Again, I'm honored to speak to the group today about practical tips and tricks as far as sedation is concerned in your local lab, quality and sedation and monitoring. I have nothing to disclose. So when we talk about sedation in endoscopies in particular, there are a lot of things that we typically take for granted, but there's a lot of nuances that may be involved in various aspects of the entire endoscopy experience from the pre-op assessment to the intra-op and obviously post-op considerations. And we'll try to touch on each one of these individually. So why do we sedate? There are many reasons for sedation in endoscopy. Certainly, sedation may possibly make the exam safer, particularly as it pertains to upper orodigestive exams. Patient comfort is very likely a strong reason to sedate. And to be totally honest and transparent, procedure efficiency is an important consideration, especially in today's practice environments. Now physiologic reasons for sedation may include, as I alluded to, things such as a gag reflex, as a safety concern. Reducing patient's anxiety is also a very important reason to sedate. And certainly in certain situations, for example, in ERCP, when we're dealing with fault tolerance of half of a millimeter or less, it is crucial to have patients as calm and still as humanly possible during that procedure. Another physiologic reason for sedation may be that it can be quite uncomfortable in certain situations, for example, during a colonoscopy when there's excessive luminal distension. So it's important to systematically think about sedation in the context of pre-procedure, post-procedure, and post-procedure. So for example, factors that may affect a patient's anesthetic risk that the endoscopist and the team, frankly, should be cognizant of include issues such as known airway issues, you know, anatomical issues such as micronathia or retronathia, where the jaw, mental jaw distance is smaller than usual. History of difficult intubation is obviously another important factor to note. Certain drugs may be very important to note in terms of their potential drug interactions. For example, individuals that take MAOI inhibitors. And for example, if you happen to use miparidine in your lab, that's actually a very dangerous contraindication that may result in potentially, worst case scenario, fatal hypertension. Certain HIV drugs such as protease inhibitors and midazolam may have a potentiated effect. Conversely, protease inhibitors and opiates may lead to an attenuated effect. And NNRTIs and opiates may lead to an attenuated effect. And those are things to keep in mind as you perform your pre-procedural assessment on the patient. History of substance abuse obviously may strongly affect your sedation choice. For example, potentially even opting for monitored anesthesia care or probe fall. NPO status, of course, we'll get to in a second. And drug safety and pregnancy, again, in terms of DEI, diversity, equity, inclusion, it's important to consider this as a regular part of your practice, especially since there are certain drug considerations in terms of safety and pregnancy. So airway issues, this is the first and foremost, especially in upper digestive tract procedures when you're sharing an airway with, sharing a space with the airway. There are many criteria, hopefully the audience will have gained a working knowledge of these various criteria. For example, the STOP-BANG criteria, it's a combination of pre-procedural questions on a physical exam. The take-home point is a score of three or more is a high risk of obstructive sleep apnea. And that may be important to note before you start the exam. A mom-potty score as shown here also similarly helps predict the risk of obstructive sleep apnea and risk of difficult intubation. And this is easily done at bedside. All physicians should be very comfortable with this grading system. It's intuitive, and that's one of the beauties of it. The less you see in the cartoon pictographic, the more likely, the higher the mom-potty score and the higher the likelihood of difficult intubation. Again, as I mentioned earlier, anatomic issues may include, for example, large tongue, small mouth opening, micro-anathea, retro-anathea, jaw issues, neck abnormalities, such as the higher mental distance being too short or the presence of a neck mass. And interestingly, situational awareness is key. This was actually a patient in my lab, maybe about a year or so ago, where you're talking to them and it's very easy to get overwhelmed by information overload in today's practice. But I noticed this classic swan's neck deformity, and that triggered the association for me to ask, hey, do you have difficulty extending your neck? I noticed you may have potential root-torn arthritis. And sure enough, the patient said, yes, I cannot extend beyond a certain point. That is absolutely critical information to assess before starting any upper digestive tract procedure. NPO status, again, just meant as a refresher. I think everybody in this group knows this, but clear liquids, you need a minimum of two hours of NPO status. Anything of full liquids or animal milk products, six hours of NPO status. Solid food, minimum of eight hours of NPO status. So now we focus, hone in a little bit more in terms of drug safety and pregnancy. And it should be worth noting that in the recent history, the FDA moved away from the classic ABCDX safety category to no proven risk or take caution, and certainly drug categories which are to be avoided in this patient population. I'm sorry to say, very few medications make the list in the no proven risk category. And that basically is just the Benadryl, oh, sorry, sorry, divanhydramine and glucagon. The majority of the medications that you will encounter in routine clinical practice are those that typically, they have the catch all couch term of, you know, try to minimize dose as much as feasible and as safe and try to be cognizant of the dose. The one thing, the take home point of this slide is to avoid midazolam, certainly in the pregnant population because of a reported congenital malformation risk. Intra-procedural management. First question, again, it may seem intuitive, but it's important to just ask, because if you don't ask, you may not even think of it. Can you get away without sedation at all? There may be several scenarios in which case, in which unsedated endoscopy is either attractive or maybe the most viable option. For example, if your local practice supports transnasal endoscopy, you may not need any sedation. Individuals that are morbidly obese that need to come in for a colonoscopy, it may ironically be safer to keep them as awake as tolerable because they may need to participate in the exam at certain points by patient repositioning. On occasion, you may see those that need to return to work immediately, and therefore they choose to be unsedated. And still others, there may be those that either admittedly say they want to drive home or you get the sense that they may want to drive home afterwards. So there are many different scenarios where unsedated endoscopy may need to be entertained at least. At a minimum, it's important to follow the standard unit protocol, which may typically include placing them on a heart monitor and insertion of an IV. And this is important, even if unsedated endoscopy is chosen because in the event, an unplanned cardiac event occurs, or in the event that the patient realizes that they cannot tolerate unsedated endoscopy, a way to potentially salvage the situation is obviously having the discussion with the patients beforehand, but transitioning to sedation. And so the principle of measuring is actually summed up very nicely in this quote. This is a quote by Carl Pearson, an academic statistician that actually was, Professor Albert Einstein actually loved to quote. And that is, that which is measured improves. And so when you're talking about sedation and you're altering the alertness continuum, the sedation continuum, it's important to be cognizant of a patient's neurologic, cardiac, and respiratory functions. And this can come in many different forms. It can come from direct observation. It can come from external monitors and blood pressure machine measurements. It can come from, again, visual inspection or advanced oximetry and capnography measurement tools. This is, again, an important concept that the American Society of Anesthesiologists espouses. And it's really the sedation continuum. And it basically goes from very light sedation all the way to deep general anesthesia. And as you can see, the deeper the level of sedation, the less and less responsive an individual is to both verbal or tactile or even painful stimuli. And the more and more likely that the individual will need respiratory support. Most practice environments now typically have some form of continuous telemetry measurement, particularly when sedation is being administered. And it's important to make sure that blood pressure checks, for example, are performed in a regular fashion at a minimum every five minutes or prior to any additional sedative dose being administered for those individuals that practice in a moderate sedation environment. It's important to have at least one person in the room at all times, ideally more, but at a minimum, one person that is certified in ACLS and familiar with ACLS rescue protocols. One pro tip, again, and again, this speaks to the importance of having situational awareness. It's important to basically treat the patient, not the so-called number. On occasion, if you're adjusting the gurney height, this literally just happened to us in our lab recently, it may occasionally cause erroneous telemetry readings. And of course, the computer may misinterpret as something as ominous as ventricular tachycardia. Again, just speaks to the importance of, you know, treat the patient, not the number. Again, it goes without saying, but it's important to keep situational awareness and monitor an individual's breathing, particularly in the setting of paradoxical or abdominal breathing, especially, particularly if you're undergoing an upper airway procedure, just be situationally aware and alert, because that may be an early indication that a person may be experiencing respiratory distress or impending respiratory distress, and you may wish to ask for help sooner rather than later. Pulse oximetry is a very elegant method, a non-invasive method of measuring a person's oxygen level, and it's actually quite accurate. It's within 2% accuracy of an arterial blood gas. Again, some of this is self-evident, but it's important to talk about this formally. Pulse oximetry may be negatively impacted by individuals with cool extremities, for example, in Raynaud's, or if they have a severe life-threatening bleed when peripheral basal constriction occurs. Similarly, pulse oximetry may be negatively impacted by the presence of nail polish, so something to keep in mind. So in those situations, you may wish to change the location of the pulse oximeter, for example, to the ear lobe is one option. One pro tip here as well, as far as respiratory concerns are concerned, is prior to calling respiratory code or rapid response, again, situational awareness and just take a look at the patient. Make sure that the low pulse oximetry reading is real. Did the sensor fall off a finger? I mean, it happens a lot more than you think. When the patient gets repositioned, it gets jostled out of position. Is the machine functioning properly? Do you see a red light reflex on the pulse oximeter itself? Capnography is a recent and very vital piece of non-invasive information that is now being incorporated into ACLS algorithms. It basically measures an individual's CO2, not only the volume of CO2 exhaled, but also the shape and the pattern of exhalation. I know this is a bit of a busy slide, but as you can see in the top left corner, that is a normal tracing for a normal pulse oximeter. I'm sorry, normal capnography reading. An individual conversely with bronchospasm or COPD, you'll see a different shaped curve. And as we know in medicine, a lot of what we do in part is related to pattern recognition. An individual who hypoventilates, for example, if they're over sedated, you may see slowly the CO2 rising with each subsequent measurement, as you can see in the bottom left of the slide. Similarly, the converse is also true. If you have a patient who's under sedated and is anxious, they may hyperventilate and progressively over time, you'll see a progressive reduction in the CO2 exhaled. This is an old saying from even my intern year of training, and it still holds true today many, many moons out. In an emergency, do not panic. Again, easy for us to say, but sometimes hard to implement. But just try to remember the old saying, if you're about to run to a code, check your own pulse first. Immediately, expeditiously try to assess the situation. Is this a potential situation of airway emergency? Is this a potential sedation emergency or a cardiac emergency? The responses are subtly, yet importantly, different. A bit of ACLS. Again, this is not meant as a substitute for formal ACLS training, but it bears repeating when we're talking about quality and safety and endoscopy sedation. It's important to be familiar with various techniques of airway emergency. For example, the very first bullet, again, is an important thing to consider, particularly if you're performing procedures in a moderate sedation setting. If a brisk upper GI bleeding suddenly occurs, the first thing you should consider doing is actually head of bed up on the gurney to about 45 degrees or more, and even foot down, so reverse Trendelenburg. That may buy you a little bit of time while you're getting your bearings and potentially asking for help. So that's the first thing you can consider doing if it's appropriate in that situation. The second thing is to be very familiar with the various different types of suction devices, and that is the classical hard-tipped, long devices in routine trade name is the Yankower. The soft tip suction tubing is the malleable tip that typically is found in dental practices that may be useful for individuals that have a very short hyoid mental distance, so you can bend the tip of the catheter to form fit in individuals' posterior oropharynx. Just a very brief overview, emergency devices typically may include things, including but not limited to a bag valve mask, an LMA mask, nasal trumpet, oral airway. Again, these are covered in much more detail in ACLS training, but just very briefly, just as a brief refresher, if an individual requires bag valve masking, it's important to have the CE configuration where two fingers are around the mask and three fingers around the jaw. Nasal trumpet, the proper size, again, just as a refresher only, is ideally from nose to earlobe versus the oral airway proper size is typically from incisors to the angle of the jaw. Or if you have the ability, as needed, it's important to know when to know your limitations and ask for help early. You may want to call anesthesia sooner rather than later. Sedation emergency, if a person becomes overly sedated, for example, during moderate sedation or even during propofol sedation, the very first thing is to see whether they are spontaneously breathing, and if so, if you're able to support them through the use of adjunctive measures such as supplemental oxygen, jaw thrust, or even airway adjuncts, as I mentioned in the previous slide, such as either a nasal or an oral airway. One note, if a reversal agent is used, for example, naloxone or flumazenil, you must have extended monitoring in the recovery area because the half-life of these agents is typically shorter than the drug itself. So that is absolutely something you must keep in mind, lest you prematurely discharge the individual and then they become resedated as a second wave when they're off of the unit. Or similarly, if you have that ability, call anesthesia staff. In a cardiac emergency, the first question to ask yourself, again, may seem logical, but it's important to discuss up front, is it a true cardiac emergency? Is it instead a vasovagal event? For example, if a person is very sensitive, high vagal tone, you may want to stop pushing, for example, in a colonoscopy. You may want to reduce loops. You may want to use water insufflation or CO2 insufflation, or maybe even using a slimmer scope, plus or minus the use of adjunctive medications such as glycopyrrolate. It goes without saying, in a true cardiac emergency, just call anesthesia staff if you have the ability, and or follow the ACLS protocol, depending on the particular algorithm involved. And so finally, we come to the concept of scoring systems to assess a patient's fitness for discharge from the endoscopy lab. And so there are two in routine clinical use. One is the Aldrete score, where you can see here, I've included this for future reference, or the PASS score, the post-anesthetic discharge scoring system. Basically, as you'll see, there are a lot of similarities between the two. The concept is the more key metrics an individual meets, the more likely they are ready for discharge. And again, these two slides are for reference, should you desire later. Discharge considerations. Currently, according to the American Society of Anesthesiologists, it is with a responsible adult. This will likely be the subject of an upcoming ASGE white paper, but currently, the ASA does recommend that the patient get, particularly those that are sedated, get discharged with a responsible adult. In summary, sedation, when properly used, is very useful for safety, comfort, and procedural efficiency. It's important to have situational awareness at all aspects of the endoscopy encounter, pre-op, intra-op, and post-op. It's similarly important for those that administer moderate sedation, but even just in general, when sedation is being administered in the endoscopy lab, it's important to have a sedation that is being administered in the lab, to be proficient and certified in ACLS, and similarly, be proficient in rescue devices and measures. The last practice pearl I will make explicitly clear is if a reversal agent is needed, you have to watch those individuals for a prolonged period of time in the recovery area, because the half-life of the reversal agent is shorter than the drug itself. And with that, I again thank you for your attention. Thank you.

sedation

endoscopies

patient comfort

monitoring methods

emergency management

fitness for discharge