Safe & Effective Abdominal Pressure During Colonoscopy: Forearm Versus Open Hand Technique

1. Safe & Effective Abdominal Pressure During Colonoscopy: Forearm Versus Open Hand Technique Presented By: St. James Healthcare Education Collaborative With The Support Of: Susan DePasquale, Barbara Dudden & Bonita Becker GI Endoscopy - Surgical Services Department

2. Safe & Effective Abdominal Pressure Purpose & Methods: • purpose is to help the scope around the colon • start abdominal pressure with patient positioned on their left side [although some endoscopists will occasionally request to reposition patient from their left to supine, right side or prone if not successful with scope advancement in the typical left side position] • scope progression through the colon (as visualized on the video monitor screen) means effective pressure is being provided

3. Safe & Effective Abdominal Pressure Purpose & Methods: • provide external abdominal pressure around the area of the scope to assist scope movement through the colon and decrease scope looping within the colon • think about the size of the “scope head” and how to provide “splinting” around the scope to help direct its movement

4. Safe & Effective Abdominal Pressure Technician needs to be aware of the following during colonoscopy: • where the scope is located in the colon • physician effort to reduce a loop by pulling back / repositioning scope (to allow technician to provide adequate counter pressure) • best place to start external abdominal pressure is the sigmoid area (a common place for loop formation) • how to apply external pressure and reposition hand(s) around other areas of the colon if sigmoid pressure is not effective • signs of patient discomfort during abdominal counter pressure and scope advancement

5. Safe & Effective Abdominal Pressure Several key factors are crucial to keep in mind when applying abdominal pressure during colonoscopy: • awareness of the amount of abdominal pressure exerted to avoid injury to technician or patient • open hand technique and increased risk of wrist injury to technician • good body mechanics and positioning to ensure optimal comfort for technician • forearm techniques which allows the technician to provide effective and safe abdominal pressure while reducing the risk of injury to technician or patient

6. Safe & Effective Abdominal Pressure SCENARIO 1: OPEN HAND TECHNIQUE Technique: technician’s hands equally applies counter pressure to the left upper and lower abdomen - sigmoid and splenic flexure of the colon Ergonomic Issue: arrow indicates areas of possible injury to the technician

7. Safe & Effective Abdominal Pressure SCENARIO 2: OPEN HAND TECHNIQUE Technique: technician’s hand covers only the left lower abdomen - sigmoid portion of the colon. Ergonomic Issue: arrow indicates area of possible injury to the technician.

8. Safe & Effective Abdominal Pressure SCENARIO 3: SINGLE FOREARM TECHNIQUE Technique: “Prechel pressure” is where the technician’s left forearm rolls into the patient with left hand under pelvic bone while right hand pulls the patient forward; allowing patient’s own weight to act as counter pressure. Ergonomic Issue: potential strain from ineffective use of patient’s own weight. hand over sigmoid / midline colon

9. Safe & Effective Abdominal Pressure SCENARIO 4: TWO-FOREARM TECHNIQUE Technique: Technician’s left forearm in Open Hand Technique, right hand under splenic flexure below diaphragm (fingers extended, knuckles down, or fisted). Ergonomic Issue: Potential strain if not performed with another person rolling the patient onto the technician’s forearm to apply counter pressure. hands over sigmoid, midline, splenic flexure, and mid-transverse colon

10. Safe & Effective Abdominal Pressure “It is advantageous for one to know the most effective muscle group in order to apply pressure correctly and safely. Communication amongst the team is also imperative to provide any compromise and consensus necessary on patient positioning, i.e., how the table height is set, if others will be available to assist with pressure, where everyone will stand, duration of pressure before a moment of release is needed, what are appropriate forces for pressure applied, if an additional monitor can be available, and an appropriate height stepstool. When pressure is needed to assist with movement of the scope or looping, the assistant applying pressure needs to be able to stand in a posture that allows the body to assist with the technique. This is one that maintains the back in a neutral spine posture and allows the knees and hips at least a slight bend to be more fluid in the stance”. Cynthia Edgelow, MSN, RN, CGRN; Ray Hucke, MPH, OT; and Jim Prechel, GI Tech. Mayo Clinic, Scottsdale, Ariz.

11. Safe & Effective Abdominal Pressure • Most pressures, when applied with good body mechanics and positioning, should be sufficient for 3-5 minutes. • When longer periods of applying abdominal pressure are needed there should be communication between the technician and endoscopist to provide a moment to relax the pressure. • Fatigue or discomfort to the arms should be communicated by the technician so that another person may take over or help with directing the patient’s weight onto the forearms.

12. Safe & Effective Abdominal Pressure • The technician needs to be aware of their own height, arm lengths, and muscle strengths while applying abdominal pressure. • Work with the various techniques of applying abdominal pressure to find the postures and position most effective to splint the scope, reduce looping, provide comfort to the patient, and protect technicians supporting the endoscopist during colonoscopy.

13. Safe & Effective Abdominal Pressure For the comfort of the patient and protecting sensitive soft tissue: • Be aware of point of pressure (increases with a smaller surface area where abdominal pressure is applied) • Splint to assist with reducing scope looping, applying pressure over as broad an area as possible to stabilize tissue around the scope along with downward pressure against the abdomen • External abdominal pressure during colonoscopy does not need to be exceptionally forceful (with possibly the exception of patients with obesity or large abdominal girth) • Duration of the abdominal pressure applied may be determined by the speed of the procedure – be aware of length of time

14. Safe & Effective Abdominal Pressure Be aware of pinpoint force being directed to a precise focal point: • Similar to wound care management, localized and prolonged abdominal pressure during colonoscopy are discouraged • If colonoscopy pressures are applied for longer duration be aware of patient discomfort and the potential injury to the patient due to pressure being applied using fingertips, elbows, or fists • Possibly less assistance in loop reduction and direction of motion can occur with external smaller pressure areas because of colon flexibility and layers pressed against the abdomen • Pressure over a broad spectrum is preferred because it allows pressure to be displaced evenly

15. Safe & Effective Abdominal Pressure References: • James A. Prechel & Ray Hucke (2009). Safe and Effective Abdominal Pressure During Colonoscopy. Gastroenterology Nursing. Vol. 32; No. 1. Jan/Feb 2009; pp. 27 – 30. • Cynthia Edgelow, Ray Hucke, MPH, OT & Jim Prechel, GTS (2007). The Importance of Positioning During Colonoscopy. ENDONURSE.