ASGE Annual GI Advanced Practice Provider Course (Virtual) (Day One) | March 2026-Pre-procedure Essentials: Informed Consent, Sedation, Bowel Preparation and Periprocedural Medication Management

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This document outlines “pre-procedure essentials” for GI endoscopy, focusing on informed consent, sedation/anesthesia, bowel preparation, and peri-procedural medication management.

<strong>Informed consent</strong> is emphasized as an ongoing communication process—not merely a signed form. Core elements include explaining the indication for the procedure; discussing risks, benefits, and alternatives; setting expectations (including possible failure, missed lesions, and a “plan B”); and ensuring the patient (or guardian/POA) has an opportunity to ask questions. Communication should use lay language (about an 8th-grade level), involve translators when needed, and encourage participation of family/support persons. Clinicians should document the discussion, consider having a witness, and address rare but serious outcomes (ICU care, transfusion, surgery, and death). Example complication rates are provided for common procedures (e.g., colonoscopy, EGD, PEG, ERCP pancreatitis).

<strong>Sedation</strong> is presented as a spectrum: no sedation, minimal (anxiolysis), moderate (“conscious”) sedation, deep sedation (monitored anesthesia care/MAC), and general anesthesia. Goals include reducing anxiety and discomfort, improving exam quality, and facilitating team focus and patient amnesia. Pre-procedure requirements include NPO status (generally 2 hours for clear liquids, 6 hours for solids/full liquids, longer with impaired gastric emptying), and a structured assessment (airway/Mallampati, comorbidities, prior sedation reactions, medications/substance use, vitals, and transportation plans). Monitoring standards and readiness for rescue (oxygen escalation, airway equipment, reversal agents) are highlighted. Moderate sedation commonly uses midazolam plus an opioid (fentanyl), with flumazenil and naloxone as reversal agents. Deep sedation/propofol use is regulated and may involve anesthesia providers, especially for high-risk patients or complex procedures (e.g., ERCP, EUS-FNA), difficult airways, or high ASA class.

<strong>Medication management</strong> notes simplification of antithrombotic and antibiotic prophylaxis practices (now limited to select indications). Guidance is also given for glycemic medications (often holding oral agents/short-acting insulin day of), while continuing most other essential meds.

<strong>Bowel preparation</strong> stresses split-dose regimens as preferred for colonoscopy, with multiple prep options (PEG-based, sulfate-based, combination agents) and special strategies for prior failed prep/constipation. The key message: quality prep is essential because lesions cannot be diagnosed if they cannot be seen.

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John A. Martin, MD, FASGE

Keywords

GI endoscopy pre-procedure essentials

informed consent communication process

colonoscopy and EGD complication risks

sedation levels minimal moderate deep MAC general anesthesia

NPO fasting guidelines clear liquids 2 hours solids 6 hours

pre-sedation assessment Mallampati airway ASA class

moderate sedation midazolam fentanyl reversal flumazenil naloxone

propofol deep sedation anesthesia provider high-risk ERCP EUS-FNA

peri-procedural medication management antithrombotics antibiotics glycemic meds

bowel preparation split-dose regimen PEG-based colonoscopy prep quality