The effects were most pronounced in younger patients. In terms of endoscopist assessment, the patients in the midazolam group were rated as easier to intubate by the endoscopist compared with the placebo

group, but there was no difference between the midazolam group and either the pharyngeal anesthesia or control groups. Interestingly, the midazolam group had a higher STI571 endoscopist rating for overall difficulty and retching during the procedure compared with the pharyngeal anesthesia group. Another study showed that performing endoscopic ultrasound without sedation, while less well tolerated, did not lead to longer procedure times, higher risks or increased reluctance to undergo a repeat procedure.12 In this study, however, there was no control group—only blinded (to both patients and endoscopists) sedation and placebo buy CH5424802 groups. More recently, male sex, previous colonic resection, a high body mass index (BMI) and the absence of gynecological surgery were shown to be associated with higher colonoscopy completion rates in unsedated patients.13 Hypnosis has also been used to facilitate endoscopy.14 Compared with intravenous midazolam, however, its use was associated with greater patient discomfort

(as assessed by the patient) and less amnesia for the procedure. There was also a trend towards its being associated with greater technical difficulty on the part of the endoscopist. However, use of hypnosis led to less patient agitation as assessed by independent observers compared with both patients receiving pharyngeal spray without intravenous sedation and those receiving midazolam. The use of pharyngeal local anesthetic sprays as a prelude to endoscopy is widespread, although only a few studies have evaluated MCE their efficacy. A recent meta-analysis15 of five randomized controlled trials comprising 500 patients showed that the use of pharyngeal spray led to less procedure-related discomfort and less technical difficulty as rated by the endoscopist. Whether it also leads to a reduction in intravenous sedation requirements is not clear. There is a small risk of methemoglobinemia,16

particularly with benzocaine, and some evidence that aspiration may be more likely to occur following pharyngeal spraying with local anesthetics.17 A recent meta-analysis of six prospective, randomized, controlled trials, found that listening to music before the procedure was associated with lower doses of analgesia and shorter procedure times.18 Anxiety levels were also lower in the ‘music’ group, and there was a trend towards a reduced level of sedative agents but this did not achieve statistical significance. Patients undergoing endoscopy should be fully informed of the risks of intravenous sedation in a preoperative consultation setting. Written information should be made available and there should be opportunity to ask questions.