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7205 Intercollegiate-british society of gastroenterology national colonoscopy (ibsn) audit: do colonoscopists follow the british society of gastroenterology guidelines regarding antibiotic prophylaxis?
7205 INTERCOLLEGIATE-BRITISH SOCIETY OF GASTROENTEROLOGY NATIONAL COLONOSCOPY (IBSN) AUDIT: DO COLONOSCOPISTS FOLLOW THE BRITISH SOCIETY OF GASTROENTEROLOGY GUIDELINES REGARDING ANTIBIOTIC PROPHYLAXIS? Cecilia J. Bowles, Roger J. Leicester, Edwin T. Swarbrick, Christopher B. Williams, Chris Romaya, Owen Epstein, Royal Free Hosp, London, United Kingdom; St George’s Hosp, London, United Kingdom; New Cross Hosp, Wolverhampton, United Kingdom; St Mark’s Hosp, London, United Kingdom; British Society of Gastroenterology, London, United Kingdom. Introduction: British Society of Gastroenterology (BSG) guidelines recommend antibiotic prophylaxis for endoscopic procedures if the patient is at high risk of endocarditis or of symptomatic bacteraemia because of immunosuppression or neutropenia. As part of the IBNC audit the practice of antibiotic prophylaxis was assessed in colonoscopists practising in 73 units (44 District General, 10 Teaching, 5 Paediatric, 14 Private). Results: Antibiotic prophylaxis for 19 clinical conditions were addressed by 228/236 colonoscopists. The number of colonoscopists who indicated they would give antibiotic prophylaxis to patients undergoing colonoscopy with conditions associated with a higher risk of endocarditis or symptomatic bacteraemia are: Prosthetic heart valve - 226/228 (99.1%), Previous endocarditis - 206/228 (90.4%), Surgically constructed systemic-pulmonary shunt or conduit - 97/228 (42.5%), Synthetic vascular graft less than 1 year old - 116/228 (50.9%), Severe neutropenia (neutrophils<100x109/litre) - 179/228 (78.5%). 96/228 (42%) of colonoscopists were members of the British Society of Gastroenterology but there was no significant difference between members and non-members responses in these higher risk clinical conditions. The BSG guidelines designate 14 other clinical conditions as having moderate, low or no increased risk of endocarditis or symptomatic bacteraemia and where antibiotics are not recommended. The number of colonoscopists who indicated they would give antibiotics to patients undergoing colonoscopy with these conditions ranged from 173/228 (75.9%) for rheumatic valvular or congenital cardiac lesions, to 20/228 (8.8%) for an orthopaedic prosthesis. Conclusion: Not all patients with disorders associated with a higher risk of endocarditis or symptomatic bacteraemia receive prophylactic antibiotics prior to colonoscopy and prophylaxis is often administered inappropriately. More effective methods are required to improve awareness and implementation of prophylactic antibiotic guidelines.
7206 INTERCOLLEGIATE-BRITISH SOCIETY OF GASTROENTEROLOGY NATIONAL COLONOSCOPY (IBNC) AUDIT: ARE ‘AT RISK’ PATIENTS APPROPRIATELY CANNULATED? Cecilia J. Bowles, Roger J. Leicester, Edwin T. Swarbrick, Christopher B. Williams, Chris Romaya, Owen Epstein, Royal Free Hosp, London, United Kingdom; St George’s Hosp, London, United Kingdom; New Cross Hosp, Wolverhampton, United Kingdom; St Mark’s Hosp, London, United Kingdom; British Society of Gastroenterology, London, United Kingdom. Introduction: Safe colonoscopy requires an understanding of sedation techniques. In 1991 the British Society of Gastroenterology (BSG) Endoscopy Committee recommended that cannulation should become standard practice for all endoscopic procedures. As part of the IBNC audit, venous access was assessed with regard to the status of the patient defined by the American Society of Anaesthesiology (ASA) Classification of physical status. 8902 colonoscopies were assessed in 73 units (44 District General, 10 Teaching, 5 Paediatric, 14 Private). Results: 95% of colonoscopies were carried out with intravenous sedation. Midazolam alone - 10.4%, Midazolam with Pethidine - 58.6%, Diazemuls with Pethidine - 9.0%, Midazolam with “other” - 14.9%. 8285/8902 (93.1%) of procedures were carried out with continuous intravenous access in situ throughout the colonoscopy. In 86.8% a plastic cannula was used and in 11.1% a butterfly was utilised. Oxygen was administered in 71% of procedures and a pulsoximeter was used in 93% of cases. ‘At risk’ patients are defined as class 3-5 in the ASA classification (Classes 1-5). There were no Class 5 patients. There were 309/8902 (3.5%) patients in Classes 3 and 4. A plastic cannula or butterfly was used in 257/302 (85.1%) and 35/302 (11.6%) respectively. 7/309 (2.3%) class 3 and 4 patients did not have continuous venous access throughout the procedure, the reasons sited were ‘patient not considered at risk’, and ‘no sedation given’. No reason was given for 2 patients. Oxygen was administered to 85.4% of ‘at risk’ patients and a pulsoximeter was used in 96.1%. Conclusion: 93% of patients undergoing colonoscopy have intravenous access throughout their procedure and are given intravenous sedation. There are some ‘at risk’ patients undergoing colonoscopy without intravenous access.
AB294
GASTROINTESTINAL ENDOSCOPY
7207 LARYNGEAL MASK AIRWAY: A NOVEL MEANS OF MAINTAINING A PATENT AIRWAY DURING ENDOSCOPY IN PATIENTS RECEIVING DEEP CONSCIOUS SEDATION. Jonathan Cohen, Jonathan M. Reiber, Irene P. Osborn, NYU Div of Gastroenterology, New Yotrk, NY; NYU Div of Gastroenterology, New York, NY; NYU Dept of Anesthesiology, New York, NY. Background: Aspiration, hypoxemia and hypoventilation are uncommon but serious complications during endoscopy. The risk of airway problems increases as higher doses of medications are used for sedation. The Laryngeal Mask Airway (LMA) is an FDA-approved device which is placed perorally and rests with its tip in the inferior recess of the hypopharynx. It is used as an alternative to endotracheal intubation. An ambu bag may be attached to the LMA for manual ventilation, if needed. Methods: We tested the feasibility of using the LMA to keep the airway open during concurrent passage of a therapeutic duodenoscope (diameter 13 mm). Patients were identified who were expected to require high doses of sedatives to undergo therapeutic ERCP. Individuals at high risk for aspiration were excluded. All patients received topical pharyngeal anesthesia with cetacaine spray. After the administration of sedation, the LMA (diameter 15 mm) was placed by an anesthesiologist with the patient in the supine position. The patient was turned to the prone position and the duoedenoscope was passed by the staff gastroenterologist. Difficulty intubating the esophagus, friction encountered during the procedure as the endoscope was manipulated and episodes of hypoxia were recorded. Patients were interviewed after all procedures. Results: Ten patients underwent 12 ERCP’s using propofol-based sedation regimens. An additional case was done using anesthetic gasses. The mean age was 51.4 years. The mean ASA class was 2.8. All procedures were successfully performed without oropharyngeal trauma. In each case, the endoscope was inserted around the LMA without dislodging the distensible rubber seal. Minimal friction between the LMA and the endoscope was appreciated by the endoscopist. In one patient, the seal loosened during the procedure leading to transient hypoxemia. The endoscope was quickly removed and the LMA was repositioned. The procedure was completed successfully without subsequent complication. There were no post-procedure complaints of inadequate sedation or oropharyngeal discomfort. Conclusion: It is safe and feasible to use the LMA to protect the airway during deep conscious sedation while inserting a large diameter endoscope alongside the LMA. Further study is warranted to determine whether the LMA confers a safety benefit over the standard nasal cannula and whether this technique will make possible the safe administration of propofol-based sedation by non-anesthesiologists. 7208 AUDIT OF PRE-COLONOSCOPY BOWEL PREPARATION. Kok Leong Diong, Malcolm Brown, Abraham Varghese, Heather Burns, Coleraine Hosp, Coleraine, United Kingdom. Northern Ireland has the second highest incidence of colorectal cancer in the world. Accurate assessment, by either barium enema or colonoscopy is essential. Both investigations require satisfactory pre-examination bowel preparation. Two prospective audits were carried out at the causeway Trust Hospitals to assess the efficacy, tolerability and side effect profiles of the belowmentioned preparations. The first audit was to compare the standard 400omls of Klean-prep (PEG) to the combined preparation (CP) of 2sachet picolax plus 2000mls of Klean-prep. A follow-up audit was performed several months later following the introduction of Fleet (PS). As the methodology and protocol were similar, these two studies have been combined for the purpose of this report. 70 patients were recruited over twenty weeks. They were counseled by a pharmacist before randomisation to PEG (25 patients), PS (20 patients) and CP (25 patients). A questionnaire was completed by the patients detailing palability, compliance and side effects experienced on the day of the examination. Compliance was high PEG=27%, CP=96%, PS=95 but most patients had some difficulty taking all the preparations, PED=60%, CP=48%, PS=32%. There were significant side effects experienced by all groups of patients including those who were tolerant of the preparation (PEG=70%, CP=80%, PS=63%) Colonoscopies were performed by a Consultant Surgeon and a Consultant Gastroenterologist who were both blinded to the preparations taken by the patients. Quality of the preparation was graded 1-5 on the basis of visual assessment. It showed similarly satisfactory results (PEG=95%, CP=90%, PS=100%). The results suggest comparable quality of bowel preparation and suitably high compliance amongst patients in all 3 groups, with no significant difference in the side effect profiles. Klean-prep costs £5.76, while Fleet is slightly cheaper at £4.79. The combined preparation costs £3.65. From this audit, we conclude that the combined preparation represents the most cost-effective method without compromise to the patients or endoscopists.
VOLUME 51, NO. 4, PART 2, 2000
7206 INTERCOLLEGIATE-BRITISH SOCIETY OF GASTROENTEROLOGY NATIONAL COLONOSCOPY (IBNC) AUDIT: ARE ‘AT RISK’ PATIENTS APPROPRIATELY CANNULATED? Cecilia J. Bowles, Roger J. Leicester, Edwin T. Swarbrick, Christopher B. Williams, Chris Romaya, Owen Epstein, Royal Free Hosp, London, United Kingdom; St George’s Hosp, London, United Kingdom; New Cross Hosp, Wolverhampton, United Kingdom; St Mark’s Hosp, London, United Kingdom; British Society of Gastroenterology, London, United Kingdom. Introduction: Safe colonoscopy requires an understanding of sedation techniques. In 1991 the British Society of Gastroenterology (BSG) Endoscopy Committee recommended that cannulation should become standard practice for all endoscopic procedures. As part of the IBNC audit, venous access was assessed with regard to the status of the patient defined by the American Society of Anaesthesiology (ASA) Classification of physical status. 8902 colonoscopies were assessed in 73 units (44 District General, 10 Teaching, 5 Paediatric, 14 Private). Results: 95% of colonoscopies were carried out with intravenous sedation. Midazolam alone - 10.4%, Midazolam with Pethidine - 58.6%, Diazemuls with Pethidine - 9.0%, Midazolam with “other” - 14.9%. 8285/8902 (93.1%) of procedures were carried out with continuous intravenous access in situ throughout the colonoscopy. In 86.8% a plastic cannula was used and in 11.1% a butterfly was utilised. Oxygen was administered in 71% of procedures and a pulsoximeter was used in 93% of cases. ‘At risk’ patients are defined as class 3-5 in the ASA classification (Classes 1-5). There were no Class 5 patients. There were 309/8902 (3.5%) patients in Classes 3 and 4. A plastic cannula or butterfly was used in 257/302 (85.1%) and 35/302 (11.6%) respectively. 7/309 (2.3%) class 3 and 4 patients did not have continuous venous access throughout the procedure, the reasons sited were ‘patient not considered at risk’, and ‘no sedation given’. No reason was given for 2 patients. Oxygen was administered to 85.4% of ‘at risk’ patients and a pulsoximeter was used in 96.1%. Conclusion: 93% of patients undergoing colonoscopy have intravenous access throughout their procedure and are given intravenous sedation. There are some ‘at risk’ patients undergoing colonoscopy without intravenous access.
AB294
GASTROINTESTINAL ENDOSCOPY
7207 LARYNGEAL MASK AIRWAY: A NOVEL MEANS OF MAINTAINING A PATENT AIRWAY DURING ENDOSCOPY IN PATIENTS RECEIVING DEEP CONSCIOUS SEDATION. Jonathan Cohen, Jonathan M. Reiber, Irene P. Osborn, NYU Div of Gastroenterology, New Yotrk, NY; NYU Div of Gastroenterology, New York, NY; NYU Dept of Anesthesiology, New York, NY. Background: Aspiration, hypoxemia and hypoventilation are uncommon but serious complications during endoscopy. The risk of airway problems increases as higher doses of medications are used for sedation. The Laryngeal Mask Airway (LMA) is an FDA-approved device which is placed perorally and rests with its tip in the inferior recess of the hypopharynx. It is used as an alternative to endotracheal intubation. An ambu bag may be attached to the LMA for manual ventilation, if needed. Methods: We tested the feasibility of using the LMA to keep the airway open during concurrent passage of a therapeutic duodenoscope (diameter 13 mm). Patients were identified who were expected to require high doses of sedatives to undergo therapeutic ERCP. Individuals at high risk for aspiration were excluded. All patients received topical pharyngeal anesthesia with cetacaine spray. After the administration of sedation, the LMA (diameter 15 mm) was placed by an anesthesiologist with the patient in the supine position. The patient was turned to the prone position and the duoedenoscope was passed by the staff gastroenterologist. Difficulty intubating the esophagus, friction encountered during the procedure as the endoscope was manipulated and episodes of hypoxia were recorded. Patients were interviewed after all procedures. Results: Ten patients underwent 12 ERCP’s using propofol-based sedation regimens. An additional case was done using anesthetic gasses. The mean age was 51.4 years. The mean ASA class was 2.8. All procedures were successfully performed without oropharyngeal trauma. In each case, the endoscope was inserted around the LMA without dislodging the distensible rubber seal. Minimal friction between the LMA and the endoscope was appreciated by the endoscopist. In one patient, the seal loosened during the procedure leading to transient hypoxemia. The endoscope was quickly removed and the LMA was repositioned. The procedure was completed successfully without subsequent complication. There were no post-procedure complaints of inadequate sedation or oropharyngeal discomfort. Conclusion: It is safe and feasible to use the LMA to protect the airway during deep conscious sedation while inserting a large diameter endoscope alongside the LMA. Further study is warranted to determine whether the LMA confers a safety benefit over the standard nasal cannula and whether this technique will make possible the safe administration of propofol-based sedation by non-anesthesiologists. 7208 AUDIT OF PRE-COLONOSCOPY BOWEL PREPARATION. Kok Leong Diong, Malcolm Brown, Abraham Varghese, Heather Burns, Coleraine Hosp, Coleraine, United Kingdom. Northern Ireland has the second highest incidence of colorectal cancer in the world. Accurate assessment, by either barium enema or colonoscopy is essential. Both investigations require satisfactory pre-examination bowel preparation. Two prospective audits were carried out at the causeway Trust Hospitals to assess the efficacy, tolerability and side effect profiles of the belowmentioned preparations. The first audit was to compare the standard 400omls of Klean-prep (PEG) to the combined preparation (CP) of 2sachet picolax plus 2000mls of Klean-prep. A follow-up audit was performed several months later following the introduction of Fleet (PS). As the methodology and protocol were similar, these two studies have been combined for the purpose of this report. 70 patients were recruited over twenty weeks. They were counseled by a pharmacist before randomisation to PEG (25 patients), PS (20 patients) and CP (25 patients). A questionnaire was completed by the patients detailing palability, compliance and side effects experienced on the day of the examination. Compliance was high PEG=27%, CP=96%, PS=95 but most patients had some difficulty taking all the preparations, PED=60%, CP=48%, PS=32%. There were significant side effects experienced by all groups of patients including those who were tolerant of the preparation (PEG=70%, CP=80%, PS=63%) Colonoscopies were performed by a Consultant Surgeon and a Consultant Gastroenterologist who were both blinded to the preparations taken by the patients. Quality of the preparation was graded 1-5 on the basis of visual assessment. It showed similarly satisfactory results (PEG=95%, CP=90%, PS=100%). The results suggest comparable quality of bowel preparation and suitably high compliance amongst patients in all 3 groups, with no significant difference in the side effect profiles. Klean-prep costs £5.76, while Fleet is slightly cheaper at £4.79. The combined preparation costs £3.65. From this audit, we conclude that the combined preparation represents the most cost-effective method without compromise to the patients or endoscopists.
VOLUME 51, NO. 4, PART 2, 2000