Role of remimazolam in gastrointestinal endoscopy: American Society for Gastrointestinal Endoscopy clinical practice update.

Match the pre-sedation assessment, the drug regimen and the monitoring to the patient's risk and the complexity of the procedure. Before every sedated procedure, check ASA class, Mallampati score, BMI, OSA risk and fasting status. Propofol and midazolam-with-opiate are both strongly recommended. Using propofol as first line depends on national legislation and staffing, not on proof that it works better. Remimazolam is an ultra-short-acting benzodiazepine, FDA-approved for procedural sedation in July 2020, with fast onset, short duration, organ-independent metabolism and flumazenil reversibility. It is an accepted alternative to midazolam and propofol. Consider it especially in high-risk patients: the elderly and those with cardiorespiratory comorbidity. ESGE/ESGENA 2026 says this, and the ASGE 2026 clinical practice update now covers it, the first ASGE document to address remimazolam (the ASGE 2018 sedation guideline covered only midazolam and propofol). Whoever gives the sedation must be able to rescue a patient one level deeper than intended. Involve an anesthesiology specialist for emergency endoscopy with raised aspiration risk, hemodynamic instability or significant comorbidities. Do the same electively for ASA >=3, Mallampati >=3, severe OSA or an expected difficult airway. Manage GLP-1 receptor agonists case by case rather than stopping them by default. Discharge the patient against a scoring system, with an adult accompanying them and 24-hour restrictions.