I am currently working at a day case endoscopy unit, the two advances in endoscopy procedures I will be looking at are, scope guide and minimal sedation. I will be assessing patients at the day case endoscopy unit I currently work at by participating in procedures which use scope guide and minimal sedation. During this period, I will be emphasising at the improvements in the care and safety of patients, to see how these have improved quality of patient care and diagnose problems at ease.
Endoscopist, Nurses and Surgeon depend largely on advancement in technology for delivering enhanced patient care and ability to diagnose problems at ease. The application of computer-assisted image guidance technology to the Endoscopic surgical procedures allow creation of new methods to address the challenges by providing the needed 3-D imager that ultimately improves accuracy, efficiency and safety during procedures. (Daniel L Farkas et al 2008). Scope guide 3-D imager, is a non contact form which uses a low intensity magnetic field to display a real time 3 – dimension view of the position and orientation of the colon scope with the abdominal cavity by means of detromagnetic transmission coils built into the colonoscope insertion tube. 3 – D imager that ultimately improves accuracy, efficiency and safety during procedures (Daniel L. Farkas et al 2008). The scope guide 3 – D imager assist in identification of the correct combination of manoeuvres necessary to straighten out the loops once formed – Olympus 2008.
A consultant Endoscopist London UK commented about scope Guide 3 – D imager “when we started to develop the electromagnetic imaging technology for scope guide. I envisioned a system that would allow colonoscopist to feel as comfortable as a tourist – driving through the most unpredictable city with the assistance of a safety navigation system he commented “today scope guide does just that i.e. improving colonoscopy by providing a real time 3 dimensional display of colonoscope position and configuration, the endoscopist no longer need to rely on guess and feel to determine the orientation of an inserted scope, scope guide will change the why you see colonoscopy, 3 – D imager is an essential part of quality colonoscopy.
3 – D imager is able to show shape both from lateral and anterior view direction simultaneously in “split screen mode”. The use of this scope guide eliminates the hazard of radiation for patients, doctors, this makes the 3 – D imager ideal for daily clinical usage and for training purpose. (Yamamate (2008) and Koichin et al, (2008) both stated that is pain free colonoscopy possible? The greatest advantage of this new technology is that when using insufflators – air is an enemy.
The 3 – D imager gives easy visualization and manoeuvres and to orientate the scope along the colon. Easily it avon loops and whenever loops occurs straightening it on and takes less time unlike long time procedures.
3 – D imager couple with EVIS EXERA 11 260 series system delivers images in high definition. There are certain scopes that can be used with the 3 – D imager which deliver image on the scope guide monitor in three dimensional, which make it possible for the patient watches it on the screen. No sedation sometimes or individual sedation given, patient tolerate the procedure well with aid of the scope guide makes the procedure quicker, safer and comfortable for most patients.
The use of this 3 – D imager is done by attaching the cord from the guide monitor to the scope, which transmits a current to the scope and shows on the 3 – D imager monitor showing where the scope is, if there are loops in the colon, and serves as a guide to the endoscopist.
3 – D imager is safe and effective equipment for treatment of making colonoscopy less painful especially in patients with long colon or loopy colon, whereas procedures are abandoned most times when patients cannot tolerate it because it’s very painful and far fear of perforation.
Some of the producing real time 3D imager is that it is capable of producing real time 3D image display of position and orientation of the colonoscopy. The endoscopist no longer needs to rely on guess work or fluoroscopy to determine the configuration of an inserted scope. The Scope Guide 3-D imager uses a low intensity magnetic field to display a real time 3-dimension view of the position and orientation of the colon scope with the abdominal cavity by means of electromagnetic transmission coils built into the colonoscope insertion tube. The scope guide assist the endoscopist in the identification of the correct combination of manoeuvres necessary to straighten out the loops once formed – (Olympus, 2008)
It shows the correct ways to manoeuvres and straightens complex looping. It is completely safe for daily usage due to the electromagnetic transmission coils within the scope creates a low intensity magnetic field. It generally reduces pain during colonoscopy which enhance advance total cave of patient in today endoscopy procedures. It helps in giving quality care throughout the procedure for the patient, endoscopist and nurses, it eliminates the hazard of radiation from X-ray during colonoscopy, but with the 3 D imager scope guide, X-ray is no longer required.
It helps to reduces time during procedure by making complicated procedure easy, hence less lengthy procedure, it helps their ability in pain management of their painful. The scope guide can be dangerous if the cords are not well attached to the scope, which could give a false picture. The nurse plays an important role in the care of the patient before during and after 3 D imager scope guide is used.
In my unit all the advantage of scope guide demonstrated at Solna conference for all endoscopists in UK and Ireland can be seen practically every day since the colonoscopist started using the equipment. We have three procedure rooms running and the unit is having only one Scope Guide 3-D Imager. It is now a competitions between the endoscopist, as to who will use the equipment even when the procedure is not too difficult as some might claim but because it give them easy visualisation and manoeuvres and to orientate the scope along the colon. Easily they can avoid loops and whenever loop occurs straightening it on was very easy and takes less time unlike before when we do not have the equipment. All the noise and shout of pains by the patient during colonoscopy procedures has drastically reduced since the introduction of the equipment in the unit, and nurse’s job in the procedure room has become less stressful unlike before. When a patient requires the use of 3 D imager scope guide due to post hysterotory operation or very difficult previous colonoscopy because of looping, we care for them in the following way.
Initially the patient is admitted for an outpatient procedure and checked in, consented, during consenting the doctor will explain to the patient for the need of using the 3 D imager what difficulties involved in manoeuvring the scope and patient during the use of it, repositioning of the patient to get a good view and to minimise the looping if that why, hence the patient will sign the consent form (nursing and midwifery council 2008), British Society of Gastroenterology 1991, 2008) (BSG guidelines) sedation is given via intravenous (IV) route and if to give any emergency injection if need be. A nasal catheter sponge is also attached to the patient for oxygen administration.
The patient is given blue knickers for privacy and because of repositioning to prevent unnecessary exposure of patient (privacy and dignity). The patient is firstly positioned on the left lateral with knees bent towards the chest, meanwhile monitory if the oxygen saturation, pulse and blood pressure are checked throughout the procedure. The patient is talked through the procedures, informing the patient when to expect more pain when negotiating the flexures of the colon. The monitor of the scope guide cord is then attached to the scope to be used, and right setting done which brings on the light on monitor of the scope guide. Sedation and if possible muscle relencant i.e. antispasmodic or analgesic is administered through the intravenous route, everyone i.e. the doctor and nurses in the room will wear an apron, gloves and goggles (Health and Safety Executive 1992).
The Endoscopist will reconfirm from the nurse whether the constant the procedure, the scope guide must be checked and the cotside on the left hand side is let down and the flexible plate is placed near the patients stomach and to be sure no damage and plate well placed prior to start of procedure. The big movable plate should be put in right position and not on the chest or let (Aorn 2004). During the procedure the scope guide setting is changed as the patient is repositioned which should be visually seen on the monitor to give a right direction of the scope in the colon and monitored. The procedure time, the patient is observed and monitored for abdominal pain and possible sweating or vasovagal reactions. The pain level of the patient is assessed which will determine whether to top up the sedation , pain reliever or antispasmodic injections by the endoscopist, through the nurse in there is there as the patients advocate, the cardiac arrest trolley with the defibrillator should be accessible within easy reach (BSG 2003).
Post care of the patient should be monitored for severe abdominal pain caused by 3 D – imager (Malick 2006). The patient will be wheeled on the trolley to the recovery ward and continuous monitory of the observations and vital signs for any of the complication must be recorded and documented. During the consenting time, the patient must have been provided with verbal and written instructions emphasising on observations for severe pain and bleeding (in case of perforation), if any unexpected symptoms arise, they should go to accident and emergency immediately (Norton et al 2008).
In the endoscopy unit where I work, 3 D – imager scope guide was implemented late last year, through it’s a new technology its own. This initially course some problems because some of the medical team I work with, some will say leave the cortside up, some say let it down because of the insufficient training on the use of the imager. Even on repositioning the patient, some medical team do not know where the arrow on the monitor should be which will affect the image.
In treating conditions or scoping patients who has had hysterectomy or with lots of looping in the colon, I have observed the differentiation between when the scope guide is used and when not. The colonoscopist find it much comfortable for the patient and each visualisation and manoeuvres, loops avoided easily and easily straightening, loops if it occurs, the scope guide used may delivers images in high definition. The scope guide has gradually wins the heart of most Endoscopists in my unit for less lengthy time on one procedure. The use of the scope guide there is no need of colonoscopy procedure under X-ray i.e. between barium Enemy or CT scan this eliminates the hazard of radiation for patients. My unit is regards as one of the best bowel cancer screening unit due to the use of scope guide 3 D imager. The procedure is quick, safer, painless and comfortable for most patients, this has really encouraged patient to come for the screening process at my unit.
Minimal sedation is given according to patients preferences in procedures (BSG 2008) such as gastroscopy, brochoscopy flexible sigmodoscopy, colonoscopy, stent insertion to my unit, minimal sedation is mandatory for endoscopic retrograde cholangiopancreatograph patients (ERCP).
Minimal sedation is a method of sedation which was formally known as conscious sedation. In this case, its a technique in which no pain relievers are used therefore making patient to be awake an aware during unpleasant procedure without too much discomfort experience for successful endoscopy, general anaesthesia and minimal sedation used, but minimal sedation is much a safer method to control pain and anxiety during procedures (Rex 2006).
In my unit, minimal sedation is used for most procedures done i.e. both lower and upper gastro intestinal endoscopies, formally in my workplace 6 – 8 mg midazolam was used which is no more used. The report of the rapid response (2008) the maximum dose of midazolam is 5mg which is now the most recent practice in my unit.
Minimal sedation has been used and accepted because it does not require an anaesthetist, which is more economical this technique is very useful for endoscopist in providing a better examination which improves patients comfort and amnesic effect (Regula and Sokol-Kobielska 2008). The drug of choice because of its rapid onset, short duration of action is Midazolam, it provide an amnesic effort and help to relax the patient (Norton et al 2008). The most common benzodiazepines are diazepam and midazolam, majority of Endoscopist prefer to use midazolam because of it fast onset of action and high amnesic effect (National Guidelines Clearing House 2003). During procedures the group called benzo diazepam’s are used either alone or in combination with an opiate e.g. pethidine or fentanyl, when it is been used alone the occurrence of respiratory complication with either midazolam or fentanyl is fairly low. Contrary, the implications increases when both drugs are given in combination.