Eden, do we have any questions from the audience? Yeah, they're starting to come in. And why don't we do a couple of polling questions first, just to remind folks of the three lectures that we just had. So our first one, I think will be yours, Dr. Shields, related to sedation. Okay. So, which of the following are indications for anesthesia assistance during endoscopy? Prolonged or therapeutic procedures, previous intolerance to moderate sedation, ASA class four or five disease, difficult airway, or all of the above? I don't think we stumped people this time. No, no, that was just a reminder of all the things that you should think about when you're considering the use of anesthesia, and it sounds like everybody is right on board with that one. Fantastic. And for our next question, we will go to Dr. Vicari. How many different PrEP instruction protocols are used within your group? One, two, three, four, five, and if it's more than five, just pick five. So, actually, that's a really good and, I think, encouraging split. I think minimizing, as I said, minimizing the number of PrEPs really helps staff. They can become experts in PrEPs, and it is less confusing to patients, so that's a really nice split. And Dr. Call, I believe this one is associated with your talk. Which of the following agents should never be stopped for any endoscopic procedure? My personal favorite. Never be stopped. Clopidogrel, aspirin, warfarin, apixaban, rivaroxaban. Wow, look at that. The first 100% answer. All right. Excellent. Congratulations. That is one thing. You know, the problem with this is, this still finds its way in pre-procedure packets, and if there's one contribution to GI that I can make is, do not stop aspirin and remove it from your pre-procedure packets. Thank you. Okay, Eden, if we could maybe hear our first question. Sure. I think we might want to address this one to Dr. Vicari and maybe go around the panel. What are experiences with SUTAB PrEP? So good question. As I alluded to in the talk, for us, it's a minimal experience to date. I've actually scoped two patients that I can think of that have had the SUTAB PrEP. Patients tolerated it. The PrEP was a quality PrEP, and the cost was a minor issue for both because of insurance companies' coverage. Again, that may vary. I talked to a few of my partners, and their experience to date, again, very small numbers, purely anecdotal, has been well-tolerated and good PrEP so far. And if anyone else wants to jump in, I think we've got a very limited experience to date. We have another PrEP question, two from the same person, so I'll read them both since I think they might go hand-in-glove. What is the preferred PrEP in the setting of end-stage renal disease, stage 3 renal dysfunction? And then they ask, stance on PlenVU in that setting? So our go-to PrEP in those patients, I'm still a big fan of the Go Lightly, New Lightly PrEP. I think that is the safest option. It's, again, it's isosmotic. There should not be any significant fluid and electrolyte shifts. Having said that, we've had a practical problem recently of a shortage of Go Lightly, New Lightly regionally. I don't know if others have experienced that. PlenVU could be a reasonable option in that choice, but if I had 100% choice and we had enough PrEP on hand, it's Go Lightly, New Lightly. Agreed. And then this question, Dr. Shields, I think might, we'll start with you. How do age and comorbidities factor into decision for choice of sedation for endoscopy? Yeah, that's a good question. You know, for many of the practices where anesthesia is used for all of your cases, this doesn't factor in at all, but in the areas where you're still sometimes considering the use of, it's usually deciding between moderate sedation or MAC. I think we do take age into consideration at both extremes. I think we all have had experience with younger patients who, you know, may or may not be on other medications that may impair their tolerance just for getting through moderate sedation. I think, especially with upper endoscopy, you know, a lot of young patients don't tolerate it very well, especially if you anticipate that it's going to be a longer procedure if you're, you know, you're doing the banding or you're doing EMR or something along those lines. So, at the younger end, I think, you know, we might be a little bit more likely to go with use of MAC. And then at the other end, for older patients, I actually find that a lot of older patients are actually pretty easy to sedate. They just take a little bit of Versed and fentanyl and they go right out. But again, if they've got other comorbidities, if, you know, anticipating a longer procedure than in those cases, then we might consider, you know, consulting the anesthesiologist and getting some assistance there. So another for you, Dr. Shields, do you have a preference for sedation in the setting of a propofol allergy when deep sedation is needed? Oh, I'm not sure that I've actually encountered anybody who had a propofol allergy. I certainly would be calling my anesthesiologist friend and say, you know, this person either didn't tolerate propofol or has a true allergy. You know, if the patient, if I didn't feel like I could do the patient with moderate sedation, I would ask the anesthesiologist to come up with some, they always seem, always some have some kind of magic cocktail that they include, sometimes a benzodiazepine and fentanyl and sometimes a little ketamine thrown in there. If that wasn't going to work, then, you know, there's always the option of doing general anesthesia in those cases. Any other? Yeah, I'll throw this out there. I think an option you might see anesthesiologists use, and it's used a lot in the ICU for alcohol withdrawal for sedation, is Presidex. We don't see a lot of Presidex used much in endoscopy. It was used a little bit. We actually did a study on Presidex in our patients. At one time, there were about two or three of us in the group that had some experience with Presidex. I'm probably the only one left. It's an option. You can have anesthesia involved, but just a little out-of-the-box thinking. Yeah, ketamine also is really, really very effective for a half an hour or 45-minute procedure. Ketamine works. It's just the familiarity, experience, awareness, you know. Anesthesiologists vary in their cocktail regimen based on where they are, where they were trained, what their experience is, so that's a whole different discussion, but ketamine works. To go back to what Aaron had said, I've never seen anyone with a propofol allergy, frankly, and we do a lot of our cases under both MAC and general anesthesia, so I think it's exceedingly rare. As endoscopists, we're never the driver of what's chosen as the anesthetic agent. That's the nurse anesthetist and the anesthesiologist's call. I think if you deliver propofol at home, you might run into some allergies, but other than that, you'll be fine. What are you alluding to there, Vivek? That's all I'm going to say, John. Sorry. Well, Dr. Vickery, you certainly sparked a few questions when you mentioned a shortage of Golightly. I don't know if that's something we're seeing across the country right now, but two people asked a very similar question. What are other preps available for cardiac and renal insufficient patients besides Golightly and Nulightly? Both these individuals did indicate they, too, are seeing a shortage. We have used some PlenVue. Aaron, since we're in the same group, anything else you can think of besides PlenVue? I don't know if we've done… I think we may have done some Miralax, but again, you have to be careful there with fluid and electrolyte shifts. It's a real clinical dilemma, but I think it's mostly been PlenVue. Aaron, anything else? Yeah, no. I know we've been using some Miralax preps, and most patients seem to tolerate and get pretty good results from that. Yeah, just remember with Miralax, make sure they stay up in their fluids and electrolytes. And again, it's not FDA approved, but widely used. And we have a hand raised, so I am going to unmute the line. Let's see. They might be self-muted as well. Joanne, if you wanted to ask a question, it looks like you've muted yourself as well. If you can unmute yourself, I've got you unmuted on my end. Okay, maybe you accidentally raised your hand, so I'll just put that down for now, and you can raise it again if you have a question. So our next question that came through was, how detailed should the review of risks and benefits for anesthesia be in the clinic setting that may occur several weeks before the scheduled procedure? Is the clinic APP responsible for assessing Malapati score? Or is this more specific to the inpatient GI APP and anesthesia provider? Should I read that again? No, I glitched out for the first part of that, if you could just read the first part of that again. Sure. How detailed should the review of risks and benefits for anesthesia be in the clinic setting that may occur several weeks before the scheduled procedure? And then they also ask, is the clinic APP responsible for assessing Malapati score? Or is this more specific to the inpatient GI APP and anesthesia provider? The second part is easier to answer. The Malapati score is something that is assessed usually immediately before the procedure documented in the chart, right before either moderate sedation or anesthesia is used. You know, the challenge, I think, for the outpatient APP, especially if you're practicing on your own and you're not necessarily running every patient by the gastroenterologist who's going to be performing the procedure. The challenge is to make the assessment, again, maybe it is a couple of weeks or even a month before the patient comes in for their procedure, and yet you have to be comfortable with making a decision on what the most appropriate anesthesia is for that patient. By the time the patient arrives on the day of their endoscopy, it's already been determined what they're going to get. They've been put into either the moderate sedation track, or they've been scheduled for a MAC procedure. So I think if you have, I think a lot of patients are cut and dried. I would say 90% of patients you see, it's pretty obvious what they're going to need. But there is going to be a group of patients that are kind of on the fence. Maybe they've got some comorbidities, and maybe their age is a concern. Maybe they've had issues with prior procedures, not tolerating sedation well. And I think in those cases, we've encouraged our APPs to talk to us. If you're not sure what's most appropriate, either talk to, ideally talk to the person who's going to be doing the procedure that day, and get their input on how they think it's going to go best for the patient, because you're right. And things can change over the course of a month. Some of you might have compensated heart failure, and then by the time they come in for their procedure, things have changed. So I think a lot of experience seeing a lot of these patients, finding out how they end up doing with whatever sedation you've chosen, and then talking with the endoscopist who's going to do the procedure. Those are the ways to try to get it right. But I can tell you, even with all of those things, there are patients that come in where we get in, we find out that what we're giving them is not going to work, and we have to change on the fly, or we have to cancel the procedure and bring them back another day, because they couldn't be safe, we were adequately sedated. Wonderful. And just a reminder, you can submit a question at any time online by using the question box on the right-hand side of your screen. If you do not see the question box, please click the white arrow in the orange box located on the right-hand side of your screen. And we do have a comment, just going back to the Go Lightly shortage. This person writes, I am in South Florida. We have absolutely had a shortage, but it seems to only be with certain pharmacies. We ask our patients to pick up the prep as soon as possible, so that if we need to send the script to another pharmacy, we may do so or suggest an alternate prep. So that was just a comment, not a question from one of our attendees. Yeah, I think that's good practical advice. I mean, if you in your area know where there's a supply, certainly try to use that pharmacy. So it's a good practical point. So we do not have any questions currently in queue. Does anyone on the panel have a question for another panelists while we're waiting for more? I do. Actually, yeah, I have a question I'd like Dr. Martin to address. We saw with the polling question what the distribution is in terms of use of moderate sedation versus MAC anesthesia as the kind of the preferred sedation for mainly for colonoscopy and upper endoscopy. And I'm just curious at the Mayo Clinic, how are you doing it? What kind of decisions are you using to decide how to go about sedation? Yeah, thanks for the question, Aaron. And as is the case with a lot of things medical, the answer is kind of complicated and it depends. So probably some background is worthwhile. I work at Mayo Clinic's what I would call mothership, which is in Rochester, Minnesota, about an hour south of the Twin Cities. And we have two campuses that are about half or three quarters of a mile apart. And what everybody thinks of as the Mayo Clinic campus is largely outpatient, but it has a smaller inpatient footprint that includes solid organ transplant, some oncology, some surgical services, et cetera, and a large outpatient practice. And then we have the St. Mary's Hospital slash Medical Center campus, which is the largest inpatient footprint and has all of the medical inpatient services, many of the surgical inpatient and outpatient services and psych. And because we have two sort of different footprints, we have three different endoscopy units. So at the largely outpatient endoscopy unit, or a largely outpatient Mayo Clinic facility, we have what you think of as a routine endoscopy unit, which is mostly screening colonoscopy and elective EGD and colonoscopy work. And that is the largest volume endoscopy unit of the three. And we have a long hallway that opens to many different colonoscopy and EGD rooms that are moderate sedation rooms where the nurse under endoscopy supervision, the RN, administers moderate sedation with fentanyl and Versed. We also, on that unit, have two anesthesia staffed rooms that provide MAC anesthesia only for EGD and colonoscopy with no general anesthesia. And those rooms are largely used for patients who either have a history of requiring overly high doses of moderate sedation to efficiently or safely undertake the case. And many of those are patients who have disorders like inflammatory bowel disease, where they may require frequent, repeated procedures that may require a lot of biopsies and resections and stuff like that, and therefore get sedation frequently and become tolerant to it. So, they're requiring anesthesia's assistance, not because of case complexity, but because of the inability to be comfortable with reasonable amounts of moderate sedation. We also, on that campus, have another unit that's completely anesthesia staffed with six rooms, two of which are ERCP EUS rooms, two of which shift between EUS, diagnostic EUS alone, and other procedures like balloon enteroscopy, and then two rooms that perform largely EGD enteroscopy and colonoscopy procedures that are more technically complex. So, for example, a lot of the EGDs are esophageal dilations. Some of the upper and lower GI procedures might be luminal stent placements and things of that nature. Most of those procedures are done under MAC anesthesia. A few of them are general, but all of our EUSs and ERCPs and bariatric endoscopy procedures are done under general anesthesia. At St. Mary's Hospital, which, again, is the largest inpatient footprint for us, we have seven rooms in that endoscopy unit. The vast majority of those procedures are ERCPs, EMRs and ESDs, various esophageal therapeutic procedures, bariatric endoscopy, full thickness resections, et cetera, some of the things that we'll be talking about tomorrow. And depending on case complexity, of course, various types of sedation or anesthesia can be used. But the vast majority of those procedures are done with anesthesia assistance. The longer ones or the more complex ones like ERCPs, EUSs, bariatric procedures, et cetera, are only done under general anesthesia. One caveat I might mention, I've been at Mayo Clinic for seven years now. I used to work at Northwestern in Chicago. And at the unit at Northwestern at that time, the endoscopy unit didn't have the ability to undertake stage one recovery for anesthetic patients. And they had to be taken up to the PACU, up an elevator. And our entire team would have to leave the room to take the patient upstairs. So we'd lose about half an hour in all of that. And so the anesthesia team was very disincented to undertake general anesthesia in that setting. And so we did a lot of ERCP under MAC instead of GA. At the unit where I work now, all that recovery can be done on site. And so the anesthesia team likes the perceived safety and ease for themselves of undertaking GA. And so we don't generally do MAC, ERCP, and EUS at Mayo Clinic. I hope that gives you some idea. I think the take-home message is that, and I think Aaron was mentioning this earlier, that age isn't the biggest driver. The biggest driver is case complexity, patient comorbidities, some efficiency issues that are going to be idiosyncratic to the unit that you're working at and the team that you're working with. And also the anesthesia culture is a real driver of that. So it depends on the anesthesia practice. And I think what I've tried to learn over the years in working with anesthesia teams is to not be overly aggressive in letting your opinion as an endoscopist drive the type of anesthesia that's administered. We're not the ones that absorb the risk for that aspect of the procedure. That's the anesthesia provider, whether that's your CRNA, your anesthesiologist, or in my unit, both. And so I try to take a step back and just remind the anesthetist, hey, it doesn't matter to me what type of anesthesia you deliver. Do what you feel is correct from an anesthesia provider's point of view. And that makes you most comfortable from a safety standpoint. I can do the case under either type of anesthetic. All I'm interested in is what you think is safest and that I don't have to chase the patient around the room to get that procedure done. Thanks. Vivek, did you have something to add there? Yeah, that was excellent. I mean, that was masterful. A couple of comments, I think, to the choice of who does what type of anesthesia. I think the only caveat I'll put on John's comments is that increasingly we are told and we have learned and we have seen is that the anesthesiologist has a very variable understanding of what you're going to be doing, especially if you're dealing with rotating teams that new people come every week. So a huddle before the procedure is critical because if you tell them this is a diagnostic EUS and it will be over in seven minutes, they may plan differently. If they think you're doing a, you know, a cystic astrostomy or a necrosectomy, they may plan differently. So that conversation, simple as it sounds, doesn't happen as regularly as I would like to see it. But I think that may have a significant impact on the choice of anesthesia in a given situation. And they welcome that and that builds the team spirit as well. And that's right for the patient too. So that's one. Second is in terms of patient selection, a lot of patients coming in on psychotropic medications, that's a red flag. You're not going to be able to moderate sedate them. Number three is my general rule. If there is a patient who had a failed procedure anywhere, I will bring them with anesthesia because I'm already dealing with a challenge. I don't want to have another second potential challenge. So, and finally, extremes of age. In the super geriatric population, it's almost always wise to go with an anesthesiology support because they have sudden cardiac death and a variety of other potential issues that can come with even the smallest levels of anesthesia. And I've had patients, I had a 104-year-old very early on my practice that flatlined with induction. And he was airlifted from a neighboring hospital and so I think those are my comments. I'll stop there. That's great. Those are all good comments. Maybe I'd like to hear from one of the APPs. Erica, what is your practice setting like out there in terms of use of anesthesia in Oregon? Yeah. So, in our ASC, we have CRNAs that use propofol and the anesthesia, it's up to them. If there's a question about the airway assessment, we have the luxury, the ASC is connected to our office so we can bring one of them over to do an airway assessment before we schedule them. So, for example, if you have a BMI of 45, but it's all kind of an apple kind of effect, lower truncal obesity, but the neck looks good and the myelopathy score is great, then sometimes they'll have a CRNA come over to do an airway assessment and they can be approved for the ASC. But we do have a category of guidelines of which is like BiPAP is Rev-X, they must go right to the hospital in addition to kind of BMI of 50 and above, et cetera. In our hospital setting, it's our anesthesiologists that are doing all the anesthesia there. A majority of them all use propofol. And then just like you all had mentioned, they kind of steer the boat. It's up to them what they want to do. So, do you have any advice that you can give the APPs out there on things that you look at when you're trying to assess appropriate sedation for a patient? Yeah. Our CRNAs did teach us how to do a myelopathy score. So, we do assess the myelopathy and we document that in our note. We also document the ASA sedation classification. So, their risk assessment for anesthesia complications in our note. And so, I think it is challenging. What has been helpful is having parameters. So, our CRNAs did sit down with us and we came up with a list of that these patients, no matter what, cannot be seen in the ASC. So, dialysis, like I said, a BMI of over 50, a stroke or an MI within the past six months. So, having those kind of parameters has been very helpful that those patients have to directly go to the hospital. In respect to the question of assessing risk and their procedure is going to be a month later, well, I guess you do the best you can. And then just making sure that you're educating the patient that if there's any change in health status from when you saw them to when they're going to be scoped, you need them to relay that information to you because that will change their risk. And you do the best you can. Sometimes patients show up right after having a heart attack and just don't understand. And that's not necessarily your fault, but just do what you can. Yeah, I know our APPs, they do a good job. They assess everything, but you can't always get it right. And sometimes these patients show up for endoscopy and we have I think you cut out a little bit on us there, Dr. Shields. Let's see. Let me just sneak in another question then, because we're coming to the close of our session here. Does anyone have experience with the HygieaPREP or HygieaCare? So I know we've had a few questions about PREP today. Does anyone have experience with that? I do not, and our group does not. So unfortunately, I've heard of it, but I have no experience with it. We don't have it, but I know centers that have it, and I've met with the team from Israel more than once. It is real. It does exist. It's not cheap. It does take some monies to set it up. It needs to be a separate setup, usually with minimum two chairs, ideally with four chairs to manage throughput. So it's an additional kind of a center that goes alongside your center. And it can take anywhere between 45 minutes to a couple of hours to do the process, and then it's all rectal. And there are no, fortunately, no concerns with regards to contamination such. They've taken care of that part of it. Outside of bowel preparation for colonoscopy, there are claims and some literature that may have some benefit in IBS and some of the SIBO syndrome managements. But that's the extent of it that I'm aware of. I think the amount of investment was not insignificant, and it needs to be a separate kind of an entity purpose-built for that particular activity. So that's the limit of my knowledge on that. And then the pandemic came, so I could not even begin to pursue it in our enterprise. Yeah, Vivek, our experience was similar to yours. We met with them and considered it too. And I think, yeah, the pandemic kind of stalled our talk about it. But one of the things that I can remember vividly about the discussion, one of the things that made it difficult for us to to realistically take it on was that it does require its own footprint. It's actually, right, it's a facility installation. So it would be like taking a big jacuzzi size thing and install it. You have to plummet and all this stuff. And then you have to sort of build what's like a sauna room or a bathroom around it. So it's not only an expensive proposition, but there's always this sort of, well, what else could your endoscopy unit do with that space, that space that could be two or three recovery bays, that space that could be a couple of procedure rooms, et cetera, et cetera. So I think there's that sort of institutional, what would you call it, opportunity cost of space that you have to compete with other departments or other potential utilizations of that space. Yeah, I think it's harder, it's much harder for those reasons in an academic medical center set up, at least those of us that are kind of this traditional model university of so and so. But it's much easier for nimble private systems to, who have space, and there's a lot of space in the Midwest. And I should add spa music is not included with that. So you'll have to get your, still get your own Spotify account. So it's a novel, groundbreaking, one of a kind, all position technology and feature. I mean, I think certainly worth exploring for those entities that have the ability to do it nimbly. Well, that's always good to remember the value of entertainment in life. You know, some attributes, those are my maximum attributes. So we have to bring that in, especially as we approach the lunch hour after these intense conversations.

sedation

anesthesia

endoscopy procedures

aspirin

renal dysfunction

sedation methods

HygiaPrep system