Our next speaker, it's my pleasure to introduce is Erika Heege, who received her master's in nursing and completed the family nurse practitioner program at the University of San Francisco, where she also completed her public health and certified nurse specialist medical surgical degrees as well. Erika is a nurse practitioner at the Oregon Clinic in Oregon, and also a key member of the IBD section at that multispecialty group. She's also a preferred provider with the CCFA and has been a key faculty and contributor to this course and returns this year to speak to us again. Erika, the floor is yours. And may I remind everybody that please do send your questions in the Q&A box. We will try to get to as many of them as possible. And Erika, the floor is yours now. So, yes, my name is Erika Heege, I'm a nurse practitioner with the Oregon Clinic in Portland, Oregon. We're a large GI clinic there. I'm going to talk to you about sedation and analgesia and GI endoscopy today. Tomorrow, I have a talk on diarrhea and inflammatory bowel disease. So, we'll go ahead and get this rolling. Okay, so here's my disclosures. So, sedation. Sedation is a drug-induced depression in the level of consciousness. Our objectives in sedating our patients is to relieve their anxiety, to relieve any discomfort, improve our outcome of the exam, and diminish the patient's memory of the event. So, there are various levels of sedation, as you know, minimal to all the way to general sedation. So, this is kind of based on responsiveness, airway, spontaneous ventilation, and cardiovascular function. So, in minimal sedation, the responsiveness of the patient is completely normal to verbal stimuli, the airway is unaffected, spontaneous ventilation is unaffected, and cardiovascular function is unaffected. And then you go all the way to general sedation, which is kind of the opposite, you know, the unarousable patient, intervention is required for the airway, frequently inadequate spontaneous ventilation, and cardiovascular function may be compromised and impaired. When we're talking about, especially procedures in our ASCs, such as just an upper vascular colonoscopy, we really are in the moderate sedation realm, and formally this is referred to as conscious sedation. Informed consent is a part that we play as APPs. This perspective of this talk is, you know, I'm definitely not an anesthesiologist, I'm not sedating patients, but it's what we as APPs need to do to get our patients prepped for these procedures. And part of that needs to be in the conversation, informed consent. So, discussion of the benefits, risks, and limitations, as well as possible alternatives to the sedation plan. An example would be, you know, we're planning a colonoscopy following a ColitePREP ASA sedation classification 2, which we'll talk about how to categorize that in a couple slides from now. And then within that needs to be that a PARQ was given. So, what is the PARQ? So, the P starts for procedures, the provider explained the procedures that are going to take place. The A is alternatives, so viable alternatives were discussed. R is risks, so the risks were reviewed. And then Q, all of the questions were answered by the provider. You also need to clarify NPO status. This may be a little bit more of an issue in the inpatient setting. In the outpatient setting, generally you're letting the patient know, you know, they're no eating after midnight, et cetera. But it needs to be clarified, because the goal is to minimize aspiration risks. Excuse me, aspiration risk. ASA guidelines are as follows, clear liquids, NPO for two hours before breast milk, four hours, formula, two feeds is six hours, and solid food is six hours. However, I will tell you, this may vary depending on your institution. For example, our main hospital system that we work at up here in Portland, Oregon, they have their own NPO policy, and it must be eight hours NPO for solid food. Of course, in emergent situations, this is very different. This is an emergency, and more than likely, the patient, if they need a procedure, and the NPO status is unknown, they will be intubated. So the pre-procedural assessment, you know, this is what we're doing in clinic or in the inpatient setting, trying to kind of size our patient up to determine if they're going to be a challenging intubation or a challenging case to sedate. Ask me about their history. Do they have a tendency to snore? Is there stridor? Do they have history of sleep apnea? What kind of medications are they on? Are they using a very high amount of narcotics? Is this going to make them difficult to sedate? Any drug allergies they may have, especially to sedatives. Have they had adverse reactions to prior sedation or anesthesia? When was their last oral intake, and did they smoke tobacco, alcohol, or substance use? I will tell you in our outpatient setting, when we have patients who use substances such as methamphetamines, our anesthesia providers prefer that the patient be without methamphetamines in their system for two weeks due to the concern for cardiovascular effects of the anesthesia mixed with methamphetamines. It's very hard to have somebody commit to two weeks, but we do educate our patients that are using drugs that that is preferred. Then you're also, of course, doing your physical exam, looking at the vital signs. Do they have uncontrolled hypertension? Level of consciousness? Can they consent? We'll chat about this a little bit. The Malin-Potty score, which I'll review on the next slide. Doing the heart and lung exam, do they have a cardiovascular history? Have they been seen by a cardiologist? Do they have a history of significant aortic stenosis, making sedation more of a risk? Do they need a recent echocardiogram? And then pregnancy tests as needed. So the Malin-Potty classification, what is this? This is something that we have these in our clinic to help remind people about how to evaluate a Malin-Potty score. So you basically have the score from class one to class four. This identifies a potential patient that would have obstructive sleep apnea that may or may not be diagnosed and predicts difficulty with having to do intubation. So as you can see in class four, there's really low clearance there. Likely an intubation may be more difficult. These patients tend to have more of a large neck and probably also have sleep apnea. But documenting the Malin-Potty score can be helpful. This is something that our CNAs evaluate when they come over to our clinic to evaluate our patients. So the American Society of Anesthesiologists, which are abbreviated ASA, sedation classification. There's classification scores from ASA one to six. This is somewhat a little subjective because some providers may feel that their mildly healthy patient is very different than someone who has severe disease. So some of it is a little bit left up to interpretation. But what you're basically trying to do here is in clinic, generally, you're going to one to three, ASA one to three is acceptable for the ASC. Anything above that should be done in the hospital with anesthesia. At least that's the policy that we have in our clinic. For the ASA three, and this can also be teetering on hospitalization or clinic as well, depending on the severity of the diseases and if they're cardiovascular or pulmonary involved. So exclusion criteria for the ASC. So ASC is ambulatory surgical center. It's a good idea to have a list of absolute exclusion criteria and relative exclusion criteria. The next slide, I will show you the list that we have and that we use at the organ clinic. This is very helpful for APPs and other providers to determine if a patient is acceptable for their surgery center or if they need to go to the hospital. And if you have that criteria, then there's really less question. Of course, there will always be one that slips through and there'll be something that comes up that wasn't expected, but it helps give some guidance, especially for those new APPs that are just learning GI and learning how to evaluate a patient for procedure. If possible, have the anesthesia provider assess the patient in question before they get scheduled. So this is something we have the luxury of our ASC is connected to. Our ASC is connected to our clinic. So we are able to have our CRNAs come over to the clinic to assess the patient if we are concerned that they need to go to the hospital or if they can be done in clinic. Ideally, we want our patients to be scoped in our ASC. It's more comfortable. It's a more streamlined process and we want to avoid them having to go to the hospital. So we do our best to do that, but yet we need to make sure it's the safest environment possible. One exclusion criteria for most ASCs is the patient being unable to transfer on their own. So someone that requires maybe a four-year lift is wheelchair bound or is going to need other interventions to try to get them on the table. That's something that wouldn't be appropriate for the ASC. So our list is mighty and it's ever-changing and fluid, but this is the exclusion criteria list for our clinic at the Oregon Clinic. So these patients, absolute exclusion on the left, will not be scheduled in our surgery center. The relative risk on the right can be a little bit gray. And so that's where sometimes discussing it with the CRNA can be helpful if you're in question. So just briefly going through the absolute exclusion, BMI greater than 50, more than likely an increased risk of having a difficult intubation and possibly adverse reaction to anesthesia. Not always. The big reason that this is an exclusion in our ASC is because our beds actually only hold up to 350 pounds. Well, at least that's the recommendation. So we've come up with the BMI of greater than 50 or weight of greater than 350 pounds needs to be at the hospital. Implanted cardiac defibrillator, they can have a pacemaker, but if they have a defibrillator, they need to go to the hospital. Recent MI or stroke within the past six months need to go to the hospital. Other cardiac conditions, as you would assume, severe aortic stenosis at the hospital, that's where having a recent echo is helpful as well. We have a hepatology clinic. So of course, we do have a lot of liver patients. We do scope our liver patients in our surgery center if they are compensated, but if there is decompensated serotics, then we recommend that they be done at the hospital because more than likely you could come up with some varices and we do not do elective variceal banding or emergent that is in our surgery center. That is all set to the hospital. Relative exclusion, like I said, this is a little bit more gray and can sometimes need the help of an anesthesia provider to help to sort this out, but the relative exclusion such as any kind of neck injury or radiation, any kind of like jaw, previous surgeries, that's something that maybe discussion with the anesthesia provider because it could be a difficult intubation. Intubation. And then also with ASA greater than three, so those kind of more severely, patients with more severe disease, it's something that can be helpful to discuss with the anesthesia provider, including severe obstructive apnea on BiPAP. For our hospital patients, and I'll talk to this a little bit more, but for our hospital patients that go to our endoscopy suite at the hospital, they're all sedated by anesthesiologists. And so if you have a very concerning patient who has multiple medical problems that does definitely need a scope of some sort, they actually have a pre-op clinic, which can be helpful so that the patient can actually meet an anesthesiologist before their procedure to have this discussion. Because I think for all of us, one of our biggest concerns is the patient's going to be totally prepped for colonoscopy, show up to the ASC or the hospital that is, and then having the anesthesia provider deny them after they've done that entire prep or then having to reschedule. If you can at all troubleshoot beforehand and have them see whomever anesthesia provider that can be helpful if you're very concerned. So risk for potential difficult airway. Most of these are rather obvious, but previous problems with anesthesia or sedation, a history of striders, snoring or sleep apnea, abnormal facial features, like I was saying, that would maybe decrease the clearance and increased risk for a difficult intubation, such as trisomy 21, oral abnormalities, neck abnormalities, especially if there's been radiation or if they've had significant neck surgeries, limiting their mobility and being able to move their neck and then jaw abnormalities. So procedural, pre-procedural documentation. So this is a JACO requirement, must be documented pre-procedural assessment. There must be a timeout, all activities stop to perform the final verification of the patient procedure and the sedation plan. Guidelines for anesthesia, or this should maybe read a little bit like guidelines for anesthesiology provider assistant during GI endoscopy. So anesthesia provider assistant should be considered in the following situations. And this is considered more of like prolonged or therapeutic endoscopic procedures during deep sedation. So this is more of our advanced endoscopist, draining pancreatic cysts or ERCP or EUS. Anticipated intolerance to standard sedatives or increased tolerance to standard sedatives or increased risk for adverse events because of severe comorbidities such as ASA4 and 5 and increased risk for airway obstruction due to anatomy. So these patients should be done at the hospital with anesthesia. Unsedated endoscopy. So believe it or not, we do have patients that request their colonoscopies and upper endoscopies to be unsedated. And we generally at our clinic do not approve upper endoscopies to be completed unsedated. We will do colonoscopies unsedated on a base case based depending on the patient. And we select them carefully. There are some providers who really just want to avoid doing any kind of procedures without sedation. So they maybe won't take those patients. It's still the standard pre-sedation evaluation that's performed in a case sedation that's required. So you still are going through all of the same standards of screening that patient for any potential adverse outcomes. The patient needs to understand they're still going to be getting an IV placement. So even if they are not requesting sedation, they still will be getting an IV just in case one, they need sedation because they're not tolerating the exam or two, if there's any kind of emergent situation. And it still requires a ride home. So our patients that don't want sedation, I still make sure that they have a driver to take them home just in case they did need sedation during that procedure. Moderate sedation. Like I said, this is kind of more on our wheelhouse here for endoscopy ASA class one, two, and three. Like I said, in our ASC, we have certified registered nurse anesthetists, CRNAs that perform all of our anesthesia. We went to that about seven to eight years ago. Prior to that, we did have sedation administered by the nurse that the guidance of the GI endoscopist and the response was also monitored by the nurse. And that still is in many other ASCs that still does occur. So moderate sedation, there's a benzodiazepines that are used to minimize anxiety, provide some amnesia, and then opioids are also used to minimize the pain and discomfort. When you're looking at deep sedation, this is something that's used kind of more in our hospital setting for, like I said, our more advanced endoscopist. This can be nurse-administered protocol sedation, so NAPS. It really depends on your state's kind of regional local policies that regulate who can sedate and if CRNAs can be used. It really depends on where you're at, not only nationally, but also your institution. So max sedation, which is anesthesiologist-administered sedation. You'll hear that sometimes the patient needs to have max sedation, meaning they need to go to the hospital to be an anesthesiologist. Potential advantages are it improves patient satisfaction, decreased distraction for the endoscopist, so they're able to focus on just scoping and not sedating as well. It can be shorter sedation and faster recovery times. There are potential disadvantages, though. One is that it's a separate charge for anesthesia, up to $1,500, and sometimes that comes as a surprise to patients. And there's actually good data that there's no demonstrated safety benefit. You may have some increased risk for aspiration, cardiopulmonary complications, perforation, and that can also be related to, A, not knowing NPO status, if it may be more emergent, and then also just being a more difficult case on a patient with more comorbidities requiring anesthesia. The practice perils. Pre-procedural assessment is essential in selecting the location of the procedures, being ASC versus hospital, and the sedation or anesthesia plan. Informed consent should include discussion of the risks of sedation or anesthesia. So, of course, you're talking about all the procedures and not answering questions, but you also need to talk about sedation and anesthesia. Informed consent must be completed with someone who is alert and oriented times three, someone that is consentable. If that patient has severe dementia or is not consentable, must contact and be in touch with their power of attorney or their health executive who is legally able to consent the person. That sometimes comes into play when we get patients from nursing homes or patients that are nonverbal, and then sorting out kind of who is the power of attorney, who is the health executive that does all their consents. That can be a little bit of a challenge. And then what can also really be helpful, as I alluded to earlier, is creating an exclusion criteria for your ASC. That can make it very clear for especially your new APPs who are starting on who is a candidate for your ASC and who should be hospital. Granted, this is always fluid, like our list is very bulky and long, but it is very helpful and puts the safety of our patients first. My references, I think that's it for me. I have a couple polling questions. So the malampotty classification identifies potential obstructive sleep apnea and predicts difficulty with endotracheal intubation. Is this true or false? So true, yes. Majority got it right. And my last one is risk or potential difficult airway includes all of the following except, so this is risk factors for potential difficult airway, previous problem with anesthesia or sedation, history of severe obstructive sleep apnea, neck abnormalities, glaucoma, or jaw abnormalities. Correct. So glaucoma is not a risk factor for difficult airway.

Erika Heege

sedation

GI endoscopy

minimal sedation

informed consent

patient safety