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Propofol is a unique sedative that combines a rapid onset of action (30–45 s) with a short duration of effect (4–8 min), which makes it an ideal agent for relatively short outpatient procedures such as esophagogastroduodenoscopy (EGD) and colonoscopy. There is no doubt that propofol-based sedation has additional benefits compared to traditional sedation. When compared with traditional sedation in previous meta-analyses, propofol-based sedation had similar rates of adverse effects, provided higher patient satisfaction for most endoscopic procedures, decreased time to sedation, decreased recovery time (and may therefore decrease discharge time compared with traditional sedation) and increased the quality of endoscopic examination [1–3]. Recently, in Western countries, the main issue with propofol-based sedation has been, not ‘‘which regimen’’ is used but ‘‘who administers’’ the sedation. Non-anesthesiologist administration of propofol (NAAP) retains the advantages of propofol-based sedation while maintaining patient safety and lowering costs [4]. With regard to safety, Rex et al. [5] reported the largest safety data with NAAP, including 223,656 published and 422,424 unpublished cases. Propofol may cause hypoventilation, hypotension, and bradycardia relatively frequently, but severe adverse effects are extremely rare. Deaths occurred in two patients with pancreatic cancer, a severely handicapped patient with mental retardation, and a patient with severe cardiomyopathy. NAAP has a lower mortality rate than published data on endoscopist-delivered benzodiazepines and opioids and a comparable rate to published data on general anesthesia by anesthesiologists. In the author’s opinion, the main point of controversy regarding NAAP is the cost. Two indirect calculation studies found that propofol was at least as cost-effective as traditional sedation for colonoscopy and EUS [6, 7]. The indirect cost-effectiveness was attributable to a higher daily number of procedures due to shorter post-procedure recovery times. Although propofol is more efficient than conventional regimens in terms of induction and recovery times, it is only cost-effective compared with standard sedation when administered by a registered nurse under the supervision of the endoscopist [8]. Anesthesia professionaldelivered sedation has become increasingly common when performing colonoscopy and EGD in both the United States and European countries. From 2003 to 2007 in the USA, the involvement of anesthesiologists in colonoscopy almost tripled, from 9 to 25 % of colonoscopies, and this will be increased[50 % by 2015 [9]. Hassan et al. [10] calculated the costs related to NAAP implementation at a national level for a screening colonoscopy program in the USA— propofol administration by nurses rather than by anesthesiologists would result in savings of 3.2 billion USD over a 10-year period. Their calculations assumed 28.3 million screening colonoscopies over 10 years, including 9.8 million colonoscopies (34.8 %) with propofol-based sedation. This would translate into savings per colonoscopy of 326.5 USD (3.2 billion/9.8 million). In France, fecal testing has been chosen for colorectal cancer screening; it is the most cost-effective method since 90 % of colonoscopies there are performed with intravenous sedation which may only be administered by anesthesiologists [11]. Anesthesiologist involvement adds 285 % to the cost of a colonoscopy (EUR 740 vs. EUR 192, respectively, for a colonoscopy with vs. without an anesthesiologist). S.-H. Lee (&) Division of Gastroenterology, Department of Internal Medicine, Cheonan Hospital, Soonchunhyang University College of Medicine, 23-20 Bongmyung-dong, Cheonan, Choongnam 330-721, Korea e-mail: ygun99@hanmail.net

Non-anesthesiologist Administered Propofol With or Without Midazolam for Moderate Sedation—the Problem Is Not “Which Regimen” but “Who’s Regimen”