualize GLP-1 receptor agonist management rather than withholding blindly. Discharge against a scoring system with an accompanying adult and 24-hour restrictions.

ESGE/ESGENA 2026 (PMID 42480549); ESGE/ESGENA/ESA NAAP 2015; ASGE 2018; ASA 2018 moderate sedation; multisociety GLP-1 perioperative guidance 2024 ↗
Triantafyllou K … Sidhu R · Endoscopy · IF 11.8 · PubMed ↗Permalink
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