Better tolerance of painful procedures ► Pethidine (Dolantin), 50-100 mg i.v.
► Respiratory depression -
► Circulatory depression ► Same as for benzodiazepines
► Bradycardia ► Have antagonists available: naloxone (Narcanti)
► Pyloric stenosis
► Duodenal biopsy
► Visualization of duodenal diverticula
► Note the contraindications for the agent used
- Glaucoma, prostatic hypertrophy, arrhythmias
► Eliminates possible interference from peristalsis
► Side effects Method
► Butylscopolamine, 5-20 mg i.v. Precautions
► No special precautions are needed
► Can be used in any endoscopic procedure Contraindications
► Provides a clearer view in the stomach and duodenum
► Several milliliters diluted with some water, administered orally just before the examination.
► In intubated patients, inject through the working channel, then flush (!) because the agent is sticky.
► Pediatric endoscopy
► Endoscopy in high-risk patients
► Age < three years Advantages
- Fall in blood pressure, occasional rise in blood pressure, bradycardia, apnea, etc.
► Better patient tolerance of the examination
► Propofol (Diprivan) Precautions
► Same as for sedation
► A second physician trained in emergency medicine should be in attendance
24 hours before the examination
0 Necessary lab tests ordered? (blood count, coagulation) 0 Antibiotic prophylaxis? (see p. 4) 0 Informed consent obtained? 0 Patient instructed about fasting? 0 Cardiac pacemaker?
0 Risk factors? (heart, lung, coagulation, general health)
Immediately before the examination
0 Patient welcomed to the unit, greeted by name 0 Signed consent form? 0 Dentures removed? 0 Defoaming agent administered? 0 Coagulation tested?
0 If necessary: peripheral venous access? (especially with sedation and for interventions)
0 Equipment check? (air, suction)
0 Endoscope tip lubricated
0 Pharyngeal anesthesia (if desired)
0 Contact with patient: "Here we go."
During the examination
0 Talk to the patient, explain what is happening. 0 Keep the patient in a left lateral position.
0 Observe the patient (sweating, restlessness, facial expression, gestures, pain manifestations, breathing, skin color).
0 If in doubt: pulse oximetry, echocardiogram (ECG) monitoring.
The patient may develop or manifest complications during or immediately after the examination, or complications may arise after a complaint-free interval. They may involve the central nervous system, respiration, cardiovascular system, infections, allergic reactions, and of course the examined organs themselves: the pharynx, esophagus, stomach, and duodenum (see also Risks and Complications, p. 3, and Disclosure and Informed Consent, p. 8).
Immediate complications. The most frequent complaints and complications that occur during or immediately after the examination are as follows:
► Restlessness, agitation, pain, coughing, retching
► Loss of consciousness
Delayed complications. The most frequent complaints and complications that arise after an initial complaint-free interval are as follows:
► Signs of upper gastrointestinal bleeding: hematemesis, melena
► Signs of hypovolemic shock
Aid to decision-making. The tables below are designed to help with decision-making when complications arise. We cannot offer one standard protocol, especially for complaints that arise acutely during the examination. The decision must be made on a case-by-case basis, taking into account the patient's age and medical history, current status, and the clinical problem. If in doubt, withdraw the endoscope because:
► The patient may actually be in danger.
► The patient should never be subjected to undue discomfort.
► In most cases, the instrument can be reinserted without difficulty.
► The instrument may become damaged. Always protect the endoscope with a bite guard!
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