Endoscopy Practice and Sedation

• Audio chapter
  Attending-narrated, 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 standardized framework for recognizing and grading endoscopic adverse events across procedures and institutions.

Podcast episodes

1. 01

   Preproc Antithrombotic

   This episode covers pre-procedure preparation and periprocedural antithrombotic management: fasting, the grid of procedure bleeding risk against patient thromboembolic risk, warfarin and DOAC holds, the narrowing of bridging, antiplatelet management after coronary stenting, and reversal in active bleeding.

2. 02

   Sedation Depth and Agents

   This episode covers the depth-and-agent half of procedural sedation: the sedation continuum and ASA physical status that decide who needs anesthesia, midazolam plus fentanyl for the routine case versus propofol for the complex one, and the alternative agents, etomidate, ketamine, and dexmedetomidine, that handle the situations the standard pair cannot.

3. 03

   Sedation Monitoring and Special Populations

   This episode covers the safety apparatus that sits on top of the sedation agents: capnography and airway prediction, the naloxone and flumazenil reversals, the special-population modifications including cirrhosis, obstructive sleep apnea, the elderly, and pregnancy, and the updated GLP-1 periprocedural guidance of twenty-four hours of clear liquids.

4. 04

   Abx Devices Capsule Lexicon

   This episode covers antibiotic prophylaxis, device management, capsule endoscopy, and the adverse event lexicon: endocarditis prophylaxis is NOT given for GI endoscopy with narrow specific indications for procedural antibiotics, pacemakers and ICDs require electromagnetic interference management with monopolar cautery, capsule endoscopy contraindications...