Practical Pediatric Gastrointestinal Endoscopy - part 3 docx

e.g., if the video processor was accidentally set to display an image from the image management software or a VCR, rather than from the endoscope, pressing Reset will restore the live en

Feature RGB sequential video Color-chip video

Image resolution Have a theoretical advantage

because each pixel has unique image intensity information The advantage is primarily seen only

in the very smallest of endoscopes.

Have a slight disadvantage because information from multiple pixels must be combined together.

Color accuracy Have a theoretical advantage

because each pixel has unique, directly measured, full-color information Ideal for research based on spectroscopy and color-analysis algorithms.

Have a slight disadvantage because color is calculated from values of surrounding pixels.

Reproduction of motion Stroboscopic illumination creates

problems with rapid motion.

Motion produces color slip and brightly colored artifacts Newer generation systems have advanced image capture algorithms to reduce the color-slip problem.

Smooth, natural reproduction of motion.

No stroboscopic effect No color artifacts A fast shutter mode reduces blurring of quickly moving subjects.

Abdominal transillumination Strobed illumination produces

very weak transillumination.

‘‘Transillumination Mode’’ results

in good transillumination but normal imaging is impossible.

The system’s bright, continuous, white light illumination is ideal for transillumination.

Light source compatibility Requires a special strobing light

source.

Videoscopes are compatible with light sources for fiberoptic endoscopes.

Compatibility with laser therapy The red He–Ne aiming beam

appears white and may mask the tissue-blanching effect Built-in filters enable the endoscope to be used with Nd:YAG lasers.

Built-in filters enable the endoscope to be used with Nd:YAG lasers.

Table 3.1 The advantages and disadvantages of the two basic endoscope imaging systems.

precautions, (ii) Occupational Safety and Health Administrationrules on exposure to blood-borne pathogens, (iii) procedures forthe safe handling of chemicals, (iv) professional society guide-lines (e.g., those promulgated by ASGE, SGNA, APIC, etc.), and(v) the manufacturer’s specific procedures for reprocessing theequipment Reprocessing personnel must also be adequatelyoutfitted with appropriate personal protective equipmentfor protection against splattering of microorganisms, organic

Poor air or water feeding (i) Check that the air pump is turned on and set at the proper setting.

(ii) Check that the water bottle contains sufficient water, that the lid is screwed on tightly, and that the water bottle tube is connected to the endoscope NOTE: If the nozzle on the tip of the instrument is obstructed by debris, air and water feeding will be compromised Thoroughly clean all instrument channels, openings, and nozzles each time the instrument is reprocessed Some manufacturers supply special adapters for bedside precleaning of the air/water system.

Image is not clear (i) Feed water and then air to wash debris off distal objective lens (ii)

If permanently obscured, clean the objective lens by carefully rubbing with gauze moistened with alcohol (iii) Repair the endoscope if the distal lens is damaged or has moisture trapped behind it NOTE: A cracked or badly scratched lens cannot produce sharp images Never let the tip of the endoscope contact the floor or other hard surfaces Protect the distal tip of the endoscope from damage Moisture trapped behind the lens will cloud the image Have the endoscope repaired.

Image color is not correct (i) ‘‘White balance’’ the image while pointing the endoscope at a

manufacturer-supplied test fixture or a piece of white gauze (ii) Make sure all color adjustment controls on both the video processor and the video monitor are set in a neutral position (iii) Check for loose or broken video cables NOTE: If the endoscope is ‘‘white-balanced’’ while pointing at a nonwhite surface, distorted color will result Many video systems use separate wires for transmitting the red, green, and blue component images If one of these wires is disconnected or broken, the color of the image on the monitor will be severely distorted.

Image is permanently frozen

or completely absent

(i) Turn off and on again both the light source and the video processor This may correct the problem if it is microprocessor related (ii) Check all wires for accidental disconnection (iii) Check the input selector on the video monitor to ensure that it is set to display the input with the endoscopic image (iv) Press the ‘‘Reset’’ button on the video processor, if one is available This will return the videoprocessor settings back to their factory defaults (e.g., if the video processor was accidentally set to display an image from the image management software or a VCR, rather than from the endoscope, pressing Reset will restore the live endoscopic image.)

The image cannot be restored

and the endoscope must be

withdrawn from the patient

(i) Close and remove all accessories from the endoscope channel (ii)

If using a colonoscope with adjustable stiffness, set the stiffness control to the ‘‘most flexible’’ setting (iii) Make sure that the angulation locks are off (iv) Return both angulation knobs to their neutral position in order to straighten the distal tip (v) Carefully withdraw the endoscope NOTE: If the endoscope cannot be withdrawn easily, stop and contact the endoscope manufacturer’s service center for additional instructions.

The endoscope is damaged If the endoscope insertion tube is damaged by a patient bite, by

accidental closure in the carrying case hinge, or by other means, do not continue to use the endoscope Futher use of the endoscope could cause additional damage to internal components of the instrument, adding to the repair cost.

Table 3.2General troubleshooting information for selective problems.

matter, and reprocessing chemicals Adequate personal tive equipment includes (i) long-sleeved gowns that are imper-vious to fluid, (ii) gloves that are long enough to extend up thearms to protect the forearms, and (iii) eye and/or face protection.

protec-Cleaning

Following patient use, the endoscope should be immediatelyprecleaned at the bedside by flushing the internal channels andwiping down the insertion tube Following bedside precleaning,the endoscope is brought to the reprocessing room for manualcleaning Thorough manual cleaning is often described as be-ing “the most important step’’ of the entire reprocessing proce-dure Cleaning removes gross debris and organic matter that candry on the instrumentation and hinder future performance (e.g.,flow through the air/water nozzle) Studies have shown thatcleaning alone can reduce the number of microorganisms andorganic load on the instrument by 4 logs, or 99.99% This signif-icantly reduces the organic and microbial challenge to the high-level disinfectant or sterilant Furthermore, residual debris mayinhibit germicide penetration and shield microorganisms fromcontact with the germicide The recommended channel-cleaningbrushes and any special brushes (e.g., channel-opening-cleaningbrush) supplied by the manufacturer must be used to mechan-ically abrade all lumens while they are wetted with detergent.After manual cleaning is complete, there should be no visibledebris left on the instrument

When cleaning and disinfecting the endoscope, the cleaningtubes and attachments recommended by the endoscope manu-facturer for flushing the internal lumens of the endoscope must

be used This ensures that the required volume of fluid for ing, disinfection/sterilization, and rinsing passes through the in-ternal channels Figure 3.19 illustrates one such manufacturer’srange of cleaning attachments The Food and Drug Administra-tion (FDA) requires that the endoscope manufacturer validatethe steps listed in each instrument’s instruction manual Theseinstructions must be followed explicitly Shortcutting the pre-scribed procedure may result in an inadequately reprocessedinstrument that presents an infection control risk to medical per-sonnel and the next patient

clean-Leak testing

Periodically performing a leak test is an essential part of the processing procedure Leak testing the endoscope ensures thatthe seals, lumens, and external surface of the endoscope are fluidtight and will not allow reprocessing fluids to enter the inte-rior of the endoscope If a leak if detected, have the endoscope

re-EQUIPMENT 39

Fig 3.19 The cleaning attachments required to flush reprocessing chemicals through the lumens of a typical Olympus 160/180-series video endoscope.

repaired immediately Fluid invasion of the endoscope can causeextensive and expensive damage Furthermore, a breach in thesurface integrity of the endoscope can allow microorganisms

to enter the endoscope body, where they can reside and lateremerge, creating an infection control risk For all these reasons,every endoscope should be leak tested on a regular basis Dur-ing leak testing, and any time the endoscope is submerged influid, it is important that all sensitive components be protectedfrom fluid contact Most endoscopes require the attachment of awater-resistant cap to the electrical connector of the endoscope.This cap must remain attached during the entire reprocessingprocedure

High-level disinfection

In 1968, Dr Earle H Spaulding devised a classification systemthat divided medical devices into three categories (critical, semi-critical, and noncritical) based on the risk of infection involvedwith their use Based on the Spaulding classification system, GIendoscopes are considered by the FDA to be “semicritical med-ical devices’’ Semicritical medical devices are instruments that

do not enter sterile areas of the body and are generally in contactwith intact mucous membranes As such, both high-level disin-fection and sterilization are acceptable methods for reprocessing

GI endoscopes

High-level disinfection via an approved liquid chemical micide is the most commonly used method for reprocessing GIendoscopes High-level disinfection destroys all vegetative or-ganisms, but not necessarily all bacterial endospores The ger-micide must be cleared by the FDA explicitly as a high-level dis-infectant The FDA has approved several high-level disinfectantsfor use on medical devices, including 2.0–3.4% glutaraldehydes,7.5% hydrogen peroxide, 0.2% peracetic acid, 0.08% peraceticacid/1% hydrogen peroxide, and 0.55% ortho-phthalaldehyde.Each of these germicides has advantages and disadvantages interms of cost, contact time, temperature, and fume control re-quirements However, it is important to note that not all of theseproducts are compatible with all endoscopes Always check withthe endoscope manufacturer regarding chemical compatibility.Endoscopes are composed of a variety of rubbers, plastics,metals, glasses, adhesives, coatings, etc., which may be eitherimmediately damaged or gradually deteriorated following long-term exposure to certain chemicals Reported damage from in-compatible chemical germicides includes the loss of exteriorbody surface color and/or luster, loss of insertion tube stiffness,peeling of the insertion tube coating material, pitting and cor-rosion of anodized aluminum parts, chipping and peeling ofpainted and coated parts, crazing of plastic parts, deterioration

ger-EQUIPMENT 41

of adhesives, and insertion tubes that become sticky to the touch

The damage produced by some chemicals is quickly apparent

However, other chemicals may initially appear to be compatible,

with cumulative effects that only become apparent following

ex-tended use of the germicide The compatibility of all reprocessing

chemicals should be determined by contacting the endoscope

manufacturer If a third-party repair organization services the

endoscope, check with the service provider regarding the

chem-ical compatibility of replacement parts

Some germicides are suitable for manual reprocessing at room

temperature Others require heating and are only approved

for use in automated reprocessors Glutaraldehydes have been

used for 30 years and are available in both room temperature

and heated formulations They are relatively inexpensive, but

may require fume control in accordance with local and state

regulations Glutaraldehyde is an irritant and some

individu-als develop acute sensitivities resulting in irritation to the skin,

eyes, and nasal membranes, headaches, coughing, sneezing, and

asthma-like symptoms The safe use of glutaraldehydes requires

adequate ventilation (e.g., exhaust hoods, ductless absorbent

fil-ter systems) or enclosed automated reprocessing systems

The efficacy of any chemical germicide is dependent upon the

manufacturer’s instructions for use The label instructions

re-garding activation (if required), reuse life, and shelf life must

be followed explicitly All reusable germicides should be tested

regularly, as recommended by the manufacturer, to ensure that

they exceed the minimum effective concentration of the active

in-gredient The addition of significant quantities of microbes and

organic matter, dilution by rinse water, and aging of the chemical

solution, will all result in a gradual reduction in the effectiveness

of reusable high-level disinfectants/sterilants

Alcohol flush

Although many automated reprocessors use 0.2-µm microbial

retention filters to produce “sterile’’ water for the final rinse

following disinfection, other endoscopy units rinse their

endo-scopes in tap water Irrespective of the quality of the final water

rinse (“tap’’ water, “bacteria-free’’ water, “sterile’’ water), the

en-tire endoscope should be dried and each of its channels flushed

with 70% alcohol, followed by an air purge prior to reuse or

stor-age Alcohol aids in the drying process and inhibits the

recon-tamination of the internal channels with water-borne organisms

Special channels

Some endoscopes have special channels, such as an

auxil-iary water or water-jet channel These channels must be fully

reprocessed after each patient use, regardless of whether thechannel was used during the preceding patient examination Pa-tient debris and microorganisms can enter these channels even

if they are not used during the endoscopy exam These channelsoften require additional steps and special attachments to accessand flush the channel with detergent, disinfectant, rinse water,and alcohol (see Fig 3.19)

Automated reprocessors

Automated reprocessors standardize the disinfection cess and decrease personnel exposure to high-level disinfec-tants/sterilants No currently available reprocessor is approvedfor automating the entire cleaning procedure As a result, all ofthe prescribed steps for manually cleaning the endoscope must

pro-be performed prior to placing it in the automated reprocessor

If an automated endoscope reprocessor is used, the endoscopemust be connected to the reprocessor using the correct set of con-necting tubes Some endoscope models, particularly those withspecial channels, may require a different set of connecting tubesfrom those used on standard instruments Failing to connect aspecific channel opening or port to the reprocessor may result inpatient debris and infectious material remaining in the channel.Failure to reprocess any part of the endoscope poses an infectioncontrol risk to both medical personnel and patients

Rinsing and disposal

Whether reprocessing manually or using an automated machine,all disinfectant must be flushed from the endoscope’s internal lu-mens during the rinse process There have been several reports

in the medical literature of patients enduring chemical burnsand/or chemical colitis when residual disinfectant solution wasexpelled from the endoscope’s channels when used on the fol-lowing patient

Some germicides require deactivation or dilution prior to posal State or local ordinances may prohibit the dumping ordisposal of certain germicides into the city waste water system.Check with the germicide manufacturer and with state and localauthorities regarding disposal requirements

dis-Accessories

Many endoscopic accessories are deemed to be “critical’’ medicaldevices by the Spaulding classification system, since they eitherpenetrate mucous membranes (e.g., endoscopic cutting devices)

or enter normally sterile areas of the body (e.g., biliary ducts) Assuch, they should be sterilized prior to reuse Steam sterilization

EQUIPMENT 43

is the preferred method of sterilizing any reusable endoscopic

accessory that is autoclavable After sterilization, store sterile

accessories in an organized and protected storage system that

prevents damage to the sterile packaging

Storage

Store reprocessed endoscopes in a well-ventilated storage area

where they are protected against damage and contamination

Endoscopes should be stored with all valves and removable

parts removed, to facilitate drying The endoscope-carrying case

should never be used for storage of patient-ready endoscopes

Carrying cases are not ventilated, easily contaminated, cannot

be reprocessed, and intended for shipping and long-term

stor-age only Never put an endoscope that has not been completely

reprocessed into its carrying case In addition, reprocess any

en-doscope that is removed from a carrying case prior to subsequent

patient use

SUMMARY

During the 1990s, video image endoscopes supplanted

fiberop-tic endoscopes as the preferred instrument for examining the GI

tract The availability of two distinct technologies for generating

color images (color-chip versus RGB sequential) provides the

endoscopist with a choice of basic systems, each with its own

advantages and disadvantages Although the basic shape and

function of the instrument have remained unchanged, recent

advancements – including the development of smaller

diame-ter insertion tubes, the incorporation of standard features into

pediatric instruments, improvements in image resolution, and

advanced video processor features – have continued the

evolu-tion of the GI endoscope Proper reprocessing equipment and

procedures and a trained reprocessing staff are essential to

en-suring the health and safety of health care workers and patients

alike

FURTHER READING

Alvarado CJ, Mark R APIC guidelines for infection prevention and

con-trol in flexible endoscopy Am J Infect Concon-trol 2000;28:138–55.

Barlow DE Flexible endoscope technology: the video image endoscope.

In: Sivak MV Jr (ed), Gastroenterologic Endoscopy, Vol 1, 2nd edn.

Philadelphia, PA: WB Saunders; 2000:29–49.

Barlow DE How endoscopes work In: Ginsberg GG, Kochman ML,

Norton I, Gostout CJ (eds), Clinical Gastrointestinal Endoscopy.

Philadelphia, PA: Elsevier Saunders; 2005:29–47.

Food and Drug Administration FDA-cleared sterilants and high level

disinfectants with general claims for processing reusable medical and

dental devices – May 13, 2005 FDA-CDRH, Rockville, MD; 2005 able at: www.fda.gov/cdrh/ode/germlab.html Accessed July 7, 2005 Kawahara I, Ichikawa H Flexible endoscope technology: the fiberoptic endoscope In: Sivak MV Jr (ed), Gastroenterologic Endoscopy, Vol 1, 2nd edn Philadelphia, PA: WB Saunders; 2000:16–28.

Avail-Knyrim K, Seidlitz H, Vakil N, et al Optical performance of electronic imaging systems for the colon Gastroenterology 1989;96:776–82 Moriyama H Engineering characteristics and improvement of colono- scope for insertion Early Colorectal Cancer 2000;4(1):57–62 Moriyama H Variable stiffness colonoscope – structure and handling Clin Gastroenterol 2001;16(2):167–72.

Nelson DB, Barkun AN, Block KP, et al Transmission of infection by gastrointestinal endoscopy Gastrointest Endosc 2001;54:824–8 Nelson DB, Jarvis WR, Rutala WA, et al Multi-society guideline for re- processing flexible gastrointestinal endoscopes Gastrointest Endosc 2003;58:1–8.

Recommended practice for cleaning and processing endoscopes and doscopic accessories AORN J 2003;77:434–42.

en-Rutala WA APIC guideline for selection and use of disinfectants Am J Infect Control 1996;24:313–42.

Schapiro M Electronic video endoscopy A comprehensive review of the newest technology and techniques Pract Gastroenterol 1986;10:8–18 SGNA Guidelines Guidelines for the use of high-level disinfectants and sterilants for reprocessing of flexible gastrointestinal endoscopes Gas- troenterol Nurs July/August 2004;27(4):198–206.

Sivak MV Jr, Fleischer DE Colonoscopy with a video endoscope liminary experience Gastrointest Endosc 1984;30:1–5.

Pre-Video colonoscope systems Health Devices 1994;23:151–205.

4

Patient Preparation

The patient preparation before pediatric gastrointestinal

endo-scopies targets anxiety reduction, reassurance of child

well-being, and creation of the optimal conditions for safe sedation

and monitoring during procedure and recovery A high level of

anxiety is typical for children and parents before endoscopy This

has to be reduced as much as possible to minimize a child’s stress

and parental frustration and to create a suitable condition for the

patient–nurse interaction during placement of the intravenous

access, obtaining baseline vital signs, and placement of the

mon-itoring sensors It is extremely important to find a delicate

bal-ance between the full disclosure of the invasive nature of the

procedure and related complications and anticipated parental

and patient responses to the disclosed information This is one

of the moments when a pediatric gastroenterologist should act

as a well-trained psychologist for the parents and the patient

be-cause parental cooperation and support is an important element

of patient preparation The preprocedure conversation

empha-sizes the fact that the routine endoscopic procedure is safe and

is going to be performed by a very well trained physician and

assistants in the medical facility, which is fully equipped for any

supportive care necessary

The assessment of the patient is focused on the child

well-being and recognition of any risk factors, such as recent meals,

allergies, recent respiratory illness, or chronic conditions, such

as asthma, gastroesophageal reflux disease, seizure disorder, or

other diseases, which may complicate a sedation or the patient’s

recovery Children with the American Society of

Anesthesiol-ogists (ASA) physical status 3 and 4 and patients who are

go-ing to have procedures such as achalasia dilation, foreign body

removal, and percutaneous endoscopic gastrostomy placement

are typically selected for general anesthesia and should be

as-sessed by an anesthesiologist Children with congenital heart

diseases or a compromised immune system are candidates for

endocorditis prophylaxis The intravenous access should be

es-tablished and secured by well-trained medical personnel Special

attention has to be paid to the right size and placement of the

pulse oximeter sensors because detachment from the skin,

dis-placement of the two diodes more than 2–3 mm, or exposure to

ambient light may lead to an optical shunt and false high or low

readings Parental cooperation and support is also an important

element of the patient’s preparation

Practical Pediatric Gastrointestinal Endoscopy

George Gershman, Marvin Ament Copyright © 2007 by Blackwell Publishing Ltd

PEDIATRIC-MONITORED SEDATION AND ANESTHESIA FOR DIAGNOSTIC AND THERAPEUTIC PROCEDURES IN ENDOSCOPY

Monitored sedation and analgesia for diagnostic and tic procedures performed by pediatric gastroenterologists andanesthesiologists outside of the operating room has dramaticallyincreased In the recent past there has been a great understand-ing on how to perform sedation and analgesia in infants andchildren within and outside the operating room in ways thatminimize their potential fear or pain

therapeu-Endoscopic procedures performed outside of the operatingroom require the same attention to anxiolysis, analgesia, andsedation as procedures performed in the operating room.Painful procedures such as endoscopy and liver biopsy requireanalgesia and often monitored sedation The sedation which isusually provided may reach levels that are quite deep or be sim-ilar to general anesthesia

Young children as well as those that are developmentally andmentally handicapped are often unable to remain motionlessfor even short periods of time This is not all that different inchildren without these disabilities The fear and anxiety, which isoften associated with the contemplation of procedures, is at timesdifficult to control and may be worsened by parental anxiety,separation from the parents, and the anticipation of potentialpain from the procedure

One of the major reasons for the increase in procedures side of the operating room that require monitored sedation andanalgesia has been the emphasis by managed care providers onlowering cost

out-Third care providers and managed care providers have thebelief that performing these procedures outside of the operatingroom will lower cost It is assumed that monitored sedation andanalgesia for diagnostic and therapeutic procedures can be pro-vided more cheaply, conveniently, and efficiently outside of theoperating room

In many instances endoscopic procedures, which in the pastmay have been performed in the operating or recovery room, arenow performed in offices or special procedure rooms, at timeswithout the direct supervision of an anesthesiologist

Anesthesiologists have helped to develop institution lines for monitored sedation as well as anesthesia outside of theoperating room as required by the Joint Commission on Accred-itation of Healthcare Organizations

guide-Definition of levels of sedation

Sedation and analgesia for diagnostic procedures such as per intestinal endoscopy and colonoscopy represents a contin-uum of consciousness to unconsciousness, with three levels more