BASICS  of Colonoscopy

 Basic Endoscope Components

Control Body

  • Angulation mechanism: control knobs and angulation wires
  • Optics OR Remote control function
  • Valves: air/water and suction

Umbilical Cord

  • Transmission

                        CCD cable, light bundle, air, water       and suction

  • External connections

                        air/water bottle, suction tubing, leak tester, diathermy safety cord, video   processor cable

Conscious Sedation - usual IVI regimens

  • Tranquillizer - Midazolam most commonly used
  • Analgesia - Pethidine or Fentenyl
  • NO “usual dose” 5mg midazolam and 50mg pethidine

What is Conscious Sedation?

  • Patient responsive to verbal commands
  • In particular, responds to request to take deep breaths, open eyes and show tongue
  • Light tactile stimulation wakens patient

What is Deep Sedation?

  • Patient un-responsive to verbal commands
  • Light tactile stimuli fail to elicit response
  • Inappropriate response to tactile/verbal stimulation
  • Reflex response to stimulation is close to general anaesthesia

Safe Endoscopic Sedation

  • Pre-procedure history - Co-morbidity, medication, alcohol, tobacco, previous experience
  • Venous access and monitoring
  • What dose to give?
  • Effect of combination Rx

Essential Background Knowledge

  • Haemoglobin oxygen dissociation curve
  • Opiate and Benzodiazepine pharmacology
  • Difference between “conscious sedation” and general anaesthetic
  • CPR Training

Sedation Background

  • Mono therapy safer than poly
  • Oxygen dissociation curve (<90% dangerous)
  • Synergism between opiates and Benzodiazepines
  • Opiate uptake by receptors rapid (1 circulation time)
  • Benzodiazepine uptake slow (2-3 mins)

Principles of Sedation

  • Minimum dose
  • Give in small increments
  • Remember Midazolam takes 3 - 4 minutes to work
  • Always give Opiate first, then Benzodiazepine
  • Must have full cannula, not butterfly
  • Antagonists must be immediately available
  • Pulse oximetry and monitoring essential
  • Routine use of oxygen supplementation
  • Extra care in elderly, COPD, IHD etc

Monitoring
Conscious Sedation

  • Always record the baseline pulse, (BP) and saturation level
  • Test level of consciousness every minute initially
  • WATCH PATIENT!!!!!!!!!
  • Pulse oximetry
  • Pulse monitoring

Safe Endoscopic Sedation - Safety at Hand

  • Flumazenil - 250ug IVI
  • Naloxone - 0.5 - 1ug/Kg
  • Resuscitation equipment

General Principles

  • Consent fully
  • Avoid complications first: hot biopsy R side, beware large polyp, beware pain
  • Recognise early
  • Inform patient and relatives
  • Consultant lead

Endoscopic skills

  • Check endoscopic function before intubation
  • Maintains luminal view inserts in luminal direction
  • Awarence of patient coniousness and pain during the procedure and take appropriate action
  • Use torque steering
  • Intermittent suction
  • Recognise and resolve loops
  • Use position change and abd pressure

5 basic rules of colonoscopy

  • Do not advance if no clear view of lumen
  • Do not advance if any resistence
  • Pull back if any doubt
  • Little air as possible
  • Attention to patient pain reaction.