Prior to performing an endoscopic procedure, careful consideration of the indications, risks, contraindications, preparation, timing, and environment for the procedure should be undertaken, and consent must be obtained from the fully informed and collaborative patient or an appropriate responsible representative. In most cases, this is a straightforward process, but in some instances, procedural planning must be altered by the issues or needs identified in the preprocedure evaluation. National guidelines define quality measures for preprocedural aspects of care, including elements relevant to all procedure types (Table 1.1
and others unique to each of the major procedure types (esophagogastroduodenoscopy [EGD],2
endoscopic retrograde cholangiopancreatoscopy [ERCP],4
and endoscopic ultrasonography [EUS]5
). Among them, the most important “priority indicators” identified for preprocedure care in all procedures include (1) documented performance for a “standard” or broadly accepted indication in at least 80% of cases, (2) appropriate use of prophylactic antibiotics in at least 98% of cases, and (3) appropriate management and documentation of antithrombotic therapy before and after the procedure in at least 98% of cases.
While GI endoscopy is generally considered minimally invasive, risks are engendered by the administration of sedation and analgesia, passage of the endoscope through the upper airway, tissue sampling, therapeutic maneuvers involving cutting, thermal ablation, stretching, or potential tearing of tissues, and
sometimes prolonged immobility.7
Assessment of a patient’s candidacy for endoscopy includes consideration of tolerance for these standard maneuvers for common and severe complications involving potential vasodilation, dehydration, agitation, suppression of ventilation, bleeding, or infection. Hence, attention should be paid to preexisting comorbidities that might be exacerbated by these stresses.
The preprocedure assessment should, at minimum, document current medications, allergies, history of prior anesthesia or sedation tolerance and adverse events, history of other specific risk factors for endoscopy or sedation, and contemporary cardiorespiratory and airway examinations. Examination for adequacy of the airway should document the presence of facial, oropharyngeal, or dental deformities which might impede resuscitative measures in the event of need for supportive ventilation or airway rescue. The Mallampati Score provides a standardized visual assessment of the oral airway, as a means of estimating potential difficulty in establishing endotracheal intubation (Fig. 1.1
). No specific laboratory testing,8
imaging, or cardiovascular studies are required for patients who are generally well and lack important risks discussed below.
Cardiovascular and respiratory:
Cardiopulmonary risks for endoscopy are predominantly related to patient characteristics and vary little by individual procedure type beyond overall complexity and duration.9
Numerous indices have been described to estimate cardiopulmonary risks during sedation or anesthesia, primarily for surgery. The American Society for Anesthesiology (ASA) Score (tange 1-5) is the most universally applied index and is now a standard expectation before administration of sedation or anesthesia (Table 1.2
Numerous specific cardiac or pulmonary limitations should be identified and noted before electing to proceed with endoscopy (Table 1.3
Their presence should prompt attention to the stability or severity of symptoms at the time of endoscopy and consideration whether intervention is required to limit the procedure risk by optimizing the patient’s status and/or altering the planned timing, monitoring, sedation, or location for the procedure. Preprocedure chest x-rays are not routinely recommended but should be considered in those with new signs or symptoms of pulmonary compromise or decompensated heart failure.
Assessment of coagulation parameters (international normalized ratio [INR], prothrombin time [PT], activated partial thromboplastin time [aPTT]) or platelet counts is not recommended unless the patient has a history of severe chronic liver disease, malnutrition, prolonged obstructive jaundice, suspected thrombocytopenia from disease or
chemotherapy, history of a bleeding disorder, prior bleeding after procedures or dental care, or ongoing therapy with anticoagulants.
FIG. 1.1 Mallampati Score Assessment of the Oropharyngeal Upper Airway. Class I: soft palate, fauces, uvula, pillars. Class II: soft palate, fauces, portion of uvula. Class III: soft palate, base of uvula. Class IV: hard palate only. (Reprinted from Vargo JJ, DeLegge MH, Feld AD, Gerstenberger PD, Kwo PY, et al. Multisociety sedation curriculum for gastrointestinal endoscopy. Gastrointest Endosc. 2012;76(1):e1-e25 with permission from Elsevier.)
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