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cardiorespiratory functions are unaffected. In moderate sedation, previously referred to as “conscious sedation,” the patient has purposeful response to verbal or tactile stimuli, there is spontaneous ventilation, and cardiovascular function is maintained. In deep sedation, there is only purposeful response to painful stimuli, the airway may require support, but cardiovascular function is preserved. In general anesthesia, there is no response to painful stimuli, the airway frequently requires support, and cardiovascular function may be impaired [14].

      A careful review of patient's medical history, pertinent medications/drug allergies, and preoperative physical exam should be undertaken and documented. Certain medications (narcotics, benzodiazepines, anticoagulants, antiplatelet agents, alcohol, and illicit drugs) may impact the choice of sedatives and therapeutic maneuvers. Any medication allergies as well as any adverse events with sedation or anesthesia in the past should be noted. The timing of the last oral intake should be noted. The patient should undergo a focused physical exam measuring vital signs, auscultation of the heart and lungs, and performing an airway assessment. If the patient suffers from chronic abdominal pain, documentation of the active level of pain and location prior to initiation of procedure is recommended.

Table 3.2 ASA classification.

ASA 1: Healthy patient

ASA 2: Patient with well‐controlled mild systemic disease (HTN, DM) with minimal functional impairment

ASA 3: Patient with severe systemic disease with moderate functional impairment

ASA 4: Patient with severe systemic disease that is constant threat to life

ASA 5: A severely ill patient who is not expected to survive without an operation

ASA 6: A brain‐dead patient whose organs are being removed for donor allocation

      Prophylactic antibiotics should be used when indicated. PEG placement and endoscopy for gastrointestinal bleeding in a cirrhotic patient call for prophylactic antibiotics as these have been shown to decrease infectious complications and, in cirrhosis, decrease mortality. In most cases, antibiotics will not be indicated for prophylaxis against endocarditis or infection of implanted devices [15]. The management plan regarding anticoagulants and antiplatelet medications should be specified, including if and when they are to be discontinued, for how long, and if stopped, when they should be resumed.

      Mandated use of electronic medical records provides instant access to lab work and previous endoscopies. It is important for the trainee to review these records systematically for important information that may alter the treatment plan. Prior endoscopic records provide key clues to anticipated needs and difficulty of the anticipated procedure. Diligent review of sedation dose, procedure difficulty, and location and type of abnormalities found allows for optimal procedure planning. For instance, if a large polyp was removed piecemeal and prior images suggest residual tissue, the endoscopist may already anticipate the need for specific therapies required and make appropriate adjustments.

      Lastly, there is an increasing mandate among institutions for a team pause in which the patient and named procedure are identified prior to the start of sedation. The purpose is to ensure that the proper patient is receiving the proper procedure and that all necessary equipment is available. Although there are no data supporting the benefit of the team pause in improving the quality of endoscopic procedures, the ASGE/ACG guidelines recommend it as a best clinical practice and a preprocedure quality measure [1]. Additionally, the team pause allows the GI provider to inform the team of any specific considerations required for the case. For example, if the procedure is being done for chronic diarrhea, the nursing staff is made aware of anticipated needs such as random colonic biopsies.

Intraprocedure

This period begins with the administration of sedation and extends to the end of the procedure when the scope is withdrawn (Table 3.3). An important consideration during this period is the appropriate documentation of care provided to the patient in the form of written intraprocedure record (sedation records) and photo documentation. During the procedure, important vital sign documentation should occur at intervals no greater than 5 minutes for pulse, oxygenation, and blood pressure. Photos should be taken to establish important landmarks were met for completion of exam. For example, a photo of cecal base or of the duodenum confirms the maximal depth of scope insertion was achieved. In addition to photos of important landmarks, care should be taken to photograph abnormalities found or therapies performed [1, 11, 14]. To improve the safety and efficacy of sedation, the use of reversal agents (flumazenil, naloxone) or discontinuation of propofol due to excessive sedation should be recorded. While data on reversal agents may be used for staff education and quality improvement, it should not be used to penalize physicians as this may cause reluctance to use these life‐saving medications.

Table 3.3 Intraprocedure quality indicators.

Patient monitoring	Vital signs (BP, pulse, oxygenation) recorded at least Q5 minutes
Medications	Dose, route, and timing of all medications used is recorded
Photodocumentation	Major landmarks and findings are photodocumented
Sedation reversal	Need to reverse sedation with naloxone, romazicon, or cessation of propofol due to oversedation is recorded

As previously stated, specific endoscopic procedures have specific quality indicators associated with their technical aspects.

      Training in endoscopy should also include a thorough familiarity with these indicators.

Postprocedure

This period extends from scope removal through patient discharge, referring provider communication and pathology follow‐up (Table 3.4). Each endoscopy unit should have an established policy regarding the criteria required before unit discharge. Detailed instructions should be provided to the patient, which address diet, activity, and medication restrictions. Patients should be provided a means of contacting the provider should questions or concerns arise. Finally, feedback to the patient regarding findings and therapies performed should be undertaken [1].

      Documentation of procedure

      Individual style practices aside, important documentation of the following should be included within each procedure report:

       Time, date of procedure

       Patient name and identifier

       Endoscopists and assistants

       Indication and informed consent

       Type of instrument

       Medication used including dosages

       Anatomic extent of procedure

       Findings

       Limitations or complications of procedure and interventions

       Tissue acquisition, use of instruments

       Diagnostic impression

       Results of therapeutic intervention

       Disposition

       Recommendations for subsequent care and follow‐up.

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