We can now offer patients procedures which, 20 yrs ago were unthinkable.  Procedures which improves health, reduces morbidity and saves lives. But, these procedures are longer and more uncomfortable and therefore patients require deeper sedation than before.  Unfortunately, at the same time, patients are older and with more comorbidities.  This dual problem of frail patients requiring deeper sedation for longer procedures, has narrowed our ‘sedation window’. The old way of monitoring patients, with a nurse and an oxygen saturation monitor, is no longer enough.  It's for this reason that the Academy of Medical Royal Colleges in February 2021, updated their guidelines on Safe Sedation practises.  Now they recommend that patients requiring 'moderate sedation' should be monitored more closely, not only by a dedicated nurse and oxygen saturation monitor but also with ECG, BP and Capnography. Of course, this is a huge change for endoscopy units.  Our staff are now asked to do three things at the same time; maintain the airway, listen to the pitch of the oxygen saturation monitor and interpret that ECG and Capnography traces.  Dr Martin Lees , Clinical Director of Cardiac Anaesthesia and Perioperative Medicine at St Barts Heart Centre in London and Nurse Specialist Andreia Trigo with SedateUK, discuss the new guidelines and the implications it has for endoscopy units around the World.