All right, welcome everybody. I get to kick it off. So thanks to Jason and Catherine for putting this all together. It's a great course. I was one of the 5,000 fellows. That's a big number. I was surprised by that about nine years ago in this course, and it's great. So I encourage you guys to try to get the most out of it. I've submitted my disclosures. I'm a consultant for STERIS. It won't be pertinent here. So we're going to review just an intro to endoscopy. We're going to talk about informed consent, patient participation, antibiotics, anticoagulation, sedation and complications. Feel free to ask questions at the end. Things may come up. Some of this will be a little bit basic and review probably for many of you, but I think there's some important points to drive home. So informed consent is really a process with the key element of disclosure. So you want to describe what you're doing, what are the benefits to what you're doing, what are the potential adverse events that are associated with what you're doing. It's important to describe what are the alternatives, right? We could do nothing. There's a surgical alternative. What other options are available? What are the potential harms of not doing anything? And then a discussion regarding needs for intubation, resuscitation, hospitalization, and blood transfusion. A lot of this stuff is going to be templated on any informed consent document that your hospital uses. These documents can get long, but I think it's important to not breeze over that, right? You want to sort of outline these points. And as time goes on, obviously you'll do so in a more efficient way, but it's important to try to be very, very thorough. You don't want to be a doomsday person, but you do want to discuss what potentially could be the worst possible outcome, right? So when I do an ERCP in somebody, I say my sort of template language is, you know, pancreatitis is the most common complication. It's usually self-limited, but rarely can be severe and life-threatening. So you want to at least mention what could go wrong and very wrong, right? So that could be ICU care, it could be the need for blood transfusions, it could be an emergent unanticipated surgery, and obviously death for some adverse events. You want to discuss for colonoscopy, mislesions, interval cancers. It's important to have witnesses or people in the room. I'll talk about this a little bit more later, but the more people who are present during that discussion, the better. And obviously we want to document the informed consent process, which is standard and required. So we don't want to get too medical when we're talking about this. They say eighth grade vocabulary, but you want to, you know, use terms instead of endoscope. You want to say things like lighted camera on a flexible tube, you know. So really describe in kid language what you're doing. Ask the patient to participate, ask them if they have any discussions. Again, if you're doing outpatient procedures, oftentimes, the majority of the time, there's going to be somebody else in the room who drove the patient, right? It's often a significant other. So make sure that that person has participated in a well. Do you have questions? Do you have questions? And just make sure that everybody understands before you close and sign that they're understanding of what they're in for. So we want to explain the risks of the procedure in a framework, you know. So here's some documents that are cited with just the overall chance of adverse events depending on procedure for diagnostic EGD, 1 in 200 to 1 in 10,000. For colonoscopy, 3 in 1,000. For an EGD with dilation, 1 in 1,000. So just use a context, right? It's important for them to really understand what are the chances of something going wrong. So patients, a lot of times, by the time you're doing informed consent, this is stuff that's all going to be addressed by pre-procedure nursing and things like that because obviously, you know, they're going to have already taken their essential medications, they're already going to have been NPO. But in general, when you're reviewing sort of what has transpired in the preceding couple of days, you want to make sure that you ask about what medications did you take this morning? Did you take your blood pressure medicine? You know, if somebody's on three blood pressure medicines, they didn't take anything, you know, that's going to need to be addressed because they're going to come in hypertensive and your anesthesiologist or you, if you're given the sedation, is going to have to sort of assess what's the benefit of moving forward. NPO guidelines set forth by the American Society of Anesthesiologists, six hours for solid food or milk or anything containing fat. So if a patient comes in and they're drinking coffee with creamer, six hours. Clear liquids is two hours and obviously, in patients who have gastroparesis, you know, all bets are off. Again, patients for colonoscopy will have already prepped by the time you're doing informed consent. But in general, if you're having that conversation with somebody who's, you know, doing an inpatient prep or something like that, you want to emphasize what happens if they don't prep well, right? So we may miss a lesion. You may have to come back within a year. We may have to repeat this in short order. It's going to increase the amount of time you're sedated because we have to clean. And if we can't see well, the risk of complications in theory goes up. All right, so we're going to review antibiotics a little bit. If you guys, I'll give you guys a minute to pop onto your phones. So the question is, which of the following patients should have antibiotic prophylaxis prior to their procedure? A, patient undergoing USFNA of a solid pancreatic mass, B, history of a knee replacement, patient having a screening colonoscopy, C, ERCP on a patient with a conduct stone in which the stone was completely removed, D, PEG-2 placement, and E, EGD on a patient requesting antibiotics because they receive antibiotics prior to dental procedure for an unclear reason. Numbers are flying in. I'll give you guys a few more seconds. All right, it's like 88 is going to be our number, nope, 90. Anybody for 90? How many do we have, anyway? 100? Okay, all right, so we're getting close. All right, I'll give you five more seconds, four, three, two, one, okay. So most of you got it right, 70%. So the correct answer is PEG-2 placement. So antibiotic prophylaxis, administration of antibiotics solely to prevent endocarditis is not recommended for anybody undergoing gastrointestinal procedures, and a patient who receives antibiotic for a dental procedure and or requests antibiotic is not necessarily a reason to give them antibiotics. We're in the area of antibiotic stewardship, right, so we got to make sure that it's warranted. So the risk of bacteremia, I'm not going to get into the duodenoscope discussion here, but the risk of bacteremia for endoscopic procedures for EGD is 0.8%, sigmoidoscopy negligible, colonoscopy, you know, 0 to 15%, and obviously the risk of transient bacteremia with things that we do every day is markedly higher. So I think these are nice, and you can refer to these as reference points to somebody who asks you about it. I don't think we get asked very commonly, but if anybody ever does, I think, you know, that's something to look at. But everybody, you know, floss your teeth because it's good for you. All right, so here's the situations in which we do give antibiotic prophylaxis or it's recommended based on guidelines. So direct PEG or PEG-2, ERCP with incomplete drainage, so this is most commonly going to be your PSC patients who have diseased intrapadics or patients with hyaluronabilliary obstruction. Those are the two most common circumstances there. USFNA of mediastinal cysts, USFNA for pancreatic cyst aspiration, and there's actually newer literature that makes that potentially more controversial, and hopefully more studies to come there, and then patients who are bleeding with cirrhosis. All right, so antiplatelet medication, there's no data to support the discontinuation of aspirin or NSAIDs prior to endoscopic procedures. Most people, I think, who are on aspirin come in and have taken it, but every once in a while, you know, people will stop it because, you know, somebody told them to and that's not necessarily warranted. In patients who are on Plavix, consider discontinuing seven days prior to a high-risk procedure. But like everything we do and, you know, we're seeing more and more patients, you have to weigh the risk of thrombosis versus bleeding. So that is a segue to the next poll question. Which of the following is considered a, quote, high-risk for bleeding? So there's definitions that exist out there for endoscopic procedures that are high-risk for bleeding. So which of the following? ERCP without sphincterotomy, EUS with fine needle aspiration, EGD with biopsies, pushulneroscopy or colonoscopy with biopsies. All right. A couple more seconds. If you haven't submitted your answer yet, I suggest you go with the majority. All right. So EOSFNA is the one of those five considered high-risk. The citation for this table is below. I won't belabor it too much, but this is from the Canadian ACG recent combined clinical practice guidelines from the Red Journal. But this breaks down the endoscopic maneuvers that are considered high-risk for bleeding or low-to-moderate risk for bleeding, as you can see. You know, it breaks it down pretty well. This is a table from the ASGE antithrombotics paper from 2016. In addition to this table, there's also very helpful information on novel oral anticoagulants and time to discontinue those based on, you know, renal function and things like that if they're pertinent. So I'd encourage you to review that document because I still, you know, refer to it commonly. But this table here breaks down low and high risk of endoscopy-induced bleeding, as well as low and high cardiovascular risks and suggestions on how to manage anticoagulants as well as antiplatelets in patients. So this is a pretty handy table to just be able to refer to. And, you know, oftentimes, like I said, these sort of things are going to be handled as clinical decision tools by the nurses and things like that who are doing pre-procedure calling and stuff. But it's obviously important for us to know that because the buck stops with us in the end. All right, so the management of antithrombotic agents and endoscopy. So in patients with low bleeding risk procedures, this document does suggest no adjustment for warfarin, lovinox, or antiplatelets and to delay the procedure if they were above therapeutic range. I will put a caveat here, you know, so it's often difficult, especially with screening colonoscopy, to figure out when something's going to go from low risk to high risk, right? So removing a big polyp is a high risk procedure. You don't necessarily know that you're going to do that until you go in there. So most people who can come off these medications for a period of time will come off of them in anticipation of doing a high risk maneuver. Otherwise, you're bringing a patient back for a second procedure. That's cost. That's anesthesia risk. That's time. That's days lost of work, things like that. For high bleeding risk procedures and low thromboembolic risk, you can stop three to five days. Again, you can refer back to that document for the novel agents, which is very helpful. And patients who are high bleeding risk and high thromboembolic risk, you can bridge with heparin or low molecular weight heparin and hold antiplatelet medications five to seven days. This slide really just reiterates how catastrophic stent thrombosis can be. And so the moral of the story here is that if somebody has a relatively new stent and they're on antiplatelets or dual antiplatelet therapy, you have to discuss with their cardiologist what the best case for this becomes shared decision making at its core. You know, so what is the risk of waiting to do this endoscopic procedure? What is the risk of doing it while they're on dual antiplatelet therapy? What is the risk of them coming off dual antiplatelet therapy? Everybody's going to be different. The indications for the procedure warrant things happen in a certain way or in a certain time frame. So you have to involve that care team to discuss what the risks are to the patient moving forward or waiting. All right. So for sedation, the procedural monitoring, so joint commission, you require a timeout. You want to make sure that you have all of these things ready and operating before you proceed. Pulse ox, blood pressure monitoring, continuous lead monitoring, know where the resuscitation equipment is, and obviously making sure we're watching the patient at all time. We want to assess the patient before the procedure to determine their risk factors and the medication requirements. Do you snore? A lot of places will do a stop bang score for sleep apnea. Have you had problems with anesthesia? Do you have drug allergies? What medications are you on? Have you had bad reactions in the past? When's the last time you had anything to eat or drink? No alcohol or substance abuse, I will say specifically that patients who are heavy marijuana users are very difficult to sedate and require high doses of moderate sedation and often fail moderate sedation. Airway assessment, what's their malampati score? All this is going to go in your pre-procedure HMP typically, and then just reasons to dose reduce sedation. Always before you start, know where your rescue stuff is going to be. So suction device typically belongs at the head of the patient ready to be used and running. We just usually tuck it under the pillow. You want to know where your oral airway are, where your nasopharyngeal airway are, where your ventilation bags are, and any reversal agents, and what the doses of those medicines are. So complications of sedation, these can be local skin reactions, just a little IV site redness, an infiltrated IV perhaps. They can be big time severe systemic allergic reactions, and then arterial oxygen desaturation, which I would say transiently is sort of part of routine sedation. You will see it often resolves with increasing oxygen, airway maneuvers, things like that, but you want to make sure that you're staying ahead of that and that's not a harbinger of the patient desaturating quickly. So adverse events in general, we're going to talk about preventing them and detecting them, right? So in general, preventing an adverse event is going to involve things like knowing the patient characteristics, knowing what your limits are as an endoscopist, and not trying to do more than you feel that you're comfortable or capable of. If you're suspicious that an adverse event might be taking place, then detecting it is sort of the next step, right? You want to take any post-procedure pain seriously. You want to be present. You want to be continuously evaluating the patient in recovery, assuming they're still there. You know, low threshold to just start with plain radiography for free air if that's the concern for a perforation. Or you know, if somebody's having chest pain, obviously you want to do the appropriate steps to work that up. And don't, you know, discharge somebody until you're very, very comfortable that whatever they were complaining of has resolved. And if any doubt, you know, get them to a higher level of care. So again, if you're doing a procedure and somebody calls you and says, oh, this patient's having pain, go get your hands on the patient, assess them, look at them. How do they look? You know, you guys have seen enough patients at this point to sort of I think even have a gut reaction of how well or unwell somebody looks. For ERCP, we're giving patients aggressive fluids. So if they wake up, you know, with belly pain right away, you know, that fluid is going in as quick as possible. Antibiotics, if there's some indication that, you know, they may be having an infectious complication. Be ever present and be there speaking with the family, speaking with the patient directly. Don't run the other direction and hide. That's the worst thing you can do. And if somebody needs surgical care, call the surgeon directly, say, here's my situation. It's important not to jump to surgery because there are circumstances when it can be avoided and people get a little, you know, hot and aggressive. But be in communication with people who need to be involved. So just to review, informed consent. You know, education goes a long way toward a successful procedure. The more a patient knows if something goes wrong, you know, it'll work out better for everybody in the end. You want to involve as many people as possible and obviously write everything down. In your patient preparation, again, you guys aren't going to be involved in doing prep education necessarily, but the patients do need to be informed on what the consequences of an inadequate prep are. Antibiotics, we talked about, you know, the few indications that require them. Anticoagulants, don't be cavalier. Involve other care teams if necessary. Again, though, that ASGE document and the Canadian and American documents are great documents to review constantly. We just see more and more people on these drugs. So, you know, you'll commit them to memory, but don't hesitate to look back at them for guidance. Sedation, the ASGE guidelines for sedation and anesthesia are also great documents to review and have handy to look at. If you suspect a complication, anticipate it and evaluate it. Do everything you can to prevent it in the first place, but don't minimize it. And furthermore, if you have a complication early in your training, you know, don't get down on yourself. It happens to everybody. Talk to people about it. Talk to your mentors about it. One of my co-fellows first year had a perforation in his second month, and, you know, he was very open and sought feedback and counseling from faculty, I would use the word. And, you know, he rebounded just fine, but I think when it happens to you, it's sort of a gut-wrenching thing the first time. Everybody rate me a four. Thanks. Thank you.

informed consent

patient participation

sedation

complications

antibiotics

anticoagulation