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OBJECTIVES FOR STATION #1DESCRIBE THE ROLE OF THE RN/GI TECH IN PREPARING THE ENDOSCOPY SUITEPosition carts and monitors in the room for easiest viewing of monitor and fluoroscope screen by MD and assistive personnelWork top organization should include and organizer with pockets or clips to hold various equipment (wires tend to be long), gauze, sterile water, normal saline and alcohol pads (to clean sticky contrast agents off gloves)Equipment preferences of the MD.PPE equipment including gowns, gloves, masks, lead aprons with thyroid collar, X-ray badges, and X-ray in use warning signs, X-ray protective gogglesRN RESPONSIBLE FOR drawing up and proper labeling of all medications used during procedure, includingcontrast agent 1/2 strength and full strength with no air bubblesNormal saline and or sterile water drawn up in 20ml syringesglucagon availablesimethicone available (not used in all institutions) sedation used during procedure (unless general anesthesia)reversal meds readily availableIDENTIFY VARIOUS TYPES OF ERCP EQUIPMENT INCLUDING CANNULATOMES AND WIRESHANDS ON DEMONSTRATION AND RETURN DEMONSTRATION OF ERCP EQUIPMENT- including cannulatomes and wiresE ndoscopic - Looking inside with a scopeR etrograde - BackwardsC holangio - BiliaryP ancreatography – Pancreas – using radiographic examinationCholelithiasis: Gallstones in the gallbladderCholangitis: Inflammation of the common bile duct, often secondary to bacterial infection or choledocholithiasisCholecystitis: Inflammation of the gallbladder secondary to gallstonesCholedocholithiasis: Gallstones, which have migrated from the gallbladder to the common bile ductWe discussed the SGNA position statements-Ergonomics in the Gastroenterology SettingRadiation Safety in the Endoscopy SettingAvailable at OBJECTIVES FOR STATION #2?Describe the role of the RN Pre-procedure/patient assessmentRN needs to completely assess the patient prior to the procedure, and accurately document all nursing measures, including the following:Date/time of arrivalHistory obtained fromWho is accompanying the pt/who is driving home?AmbulationIndications for procedure- (evaluation of s/s of malignancy, acute/recurrent/chronic pancreatitis, CBD stones, unexplained chronic abdominal pain, jaundice, possible bile duct disease, pre or post cholecystectomy stone removal, ampulla and bile duct manometryPt ID and Allergy/other Alert BandsPrevious sedation problemsMedical and surgical historyMetal implants/ICD for grounding pad placementCurrent MedicationsCurrent Physical exam including- vital sign, lungs sounds, bowel sounds, Ht and wt, pregnancy statusNPO statusDenturesAdvanced directivesBelongingsCurrent Lab resultsStart or check for patent IV lineAssess knowledge deficits for patient education related to ERCP length of procedurePositioninguse of flourosedation and monitoringindicationsrecovery expectationsEnsure any preoperative MD orders are implementedIdentify various types of ERCP equipment including those to facilitate access and opening of the ampulla such as a needleknife, dilators and biliary balloon dilatorsHANDS ON RETURN DEMONSTRATION OF ERCP EQUIPMENT including those to facilitate access and opening of the ampulla such as a needle knife, dilators and biliary balloon dilatorsWe discussed the SGNA Standards and guidelinesGuidelines for Documentation in the Gastrointestinal Endoscopy SettingAvailable OBJECTIVES FOR STATION #3Describe the role of the RN Intra-procedure, including proper positioning and possible complications of poor positioning of the ERCP patientGoal is to position for patient comfort with the least chance for complicationsusually prone or slight left lateral (prone is best anatomically)if pt is to be intubated, done supine and then turned prone with a minimum assist of 4 peoplepreserve cervical spine and body alignmentpad under bony prominencespad or pillow under shins will prevent foot dropask ladies if their breasts are comfortable, men if their scrotum is comfortablearms should never be >90 degrees at the shoulderPotential Complications from poor positioningnerve damage (axillary, radial, ulnar, peroneal or tibia nerves)vessel compressionpressure ulcerscompartment syndrome (straps too tight)V/Q mismatch (one lung perfusing, one lung oxygenating)atelectasis (shallow breathing due to pressure on chest)corneal abrasionsIdentify various types of ERCP equipment for stone retrievalHands on return demonstration of ERCP equipment- including stone retrieval balloons and basketsPRONE POSITIONING SHOWING PROPER PADDING UNDER BONY PROMINENCES00right18161000 POSSIBLE NERVE DAMAGEDUE TO CHEST COMPRESSIONV/Q MISMATCHA VQ Mismatch in respiratory pathophysiology is a problem with either the Ventilation (air going in and out of the lungs)?or the Perfusion (Oxygen and Co2 diffusion at the alvioli and the pulmonary arteries). VQ ratios compare the amount of air reaching the alveoli to the amount of blood reaching the alveoli.Ventilation Problems include: inadequate rate or tidal volume during respiration. For example, the person has an adequate rate of respirations (say, 18 breaths per minute), but the tidal volume is insufficient). This would be considered a V/Q mismatch relating to a problem with the V side of the equation.Alternatively, you may have a perfusion problem. For example, excess pulmonary dead space,such as: emphasema, bronchitis, pneumonia, atelectasis, low pulmonary artery pressures, RVF, lack of haemoglobin availability (as a result of haemorrhage or Carbon Monoxide Poisoning).OBJECTIVES FOR STATION #4Describe the roles of the RN or GI tech during ERCP, intra-procedureOne RN to be considered the "circulating" RNliason between the outside and the procedure roomadminister and monitor sedation (unless general or MAC)be responsible for accurate and thorough documentation of all nursing measuresbe able to retrieve equipment, troubleshoot, and carry out MD orders during procedureOne RN or tech to be considered the "scrub or assist" role (some institutions may use GI techs during ERCP)has to be extensively familiar and competent with ERCP equipment to work with the MDCirculating RN roleRN responsibility of accurate documentation of the following:re-verify Pt ID and procedure during time outverify consent form signedall personnel involved in casescope ID usedevents or occurrencesvital signs per protocolany specimens retrievedtherapeutic devices used (cautery, balloons, dilators)grounding pad placement and evaluation of skinIV fluidsfluoroscopy timeif pt was shieldedcontrast media(amount and strength)RN is responsible for monitoring of the sedated patientmedications and reversals used during endoscopic sedationindications for and levels of sedationsedation policies and guidelinesairway managementcontinuous monitoring of the sedated patientrisks and complications including cardiac, respiratory and paradoxical, precautions during pregnancy, pediactric and elderly, difficult to sedate pt, sleep apnea.?Identify various types of ERCP equipment?- including biliary and pancreatic stentsHANDS ON RETURN DEMONSTRATION OF ERCP EQUIPMENT- including biliary and pancreatic stentsSEDATION SCALE (CHECK YOUR INSTITUTION GUIDELINES)Dosage Guidelines for AdultsTable 1. Commonly Used Drugs for Procedural Sedation and Analgesia in Adults HYPERLINK "javascript:reftableshow('layertabletw2aab6b8b2');" (Open Table in a new window)DrugAdult DoseOnset of ActionDuration of Action*CommentsMidazolam(Versed)0.02-0.1 mg/kg IV initially; if further sedation is required, may repeat with 25% of initial dose after 3-5 min; not to exceed 2.5 mg/dose (1.5 mg for elderly persons) and 5 mg cumulative dose (3.5 mg for elderly persons)1-2 min30-60 minRespiratory depression or hypotension may occur, particularly when rapidly administered or combined with fentanyl (may need to decrease midazolam dose); does not provide analgesia; action reversed by flumazenilFentanyl1-2 mcg/kg slow IV push (over 1-2 min); may repeat dose after 30 min1-2 min30-60 minMay cause chest wall rigidity, apnea, respiratory depression, or hypotension; elicits minimal cardiovascular depression; may cause dysphoria, nausea, vomiting, or EEG changes; action reversed by naloxoneEtomidate(Amidate)0.1-0.2 mg/kg slow IV push over 30-60 sec< 1 min3-5 minCommonly causes myoclonus, pain upon injection, adrenal suppression (typically no clinical significance unless repeated doses are used within a limited time span); may cause nausea, vomiting, and lower seizure threshold; does not alter hemodynamics; causes a slight to moderate decrease in intracranial pressure that only lasts for several minutes; does not cause histamine release; useful for patients with trauma and hypotensionPropofol(Diprivan)0.5-1 mg/kg IV loading dose; may repeat by 0.5-mg increments q3-5min< 1 min3-10 minProvides rapid onset and recovery phase, and brief duration of action; has anticonvulsant properties; can rapidly cause deepening sedation;causes cardiovascular depression and hypotension*Duration of action based on normal drug elimination (ie, nonelderly adult with normal renal and hepatic function)OBJECTIVES FOR STATION #5?Describe the role of the RN in ERCP related complications.?frequent assessment intra and post procedurePerforation-can be from guidewire, sphincterotomy, or luminalincreased chance with a hx of bilroth 1 or 2s/s can include- sudden or worsening painchanges in body temperaturerigid abdomenloss of bowel soundsformation of crepitus (prepare for possible x-ray with gastrograffin)Hemorrhage from sphincterotomy (prepare for possible injection with epi, cautery or clips)pancreatitis- (usually occurs 2-4 hours post procedure, monitor for fever, chills, abd pain, nausea or vomiting)compromised airway-( watch head and neck angle, scope can occlude airway, make corrections)respiratory depression (adequate oxygen, and prepare for reversal of medications)cardiopulmonary- hypoxemia can lead to cardiac arrhythmiasIdentify various types of ERCP equipment- including brushes, and emergency handle??HANDS ON RETURN DEMONSTRATION OF ERCP EQUIPMENT- including brushes, and emergency handle Sphincterotomy bleed with clipsPost-ERCP Pancreatitis: Presentation and ManagementTypically, if a patient is going to develop post-ERCP pancreatitis, the probable diagnosis becomes apparent within a few hours of the procedure. It is characterized by; severe abdominal painfrequently, back painnausea (with or without vomiting)mild feverUnfortunately, the usual 1-hour observation period after ERCP is often insufficient for post-ERCP pancreatitis to declare itself. If the patient can be kept under observation longer, or returns with symptoms, a 2-hour serum or urinary amylase level (> 1000 IU/L) is highly predictive of evolving post-ERCP pancreatitisPatients presenting with post-ERCP pancreatitis should receive: adequate (narcotic) analgesiatreatment for nausea (if present)copious intravenous fluids (starting with a 1-2 L bolus of Ringer's lactate solution and continuing with 250-300 mL/hr)A nasogastric tube should be placed only if the patient has unrelieved nausea or vomiting.Urine output should be monitored and charted, with the aim of at least 50 cc/hr of urine output (100 cc/hr is better). In patients unable or unwilling to spontaneously pass urine, placement of a urinary catheter is necessary to monitor urine output. Patients should be watched for signs of severe inflammatory response syndrome, which includes: fever (> 38? C)tachycardia (> 90 beats/min)tachypnea (> 20 breaths/min)and low or high peripheral white blood cell count (< 4000/mm3?or > 12,000/mm3).- SEDATION AIRWAY MANAGEMENTGo to Go to issues tab, then under that tab is ‘’ – Read all about sedation and patient management there. Reversal AgentIndicationAdult DosePediatric DoseCommentsNaloxone (Narcan)Reverses opioid agonistsPostanesthetic or opioid dependent: 0.1-0.2 mg/kg IV; may repeat q2-3min prnOpioid overdose: 0.4-2 mg IV; may repeat q2-3min prnPostanesthetic reversal: 0.005-0.01 mg/kg IV/IM; may repeat q2-3min prnOpiate intoxication: 0.01-0.1 mg/kg dose IV/IM; may repeat every min; not to exceed 2 mg/doseOnset of action for IV is 1-3 min vs 10-15 min for IM; rebound sedation may occur; if used in patient with chronic opioid use, will precipitate acute withdrawal and abrupt sympathetic discharge possibly leading to acute pulmonary edemaFlumazenil(Mazicon)Reverses benzodiazepinesPartial antagonism (for sedation reversal): 0.1-0.2 mg IV infused over 15 sec; may repeat after 45 sec and then every min; not to exceed total cumulative dose of 1 mgComplete antagonism (for overdose): 0.2 mg IV infused over 30 sec; may repeat with additional doses of 0.5 mg over 30 sec at 1-min intervals; not to exceed a total cumulative dose of 3 mg0.01 mg/kg/dose IV infused over 15 sec; not to exceed 0.2 mg/dose; may repeat every min; not to exceed total cumulative dose of 0.05 mg/kg or 1 mg (whichever is lower)Rebound sedation may occur; if used in patient with chronic BZP use, will precipitate acute withdrawal; may precipitate seizures unresponsive to BZPs- Commonly used reversal agents.OBJECTIVES FOR STATION #6DISCUSS CASE STUDY – BILIARY STRICTURENew onset jaundice associated with solitary biliary strictures in the elderly is concerning for a malignant stricture such as cholangiocarcinoma. Patient, 70 year old maleSymptoms- Painless jaundiceLabs- His bilirubin was 7.0 mg/dlalkaline phosphatase was 294 U/LUltrasound and CT scan were normalERCP- revealed a biliary stricture below the bifurcation of the right and left hepatic ducts, concerning for cholangiocarcinoma – a stent was placedBiopsies and brushings were negativeCEA and CA 19-9 were normalOne month later, repeat ERCP and cholangioscopy revealed that the stricture had resolved. Ampullary biopsies revealed infiltration with IgG4 plasma cellsLiver function tests returned to normalNine months later, the patient represented with painless jaundiceLabs-bilirubin was 8.1 mg/dlalkaline phosphatase was 282 U/LCT scan was normal2nd ERCP- revealed a new stricture in the distal bile duct- concerning for a malignant stricture. The previously seen proximal biliary stricture remained resolved. Biopsies and brushings were negative. Repeat CEA and CA 19-9 were normal.Endoscopic ultrasound- revealed a mass surrounding the biliary strictureHe was treated with prednisone 20 mg, and a slow taperHis liver enzymes returned to normalRepeat ERCP showed resolution of the biliary stricture. His liver enzymes have remained normal after 10 months of follow-upDISCUSSION-IgG4-Related Sclerosing Cholangitis (IgG4-SC) is a rare condition which can cause biliary strictures mimicking malignant strictures. It is most often seen in association with autoimmune pancreatitis, which our patient did not have. It can also be associated with IgG4-related lymphoplasmacytic infiltration in other organs. We report a rare case of IgG4-SC causing metachronous biliary strictures responsive to medical therapy. This is an important differential diagnosis to consider, particularly to avoid drastic unnecessary surgery or chemotherapy in benign disease.DESCRIBE VARIOUS EQUIPMENT USED TO CANNULATE THE COMMON BILE DUCTCannula: Catheter used to gain access to CBD and/or PD. Can have multiple lumens for injection and guide wire usage.Guide wire: Wire placed into the CBD/PD. Can be used for cannulation. Left into the duct to maintain access while devices are exchanged over it.HANDS ON DEMONSTRATION AND RETURN DEMONSTRATION OF ERCP EQUIPMENT- including cannulatomes and wiresBiliary strictureSource- OBJECTIVES FOR STATION #7Discuss Case Study- Primary Sclerosing Cholangitis52 year old with history of Htn and hyperlipidemiaCurrent symptoms-Progressive fatiguePruritisLabs- rising bilirubinTests-Diagnosis of PSC typically does not require ERCPERCP is reserved for treatment of dominant stricture or sampling to rule out cholangiocarcinomaCan be diagnosed with MRCPERCP was performed with stent placement in hepatic strictureLiver biopsy performed to confirm “onion skin” or fibrosis in hepatic tissueConsiderations with PSCConsider in patients with IBD, unexplained cholestasis, and normal MRCP6% overlap with autoimmune hepatitisERCP is done for patients with PSC and worseningsymptoms to evaluate for dominant main duct disease→ concern for cholangiogramDilation or dilation + stenting are both effective to treat stricturesdilation + stenting associated with more infectious complicationsNo randomized control trial comparing dilation to dilation + stenting Risk of cholangiocarcinoma is 1-2% per yearAs with all indeterminate biliary strictures, yield of brushing is poor. Slightly improved withbiopsy, however, overall sensitivity is still suboptimalDESCRIBE VARIOUS EQUIPMENT USED FOR OPENING AND ACCESSING THE COMMON BILE DUCTSPHINCTEROTOME: Catheter used to gain access to common bile duct (CBD) and/or pancreatic duct (PD) and perform sphincterotomy. Can have multiple lumens for injection and guidewire usage.DILATION BALLOON: Balloon catheter used to open the ampulla. Commonly done following a sphincterotomy. Dilation balloon can also be used to open up strictures within the CBD and PD.NEEDLE KNIFE: A slender surgical knife with a needle point, used to gain access of the CBD. Needle is advanced into the tissue, heat is applied to cut through mucosa and gain access.HANDS ON DEMONSTRATION AND RETURN DEMONSTRATION OF ERCP EQUIPMENT including those to facilitate access and opening of the ampula such as a needleknife, dilators and biliary balloon dilators.OBJECTIVES FOR STATION #8Discuss case study- choledocholithiasis35 year old with no past medical historyCurrent symptomsepigastric abdominal painnausea and vomiting x 48 hoursLabs- liver enzymes elevated 2x ULNbilirubin 2.0Lipase is normalUltrasound is ordered which reveals dilated intra and extrahepatic ducts with no stone inthe CBD. Choledocholithiasis is suspected on the basis of clinical symptoms and initial laboratoryevaluationNormal liver enzymes have a negative predicitive value of 97% for choledocholithiasisRUQ ultrasound has a sensitivity of 22-50% for choledocholithiasisGuidelines from ASGE-The Role of Endoscopy in the Evaluation of Suspected?CholedocholithiasisGastrointest Endosc 2010;71:1-91. We recommend that the initial evaluation of suspected choledocholithiasis should include serum liver biochemical tests and a transabdominal US of the right upper quadrant. These tests should be used to risk-stratify patients to guide further evaluation and management.2. We recommend that patients with symptomatic cholelithiasis who are surgical candidates and have a low probability of choledocholithiasis proceed to cholecystectomy without additional biliary evaluation 3. We recommend that patients with an intermediate probability of choledocholithiasis undergo further evaluation with preoperative EUS or MRC or an IOC. In this group of patients, we suggest that ERC be deferred unless EUS, MRC, and IOC are unavailable, given the less favorable risk profile of ERC.4. We recommend that patients with a high probability of choledocholithiasis undergo an evaluation of the bile duct with therapeutic capability, generally preoperative ERC. When available, laparoscopic bile duct exploration can serve as an alternative to ERC.5. We suggest that EUS or MRC be considered in the diagnostic evaluation of postcholecystectomy patients suspected of having choledocholithiasis when initial laboratory and US data are abnormal yet nondiagnostic.6. We recommend against early ERC in the evaluation and management of patients with mild ABP in the absence of clear evidence of a retained stone.7. We recommend early ERC in patients with acute biliary pancreatitis and concomitant cholangitis, given the observed benefits in morbidity and mortality. 8. We suggest that patients with acute biliary pancreatitis and clinical evidence of biliary obstruction be considered for early ERC. We cannot recommend for or against early ERC in patients with predicted severe acute biliary pancreatitis in the absence of overt biliary obstruction or cholangitis, given the lack of consensus in the available data.9. As patients with acute biliary pancreatitis are at least at intermediate risk for choledocholithiasis, we suggest pre-operative EUS or IOC be considered for these patients when cholangitis or biliary obstruction are absent. Patient had cholecystectomy without complications. Identify and describe various equipment used during ERCP for stone retrievalRETRIEVAL BALLOON: catheter with a balloon on the end. Balloon is inflated in the proximal CBD and pulled through the duct to remove stones. Device can be placed into the duct over a guidewire and can have an injection port.?RETRIEVAL BASKET: catheter with a basket on the end. Basket is opened and closed by manipulating the handle. When opened inside the duct the basket can grasp stones. Stones can be crushed inside the duct or pulled out. Baskets can be used with or without a guidewire and may have a lumen for injection.HANDS ON DEMONSTRATION AND RETURN DEMONSTRATION OF ERCP EQUIPMENT- including stone retrieval balloons and basketsOBJECTIVES FOR STATION #9?Discuss Case study- Bile leak48 year old with intermittent RUQ pain presents with fever and severe RUQ pain. Ultrasound reveals acute cholecystitis. The patient is taken to the OR for cholecystectomy where dense adhesions are noted. Laparoscopicprocedure converted to open and only partial cholecystectomy was able to be performed.Bile leak is a common surgical complicationLaparoscopic > OpenSevere inflammation and adhesion is also a risk factor. Bile leak is suspected with pain post cholecystectomy with imaging revealing bilomaIf JP drain is placed, bilious output is diagnosticHIDA scan can make diagnosis, but does not provide detailed anatomic informationTherapy for bile leak involves percutanous drainage of the existing leakERCP to prevent further leakGoal of ERCP is to reduce the transpapillary pressure gradient → not necessary to “bridge” theleak for simple leakStenting is better than sphincterotomy alone, however, unclear if stenting plus sphincterotomy isbetter than stenting aloneERCP with CBD stent was placed, pt symptoms resolved over timeIdentify and describe various equipment used for stenting the common bile duct and pancreatic duct.BILIARY PLASTIC STENTS: a plastic tube that is inserted into a bile duct to relieve narrowing of the duct (also called bile duct stricture). Comes in center bend, duodenal bend & double pigtail shapes. Can be placed in CBD or PDBILIARY METAL STENTS: a metal tube that is inserted into a bile duct to relieve narrowing of the duct (also called bile duct stricture). Can be fully covered, partially covered, or uncovered. Design can be open or closed cellHANDS ON DEMONSTRATION AND RETURN DEMONSTRATION OF ERCP EQUIPMENT- including biliary and pancreatic stentsSource- American Journal of Gastroenterology- - Am J Gastroenterol?2010; 105:100–105; doi:10.1038/ajg.2009.546; published online 22 September 2009Assessment of Need for Repeat ERCP During Biliary Stent Removal After Clinical Resolution of Postcholecystectomy Bile LeakOBJECTIVES FOR STATION #10Discuss case study- Pancreatic head mass58 year old with history of CAD presents with progressive jaundice, weight loss and anorexia.CT reveals a 3.9 cm pancreatic head mass with associated biliary dilatation and pancreatic ductdilatation.EUS confirmed a 3-4cm mass in the head of the pancreas. Portal vein was not involved andthe mass was not adjacent to splenic artery.EUS-FNA revealed adenocarcinomaERCP with brushings of pancreatic ductPt referred for whipple procedure due to no evidence of metastasis found on CT scanSince surgery couldn’t be done immediately, a pancreatic stent was placedFrom The American Society For Gastrointestinal EndoscopyThe role of endoscopy in the evaluation and treatment of patients with pancreaticobiliary malignancyIdentify and describe various equipment used during ERCP for collection of cells for diagnosesCytology Brush: catheter with a brush on the end. Brush is operated by opening and closing the handle of the device. Used to collect cells from the CBD/PD to diagnose diseases.?SpyGlass Cholangioscopy: Four way steering catheter with four lumens allows for direct visualization of the duct. EHL and laser probes can be passed to fragment large stones. Biopsy forceps can be passed for direct visualization biopsiesHands on demonstration and return demonstration of ERCP brushes and possible Spyglass probesNote- pancreatic head mass is usually diagnosed through EUS/FNA. This case study was put at this station randomly, not because brushings or Spyglass is used as a primary method for diagnosis. ................
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