Chapter 28 HOW TO PREPARE PATIENTS FOR ENDOSCOPIC PROCEDURES
Correct patient preparation involves:
INTRODUCTION
ASSESSMENT OF PATIENT FITNESS FOR PROCEDURE
Health professionals assessing patients for endoscopy should be aware of the American Society of Anesthesiologists (ASA) classification of patient risk (see Table 28.1). The degree of concern will be dictated somewhat by the level of anaesthetic support available for the procedure (which ranges between institutions from none to an anaesthesiologist, as well as varying for different types of procedures). In general, procedures on ASA class I and most class II patients can be safely performed in a well equipped endoscopy suite with appropriately trained staff. ASA class III patients might be better triaged to the operating room. This degree of patient risk must be identified prior to the endoscopy list so that appropriate patient assessment (and informed consent) can be undertaken as well as ensuring that the procedure is performed in the appropriate environment.
Table 28.1 Definition of American Society for Anesthesiologists comorbidity status
| Class 1 | Patient has no organic, physiologic, biochemical or psychiatric disturbance. The pathologic process for which the operation is to be performed is localised and does not entail systemic disturbance |
| Class 2 | Mild to moderate systemic disturbance caused by either the condition to be treated surgically or by other pathophysiologic processes |
| Class 3 | Severe systemic disturbance or disease from whatever cause, even though it may not be possible to define the degree of disability with finality |
| Class 4 | Severe systemic disorders that are life-threatening, not always correctable by operation |
| Class 5 | The moribund patient who has little chance of survival but is submitted to the operation in desperation |
PROCEDURE-SPECIFIC ISSUES
Gastroscopy and endoscopic ultrasound
The main issue for gastroscopy (also known as oesophagogastroduodenoscopy [EGD] or simply ‘endoscopy’) and endoscopic ultrasound (EUS) is safety to the patient through ensuring an empty stomach. Patients should not eat solid food for at least 6 hours or clear liquids for 4 hours prior to a gastroscopy. If the patient is known to have poor gastric emptying fasting for longer or dietary restriction to clear fluids for 24–48 hours prior to the procedure should be considered. In the emergency situation, airway protection via endotracheal tube should be considered.
Endoscopic retrograde cholangiopancreatography
Patients with biliary obstruction should receive prophylactic antibiotics prior to the commencement of the procedure (see below for a more detailed discussion of antibiotic prophylaxis). Endoscopic sphincterotomy (ES) of the ampulla of Vater is a common procedure during ERCP. Patients in whom ES is considered should have an international noramalised ratio (INR) <1.7 (ideally normalised) and should not take IIb/IIIa inhibitors such as clopidogrel for 7–10 days if the procedure is elective. Aspirin use does not preclude ES, but ideally should also be ceased 5 days before the procedure.
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