Bedside Procedures for the Intensivist

Heidi L. L. Frankel and Bennett P. P. deBoisblanc (eds.)Bedside Procedures for the Intensivist10.1007/978-0-387-79830-1© Springer Science+Business Media, LLC 2010

Editors

Heidi L. L. Frankel and Bennett P. P. deBoisblanc

Bedside Procedures for the Intensivist

Editors

Heidi L. L. Frankel

Penn State Hershey Medical Center, Hershey, Pennsylvania, USA

Bennett P. P. deBoisblanc

Health Sciences Center, Louisiana State University, New Orleans, Louisiana, USA

ISBN 978-0-387-79829-5e-ISBN 978-0-387-79830-1

Springer New York Dordrecht Heidelberg London

Library of Congress Control Number: 2010930507

© Springer Science+Business Media, LLC 2010

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On December 25, 2008 while serving his second tour of duty, an a combat surgeon for the U.S. Army, Dr. John Pryor, JP, was felled by enemy fire. We are extraordinarily grateful to him for his many contributions in the field of trauma and critical care surgery and his accomplishments and spirit that lives on in all of us whose lives he touched. This book is but one of those accomplishments. We dedicate it this book to his wife, Carmella, and three children and to all of those who serve their country and profession so selflessly.

Preface

Since the establishment of the first intensive care unit (ICU) in 1953 by Danish anesthesiologist Bjorn Ibsen at Copenhagen’s university hospital, critical care medicine has evolved from a specialty focused primarily on mechanical ventilation of polio patients into a complex multidisciplinary specialty that provides care for a broad range of life-threatening medical and surgical problems. Dramatic technological advances in monitoring equipment and treatment modalities have improved the clinical outcomes for such patients. The miniaturization of microprocessors and the refinement of minimally invasive techniques have allowed many critical care procedures that were once performed in the operating room (OR) to now be performed at a patient’s bedside in the ICU.

This evolution towards performing procedures at the bedside instead of in the OR has had distinct advantages for both patients and hospitals. First, it avoids the potential hazards and manpower costs of having to transport a critically ill patient out of the ICU. Second, procedures do not have to be worked into a busy OR schedule; they can be performed when they are needed – immediately, if necessary. This saves OR time and expense. Finally, by their nature, bedside procedures are less invasive than the parent procedures that they replace and therefore are usually associated with less risk to the patient, e.g., transbronchial lung biopsy versus open lung biopsy.

All procedures undergo refinement as more and more operators gain experience with them. The idea for Bedside Critical Care Procedures was born out of the idea that there should be a how-to reference that consolidates the cumulative experience of expert proceduralists into a single pocket manual that students, residents, fellows, and staff intensivists of diverse training can reference. Within these pages, practitioners will find easy-to-read descriptions of all aspects of the performance of safe, efficient, and comfortable procedures in the ICU. Each chapter includes bulleted lists of needed supplies and equipment, patient preparation and positioning, and the step-by-step technique. Included are procedures performed with and without ultrasound guidance.

Heidi Frankel

Ben deBoisblanc

Division of Trauma Acute Care and Critical Care Surgery and Director Shock Trauma Center Penn State Milton S. Hershey Medical Center

Contents

1 General Considerations 1

Heidi L. Frankel and Mark E. Hamill

2 Conscious Sedation and Deep Sedation, Including Neuromuscular Blockade 19

Russell R. MillerIII

3 Airway Management 37

Patricia Reinhard and Irene P. Osborn

4 Ultrasound Physics and Equipment 57

Sarah B. Murthi, Mary Ferguson and Amy C. Sisley

5 Ultrasound-Guided Vascular Access Procedures 81

Christian H. Butcher and Alexander B. Levitov

6 Ultrasound-Guided Drainage Procedures for the Intensivist 113

Kathryn M. Tchorz

7 Focused Echocardiography in the ICU 139

Steven A. Conrad

8 Procedures in Critical Care: Dialysis and Apheresis 183

Matthew J. Diamond and Harold M. Szerlip

9 Pericardiocentesis 205

James Parker and Murtuza J. Ali

10 Bedside Insertion of Vena Cava Filters in the Intensive Care Unit 217

A. Britton Christmas and Ronald F. Sing

11 Percutaneous Dilational Tracheostomy 233

Bennett P. de Boisblanc

12 Open Tracheostomy 247

Adam M. Shiroff and John P. Pryor

13 Transbronchial Biopsy in the Intensive Care Unit 255

Erik E. Folch, Chirag Choudhary, Sonali Vadi and Atul C. Mehta

14 Percutaneous Endoscopic Gastrostomy 275

Jennifer Lang and Shahid Shafi

15 Chest Drainage 287

Gabriel T. Bosslet and Praveen N. Mathur

16 Intracranial Monitoring 307

R. Morgan Stuart, Christopher Madden, Albert Lee and Stephan A. Mayer

17 Billing for Bedside Procedures 323

Marc J. Shapiro and Mark M. Melendez

Index333

Contributors

Murtuza J. Ali

Assistant Professor, Department of Internal Medicine, Section of Cardiology, Louisiana State University School of Medicine, New Orleans, LA, USA

Gabriel T. Bosslet

Fellow, Departments of Pulmonary and Critical Care Medicine, Indiana University, Indianapolis, IN, USA

Christian H. Butcher

Staff Pulmonary and Critical Care Physician and Assistant Program Director, Department of Medicine, Carilion Clinic and Virginia Tech Carilion School of Medicine, Roanoke, VA, USA

Chirag Choudhary

Clinical Associate, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA

A. Britton Christmas

Attending Surgeon Trauma, Critical Care, and Acute Care Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA

Steven A. Conrad

Professor, Department of Medicine, Emergency Medicine, Pediatrics and Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, LA, USA

Bennett P. de Boisblanc

Professor of Medicine and Physiology, Section of Pulmonary/Critical Care Medicine, Louisiana State University Health Sciences Center, New Orleans, LA, USA

Matthew J. Diamond

Assistant Professor, Department of Hypertension and Transplant Medicine, Section of Nephrology, Medical College of Georgia, Augusta, GA, USA

Mary Ferguson

Supervisor of Adult Echocardiography, Departments of Medicine and Surgery, University of Maryland Medical Center, Baltimore, MD, USA

Erik E. Folch

Fellow, Interventional Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA

Heidi L. Frankel

Chief, Division of Trauma Acute Care and Critical Care Surgery and Director, Shock Trauma Center, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA

Mark E. Hamill

Assistant Professor of Surgery, Department of Surgery, State University of New York Upstate Medical University, Syracuse, NY, USA

Jennifer Lang

Resident, Department of Surgery, UT Southwestern Medical Center, Dallas, TX, USA

Albert Lee

Department of Neurosurgery, UT Southwestern, Dallas, TX, USA

Alexander B. Levitov

ICU Director, Departments of Pulmonary and Critical Care Medicine, Carilion Clinic, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA

Christopher Madden

Associate Professor, Department of Neurological Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA

Praveen N. Mathur

Professor of Medicine, Departments of Pulmonary and Critical Care Medicine, Indiana University, Indianapolis, IN, USA

Stephan A. Mayer

Director, Neurological Intensive Care Unit, Department of Neurology, Columbia New York Presbyterian Hospital, New York, NY, USA

Atul C. Mehta

Chief Medical Officer, Sheikh Khalifa Medical City managed by Cleveland Clinic, Abu Dhabi, United Arab Emirates

Mark M. Melendez

Chief Resident, Department of Surgery, Stony Brook University Medical Center, Stony Brook, NY, USA

Russell R. MillerIII

Medical Director, Respiratory ICU, Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT, USA

Department of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT, USA

Sarah B. Murthi

Surgical Critical Care Attending and Assistant Professor of Surgery, Department of Surgery, University of Maryland Medical Center, Baltimore, MD, USA

Irene P. Osborn

Director of Neuroanesthesia, Department of Anesthesiology, Mount Sinai Medical Center, New York, NY, USA

James Parker

Fellow, Section of Cardiology, Department of Internal Medicine, Louisiana State University School of Medicine, New Orleans, LA, USA

John P. Pryor

Assistant Professor of Surgery and Trauma Program Directory, Division of Traumatology and Surgical Critical Care, Department of Surgery, University of Pennsylvania School of Medicine and University of Pennsylvania Medical Center, Philadelphia, PA, USA

Patricia Reinhard

Attending Anesthesiologist, Munich, Germany

Shahid Shafi

Staff Surgeon, Department of Surgery, Baylor Health Care System, Grapevine, TX, USA

Marc J. Shapiro

Professor of Surgery and Anesthesiology and Chief, General Surgery, Trauma, Critical Care and Burns, Department of Surgery, SUNY – Stony Brook University and Medical Center, Stony Brook, NY, USA

Adam M. Shiroff

Fellow, Department of Trauma and Surgical Care, University of Pennsylvania and Hospital of the University of Pennsylvania, Philadelphia, PA, USA

Ronald F. Sing

Trauma Surgeon, Department of General Surgery, Carolinas HealthCare System, Charlotte, NC, USA

Amy C. Sisley

Section Chief, Emergency General Surgery, Department of Trauma and Critical Care, R. Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD, USA

R. Morgan Stuart

Neurosurgeon, Department of Neurosurgery, Columbia University Medical Center, New York, NY, USA

Harold M. Szerlip

Vice-Chairman, Section of Nephrology, Department of Hypertension and Transplant Medicine, Medical College of Georgia, Augusta, GA, USA

Kathryn M. Tchorz

Associate Professor, Department of Surgery, Wright State University – Boonshoft School of Medicine, Dayton, OH, USA

Sonali Vadi

Department of Internal Medicine, Maryland General Hospital, Baltimore, MD, USA

Heidi L. Frankel and Bennett P. deBoisblanc (eds.)Bedside Procedures for the Intensivist10.1007/978-0-387-79830-1_1© Springer Science+Business Media, LLC 2010

1. General Considerations

Heidi L. Frankel¹   and Mark E. Hamill

(1)

Division of Trauma Acute Care and Critical Care Surgery, Shock Trauma Center, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA

Heidi L. Frankel

Email: [email protected]

Abstract

As ICU patient volume and acuity increase, there has been a parallel growth in the use of technology to assist in management. Several issues must be considered when determining where and how to perform certain procedures in critically ill and injured patients. Much forethought and planning are required to establish a successful intensive care unit (ICU)-based procedural environment – from concerns regarding the availability and reliability of pertinent equipment to more complex issues of acquiring competency and pursuing credentialing. It is essential to pay adequate attention to these general ­considerations to ensure that ICU-based procedures are accomplished with equivalent safety and results as those performed in more traditional settings.

Introduction

As ICU patient volume and acuity increase, there has been a parallel growth in the use of technology to assist in management. Several issues must be considered when determining where and how to perform certain procedures in critically ill and injured patients. Much forethought and planning are required to establish a successful intensive care unit (ICU)-based procedural environment – from concerns regarding the availability and reliability of pertinent equipment to more complex issues of acquiring competency and pursuing credentialing. It is essential to pay adequate attention to these general ­considerations to ensure that ICU-based procedures are accomplished with equivalent safety and results as those performed in more traditional settings.

Why Perform Bedside Procedures

Shifting the venue of procedure performance into the ICU from the operating room, interventional radiology, or gastroenterology suite may benefit the patient, the unit staff, and the hospital in general. In the ­ensuing chapters, we will demonstrate that procedures as diverse as open ­tracheostomy and image-guided inferior vena cava insertion can be performed in the ICU setting with equivalent safety and lower cost. For example, Grover and colleagues demonstrated that an open tracheostomy performed in the ICU resulted in a cost savings of over $2,000 compared to a similar procedure performed in the operating room.1 Upadhay noted that elective tracheostomy can be performed as safely in the ICU as in an operating room (complication rates of 8.7% vs. 9.4%, p=NS).2 In fact, with the increased availability of ultrasound guidance for procedures such as thoracentesis and central venous catheter placement, it is possible to both improve the success and decrease the complication rate of procedures.3,4 Moreover, it is apparent that a well-trained intensivist can perform a variety of bedside procedures with minimal focused training that can be acquired at such venues as the Society of Critical Care Medicine’s annual Congress.5 Some skills, such as open tracheostomy and performance of focused bedside echocardiography may require additional training and experience.6,7 Multiple groups have suggested training guidelines to ensure accurate and reproducible exams.8 – 10 Nonetheless, it is apparent that ICU practitioners from diverse backgrounds – be they pulmonary critical care, anesthesiology, surgery, or pediatrics – are able to perform a host of bedside procedures safely and competently after adequate training.11

Bedside performance of procedures diminishes the need to transport complex patients and incur adverse events. Indeck stated that, on an average, three personnel were required to supervise each trip out of the ICU for diagnostic imaging with two-thirds of the patients suffering serious physiologic sequelae during the transport.12 In another study, a significant number of patients experienced a ventilator-related problem during ­transport, leading to two episodes of cardiac arrest in 123 transports.13

The benefits of avoiding transport must be balanced with the additional requirements placed upon the bedside ICU nurse to assist in the performance of the procedure. At our institution, we have created an additional float/procedural nurse position during daytime hours to assist in this role. Moreover, even though we have eliminated many transports from the ICU by performing bedside procedures, there are still many instances of travel for our patients. Finally, to assist the intensivist to perform some of these bedside procedures, we often move the patient from his ICU bed onto a narrower gurney, making it easier for the intensivist to be properly positioned. Alternatively, the so-called cardiac chair used in many ICUs can be flattened out to accomplish this end.

Some facilities are expanding the availability of procedures undertaken at the bedside in the ICU in an effort to streamline their ability to take care of their patients in an expeditious and safe manner.14 Simpson found that after the introduction of bedside percutaneous tracheostomy, the percentage of patients receiving tracheostomies doubled (8.5–16.8%, p < 0.01) and the amount of time from ICU admission to tracheostomy was cut in half (median of 8 to 4 days, P = −0.016).15 Limitations in scheduled time slots in the operating room, endoscopy suite, or interventional radiology suite have also pushed some centers to expand the use of bedside procedures in an effort to expedite patient care.

Equipment

Ultrasound

Many of the procedures discussed later in this text use ultrasound guidance. Ultrasound technology has advanced dramatically over the past several years, with economical portable or hand-held units now ­providing many of the same capabilities formally found only on expensive, full-sized units. The availability of portable ultrasound has dramatically increased the placement success of peripherally inserted central venous catheters (PICC).16 Portable and hand-held ultrasound units can also provide valuable clinical information regarding volume status and cardiac function in high acuity populations.7, 17 Ultrasound devices have proved useful in a variety of image-guided ICU procedures, ranging from thoracentesis to placement of central venous catheters and inferior vena cava filters, to drainage of abscesses in multiple locations.18 The features available on different portable and hand-held units range from simple 2D imaging with single-frequency transducers to units with advanced cardiology packages and Doppler imaging with the availability of multiple, interchangeable transducers. The specific features of different units can vary dramatically. However, with the rapid advancement of technology, even portable lap-top style units are now available with interchangeable transducers in both lower frequency probes (suitable for abdominal imaging and procedure guidance) as well as higher frequency models (with increased image resolution at the expense of tissue penetration). In our institution, we have two units available in the ICU: a small, extremely portable unit with a fixed transducer used solely for the guidance of vascular access, as well as a more robust lap-top style unit with interchangeable transducers that functions in a variety of roles including focused echocardiography. Both units are dedicated to our surgical ICU; however, in a lower volume center, it might be possible to share the units between different procedure areas to limit cost.

Procedure Kits

In order to ensure a successful ICU bedside procedure environment, it is vital to guarantee the immediate availability of required supplies and instruments. Many common procedures utilize all-inclusive commercially available kits (e.g., for central venous catheter placement and percutaneous tracheostomy insertion). These kits can be further customized to include drapes, gowns, caps, and masks, so that the only additional component necessary is the provider’s gloves. This customization can dramatically improve compliance with maximal barrier precautions and can lower iatrogenic infection rates. Figure 1-1 demonstrates the contents of our customized central catheter insertion kit. We believe that this customized kit obviates the need for a dedicated line cart that is referenced in the literature.19 However, kit contents can vary from one manufacturer to another; so, prior to use, the available components should be evaluated.

Figure 1-1.

Customized central line kit components at Parkland Memorial Hospital.

Generic Procedure Cart

At our institution, we have developed a self-contained cart to assist in the performance of a variety of procedures including open tracheostomy, open abdominal washout, and chest tube insertion. We have customized our instrument kits to ensure that all necessary components are present without redundancy. The cart is restocked by our team of nurse practitioners assisted by the bedside nurses. Mounted to the top of the cart are both a small headlight and an electrocautery. Table 1-1 lists the contents by drawer; Fig. 1-2 illustrates the cart. Although there are many ­medical manufacturers of such carts, it is also possible to utilize a commercially available tool chest at a substantial cost savings. The cart should be locked or stored in a secure location that can be readily accessed in case of emergency.

Table 1-1.

Contents of the generic procedure cart of the surgical intensive care Unit at Parkland Memorial Hospital.

Figure 1-2.

Procedure cart at Parkland Memorial Hospital with drawers labeled.

Endoscopy Cart

It must be determined who will own and service the equipment prior to embarking upon an ICU-based endoscopy program. Ideally, a central entity in the hospital would purchase, house, and service all endoscopes and would offer 24-h availability. In many institutions this is not the case. At our institution, although we have purchased our own bronchoscope, GI endoscope, and tower, we have partnered with both the operating room and the gastroenterology suite to take advantage of resources and expertise and to minimize costs to the ICU. Endoscopes are very expensive and finicky; improper handling and cleaning can result in the transmission of disease and the breaking of equipment. Regardless of where endoscopes are housed and cleaned, we would recommend that a service contract be maintained to handle unavoidable endoscope damage that occurs in the ICU setting. To ensure rapid availability of endoscopy equipment at the bedside, mobile endoscopy towers should be employed. These carts should be stocked with all necessary video imaging equipment as well as replacement endoscope valves, tubing, and bite blocks.

Fluoroscopy

Procedures that utilize fluoroscopy for imaging may require a separate procedure area to store bulky radiologic equipment and to shield or minimize the radiation exposure of those not involved.

Centralized Procedure Areas

Some hospitals have set aside specific procedure areas in their ICUs. While the use of these areas requires patient transport within the ICU, it does provide several advantages. First, a separate ICU procedure area allows for a more controlled environment, reduced traffic, and fewer breaches of sterile areas. In addition, centralized procedure areas may help minimize disruptions in the ICU routine for other patients and families while the procedures are in progress. Finally, use of such a strategy may allow for centralized storage of procedure-specific items.

If space constraints prevent the use of a separate procedure room, most ICU procedures may be performed at the bedside. A few specific details must be kept in mind before deciding to perform a procedure at the bedside: First, depending on the physical setup of the ICU, it might be necessary to limit visitors to either the immediately surrounding patients or possibly the entire unit while an ICU-based procedure is underway. This may be necessary both to ensure that a sterile field can be maintained as well as to provide some measure of privacy. Secondly, there must be adequate means to separate the procedure area from the rest of the ICU. This is necessary both to minimize distractions and disruptions while the procedure is being performed and maintain a sterile procedure field. While some units may provide adequate separation by virtue of physical barriers, others may use simple curtains or mobile partitions. Finally, several of the procedures discussed in later chapters involve some degree of radiation exposure. As long as adequate spacing is provided between the C-arm of an X-ray machine nearby patients and staff and as long as standard protective equipment is utilized, exposure risk from fluoroscopic-guided procedures is small.20 Certainly, prior to embarking on a protocol of fluoroscopically guided procedures, the institution’s radiation safety personnel should be involved to ensure that appropriate safety measures are being applied.

Personnel And Credentialing

Credentialing for providers who perform ICU-based procedures should follow the same principles that the institution applies to practitioners who perform these procedures elsewhere. Application of guidelines established by the Society of Critical Care Medicine (SCCM) for Granting Privileges for the Performance of Procedures in Critically Ill Patients may be helpful.5 In addition, once privileges have been granted, a mechanism must be easily available to verify privilege status at the areas where the procedures will be performed (i.e., electronically). Quality assurance and improvement mechanisms must also be put in place, along with an appeals process for any denials or revocations of privileges.

A variety of pathways should be made available for initial ­credentialing. In general, privileges should be granted based on a training pathway (i.e., competency by virtue of graduate medical education or continuing medical education), a practice pathway (i.e., competency inferred from credentials granted at other institutions or in other hospital areas outside the ICU), or an examination pathway (i.e., competency demonstrated by examination and demonstrated performance). Following initial privileging, maintenance of certification should be subjected to demonstration of continuing experience as well as participation in quality assurance and improvement mechanisms to ensure acceptable outcomes.

Various societies and boards are presently at work to further describe the components of successful maintenance of certification.21 Several procedures associated with relatively steep learning curves, such as the insertion of intracranial pressure monitors and bedside ultrasonography, may require more specific guidelines to ensure competency. Training curricula for the use of ultrasound in critical care have been proposed, requiring a specific number of proctored exams to demonstrate competency.22 Considering ventriculostomy placement, performance outside the realm of neurosurgical practice would require extensive training with monitored procedures until competency has been established. Percutaneous airway techniques, which can certainly be performed by nonsurgeons, require the ability to immediately convert to an open procedure in an urgent fashion. If these techniques are to be used outside the surgical realm, advance arrangements should be in place to ensure the immediate availability of surgical back up should it be required.

A recent review of privileging practices in community hospitals revealed that strict adherence to the SCCM guidelines is not always observed.23 Most small hospitals used an inclusive rather than an exclusive privileging process. Many do not distinguish ICU admission privileges from procedure privileges. Finally, most small community hospitals do not require documentation of previous or direct observation of current successful procedure performance before granting privileges. These less stringent requirements likely reflect the realities of the local or regional practice of medicine. However, due to the high acuity of patients involved, more stringent privileging practices may be recommended. The use of actual numbers as a benchmark for competency is very controversial, although many hospitals are actively pursuing credentialing language that incorporates this concept. On the other hand, Sloan and colleagues found no consistent relationship between more stringent credentialing practices and improved outcome.24 Indeed, the successful acquisition of procedural skills in medicine is a complex issue. The adage of see one, do one, teach one with the assumption of competency is not valid today.25 Even in areas such as endoscopy where a national society does make specific recommendations for procedure numbers for credentialing, Sharma and Eisen found that most centers do not follow the recommendations when considering the credentialing of individual providers.26, 27

Nursing and support staff members also require education regarding proper conduct around and safety concerns regarding ICU bedside procedures. It is essential that all ICU staff members involved are familiar with the nuances of the procedure. While some aspects, such as the administration of adequate procedural sedation, should be commonplace for the ICU staff, in other areas these practices would be considered unusual. Prior to assisting in new procedures, adequate in-service training is essential. A period of observation in specialty areas is advisable if staff members do not have prior experience. For low-volume units, periodic retraining of support personnel is necessary to ensure staff familiarity with the details of each procedure. ICU bedside nurses should play an important role in development of local institutional policies governing bedside procedures. For example, due to the small size of ICU rooms at our institution, it is very difficult to access a patient’s arms and torso during performance of certain bedside procedures. To overcome this obstacle, our nurses have developed practice guidelines for the administration of conscious sedation through intravenous lines placed in the foot.

Considerations For The Actual Procedure

There are several general considerations applicable to all procedures. These include the use of sedation, adequacy of intravenous access, preprocedure preparation, and intraprocedure monitoring to maximize patient safety.

Conscious sedation is an important consideration for most bedside ICU procedures and will be discussed in detail in an upcoming chapter. ­Specific guidelines for sedation, analgesia, and monitoring have been established by a number of national societies including the American Society of Anesthesiologists (ASA), the American Academy of Pediatrics, and the Association of Operating Room Nurses.28 While guidelines for the use of sedatives and analgesics for specific procedures are beyond the scope of this chapter, several general principles are important to note. Foremost, to ensure patient safety during the procedure, all procedures should have at least one care provider assigned specifically to administer sedatives and analgesics and to monitor the patient’s physiologic response. For conscious sedation involving stable patients, this task is easily be accomplished by appropriately trained nursing staff; however, for either deeper levels of sedation or with hemodynamically unstable patients, this task may need to be delegated to an appropriately trained physician not otherwise involved with the procedure. When a patient does not already have an adequate artificial airway, advanced airway equipment must be immediately available both during and postprocedure.29

Another important area is the status of the patient’s oral intake prior to the procedure. While tradition may dictate that all patients be made nil per os from midnight on the day of the procedure, this practice has been reexamined by a number of different groups over recent years. A recent Cochrane review demonstrated that, compared to usual fasting practices, a less restrictive fasting policy in adults was associated with similar risks of aspiration, regurgitation, and related morbidity.30 A similar