Solon Doskip, we appreciate your participation in tonight's webinar. My name is Ed Deller, Chief Publication and Learning Officer here for ASGE, and I will be one of your facilitators throughout tonight's presentation. Our program tonight is entitled Sedation Strategies by Gastroenterologists and GI Nurses. Please note that this presentation is being recorded and will be posted on GILeap, ASGE's online learning management platform. You will have ongoing access to the recording and GILeap as part of your registration. I also want to recognize the gracious educational programming support from Olympus for the remainder of the 2021 ASGE Thursday Night Lights programs. Thank you to them. Before we get started, please note a number of features that are in our platform. Currently, you are all located in the auditorium. As you entered the lobby, you should have noted meeting information, which has tonight's agenda and a few reference articles that may be of interest to you. 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Tonight's objectives here is to understand guideline recommendations of sedatives and analgesics used in the endoscopy unit, and two, assess how the endoscopy unit team works effectively in achieving optimal administration of sedatives and analgesics for the purpose of induction and maintenance of moderate sedation for various types of endoscopic procedures. Our presenter tonight is Dr. Charles Dye, who is a professor of medicine at Penn State Health in Hershey, Pennsylvania. We are very honored to have him be able to provide an overview of this topic. It is with great pleasure that I introduce Dr. Dye. Dr. Dye, please take it away. Thanks a lot, Ed, and I'd really like to thank the ASGE and all you all out there tonight joining for making it possible. I'm going to try and actually just cover this a little bit differently than maybe a normal, typical lecture and keep it interactive, and Ed's going to help me watch the chat box too. So I know we probably have people from a lot of different backgrounds and places and practice aspects, but just a little bit about my background. I am currently a salaried employee of an academic medical center. It's part of a regional healthcare system, and I've been a part of another system similarly, an academic system in the past, as well as worked as part of a VA system as a care provider as well. So in my current job, I do provide no sedation and sedated endoscopy procedures with and without anesthesia department participation. And I actually have an ownership interest in an LLC providing endoscopy services as part of a strategic agreement with the regional healthcare system. And there we do provide no sedation procedures at times with a focus really on monitored anesthesia care for EGDs and colonoscopies performed with a CRNA or a certified registered nurse anesthetist. I do want to point out that really, in terms of the true nuts and bolts of a practice of sedation, at least in the United States, these are a couple of resources available through the AHGE. And particularly if we have any fellows joining us, there's really a curriculum that was published previously. Dr. Bargo has done a lot of work on both of these, and I know it's just been a great resource for everybody who does this. I do want to start just the conversation a little bit with some historical background, but do it in a little different way maybe than you're used to hearing the history of sedation through endoscopy, because that's been going on for a long time since the days of the old rigid scopes for doing EGDs. And there was no sedation at all, except for the calming voice of the nurse in the room. But we'll take it a little bit from more current times, some practice that some of you have lived through, and I certainly did. And it involved the Centers for Medicare Services in the United States bundling payment for colonoscopy. Really that sort of centered on them deciding that the cost estimate for a colonoscopy should be about $1,500, and the sedation component estimate should be about $125. Around that time, there was also a lot of discussion out there in society and politically, and in the media certainly as evidenced by this New York Times article about why colonoscopies can cost so much in charges and in payments, as you can kind of see here. And really it involves more than just the gastroenterology provider. It does involve sort of other providers, including anesthesiologists and facility fees. And the article really went on to talk about that while Medicare negotiates for an average of $531 for payment for a colonoscopy in 2011, that does not include charges for anesthesia services if they're deemed necessary. And that is a separate payment that Medicare has to make. So one of the sort of people quoted in the article did talk a little bit in a particular patient case about the different charges that may come down from a facility for different providers, including not only gastroenterologists, but anesthesia providers. And they threw out an estimate that was out there that if they ended the practice of the anesthesia billing component for colonoscopy, it could save more than a billion dollars a year. So really a lot of what was occurring around the time and since then was a controversy over who can administer Propofol. And we'll talk a little bit later about some of the other agents, but Propofol, because of its faster onset and recovery, was really a game changer for endoscopic sedation procedures. There were aspects of this about credentials and privileges, which we won't go into in great detail. And also a lot of aspects that involved the supervising physician role, which we'll talk about a little bit. And one of the players that was really involved a lot in this debate was the American Society of Anesthesiology, which we all commonly refer to as the ASA in the United States. And they really have this definition of the sedation continuum that many of you are familiar with. And there's a red line drawn there between moderate sedation, which we had always talked in the past as conscious sedation for the patients more wakeful, and the deeper sedation or general anesthesia levels of spectrum. And really for the purposes of Propofol here, it's classified as a general anesthesia agent. So many of us have seen it used in other ways for more moderate sedation, smaller doses, but it can be titrated pretty quickly to a general anesthesia level. And at that level, the ability to maintain independent ventilatory function is often impaired, meaning you need to be able to ventilate for the patient. And cardiovascular function may be impaired too. There can be hypotension, particularly in people with more advanced comorbidities, and that can be a very dangerous thing very quickly. So the American Society of Anesthesiology has had a classification system, the ASA class, which many of you are familiar with, and really was originally conceived as a physical status classification system. And when I started out doing this, an ASA3 patient with severe systemic disease was really a decompensated patient in the hospital. So decompensated heart failure on active oxygen and other therapy for that disease in the hospital. There's been more of a reclassification within the system, and that category ASA3 severe systemic disease is now defined to include patients with obesity, heavy alcohol use, diabetes and hypertension, not in good control, and a prior cardiac history such as MI and stent or concern for prior stroke. And I will mention that it includes patients in the ASA3 classification that may have a higher than average exercise capacity, fairly low risk for sedation events. But there has been an emphasis in the literature on higher risks in certain studies really that involve deeper sedation spectrum, and also that involve perioperative period risks. So things like surgeries that included esophagectomy or Whipple, where there's wound healing and there's a long course of hospitalization. And so, depending on what you're looking at, are you looking at the risk for an endoscopy that doesn't typically have a hospitalization period, or are you looking at surgery? These classifications can mean different things. So with that as a little bit of background, there was data out there from Dr. Rex, led by Dr. Rex, but also from others around the world on using propofol to target moderate and moderately deep sedation, like many of us use other agents for before propofol availability. And although that appeared very safe and comparable with some potential advantages over the typical Versa and opiate strategies in our country, the Centers for Medicare Services in 2009 ruled that propofol must be delivered by an anesthesia provider trained in the administration of general anesthesia care, essentially ending the practice of nurse-administered propofol sedation for most areas of the United States. A lot of us were very interested in the Sedasys system, which was an FDA-approved system and shortly after these discussions evolved, but was subsequently withdrawn from the market. And what the system also emphasized is in those healthier patients, the ASA one and two patients, not the sicker three or four patients, giving propofol targeted towards moderate and moderately deep spectrum. And the addition of capnography monitoring is one of the aspects to help make that safe as an early warning system against accumulation of propofol to the point where people were not ventilating well. So with capnography, you detect that trajectory a lot sooner than if you're just using pulse oximetry. And for those of you who aren't really familiar with capnography for sedation monitoring, this is a tracing that shows what might happen if you have somebody retaining CO2. And if you go ahead and advance the next slide, we'll see sort of a couple of other curves over here, the normal sort of capnography in somebody who's breathing normally on the left, and then down below on the dotted line, sort of a slanted dotted line shows you what somebody who is an asthmatic, who has a prolonged expiratory phase may look like. And then go ahead and advance next. And this is one that is a patient who's losing their perfusion, and therefore their measure of ventilation and is going into cardiac arrest and what may happen to the curve. So there are earlier indicators before hypoxemia that hypoxemia will soon occur or worse potentially may occur by using capnography. So the computer assisted or sedasys model for propofol really emphasize this. So not really requiring a CRNA, but a nurse using the system to administer propofol targeted towards that moderate to moderate, the maybe borderline deep range. And they took healthy patients and they found that actually this group of patients did well with higher satisfaction process for providers and patients, and also seemed to have an easier course through the recovery period than those on Versed and fentanyl. So let's kind of stop there. And I wanna throw a true or false question out at you. Now, obviously can't get everybody chiming in all at once, but take a minute to kind of look at this. Patients are more likely to experience aspiration pneumonia during exposure to deep sedation and general anesthesia than during exposure to the moderate sedation range. So true or false? I'll give you guys a few seconds. We're getting a couple of trues coming in. Trues in the chat. Yeah, well, I mean, I think that there is data out there to support that. If you look at some of those ASGE references that I put up there in the beginning, and it makes sense that if you have patients who are now maybe having blunted gag reflexes and a blunted cough reflex that may have secretions in their mouth or coming up during the procedure, that they may not handle that and tolerate that as well as somebody who is more conscious and able to really use those reflexes to alert you and to sort of have other measures taken, including them protecting themselves. And we've certainly seen that at our institution as well. Okay, so let's use that as a transition. At the same time, all this was happening with, we got a better medicine for endoscopic sedation that could give us that moderately deeper sort of spectrum of sedation quicker and wear off quicker. We're also getting advances in other areas of endoscopy, really in thinking, making the procedure easier and more comfortable for patients. And the first one is lumen distension. So let's go ahead and advance. We really moved from air to carbon dioxide and water facilitating passage. And a lot of that was possible in the move to water with prep preparations for colonoscopy, getting more robust and better and cleaner colons. But clearly data out there that these things really help us do less sedation procedures more comfortably for patients. Scopes, we all know what's going on with the scope revolution. They get slimmer and they still keep getting sort of fairly favorable working channel characteristics that allow us to use the accessories that might help us complete procedures. And all that can be less stretch, less space in kind of the oral procedures and still allow us to do what we need to do. And then I'll throw this out there. Some providers in anesthesia critical care had taught me a long time ago that a lidocaine 5% ointment or 4% atomized lidocaine or inhaled lidocaine provided a very topical or very effective topical block that would limit the gag nearly completely for about 20 minutes or so. And I have some arrows over there pointing to a ideal airway classification patient where you can see their whole tongue. You can see the whole back of their mouth including their whole uvula hanging down. And you can even see their tonsils. You could tell if they had a tonsil infection. So that's ideal, that's class one. And if you block those structures that those arrows are pointing to with some topical lidocaine on a stick maybe, and then on some Q-tips, you take a minute or two to do that for the patient, you will have a great block. And that is something that can really limit the gagging and that part of the procedure. It's not usually a painful procedure for patients to go down endoscopically through the mouth, but the gagging is the part that's bad. So if you limit that, you can actually sort of change the dynamics of the procedure and limit how much sedation you need to use. While we're on that topic of airways and melipotic class, you see on the right, the far right side, the class four, well, that's somebody who you look in the mouth and sometimes you can't even see the area where the uvula is hanging down or any of the tonsil regions because it's obscured by the anatomy and by oftentimes soft tissue. And these airway classifications, melipotic classifications correlate with the grade airway views that you see anesthesia providers document. So you can imagine if you're trying to use a blade, a Miller blade to go through the mouth, you know, your ability to get into the cords is a lot less as you move further to the right of the spectrum. And that's the risk for giving anybody deep sedation or general anesthesia. So sometimes, you know, we'll talk about that a little bit later in my book, maybe you try not to give them deep sedation or general anesthesia in these high-risk patients. So that's a good segue. True or false, our next one, there are patients who can benefit from endoscopic procedures, but should not be subjected to deep sedation for those procedures. So I know that one's done. Give it a minute here, they're typing in. So a couple of trues are popping up. That one's starting to get to a little bit of, what am I thinking there? And I don't know, but it depends on the perspective you're kind of approaching that from, really. But yeah, we'll give everybody a minute to kind of think about that in their own practices. And I think sometimes, whoop, go ahead, Ed. Yeah, I was just gonna say a couple more trues. Pretty much everybody's saying true. Okay, well, I think about this sometimes when I'm sitting with patients in clinic who are older that are really sick, and I just think, boy, I think it'd be relatively dangerous for you to go through a general anesthesia for sure. Do we really need to do this procedure to get information we need to treat you? And how can we do that safest way? And sometimes, I think, how can we do that safest way? And sometimes, the safest way is not more sedation, it's lesser sedation. So that's one example. I'm sure you're all thinking about examples from your perspective. I typically, in my practice, do have some procedures that I don't do with sort of deep sedation general anesthesia. And those include endoanal ultrasounds for rectal sphincter assessment or anal sphincter assessment, almost all pouchoscopies or sigmoidoscopies, and certainly the transnasal procedures that I do. So for those diagnostic procedures, I do not feel that it's worth subjecting the patients to those increased risks, including aspiration of deeper sedation or general anesthesia, with rare exceptions. So some of that just depends on how your practice is set up and what you can and can't do. But I keep in my mind that I remember that in the clinics upstairs that I work in, in ENT and colorectal surgery, a lot of these procedures like that are really done in the offices without IV placement. So that's kind of how I feel sometimes about the sedation part. Okay, let's go ahead and move on. So we're gonna leave this one up here a little bit and spend a bit of time on it. And I think we do have some folks from around the world, really, which are honored to be here with you. And hopefully we'll get plenty of time to kind of have folks chime in and share some experience and questions and interaction. But most of what I've seen in the United States and what I hear about in other units involves fentanyl and Versed. And what you need to know about that is that it's still pretty quick onset, but the peak is gonna be a few minutes out. You need to wait three or four minutes to see the peak of that dose that you're gonna be giving. And I have some typical dose ranges in there that you have to tailor a little bit depending on what you're trying to do. Is it minimal sedation? Is it moderate? And your patient, do they have chronic pain? And is this gonna be maybe a little bit more of a painful procedure that you're treating or are we just treating anxiety? But if we go ahead and click the slide forward, I think it does sort of show you that the duration of these medicines can be fairly long, depending on what range you're shooting for, minimal or moderately deep. And if we click the slide one more time, once again, our propofol sort of example that we went through kind of shows you some of the characteristics that make that a better agent when you're trying to target that sort of moderately deep or deep range. And a typical first dose for propofol in that situation. Branching out from there, if we can go back again, I do have a couple of things listed. I'm gonna go in between the fentanyl and the Versed. You'll see Demerol or Meparidine. And that does have a longer action sort of time. Many of us have used that pretty extensively in the past when we do non-propofol sedation for things like endoscopic ultrasound or ERCP or deep enteroscopy. And it can be very effective there. Don't typically use it in large doses where you may run into some of the issues with accumulation and seizures. And it can be a good adjunct. And then I'm gonna throw your attention all the way to the bottom of the screen to Phenergan. For some people that would include Diphenhydramine or Benadryl. And that's something that for procedures that are gonna last a little bit longer, especially when you're using some narcotics, it can be a very effective anti-emetic to avoid that effect of narcotics. And it can be a bit of a sedation, potentiation, a combination agent that works very well. Moving a little bit up, there are some agents in there that include Ketamine. Ketamine is getting a lot of attention because it can be used, including in people who are very ill, including sort of decompensated people to give that dissociative effect and to not cause sort of hypoxia, hypoventilation. And a fairly favorable agent with regards to hemodynamics and hypotension. It does cause bad dreams, hallucinations, maybe even some suicidal aspects. And so depending on your state and local regulations, there are aspects there in terms of use of Ketamine and how to get it, how to monitor it, and those side effects. The two that are listed below Atomidate and Presidex or Dexamethamidine, you'll see out there, we have cardiology providers who use Atomidate a fair amount for certain parts of their procedures, like ablations, when they want to get a short effect because there's less tendency than giving a big propofol bolus to cause hypoxia, hypoventilation in that setting. We have a lot of the ICUs that are using Presidex. And that's also touted as being a little bit less likely to cause that profound respiratory depression that propofol can in higher doses. And to some extent, marketed is less hypotension, but particularly for people in the units on drips, you can see a lot of hypotension with Presidex, and that can be something that limits its use as an adjunct for endoscopic procedures. And then I kind of put one last class in there, Remifentanil, and one that most people probably aren't aware of, Remimazoline. And these are basically ultra short narcotic and benzodiazepine analogs that have been described. And you don't see them a lot because they're expensive, but they can be very effective. And I can see them sort of in ICU patients where there's concern about long-acting agents, delirium, things like that, but they can be very effective for use in endoscopic sedation procedures for things like ERCP. So here, this is gonna be a bit confusing to you, and I know it's not the prettiest slide, but focus on that box top left that says a top of a paper form like this involved the nursing assessment and the cardiovascular parameters, including the vital signs, blood pressure, heart rate. And this was a pre-procedure assessment that needed to be documented prior to putting somebody through a sedation procedure. The bottom of the form, and sort of the highlighted box on the right, was the part by the physician provider. And this was really required because in the United States, the Centers for Medicare Services deems endoscopy a high-risk surgical procedure due to the sedation component, not because of the endoscopy component, because of the sedation component. And the focus of that includes aspects including airway assessment, the mill and potty class, the ASA classification, and a sedation plan. Most places have moved away from paper documentation, although it can be very effective and still used sort of in an emergency when your computer system goes down, hopefully that doesn't happen too much, or when you're in areas where you don't have access to a computer. The computer systems can be great in prompting you through pathways, like you see some of these green arrows that are even some of the ASGE's quality metrics for some of the things that we do, things like what anticoagulation agents are they on, or anti-clotting agents, and are antibiotics appropriate in this case? And that can be used in your pre-procedure physical assessment. So, I mean, that's all very important if you're going to be supervising and providing sedation for the patient. But really, I threw this slide up here because over the years, these are the things that I see recurring time and time again as the keys. And the first one is the recovery position. So, left lateral leaning forward, the position you'd put somebody in if they were vomiting and going unconscious so that that vomit didn't end up pooling kind of over their cords and spilling. And the picture you see at your right side with that big green kind of sunshine thing, that's the dependent piriform sinus in the left lateral position. And that's where you'll see all the saliva and everything accumulating, the frothy foam when you're about to pass your scope. And what happens is the further you have them leaning to the left, the less likely it is for that fluid to spill straight across and go into the cords and down into the trachea, more likely it is to come back out the mouth or at least be accessible for your suction catheter, which you should always have at the ready. So, that's really quintessential to sort of safety, maintaining a good airway and preventing aspiration. The other thing that's mentioned is oxygen and capnography. And these things have some data depending on where you are on the spectrum about whether you really need them or not. But I underline capnography because at least in the United States and most institutions and states, there's a big push towards that modality to help be an earlier indicator towards over sedation and needing to make adjustments before that pulse ox is not registering and the patient's starting to get dusky and blue. The chin tilt jaw thrust is really a maneuver you have to know how to do, kind of almost unconsciously in your sleep if you're gonna be giving sedation to patients. And that's gonna be necessary to make it effective to use an Ambu bag as a rescue device to breathe for the patient if they hit that deep sedation general anesthesia level and just aren't ventilating well enough. Oral and nasal airways are very important, particularly when the tongue gets in the way when you're trying to do those maneuvers and breathe for the patient with a bag. And you need to have skills and know how to insert those and use them in the appropriate circumstances. Of course, if you get to that point, concomitantly, you may need to give reversal agents. And although for use of narcotic and benzodiazepine compounds, you'll also see flumazenil mentioned as the reversal for the benzodiazepines. Narcan is the one you really wanna go to first if narcotics are part of your cocktail. Usually you get the most bang for what you're giving from that, and that's usually the more likely offending agent in the decompensation. And then I put at the bottom there, you know, kind of for all of us, non-anesthesia providers who don't typically use Miller blades and intubate the airway, the laryngeal mask airway device is something that can be very effective, particularly when patients are already in that recovery position, left lateral leaning position, and you're not able to get the embu bag to do what it needs to do. Sliding that device in almost like you'd slide an endoscope in, in that left lateral position, and using that to create a seal around the airway structures and hopefully, you know, kind of be able to allow you to ventilate more effectively is key. So a few other friends, I'm not going to spend a lot of time on this, but, you know, you really need to pay attention to IV access and the ability to give an IV fluid bolus if you do run into problems with blood pressure, but you have to be very cautious about that in patients with severe pulmonary hypertension and right heart failure. So that should always be something at your disposal. We always make sure that we have agents to treat bradycardia and that we also have agents to treat severe hypertension, particularly if it was in the setting of an atrial fibrillation event that occurred during sedation or an endoscopy procedure. Of course, if you had major events with those things where medicines weren't responding, you also have to have a crash cart at your disposal where you could actually do defibrillation or you could do pacing or whatever else you need to do in addition to activating your emergency systems. And that is where you really get into sort of things with vasoactive substances. And I just, you know, kind of mentioned a few things here, depending on if you're working in an ICU or if you're grabbing something off a crash cart, dopamine is often available, at least at our institution, premixed, or you can use epinephrine, which most of us have on our endoscopy carts, but you have to make sure that it would be in the appropriate concentration, 10 mics per ml. So not a hundred mics per ml like many of us mix. So one thing that I harp on a little bit at our institution, I know we have a couple of people that joined and they're probably getting really sick of hearing this mnemonic, this HIPAA. So no matter what you feel about the act that was put in place a bunch of years ago, and every time I see an anesthesiologist come in to talk to a patient that they're going to give deep sedation or general anesthesia to, or any type of sedation to, they go through some version of these questions. And so history, H for history, is there a known problem out there? I is IV access adequacy and your circulatory support medicines. We talked about that. You never want to be giving somebody an IV sedative without knowing that IV is working well, if you have to address problems that can occur afterwards. And you have to know that those medicines are available and around, not someplace that may take a few minutes to get to, but they're there. Pulmonary considerations and precautions. So how are they going to ventilate? And you need to have your rescue supplies and you need to have your plan for how you're going to handle that. And capnography comes in there in terms of patients who are ill or patients that you're going to be really giving a true moderate or a moderately deep sedation regimen to. Airway and aspiration for the A. So I'll lump them together. You need to have your rescue supplies and you know, your aspiration precaution is always that position where they're leaning forward. They are not on their back. They are not in a compromised position when you are doing your procedure. I mentioned at the bottom in red that at least through our state and in Pennsylvania and through our institution, if you've documented your pre-procedure H&P, you've documented your medication and allergy reconciliation steps and you've documented appropriately in paper or an electronic system, including these considerations, you are in fulfillment of criteria, at least for us to be giving minimal moderate sedation to patients. And, and, and then there's a monitoring aspect to that too, which I'm not going to go into to any great extent. So we're going to skip through this a little bit. This is a surgical timeout, old form that was very appropriate for operating rooms. Go ahead and flip through. This is sort of more of an endoscopic timeout that we use, which is a little bit more germane to endoscopy procedures. And you'll see some things highlighted on the left side that we've been talking about that, you know, are very important. You'll see something on the right, a post post timeout, which is talked about sometimes, but not always done can be very effective as a confirmation point, including, you know, talking about other concerns in the recovery management of the patient. I didn't talk a lot here about recovery and criteria for recovery when you're administering sedation, but I will refer you to those AHG documents in the beginning. There's a lot of great discussion about that. So go to a true and false question here. Recovery room utilization is longer with Versed and Fentanyl moderate sedation strategies. When you're talking about those compared to a Propofol delivery strategy. So recovery room utilization is longer with Versed and Fentanyl and I underline moderate sedation strategies when you compare them with Propofol. Let me give them a minute to respond to chat on their responses here. Okay. So that one's also a little one kind of, you know, what am I thinking there with underlying moderate for you guys? And, and I, I think that the, you know, the data out there, including stuff that I talked about with the targeted moderate deep Propofol and sort of the caps issues really would, would support this statement. But I will say in my own practice, when I'm really sort of targeting more minimal, just a little anxiolysis or moderate patients who are really, you know, they're kind of awake and they're, they can talk to me. You know, remember that in most institutions and at ours, you're, you're kind of front-loading those medicines typically for these procedures and a 30 minutes after they've been given, as long as their vital signs are within 15 or 20%, they typically meet criteria for discharge. So that's not the case when you turn off a Propofol infusion. You, in most places, certainly where we practice have a mandatory, at least 30 minute timeframe after you turn off the infusion, where you have to watch the patient. So, you know, if I have a nurse, who's the same nurse who checked the patient in, was in the room with me and gets the patient off to the recovery area and takes care of him in recovery and then rotating through. And the nurse really knows the patient from start to finish. And I'm only giving minimal sedation or that lower end of the moderate range, the patient staying awake. Their last dose of medicine was 20 minutes ago when they leave the procedure room. You know, that that's really not the case that it's kind of taken longer. So it depends on where you are on the sedation spectrum and how you've set up your practice. And I did see one question come in the chat about how many nurses do you need? You know, if you're, if you're giving sedation and it really does depend upon what procedure you're doing, what sedation spectrum you're targeting and you know, how that's set up in your unit. But typically if you're going into a deeper sedation range so deep or general anesthesia, that individual who's monitoring sedation be it a nurse or a nurse anesthetist, typically a nurse anesthetist for deep sedation or an anesthesia provider has to have their sole focus as being the patient. So they can't be doing other activities, but minimal and moderate sedation depends on the institution and depends on sort of you know, the level of patient sedation and what you're expecting them to do. So this is going to be my last slide and I'm going to jump off and leave some time for us to hopefully get into some of those questions and talk about other things. But I'll just say, you know, this is very dependent upon your state and your institution. Keep up annually with what the regulatory and institutional trends are and what the requirements are. My suggestion would be including for all the fellows out there that are moving forward and going to be practicing, maintain your institutional privileging steps for moderate sedation. Some places that may include deep, depending on sort of where you are and what you're doing. And maintain current ACLS, BLS status. So I think that is important to emphasize that, you know, you have both of those skills, you're practicing them regularly, that you're familiar with airway rescue, particularly from deeper sedation spectrums. Next is to document possible deep sedation with patient written consent, you know, when performing these gastroenterologist directed endoscopic sedation procedures, because it can happen with targeted moderate sedation. And you need to just make the patient aware that you're trained and you have the ability to, you know, kind of provide assistance should that occur. Use an electronic process if possible, if at all possible for assessment and include something like that, that little HIPAA stop gap there, you know, you're going to have your time out that you have to do for your institution or your practice site or whatever it is, but get in your mind, your own, your own set of questions that you're going to go through every time before you start that sedation procedure, because you'll be surprised at how much you'll catch and, and how much your process will improve and the safety of those procedures will improve if you start doing it. And then I'll throw out there to kind of end with, and I'm going to try and shut up for a while, hear from you guys, sedation codes. So how do you, how do you bill for sedation? If you're not administering anesthesiology directed sedation, there's a G code that is for sedation involving endoscopy. It is not billable for increments beyond 15 minutes. It's a one-time thing. And although you know, there, there may be facility type aspects, this is more on the professional side for gastroenterologist. There's also a 99152 code that you'll see if you're using some of the automated coding systems. But you know, I think depending on your state and your payers, that may or may not be something that they actually pay for. It appears that that G code is, is pretty universally covered, although it's a lesser code, a lesser value and amount reimbursement than, than the other ones. But that's something I'm kind of interested in, in hearing from folks, at least in the United States. And I don't know about in other countries, how it's handled when you're not working with an anesthesiologist, but kind of seeing what people are doing and how they're handling that. So Dr. Dye, just to follow up on that last question on the nurses, one of the questions that came in was what kind of training do you provide your endoscopy nurses? And is there a competency module that they can do or something else that is offered out there? So maybe, maybe a little bit on what you do in your own practice and what other resources, you know, that are out there. I would say, so in our practice, our institution really requires a curriculum where people are trained in both basic life support and ACLS, at least one of the providers in the room. So a lot of times that can fall in our state and PA, at least towards the nurses who are involved. But our institution in particular goes beyond that to require the physicians who are involved, if they want to be privileged to give moderate sedation, to also have that certification. Beyond that is a division. We actually have an organized process where we have two representatives, our director of endoscopy and myself on the quality side who attend the institutional sedation meetings, committee meetings, and provide updates to the providers as they come out for our local institution. And then we have another component, which is we actually participate and administer the BLS and ACLS modules within our division that are geared towards endoscopic scenarios and endoscopic sedation. I think that I've been at a couple other institutions and they've operated similarly where they have mechanisms, but they may not be as organized and they may not be as directed towards making sure that both the nurses involved and the physicians involved are current and competent and comfortable. Excellent. Thank you, Dr. Dye. Another question on how effective do you think transnasal endoscopy is with either local anesthetic or very light sedation for diagnostic endoscopy? Yeah, that's a great question. And there are some publications out there on this. I think some of the technique things that you might learn if you're looking to get into this and haven't done it before, including, you know, maybe even seeing how the ENT providers do their indirect exams are key there. And the one thing I will throw out is that topical lidocaine can be very effective to help you with that procedure. That and really talking to the patient, setting their expectations for it. And I know there are a couple of people in our group and I'm one of them that we've had our endoscopies done to kind of look down there and see if we have reflux and Barrett's and we've done them just transnasal awake on each other as providers. And I will say that that's not something I'm advocating from an ASGE perspective, but if you, you know, sort of have somebody who's experienced in doing it and you go through one of the procedures yourself, I think you will learn all aspects of it and be much more comfortable when it comes down to kind of doing it for others. It can be done very safely, very effectively, very comfortably, but there are some tricks and that involves, you know, preparing the patient, talking with them and it involves using the lidocaine topically effectively. And then the third thing I would say is there are some people that just their anatomy is not great on either side, nasal passage, and you have to be able to recognize that, not force it. And maybe think about doing your topical mouth block and using that thin scope across the tongue if you get to that point. Excellent. Thank you, Dr. Dye. Another question in your experience, can you provide some guidance on when you think there are certain patients or conditions that would put you on red alert for sedation complications and you would tend to keep then anesthesia a little bit more on the extra light side? And are there maybe critical AS or others that might, you know, put a framework for how you approach, you know, various patient scenarios? Yeah, that's a, that's a great question. I'll just say that, you know, in my experience, the, the two situations that I think are, are most, most precarious are somebody who has pulmonary hypertension, right? Heart failure physiology, and is hypoxic and decompensated and sort of struggling to breathe. You know, that, that patient really, if you have to do an upper endoscopy on them, or even, you know, something on the colon is just somebody who is very difficult to manage in any way, even with minimal, moderate sedation. And you want to get the help of your anesthesia providers for, if you try and do an upper procedure on those patients and you try and give them even topical stuff to kind of help you, you know, even just a little bit of coughing or that type of thing can really cause them to decompensate. And the second group of patients I'd say is, you know, patients who are really in shock and need vasopressors. And I'd say, you know, even beyond doing those procedures and, you know, going to an OR to do them, you know, some of those patients probably just need a hospitalized endoscopy procedure at the ICU bedside where they stay on their drip, they stay with their ICU nurse and, you know, you, you manage them on, on that level. So I don't know if that's a, that's a great answer. And, you know, other people out there have other, other scenarios where, where they kind of have seen, you know, really just problem areas. I will throw out that, you know, you'll hear a lot written and you'll see in those guidelines that a difficult airway is often included in that, or your severe sleep apnea type patient is often included in that. I, I find that you can give that group of patients minimal, moderate sedation, even for upper procedures, certainly for colonoscopy procedures. I would put that group of patients in the ones that if there's a way to talk to them and if you're experienced with these other techniques to maintain comfort besides deep sedation, you know, steer those patients that way if you have that level of experience, because you can a lot of times take care of those patients very effectively and without putting them at risk through those deeper sedation ranges. I'm going to jump ahead here on another question, because I think it's a great follow-up to what you were just talking about here. It's kind of a three-parter and you touched a little bit upon on one of these already, but I'll, I'll read it through to you. So first of all, can you expand a little bit more on patient positioning and how that affects scenarios for you? A little more discussion on sedation for patients in the ICU setting. I know you touched upon that already. And number three is what sedation strategy would you choose for yourself when you reach 50? And I guess they're assuming you're 50 years of age or greater. I don't know. Yeah. Yeah. Thanks guys. You know, I, all right, so I'll take that last one first. So I think just from being involved with some of this evolution and, and being involved with talking about and teaching about sedation strategies at a couple of places, I really did find a lot of value in going through awakened diascope procedures myself. And so I did have my colonoscopy done with, with just actually just a little bit of fentanyl about 50 micrograms, I think by one of my really seasoned colleagues. And, you know I did that kind of because I do a lot of unsedated colonoscopy and I do a lot of procedures with minimal, moderate sedation for patients who are sick. And I think that that was helpful. And I, having said that, you know, if you're somebody who just is unfortunate and doesn't have great anatomy, or you've got a problem going on where you've already got pain, you know, that, that may not work. And you, you may need something more than just a wake or minimal sedation for this. So that's, that's the last one first. I think I heard one in there about elaborating on ICU sedation procedures. And, you know, that is one where oftentimes the patient is, is already intubated. And so most institutions that I've seen and the current one I practice in, if the airway is maintained, they're oftentimes on a, an anesthesia inducing or a deep sedation inducing drip. Oftentimes it's propofol, maybe Presidex, depending on where you practice and the patient, you know, may just be fentanyl. A lot of times it's not a heavy Versed drip because of that sort of ICU delirium concern. But, but, you know, once the airway is protected, just titrating that drip, not having to kind of induce your sedation level is something that a lot of places will have protocols for is the endoscopist involved with kind of that titration or is an ICU team involved depending on the unit that you're in. And I think that that kind of depends on experience and also on your institution in terms of, of where you go with that. But I do think that for hospital practice, that that can be a very effective venue for very safe patient care to do those procedures in an ICU setting. And I can't, I know there was one more on patient positioning. If you had any comments on, if you want to expand on that. Yeah. Yeah. I mean, I think there are, there are occasional times where you can't put somebody in a left lateral position, but I would say it's beyond that, you know, to really put them in the appropriate position you need to have them leaning forward. You need to have their, their neck. I'm going to kind of lean it over kind of leaning to the side and you need to, you want to see that saliva and the drool kind of coming out of the corner of their mouth, not pulling back there where they're going to have to cough or, or aspirate it. And you do that by really shifting the shoulder underneath them. And by using that, that sort of that leg, that'll be the top leg when they're laying on their side, shifting that top leg far out towards you over the bed and kind of really meaning those hips forward too. And, you know, my typical sort of approaches when, when the procedure starting, whether I'm the one who's giving sedation or whether it's an anesthesia team is I, I try and get over there and I try and make sure the patient's in that position, that leaning forward position, because sometimes I'm surprised at how often a patient's given, you know, sort of a pretty deep inducing propofol dose. And they immediately kind of flop over a little bit and they're more on their back and they've lost their gag reflex and they've got a blunted cough. And, you know, that is just not, not a good position to be in for endoscopy. Okay. I'm going to switch gears a little bit on you with this question, which is on, from the approach of rising costs of anesthesia service and reduced reimbursement, do you anticipate a trend back towards increased use of conscious sedation? That's a good question. I think it's, I think it's going to depend upon the state and the institution. And I'm not quite sure I'm pulling out a crystal ball with even in my own home territory, sort of where that might go. But I guess I'll sort of sidestep it a little bit and just say, you know, having been at places where we've shifted pretty heavily towards reliance on deep sedation and general anesthesia, a lot of cases, I kind of look back and I see things in my practice that I really go, boy, it's just not easy for me anymore to do these minimal, moderate things. It's just, we've kind of moved to a different model. And I think, you know, no matter where it really goes based on cost and on payers driving it in the United States, I think for some of our patients and just kind of doing the right thing and not subjecting them to more than they need, you know, we need to keep that tool in our boxes and we need to be able to provide it safely and effectively in our practices. Excellent. A couple more questions here as we kind of come up on top of the hour. This one is, do you think ketamine will become a standard part of conscious sedation and endoscopy? And then the comment follow-up, it seems to be used a lot in the emergency room. Yeah, you know, great question. I think it'll depend upon the institution and on, you know, sort of their practice policy on it. At our institution, it's pretty easy to be used by anesthesia services. It's a little bit more challenging to use it because of some of the state directions on monitoring if you're a non-anesthesia provider. And it involves, you know, kind of a screening for suicide and follow-up calls over the next 24 hours with the patient. So, you know, I've kind of looked at ketamine as being, you know, a really nice agent to use as an adjunct of cocktail. When I see it used by our anesthesia providers, I don't personally give it. But I also don't really see it being that much different than benzodiazepines, particularly Versed, in terms of what you can do with it and how you can use it, you know, if you're just sort of choosing an agent between the two. The final question, but I want to, before I do the final question, I want to put a shout out that there's a Dr. Dye fan out there that says that they've been using the dye technique for totally uncinated EGD and consistently works well. So, so there's your one fan person that's out there, Dr. Dye. I'm going to throw out there that whenever that person wants to come in for one of those procedures, I'll be happy to walk them through it, have them do their procedure that way too. All right. The final question this evening, Dr. Dye, is have you seen or heard any updates to protocols as a result, sedation protocols as a result of, you know, the COVID pandemic, or do you anticipate any changes or modifications as a result of things that are happening in the endoscopy unit? Boy, that is a great question. I can tell you that at our institution, for those hospitalized patients, I'm assuming we're talking a little bit about the hospitalized patients that are having the bleeding complications and things like that. You know, we've shifted much more to, I think, kind of COVID unit directed endoscopy procedures when they're urgent and emergent need to be done and going to them rather than sort of trying to move those patients around the OR if we can avoid it. And for, for the outpatients, boy, I think it's probably depends on your, your institution and, and sort of how you're approaching that. But, you know, we've sort of tried to defer things on outpatients who may be in the still COVID transmissible windows if possible, and, and just sort of, you know, delay it until they've recovered from it. I don't know if other places have had similar experiences, probably depends on if you're at an acute hospital practice, or if you're, you're, you know, kind of dealing with those issues more from an outpatient procedure perspective. Well, thank you, Dr. Dye. That excellent presentation, excellent discussion. We're going to close out this evening's presentation. I just want to thank Dr. Dye for his time and expertise and sharing that with all of you tonight. In closing, I want to also thank you for all of you participating in tonight's presentation. But before you log off, we would really appreciate your feedback on tonight's event by going to that networking lounge and completing our evaluation. Again, it's only just a couple of questions and takes about a minute or less to complete. We do take a look at those evaluation comments. And just a reminder that we will have tonight's presentation on GILA. We usually get it up in about 24 hours. But it is at learn.asge.org. And we usually send out an email reminder about where that's located at. This does conclude our presentation. We do hope that the information is useful to you and your practice. As a reminder, you can access that recording on GILEAP as I was indicating. Again, you do not have to be an ASGE member to access this content as our goal is to provide this information from Thursday Night Light webinars as a free and open source resource to all gastroenterologists globally in improving their practices. Our next webinar for next Thursday will be November 4th at 7 p.m. Central. And it will be focusing on our GI Fellows Indo Hangout by foreign body impactations. It will be moderated by Dr. Praveen Jha from the Cleveland Clinic. Thank you all again. And I wish you a very wonderful evening.

sedation strategies

endoscopy procedures

patient positioning

topical lidocaine

capnography

sedative agents

patient assessment

recovery protocols

future trends