What should I learn about endoscopy?

Essential Knowledge and Skills for Endoscopy Training

For optimal patient outcomes in endoscopy, training should focus on airway management, sedation principles, and technical skills, as these directly impact patient morbidity and mortality.

Airway Management and Patient Safety

• Understanding airway anatomy is critical, including the mouth, pharynx, hypopharynx, and nasopharynx, with knowledge of the modified Mallampati classification to predict intubation difficulty 1
• Learn to recognize clinical signs of apnea (absence of chest wall movement, no air movement at mouth) and airway obstruction (snoring, laryngospasm, paradoxical chest movement) 1
• Master airway management techniques including head-tilt maneuver, chin-lift/jaw-thrust, placement of nasopharyngeal and oropharyngeal airways, and bag-mask ventilation 1
• Identify patients at increased risk for pulmonary aspiration (active GI bleeding, achalasia, bowel obstruction, delayed gastric emptying) 1
• Complete Advanced Cardiac Life Support (ACLS) certification, including recognition and management of arrhythmias 1

Sedation Management

• Understand pharmacology of sedative medications, including midazolam, which is 3-4 times more potent per mg than diazepam 2
• Recognize that midazolam's onset of sedative effects occurs within 3-5 minutes after IV injection, with peak effect requiring adequate time between doses to prevent oversedation 2
• Learn proper dosing and administration of reversal agents (naloxone, flumazenil) 1
• Appreciate that combining benzodiazepines with opioids creates synergistic, not just additive, effects that increase cardiorespiratory risks 1
• Understand that sedation is a continuum; patients can easily move from light to deep sedation with potential loss of protective reflexes 2

Physiologic Monitoring

• Master continuous monitoring of respiratory and cardiac function using pulse oximetry 2
• Consider capnography in cases targeting deep sedation or when direct observation of respiratory activity is difficult 1
• Learn to interpret capnography readings to detect early signs of respiratory compromise 1
• Understand the relationship between hypoxemia and impaired ventilation, with and without supplemental oxygen 1
• Recognize that monitoring must continue into the recovery area 1

Technical Skills and Anatomical Knowledge

• Develop manual dexterity through simulation training before performing procedures on patients 1, 3
• Master bimanual techniques (handling endoscope in one hand and instruments in the other) 1
• Understand anatomical orientation from different perspectives (endoscopic vs. microscopic views) 1
• Learn to recognize normal anatomy and common anatomical variations 1
• Understand principles of electrosurgery for cutting, coagulation, desiccation, and fulguration during endoscopic procedures 4

Special Considerations

Pregnancy

• Know indications for endoscopy during pregnancy (significant GI bleeding, severe refractory nausea/vomiting/abdominal pain, dysphagia, suspected colonic mass, biliary pancreatitis) 1
• Understand trimester-specific approaches, with delay until second trimester when possible 1
• Learn proper patient positioning (left pelvic tilt or left lateral position) to avoid vena caval or aortic compression 1
• Know which medications are safe during pregnancy based on FDA categories 1

Appropriate Use of Endoscopy

• Recognize that overuse of endoscopy is common, with approximately 30% of procedures having questionable indications 1
• Learn to identify appropriate indications for endoscopy to avoid unnecessary procedures 1
• Understand that unindicated procedures are less likely to yield clinically relevant information while still carrying the same risks 1
• Develop risk stratification skills to select appropriate patients for screening and surveillance 1

Common Complications and Prevention

• Recognize that perforation and hemorrhage are major procedural complications 5
• Understand medication-related complications, including respiratory depression from sedatives 1, 2
• Learn to identify patients at higher risk for complications (ASA Physical Status 4 or greater, elderly, those with heart disease, severe lung disease, liver failure) 1
• Know that having immediate availability of resuscitative drugs and appropriate equipment is essential 2

Assessment of Competence

• Demonstrate proficiency through simulation training before performing procedures on patients 3
• Complete ACLS certification and examinations covering aspects not addressed by ACLS 1
• Show ability to prevent aspiration, assess airway risk, and manage airway compromise promptly 1
• Master interpretation of physiologic monitoring data and recovery assessment 1
• Develop technical skills through a structured curriculum with defined proficiency levels 3