Complications During the Examination

Restlessness, Agitation, Pain, Coughing, Gagging

Causes

► Normal response to the examination

► Faulty examination technique (especially, poor intubation technique)

► Not enough verbal reassurance, inadequate preparation for the procedure

► Misdirected intubation, retroflexion in the pharynx

► Pain due to unfavorable patient position

► Paradoxical reaction to sedation

► Respiratory distress, pain, angina pectoris

► Preexisting illness:

- Bronchial asthma, chronic obstructive lung disease

- Alcohol abuse

- Previous unpleasant endoscopy Brief assessment

► Endoscope position (retroflexed? misdirected?)

► Verbal responsiveness of patient, cooperativeness

► O2 saturation

Reasons for stopping the examination and withdrawing the endoscope

► Serious preexisting illness

► Elderly patient

► Tachycardia > 140 bpm, arrhythmia

► Uncooperative patient

► Angina pectoris

Reasons for pausing but leaving the instrument in place

► No preexisting illness

► Young patient

► Patient responsive to verbal commands

► Patient and endoscopist agree to continue

Treatment

► According to cause

Dyspnea

Causes

General treatment

► Psychogenic

► Obstructed nasal breathing

► Misdirected intubation, aspiration

► Bronchoconstriction, mucus congestion

► Cardiac decompensation

Brief assessment

► Respiratory rate, breath sound, cyanosis

► O2 saturation

Reasons for stopping the examination and withdrawing the endoscope

► Elderly patient

► Preexisting cardiopulmonary disease

Reasons for pausing but leaving the instrument in place

► No preexisting illness

► Young patient

► For significant dyspnea, treat according to the general rules for cardiopulmonary resuscitation: A Clear the airway and keep it open (suction out mucus, vomitus, etc.).

Ventilate (O2 by mask or nasal catheter); intubate if response is poor. C Maintain and stabilize the circulation, if necessary using external cardiac massage. D Place an intravenous line, give specific pharma-cotherapy.

Specific treatments

► For bronchoconstriction

- Beta-2 mimetics by aerosol

- Beta-2 mimetics s.c. (e.g., Bricanyl 0.5-1.0 mg s.c.)

► For cardiac decompensation

- Nitroglycerine subl.

- With concomitant bronchospasm: theophylline, 200 mg i. v.

- Treatment of cardiac arrhythmias

Apnea

Causes

► Pharmacological: sedation, analgesia

► Cardiac: asystole, ventricular fibrillation, bradycardia

► Anaphylactic shock

Course of action

► Discontinue examination, withdraw endoscope

Brief assessment

► Respiratory excursions, O2 saturation

► Carotid pulse

General treatment

► Follow the general rules for cardiopulmonary resuscitation:

A Clear the airway and keep it open (suction out mucus, vomitus, etc.). B Ventilate (O2 by mask or nasal catheter); intubate if response is poor. C Maintain and stabilize the circulation, if necessary using external cardiac massage. D Place an intravenous line, give specific pharma-cotherapy.

Specific treatments

For antagonizing the effect of benzodiazepines

- Flumazenil (Anexate), 0.5-1 mg i.v., repeat after three minutes if necessary

- Caution: half-life of flumazenil < half-life of midazolam << half-life of diazepam

For antagonizing the effect of opiates

- Naloxone (Narcanti), 0.4-2 mg, repeat after three minutes if necessary

For a cardiac cause

- Bradycardia: 0.5-1 mg atropine i.v., may require temporary pacemaker

- Asystole: precordial thump, 0.5-1 mg epinephrine in 10 mL NaCl i. v., temporary pacemaker

- Ventricular fibrillation: cardioversion (200, 300, 360J), repeat after 1 mg epinephrine in 10 mL NaCl i.v.

For anaphylaxis

- Volume: 500-1000 mL (e.g., crystalline or colloidal plasma substitute)

Loss of

Consciousness

Causes

► Sedation or analgesia

► Asystole or ventricular fibrillation

► Anaphylaxis

Course of action

► Discontinue examination, withdraw instrument Brief assessment

► Verbal responsiveness, response to painful stimuli

► Respiratory excursions, O2 saturation

► Carotid pulse

General treatment

► Follow the general rules for cardiopulmonary resuscitation:

A Clear the airway and keep it open (suction out mucus, vomitus, etc.).

Ventilate (O2 by mask or nasal catheter); intubate if response is poor.

C Maintain and stabilize the circulation, if necessary using external cardiac massage.

D Place an intravenous line, give specific pharma-cotherapy.

Specific treatments

► Antagonize effects of benzodiazepines (see Apnea, p.

► Antagonize effects of opiates (see Apnea, p. 13).

Bleeding

Causes

► Instrument tip contact (pharynx, upper esophageal sphincter, duodenal bulb)

► Varices (ulcerations in the esophagus, stomach, and duodenum)

► Mallory-Weiss syndrome

► Coagulation disorders, thrombocytopenia

Course of action

► Do not withdraw the endoscope! Treatment

► Treat for upper gastrointestinal bleeding (see p. 146)

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