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CONSENT:PATIENTS + DOCTORS MAKING DECISIONS TOGETHER. GMC. June 2008. CONSENT FOR ENDOSCOPIC PROCEDURES. UHCW JULY 2012. CONSENT FOR ENDOSCOPY. PRINCIPLES OF CONSENT. PATIENTS LACK CAPACITY. OGD COLON FOS ERCP DIABETES CJD.
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CONSENT:PATIENTS + DOCTORS MAKING DECISIONS TOGETHER.GMC. June 2008. CONSENT FOR ENDOSCOPIC PROCEDURES. UHCW JULY 2012.
CONSENT FOR ENDOSCOPY. • PRINCIPLES OF CONSENT. • PATIENTS LACK CAPACITY. • OGD • COLON • FOS • ERCP • DIABETES • CJD.
PRINCIPLES OF CONSENT .FROM MINOR INTERVENTIONS TO MAJOR DECISIONS + SCREENING. • 1. LISTEN TO THE PATIENT-THEIR FEARS /CONCERNS. • 2. DISCUSS SYMPTOMS – WHAT IS DIFF . DIAGNOSIS, WHAT ARE THE LIKELY INVESTIGATIONS / TREATMENTS. • 3. SHARE INFORMATION – BENEFITS + RISKS OF INVESTIGATIONS/ EXPLAIN MEDICAL JARGON . • 4. MAXIMISE PATIENTS OPPORTUNITIES TO MAKE DECISION THEMSELVES. • 5. RESPECT THEIR DECISION. • 6. IF PATIENT HAS CAPACITY – ONLY THEY CAN MAKE DECISION. • 7. IF PATIENT ALLOWS DR TO MAKE DECISION – THEY MUST STILL BE TOLD BENEFITS / RISKS- DOCUMENT • 8. 2nd opinion
CONSENT- PATIENTS WHO LACK CAPACITY.Exclude deafness/ acute confusion/ depression/ medication. • 1. WHAT IS IN PATIENTS BEST INTERESTS? • 2. INVOLVE FAMILY MEMBERS/ CARERS. • 3. PATIENT NEED ADVOCATE ? • 4. TAKE INTO ACCOUNT PATIENTS VIEWS BEFORE LOSS OF CAPACITY. • 5. FOLLOW LAW . • 6. NEEDS AT LEAST 2 DOCTORS TO CONSENT FOR PROCEDURE – CONSULTANT . • 7. CEILING OF TREATMENT .
OESOPHAGO-GASTRO-DUODENOSCOPYOGD. • DIAGNOSTIC/ THEUAPEUTIC. • Preparation-EMPTY STOMACH- DO NOT EAT 6 HOURS BEFORE. • MEDICATION TAKEN+ tell nurse allergies. • Aspirin – stop 10 /7 , clopidogrel- stents/ cardiology. • WARFARIN – STOP 5/7 BEFOR + CHECK DAY PROCEDURE. • SEDATION – • 1. THROAT SPRAY –cannot eat 1 hour post . • 2. ivi sedation – need O2 SAT MONITOR, HR+ BP. • Can not drive/ operate machinery / sign legal documents. • REMOVE DENTURES.
OGD 2.RISKS TO DISCUSS –PRE CONSENT. • DAMAGE TEETH. • PERFORATION- 1 IN 1500. OGD. RARE BUT SERIOUS. • BLEEDING.1 IN 150. • COMPLICATION OF SEDATION – HYPOTENSION/ RESPIR ↓-transient. • THEUAPEUTIC OGD . • 1. DILATION – PERFORATION RATE= 10% • Life threatening- hospital admission/ surgery. • 2. SEMS/ STENT INSERTION. • 10% complication rate – bleeding, migration+ pain. • RECOVERY • Explain findings, eat / drink, given report+ telephone nos.
COLONOSCOPY.DIAGNOSIS+ THERAPEUTIC . • WHY COLONOSCOPY – CT blind since collapsed bowel/ no bx. • MEDICATION- STOP IRON 1 WEEK BEFOR COLON. • STOP OPIOIDS, CODEINE, LOPERAMIDE 3/7 BEFOR. • WARFARIN STOP 5/7 BEFOR. • DIABETES – LATER SLIDE. • ALLERGIES. • DIET- MUST BE LOW RESIDUE DIET 2/7 BEFOR COLON. • NO FIBRE- no vegetables/ fruit/ cereals / brown bread. • PROTEIN- meat/ fish with pasta + white rice. • ↑ fluids . • BOWEL PREP ~RENAL FUNCTION/ GFR. • HAEMODIALYSIS / CRF gfr< 50-25 –alternative bowel prep.
COLONOSCOPY BOWEL PREP.MUST KNOW GFR/ RENAL FUNCTION. • 1. 5 SENNAKOT TABLETS • 2. MOVIPREP SACHET IN 2 PINTS WATER. • 3. 4 HOURS LATER –ANOTHER MOVIPREP 1-2 PINTS. • SEDATION -can not drive home/machinery 24 hrs. • RISKS- • 1.PERFORATION- 1 IN 1000 COLONS. • 2. BLEEDING. RISK 1 IN 100-200. • 3. SEDATION – TRANSIENT . • RECOVERY – see copy report / explanation HOME ALONE – admission 24 hours. • Telephone nos if emergency.
FOS- FLEXIBLE SIGMOIDOSCOPY. • LOW RESIDUE DIET -2/7 PRIOR . • No vegetables/ fruit / cereals. • Same medication to be avoided- • WARFARIN STOP 5/7. • GIVEN ENEMA PR BEFOR PROCEDURE. • RISKS OF FOS- • VERY LOW IF DIAGNOSTIC. • 1 IN 15,000 SUFFER PERFORATION. • 1 IN 200 – BLEEDING ( POLYPS REMOVAL) • Needs injection tx adrenaline/ clips / thermal. • RECOVERY • Explain report, eat + drink.
ERCPENDOSCOPIC RETROGRADE CHOLANGIO-PANCREATOGRAPHY. • Side viewing endoscope advanced into prox. Small bowel to cannulate ampulla + visualize biliary tree under XR imaging. • Remove stones, sphinctomy+ insert stents. • PREPARATION –no eating 6 hr prior. • Check – warfarin, aspirin + clopidogrel. • SEDATION. • RISKS- • 1. PANCREATITIS 1-2% , 1 IN 50 CASES. • 2. BLEEDING –SPHINCTOMY 2%. • 3. PERFORATION . • 4. REACTION TO SEDATION . • RECOVERY – findings explained/ report / telephone nos.
DIABETES + ENDOSCOPY PREPARATION + DIET FOR COLON/ FOS • 1. IDDM. • 2 DAYS PRIOR TO ENDOSCOPY- follow low residue diet. • Bed time insulin reduce by 50% • 1 DAY BEFORE PROCEDURE- low residue diet . • Take am insulin as normal. • Commence bowel prep / fluids +reduce insulin by 50% • MONITOR BM, take glucose if necessary. • DAY OF PROCEDURE. • DO NOT TAKE INSULIN AM. • CHECK BM, • Bring insulin with you – post procedure dose/ eating.
DIABETES + ENDOSCOPY PREPARATION FOR COLON. 2 • 2. NIDDM / DIET • 2 DAYS PRIOR – • Low residue diet . • 1 DAY BEFORE PROCEDURE- • Once on bowel prep / fluids DO NOT METFORMIN. • If on GLICLAZIDE –DO NOT TAKE PM DOSE. • MONITOR BM- take glucose if low. • DAY OF PROCEDURE- • DO NOT TAKE DIABETIC MEDICATION. • Bring medication so post procedure .
ENDOSCOPY +CREUTZFELDT-JAKOB DISEASECJD. • CJD RARE+ FATAL NEURO DEGENERATIVE BRAIN DISEASE. • GROUP DISEASES-CALLED TSE (TRANSMISSIBLE SPONGIFORM ENCEPHALOPATHIES ) – affect humans + domestic animals. • Mechanism of TSE- ↑ in naturally occurring prion protein. • CJD –sporadic =no cause (80% , rare) • --inherited types (15%) • --variantCJD = strongly linked to ingestion of food containing a TSE called BOVINE SPONGIFORM ENCEPHALITIS . • IATROGENIC CJD very rare. 4 cases via blood transfusion. • CJD can be accidentally transmitted during medical ( endoscopy ) or surgical procedures- no cases so far. • Identify patients who may be risk gp for CJD – since endoscopy might pass infective agent on.
RISK ASSESSMENT FOR IDENTIFICATION OF PATIENT WHO MIGHT CARRY TSE DISORDER. • 1. HAS PATIENT RECEIVED NATURAL GH? • 2. PATIENT RECEIVED NATURAL PITUITARY HORMONE? • 3. FH OF CJD / TSE • 4. ANY NEUROSURGICAL / ENT IMPLANT BEFOR 1993- implantation of human dura mater graft. • 5. is CJD PART OF DIFF DIAGNOSIS ? • IF YES TO ANY OF THESE- • ALL INVASIVE PROCEDURES STOP. • INFORM INFECTION CONTROL.
