What precautions and medications are recommended for the Sesame procedure?

Precautions and Medications for the SESAME Procedure

For patients undergoing the SESAME (Septal Scoring Along the Midline Endocardium) procedure, GLP-1 receptor agonists should be withheld for at least three half-lives prior to the procedure, and standard pre-procedural fasting guidelines should be followed to minimize aspiration risk. 1

Pre-Procedure Assessment and Preparation

Patient Evaluation

• Complete focused history including:
  • Medication history (especially anticoagulants, GLP-1 receptor agonists)
  • Food and drug allergies
  • Relevant diseases and physical abnormalities
  • Previous sedation/anesthesia experiences and complications
  • For females of childbearing age: pregnancy status 1

Airway Assessment

• Evaluate for potential difficult airway using Mallampati score
• Identify risk factors: obesity, short thick neck, cervical spine disease, structural abnormalities of mouth/jaw 1

Medication Management

1. GLP-1 Receptor Agonists (Semaglutide, etc.)

   • Withhold for at least three half-lives before procedure (e.g., 3 weeks for semaglutide)
   • For patients with diabetes, consult endocrinologist regarding:
     • Risk/benefit of holding medication
     • Alternative glycemic management during this period 1

2. Other Medications

   • Routine necessary medications may be taken with a sip of clear liquid 1

Fasting Guidelines

Follow standard pre-procedural fasting guidelines:

• Clear liquids: 2 hours
• Human milk: 4 hours
• Infant formula: 6 hours
• Non-human milk: 6 hours
• Light meal: 6 hours 1

Procedural Medications and Monitoring

Sedation Medications

Select appropriate agents based on procedure duration and patient characteristics:

• Moderate Sedation: Benzodiazepines (midazolam) + opioids (fentanyl)
• Deep Sedation: Propofol, etomidate, or ketamine
• Local Anesthesia: For access site 1

Prophylactic Antibiotics

• Cefazolin 1-2g IV administered 30-60 minutes before procedure start
• For lengthy procedures: Additional 500mg-1g during procedure
• Continue 500mg-1g every 6-8 hours for 24 hours post-procedure 2

Required Monitoring

• Continuous pulse oximetry
• Electrocardiogram
• Non-invasive blood pressure (every 5 minutes)
• Respiratory rate
• Level of consciousness
• Consider capnography for deeper sedation 1

During Procedure

Specific SESAME Considerations

• Use carbon dioxide insufflation instead of air to minimize luminal distension and post-procedural pain 1
• For complex cases, consider fluoroscopic guidance 1
• Maintain wire-guided or endoscopically controlled techniques to enhance safety 1

Sedation Management

• Titrate sedatives to desired level of sedation
• Maintain patient's ability to respond purposefully to verbal or tactile stimulation
• Have reversal agents readily available (naloxone, flumazenil) 1

Post-Procedure Care

Recovery and Monitoring

• Monitor for at least 2 hours in recovery room
• Document vital signs until return to baseline
• Assess using standardized discharge criteria (e.g., Aldrete score ≥9) 1
• Ensure patient is tolerating oral fluids before discharge 1

Complication Surveillance

• Monitor for chest pain, fever, breathlessness, or tachycardia
• If symptoms develop, consider CT scan with oral contrast to evaluate for perforation 1
• Provide patients with contact information for on-call team 1

Discharge Instructions

• Provide clear written instructions on:
  • Diet progression
  • Activity limitations
  • Medication resumption (including when to restart GLP-1 agonists)
  • Signs/symptoms requiring immediate medical attention 1

Special Considerations

High-Risk Patients

For patients with increased aspiration risk:

• Consider prokinetic drugs (metoclopramide)
• Use point-of-care gastric ultrasound to assess gastric contents
• Consider rapid sequence intubation 1

Pediatric Patients

• Adjust medication dosages based on weight
• Consider additional monitoring requirements
• Ensure appropriate sized equipment is available 1

By following these comprehensive precautions and medication guidelines, the SESAME procedure can be performed safely while minimizing the risk of complications such as aspiration, sedation-related adverse events, and procedural complications.