Chapter 28, Ep 1 of 4: Fasting and Periprocedural Antithrombotics

Episode one of the Endoscopy Practice and Sedation chapter frames the morning of the procedure around two preventable disasters: aspiration and thromboembolism. The organizing idea is that fasting intervals are gastric-emptying kinetics on a clock, and every anticoagulant decision sits at the intersection of procedure bleeding risk and patient thromboembolic risk. That grid tells you who holds, who continues, and who bridges. A single asymmetry runs the antiplatelet decisions: an unrecognized stent thrombosis dwarfs endoscopically manageable bleeding, which is why aspirin usually stays on. Reversal closes the loop, each agent matched to its target.   Topics covered Fasting intervals and delayed-emptying exceptions GLP-1 receptor agonists and aspiration risk Procedure bleeding risk versus patient thromboembolic risk Warfarin holds and morning-of INR DOAC holds scaled to half-life and kidney function The narrowing of bridging Antiplatelet management after coronary stenting Reversal agents in active bleeding     Key decisions Follow the two-two-six-eight fasting rule for all sedation depths: clear liquids to two hours, breast milk to four, formula or a light meal to six, a fatty or heavy meal to eight. For elevated-risk GLP-1 patients (active GI symptoms, dose escalation, weekly dosing), give a clear liquid diet for at least twenty-four hours before the procedure while continuing the drug, rather than a reflex hold. Hold warfarin five days before a high-bleeding-risk procedure and confirm an INR below one and a half the morning of, because prothrombin's roughly sixty-hour half-life is the rate-limiting factor. Hold apixaban and rivaroxaban one to two days for low-risk and two to three days for high-risk procedures; extend dabigatran holds as creatinine clearance falls since it is renally cleared. Reserve bridging for high-thromboembolic-risk patients only (mechanical mitral valve, recent stroke or TIA, prior clot on warfarin, recent VTE, severe thrombophilia), because trials showed no benefit and excess bleeding in lower strata. Defer elective procedures for thirty days after a bare-metal stent and six months after a drug-eluting stent, continuing aspirin throughout and using cangrelor as a true bridge when a procedure must proceed early. Reverse life-threatening warfarin bleeding with four-factor PCC plus vitamin K, dabigatran with idarucizumab or dialysis, and factor Xa inhibitors now with four-factor PCC since the decoy agent left the US market.     This is an AI-generated podcast, and some pronunciations may be imperfect. Thank you for your understanding, and we hope you enjoyed this content.   For the full chapter with MCQs, tables, and primary-guideline references, visit www.boardpearls.com.   Questions or feedback: [email protected]. (00:00) - Two preventable disasters: aspiration and thromboembolism (00:53) - The fasting rule and its exceptions (02:28) - GLP-1 agonists and the new risk-stratified guidance (03:45) - The grid: bleeding risk against thromboembolic risk (05:53) - Warfarin and DOAC holds (08:06) - Why bridging narrowed (09:54) - Antiplatelets and the stent-thrombosis asymmetry (12:42) - Reversal in active bleeding