Practical Pediatric Gastrointestinal Endoscopy

George Gershman, Mike Thomson

• Publisher: Wiley-Blackwell
• Year: 2011
• ISBN:
  9781444354553
• Edition: 2
• Topic: Medizin
• Subtopic: Gastroenterologie & Hepatolgie

This practical step-by-step guide to performing GI endoscopy safely and effectively in children covers the use of endoscopy as both a diagnostic and a therapeutic modality. Now with an entirely new section focusing on advanced endoscopic techniques, such as such as pancreatic cysto-gastrostomy, confocal endo microscopy, and single balloon enteroscopy, the new editiongives trainees and practitioners access to the most recent, as well as the most dependable, information.

Part One: Pediatric Endoscopy Setting

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Introduction

George Gershman

Esophagogastroduodenoscopy (EGD) was an exotic procedure in children until the mid-70s when prototypes of pediatric flexible gastro- and panendoscopes became commercially available. Within the next few years, hundreds of pediatric EGDs were performed in Europe and the US leaving no doubts about safety, high-efficacy and cost-effectiveness of upper gastrointestinal (GI) endoscopy in children.

Over the next ten years, EGD and ileocolonoscopy became routine diagnostic and therapeutic procedures for pediatric gastroenterologists around the world.

Flexible gastrointestinal endoscopy is a unique method of investigation of the GI tract. It combines direct visualization of the GI tract with a target biopsy, application of different dyes, endoluminal ultrasound, injection of contrast materials with various therapeutic procedures. By definition, it is an invasive procedure. When applied to pediatric patients, safety becomes the major priority. In order to minimize morbidity associated with pediatric GI endoscopy, the endoscopist, especially the beginner, should familiarize themselves with all technical aspects of the procedure including:

• Endoscopic equipment: endoscopes, light sources, biopsy forceps, snares, graspers, needles, electrosurgical devices and all other accessories
• Appropriate setting for the endoscopic equipment and doses of commonly used medications and solutions such as epinephrine, glucagon and sclerosing agents.
• Proper techniques of basic diagnostic and therapeutic procedures.

In addition, a pediatric gastroenterologist should also become familiar with age-related characteristics of the esophagus, stomach, duodenum, and common adoptive reactions induced by intubations of the esophagus and insufflation and stretching of the stomach and the colon.

The evolution of the equipment and technological innovations of the last decade opened the door to the new diagnostic and therapeutic procedures in pediatrics such as double-balloon enteroscopy, confocal laser endomicroscopy, removable and biodegradable stents for treatment of refractory esophageal strictures, and endoscopic treatment of gastroesophageal reflux disease.

We believe that the second edition of Practical Pediatrics Gastrointestinal Endoscopy will serve as a perfect guide to trainees, simplifying the learning process of basic endoscopic techniques and highlighting the important background data, technical aspects and outcomes of new endoscopic procedures in children to both pediatric and adult gastroenterologists.

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Settings and staff

George Gershman

KEY POINTS

• Endoscopy is complex procedure.
• A proper setting of the endoscopy unit is essential for provision of the optimal working environment and maximal patient flow.
• Meticulous preparation of endoscopic equipment is necessary for a “smooth” operation during endoscopy.
• A well-trained endoscopy nurse is an important key for safety and quality provision of the endoscopic procedure.
• High-quality disinfection of the instruments is a vital component of patient safety.
• Accurate paper type and electronic documentation of information related to the endoscopic procedure is vital for immediate and follow-up treatment.

Pediatric GI endoscopy can be performed in three different settings: an endoscopy unit, the patient’s bedside, and the operating room. The endoscopy unit is designated for elective procedures. Typically, it has five functional areas:

• A pre-procedure area consisting of a reception lobby and admitting room dedicated for parental consent, patient dressing, triage, and the establishment of an intravenous access;
• A procedure area with examination rooms;
• A recovery area;
• A medical staff area with a working station for units with more than three procedure rooms;
• A storage space and a section dedicated for cleaning and disinfection of endoscopes.

The average volume of pediatric GI endoscopic procedures is usually not high enough to run a separate pediatric endoscopic GI unit. Typically, pediatric and adult gastroenterologists share the same endoscopy units, either in the hospital or the outpatient surgical center.

Such units must have a nursing and ancillary support staff trained to work with both children and adults. Although some units designate a special room for pediatric patients, it is more convenient if pediatric procedures can be performed in all examination rooms.

Most bedside endoscopies for infants and children are done in pediatric and neonatal intensive care units.

Bedside pediatric endoscopy is typically limited to children with acute GI bleeding or complicated recovery following bone-marrow or solid organ transplantation. It is usually a complex and labor-intensive procedure in critically ill patients, which requires:

1. Full cooperation between a skillful endoscopist, a resident, an endoscopy nurse and an attending physician;

2. Proper function of all endoscopic equipment;

3. A well-organized and appropriately equipped mobile endoscopy station.

The mobile station should be loaded with age-appropriate endoscopes and bite-guards, a light source, electrosurgical unit, biopsy forceps, retractable needles, polypectomy snares, graspers, hemostatic clips, rubber bands, epinephrine, biopsy mounting sets, fixatives, culture medias, cytology brushes and slides. The bedside area should be large enough to accommodate the endoscopic station, a portable monitor and equipment for general anesthesia. Two separate suction canisters should be available for endoscopy and oral or tracheal aspiration.

The position of the bed should be adjusted to the height of the endoscopist and any specific indications for the procedure. For example, reverse Trendelenburg position reduces the risk of aspi­ration and improves visibility of lesions (acute ulcers or gastric varices) in the gastric cardia and subcardia.

Endoscopic procedures in the neonatal intensive care unit should be performed under the warmer.

Pediatric GI endoscopy in the operating room is restricted to children with obscure or occult GI bleeding, Peutz–Jeghers syndrome, or other conditions which require intraoperative enteroscopy. The needs for such procedures have been recently reduced due to the availability of capsule or double-balloon enteroscopy. The endoscopy team should be familiar with the operating room environment and regulations.

Pediatric Endoscopy Nurse

A well-trained nurse is the key to a successful pediatric endoscopy team. This individual should be skilled in many areas such as:

1. Communication with the parents and the child targeting the level of stress and anxiety before the procedure;

2. Establishing and securing intravenous (IV) access;

3. Preparing all monitoring devices including EKG leads, pulse oximeter sensors, blood pressure cuffs appropriate for the child’s size and life-support equipment such as nasal cannulas, correct size of oxygen masks, ambu-bags, and intubation trays;

4. Selecting and preparing appropriate endoscopic equipment for the procedure;

5. Monitoring patients during sedation, procedure and recovery;

6. Proper mounting of the biopsy specimens and preparation of the cytological slides;

7. Mechanical and chemical cleaning of the equipment and disinfection of the working space;

8. Quality control maintenance.

It is very convenient having an endoscopy nurse on-call for urgent procedures which occur after hours.

Disinfections of the Endoscopes and Accessories

Thorough mechanical cleaning of the endoscope and any non-disposable instruments is an essential part of any procedure especially a bedside endoscopy. It is an important initial phase of disinfection and is also an effective preventive measure against the clogging of the air-water channel and future mechanical failure of very expensive devices. The final cleaning of the endoscopic equipment is usually performed with glutaraldehyde, which destroys viruses and bacteria within a few minutes. Typically, endoscopes soak for a 20 minute period, although high-risk situations including known or suspected mycobacterial infections may require longer chemical exposure.

Glutaraldehyde can exacerbate reactive airway disease, asthma or dermatitis in sensitive patients or staff. For this reason, instruments are thoroughly rinsed in water and allowed to dry prior to their next use. Air-water and suction channels are further rinsed in a solution containing 70% alcohol and also require compressed air-drying to prevent bacterial growth. Instruments should be hung and stored in a vertical position in a well-ventilated cupboard to ensure dryness and minimize any opportunity for bacterial growth.

A more detailed description of disinfection technique is presented in Chapter 3.

Documentation

Different types of photo-documentation are available during endoscopy. Polaroid photographs and real-time videotaping have been replaced by digital photo printers since the early 1990s. Currently, digitized endoscopic images can be stored on a computer hard-drive or external device. The snapshots of the procedure can be printed on paper or recorded on DVD in real-time. Images can be e-mailed through a secure website for a second opinion or on-line discussion.

FURTHER READING

Association of periOperative Registered Nurses. (2002) Recommended practices for managing the patient receiving moderate sedation/analgesia. Association of Operating Room Nurses Journal, 75, 649–652.

Association of periOperative Registered Nurses. (2005) Guidance Statement: preoperative patient care in the ambulatory surgery setting. Association of Operating Room Nurses Journal, 81, 871–888.

Association of periOperative Registered Nurses. (2005) Guidance Statement: postoperative patient care in the ambulatory surgery setting. Association of Operating Room Nurses Journal, 81, 881–888.

AGA. (2001) The American Gastroenterological Association Standards for Office-Based Gastrointestinal Endoscopy Services. Gastroenterology, 121, 440–443.

ASGE. (2007) Informed consent for GI endoscopy. Gastrointestinal Endoscopy, 2, 626–629.

Berg JW, Appelbaum PS, Lidz CW, et al. (2001) Informed consent: Legal Theory and Clinical Practice. Oxford: Oxford University Press.

Braddock CH, Fihn SD, Levinson W, et al. (1997) How doctors and patients discuss routine clinical decisions: informed decision making in the outpatient setting. Journal of General Internal Medicine, 12, 339–45.

Foote MA. (1994) The role of gastrointestinal assistant. In: Sivak MV (Ed), Gastrointestinal Endoscopy Clinics of North America, 523–39. Philadelphia: WB Saunders.

Guidelines for documentations in the gastrointestinal endoscopy setting. (1999) Soc Gastroenterol Nurses Associates Inc. Gastroenterology Nurse, 22, 69–97.

Kowalski T, Edmundowicz S, Vacante N. (2004) Endoscopy unit form and function. Gastrointestinal Endoscopy Clinics of North America, 14(4), 657–666.

Marasco JH, Marasco RF. (2002) Designing the ambulatory endoscopy center. Gastrointestinal Endoscopy Clinics of North America, 12(2), 185–204.

Role delineation of the registered nurse in a staff position in gastroenterology. Position statement. (2001) Soc. Gastroenterol Nurses Assis­tants. Gastroenterology Nurse, 24, 202–3.

Society of Gastroenterology Nurses and Associ­ates Inc. Guidelines for documentation in the gastrointestinal endoscopy setting. http://www.sgna.org/Resources/guidelines/guideline7.cfm [accessed on 22 October]

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