YKHC Low-Risk Endoscopy Criteria

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OVERVIEW

Because YKHC has no ICU, serious endoscopy complications require transfer to the Emergency Department and/or Medevac transfer. Prevention of this occurrence is a priority. Therefore endoscopy in Bethel is limited to low risk patients.

The intention of this page is to provide transparent criteria for the most common conditions which increase the risk of an endoscopy complication. This page is not all-inclusive.

These criteria are written with isolated diagnoses in mind. The presence of multiple comorbidities may yield a higher risk than either individually and this effect is not incorporated into these criteria.

The intention of these criteria is to risk stratify based on the functional status of a disease rather than its mere mention in a patient's chart.

In unusual circumstances, exceptions to these criteria will be considered on a case-by-case basis and must be approved in advance by both the endoscopist and anesthetist.


GENERAL

BMI

  • BMI < 45 (non-negotiable limit)
- for BMI 40-45: anesthesia approval (for non-Bethel patients this should occur PRIOR to ordering)

Acute Illnesses

Patients should be at their baseline health status for outpatient endoscopy in Bethel.

Acute illness is a contraindication for Bethel endoscopy unless the illness is mild and does not involve the nasopharynx, gastrointestinal system, or cardiopulmonary system. Fever or acutely abnormal vital signs are a contraindication. Additionally, patients must be comfortable laying on their side and extending their neck.

Urgent inpatient procedures require discussion with and approval by the endoscopist and the anesthetist. It is accepted that these patients are not at their baseline, but the urgency of the condition frequently necessitates prompt performance of the procedure.

Acute Contraindications

  • Fever
  • Tachycardia
  • SBP > 180 or DBP > 110
  • Tachypnea
  • Dyspnea
  • Chest pain
  • Decompensated heart failure (pulmonary crackles, pedal edema, etc)
  • Significant rhinorhea or nasal congestion
  • Cough
  • Wheezing
  • Any infection requiring antibiotic treatment and for which symptoms have not completely resolved
  • Dizziness
  • Weakness
  • Mental status change


CARDIAC

CHF

  1. Most recent LVEF >= 40%
  2. Recent (<6mos) BNP <= 125 pg/mL (or YKHC laboratory’s current upper limit of normal)
  3. No loop diuretic use (chronic or acute) within the last 12 months
  4. No current or recent cardiac-like symptoms which have not been thoroughly investigated

CAD

  1. No Acute Coronary Syndrome within the last 12 months unless cleared by cardiology
  2. No coronary revascularization (either surgical or endovascular) within the last 12 months unless cleared by cardiology
  3. No use of anti-angina agents in the last 12 months
  4. Normal cardiac stress test within the last 12 months
  5. No current or recent cardiac-like symptoms which have not been thoroughly investigated

A-Fib

  1. Currently in sinus rythm
  2. No subjective or objective A-Fib occurrence within 12 months
  3. No use of anti-arrythmic drugs within 12 months
  4. Meets all of the "CHF" criteria above
  5. No current or recent cardiac-like symptoms which have not been thoroughly investigated


PULMONARY

Asthma

Prior to endoscopy (and preferably prior to the referral), asthma severity should be classified in accordance with the Guidelines for the Diagnosis and Management of Asthma (EPR-3).

Asthma Classification Resources:
- when the ACT is performed, please scan into the multimedia manager and reference it in the visit note

Endoscopy in Bethel is limited to only those asthma patients who meet the following criteria:

  • If treated, must meet criteria for Well Controlled asthma.
  • If UNtreated, must meet criteria for Intermittent asthma.


COPD

  • Post-bronchodilator FEV1 >= 60% of predicted
    - order as "PFT (Pre-&Post-Albuterol) Eval"
    - view results in Multimedial Manager —> EKG Folder

OSA

  • Positive pressure ventilation has NOT been recommended/prescribed
  • Anesthesia approval (for non-Bethel patients this should occur PRIOR to ordering)


MEDICATIONS

Antiplatelets and Anticoagulants

Endoscopy with simple biopsy is considered low risk for bleeding, therefore antiplatelets/anticoagulants usually do not require adjustment/cessation for EGD.

However, polypectomy is considered high risk for bleeding, therefore colonoscopy may require antiplatelet/anticoagulant adjustment or cessation. Antiplatelet/anticoagulant management is a decision best made by the referring physician (possibly in consultation with a managing specialist and/or the anticipated endoscopist). Patients on antiplatelets/anticoagulants should not be referred prior to formulating (and documenting) a medication management plan. The referral order comment section should specify where to find the plan.

  • Aspirin[1]
    • Aspirin and NSAIDs can be continued safely during colonoscopy with polypectomy.
  • Thienopyridines[1]
    • Drugs in this class include: clopidogrel (Plavix), prasugrel (Effient), and ticlopidine (Ticlid).
    • Thienopyridines, either as a single agent or in combination with aspirin (dual anti-platelet therapy, a.k.a. DAPT), present a meaningful risk of a post-polypectomy bleed (approximately 2.4%). Additionally, the fact that many of our patients will return to a village means that delayed post-polypectomy bleeding (which can occur up to 2 weeks post-polypectomy) may have worse outcomes than those in the published literature (due to lack of easy access to intervention and/or transfusion).
    • DAPT is frequently used only for limited duration (i.e. 3-12 months) after an event (such as thromboembolic CVA) or procedure (such as coronary stent placement). Therefore serious consideration should be given to the urgency of the indication and the possibility of postponing the referral until the DAPT period is complete.
    • If there is strong rationale that colonoscopy will not involve polypectomy, then colonoscopy referral can be placed while on a thienopyridine or DAPT.
    • If the colonoscopy indication is truly urgent and the risk of thienopyridine discontinuation is unacceptably high, then the patient should be referred to Anchorage.
  • Warfarin[1]
    • Warfarin presents a substantial risk of post-polypectomy bleeding, whether stopped, bridged, or continued. If polypectomy is expected, these patients should be referred to Anchorage.




Opioid Replacement Therapy

  • _



References

  1. 1.0 1.1 1.2 Feagins LA. Colonoscopy, Polypectomy, and the Risk of Bleeding. Med Clin North Am. 2019 Jan;103(1):125-135. doi: 10.1016/j.mcna.2018.08.003