Endoscopy Practice and Sedation

• Audio chapter
  Single-voice audio, listen on the commute.
• ABIM-format MCQs
  5-option vignettes with full wrong-answer teaching.
• Study guide
  Tables, decision trees, primary sources.
• AI tutor
  Chapter-grounded, answers the question you're stuck on.

What this chapter covers

• Section 28.1: Pre-procedure fasting and pregnancy testing

  Pre-procedure fasting reduces the gastric volume and acidity that drive aspiration risk during sedation.

• Section 28.2: Procedure bleeding risk and thromboembolism risk stratification

  Periprocedural antithrombotic management starts with two questions: what is the bleeding risk of the planned procedure, and what is the thromboembolic risk of the patient.

• Section 28.3: Warfarin and DOAC periprocedural management

  Warfarin and direct oral anticoagulants share the same goal (anticoagulation through factor inhibition) but differ in pharmacokinetics, reversibility, and procedural hold strategy.

• Section 28.4: Bridging and the BRIDGE/PERIOP-2 evidence

  Bridging with low-molecular-weight heparin during warfarin interruption was once standard practice but has been narrowed dramatically since 2015 based on randomized trial data.

• Section 28.5: Antiplatelet management and DAPT after coronary stenting

  Antiplatelet management in endoscopy turns on a single principle: the risk math is asymmetric.

• Section 28.6: Antithrombotic reversal in active bleeding

  When active bleeding requires antithrombotic reversal, the choice of agent depends on the drug being reversed and the urgency.

• Section 28.7: Sedation depth, ASA, and pharmacology

  Sedation choices for endoscopy span minimal sedation (anxiolysis), moderate (conscious) sedation, deep sedation, and general anesthesia.

• Section 28.8: Capnography, difficult airway, and reversal

  Sedation safety depends on three layers: real-time monitoring of ventilation, anticipation of the difficult airway, and prompt reversal when respiratory or sedation depression overshoots the intended target.

• Section 28.9: Sedation in special populations

  Standard sedation regimens require modification in specific populations because pharmacokinetics or aspiration risk changes the calculation.

• Section 28.10: Antibiotic prophylaxis

  Antibiotic prophylaxis is recommended for a narrow set of endoscopic scenarios and is explicitly not recommended for many situations where it is reflexively given.

• Section 28.11: GLP-1 and SGLT-2 inhibitors

  The 2024 to 2025 multi-society guidance addressed two newer drug classes that affect endoscopy and were not part of earlier curricula: glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and sodium-glucose cotransporter-2 inhibitors.

• Section 28.12: Pacemakers, ICDs, and electromagnetic interference

  Cardiac implantable electronic devices (CIEDs) interact with endoscopic electrosurgery through electromagnetic interference.

• Section 28.13: Capsule endoscopy

  Capsule endoscopy uses a swallowed wireless camera that traverses the gastrointestinal tract and transmits images to an external recorder, providing visualization of the small bowel that conventional endoscopy cannot reach.

• Section 28.14: ASGE adverse event lexicon

  The ASGE adverse event lexicon (Cotton 2010, Gastrointestinal Endoscopy) provides a standard way to recognize and grade endoscopic adverse events across procedures and institutions.

Podcast episodes

1. 01

   Endoscopy Practice and Sedation: Before the Scope

   Everything that has to be right before the scope goes in comes down to matching the preparation to the patient. The episode starts with fasting windows by what was eaten and who counts as a full stomach, then pregnancy testing. It next covers risk-stratified GLP-1 agonist management, with urgent endoscopy never delayed, and the three to four day SGLT-2 inhibitor hold that prevents euglycemic ketoacidosis. It then turns to antithrombotics, weighing procedural bleeding risk against the patient's clotting risk. That means warfarin holds and the near end of bridging, direct oral anticoagulant holds, stent timing and antiplatelet drugs, and finally reversal by drug.

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2. 02

   Endoscopy Practice and Sedation: The Sedation Plan

   Sedation planning starts with the patient's risk, not the drug. A man with COPD, poorly controlled diabetes, and a BMI of 42 is booked for EUS with fine-needle aspiration, and his case drives the episode. First the ASA class frames his risk. Then the defined depths of sedation show what he means by wanting to be completely out, and why the team must rescue one level deeper. Next comes midazolam with fentanyl, its dosing, and why it suits healthier patients. Propofol follows, with its advantages, its lack of an antagonist, and who should give it. Short cases then place etomidate, ketamine, and dexmedetomidine, before the common board traps.

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3. 03

   Endoscopy Practice and Sedation: Safe Sedation

   Safe sedation depends on catching apnea early and on knowing which patients change the standard plan. The episode starts with a colonoscopy patient whose capnography goes flat while her saturation looks normal. It then covers airway prediction with Mallampati class and other markers, full-stomach precautions, titrated naloxone, and flumazenil, including who must never receive it and how long to keep monitoring after reversal. Four more patients follow: a man with cirrhosis, an older woman living alone, a man with sleep apnea, and a pregnant woman needing urgent ERCP. The episode closes with the board traps and a start-to-finish summary.

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4. 04

   Endoscopy Practice and Sedation: Hardware and Harm

   The episode is built on one idea: decisions follow the procedure or the event, not the label on the patient. A prosthetic valve, joint, pacemaker, or defibrillator does not by itself call for antibiotics, which are reserved for procedures that introduce bacteria into a closed space that cannot drain. The first case then covers electrosurgery, with the grounding pad kept away from a pacemaker and detection suspended and restored for an ICD. The second case turns to capsule endoscopy: modern cardiac devices are not a barrier, retention is the real risk, and a patency capsule or enterography comes first in high-risk patients. It ends with ASGE grading of adverse events by what they required.

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Key topics

• ·Fasting windows and full stomach
• ·Pregnancy testing before endoscopy
• ·GLP-1 agonist risk stratification
• ·SGLT-2 inhibitors and euglycemic ketoacidosis
• ·Procedure bleeding risk categories
• ·Thromboembolic risk groups
• ·Warfarin hold, INR check, and restart
• ·Why bridging has narrowed
• ·Direct oral anticoagulant holds
• ·Coronary stents and antiplatelet drugs
• ·Reversal of anticoagulants
• ·ASA physical status classes
• ·Minimal, moderate, deep sedation, and general anesthesia
• ·Rescue one level deeper
• ·Midazolam and fentanyl dosing
• ·Respiratory synergy and capnography
• ·Propofol indications and dosing
• ·Propofol hazards and who gives it
• ·Etomidate in unstable patients
• ·Ketamine and dexmedetomidine
• ·Board traps in sedation
• ·Capnography versus pulse oximetry
• ·Rescuing a patient from deeper sedation
• ·Predicting the difficult airway
• ·Full-stomach and aspiration risk
• ·Naloxone dosing and monitoring
• ·Flumazenil dosing and contraindications
• ·Sedation in cirrhosis
• ·Sedation in patients over sixty-five
• ·Sedation in sleep apnea