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Diabetic Colon Preparation for GI Procedure. Ann Hayes BSN, RN, CGRN Marti Buffum DNSc , RN, PMHCNS-BC Joyce Hughes MS, RN, CGRN Veterans Affairs Medical Center San Francisco. Background. Colon cancer second leading cause death from a cancer in North America

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diabetic colon preparation for gi procedure

Diabetic Colon Preparation for GI Procedure

Ann Hayes BSN, RN, CGRN

Marti Buffum DNSc, RN, PMHCNS-BC

Joyce Hughes MS, RN, CGRN

Veterans Affairs Medical Center

San Francisco

background
Background
  • Colon cancer second leading cause death from a cancer in North America
  • 150,000 colon cancer diagnosed per year
  • Totally preventable
colonoscopy
Colonoscopy
  • Increasingly used for screening
  • Adequate bowel prep significant for GI units and patients
clinical problem
Clinical Problem
  • Inadequate colon preparation means repeat procedure
  • Colonoscopy has potential risks
    • Bleeding and perforation
    • Sedation complications:
      • Cardiac
      • respiratory
required bowel cleansing
Required bowel cleansing
  • Day prior to procedure
  • Wide variety of colon preps
  • Patients often complain about prep
preventing repeat procedure
Preventing repeat procedure
  • Decreases availability of colon screening
  • Maximizes patient safety
  • Ensures organizational efficiency
clinical problem in gi unit
Clinical Problem in GI unit
  • 1997 Survey of 64 patients colonoscopy preps

19% had good preps

81% poor prep means repeat exam

  • GI nursing staff began QI project to improve patient care by improving colon preps
nursing interventions to improve colon preps
Nursing Interventions to Improve Colon Preps
  • Improve patient education
  • Phone call week prior to procedure
2001 survey
2001 Survey
  • 50 colon preps = 79% good to excellent
  • But diabetic colon preps = only 63% good

New finding!!

prep survey
Prep Survey
  • Suggests diabetic patients having more difficulty attaining adequate colon prep
  • Needs to improve / change the way diabetic patients are prepped
are diabetics different
Are diabetics different?
  • Need to do a literature review
  • Found no colon prep studies with diabetic
literature review
Literature review
  • Nakahara et al., (2002)
    • Gastroparesis: slow emptying of stomach
  • Well known in medicine
  • Causes nausea and often vomiting
literature
Literature
  • Taylor & Schubert (2001) diabetic patients prepped significantly less effective prep
  • Using PEG solution for colonoscopy
  • 17 of 45 diabetic patients had inadequate colon prep
literature17
Literature
  • Fincher et al (1999) : preps for sigmoidoscopy less likely to be adequate
  • Study of 299
  • Regardless of which 3 preps used, diabetics less likely to have adequate prep
literature review18
Literature review
  • Study by Maleki et al., (1998): significantly slower colonic transit times
  • Ascending and transverse colon slower
  • Study by Celik et al., (2001)
  • Constipation a problem for 2/3 diabetics
special needs of diabetic
Special Needs of Diabetic
  • Approach to colon prep in diabetic patients needs to be different
  • Need to change standard prep used
peg solution
PEG Solution
  • Polyethylene glycol-based isotonic salt solution
  • Davis et, al 1980
  • Safest and most commonly used
sodium phosphate solution
Sodium Phosphate Solution
  • Low volume, strong laxative
  • Associated with dangerous fluid & electrolyte shifts
  • FDA issued a warning
magnesium citrate mg
Magnesium Citrate (Mg)
  • Study by Berkelhammer 2002 showed Mg citrate milder, low volume laxative
  • Minimizes electrolyte imbalance, dehydration & aphthous ulcers
    • Sodium phosphate solution = 5.5% ulcers
    • Mg = 1% ulcers
    • Significant finding: p< 0.01
mg citrate
Mg Citrate
  • Aphthous ulcers lead to diagnosis confusion
  • Could be: IBD, ischemic colitis or infection
mg citrate24
Mg Citrate
  • Available over the counter & low cost
  • Minimal fluid and electrolyte shift
  • Fewer incident aphthous ulcers
mg citrate electrolytes
Mg Citrate & Electrolytes
  • Sharma et, al 2001 study showed:
    • No significant shifts in BP, pulse and electrolytes
    • Mg citrate safe & effective for colon cleansing
usual reaction to failed colon prep
Usual Reaction to failed colon prep
  • Repeat colonoscopy
  • Double PEG = 8 liters
double prep problem
Double Prep Problem
  • Diabetics have slow gastric emptying
    • Would have difficult consuming large volumes
    • Possible vomiting and non adherence
constipation problem
Constipation Problem
  • Large percentage of diabetic are constipated
  • Need to correct this prior to starting colon prep
decision process
Decision Process
  • Conferred with Dr McQuaid, Chief GIDC
  • Tried new prep on small group with good success
standard colon prep
Standard Colon Prep
  • Clear liquids day prior to colonoscopy
  • Late afternoon:
    • 10 oz Mg citrate
    • 4 liters PEG
new diabetic colon prep
New Diabetic Colon Prep
  • All patients have clear liquid diet day prior
  • Diabetics: two days prior to exam 10oz. Mg citrate
  • All patients: day before test, 10oz Mg citrate and 4 liters PEG
research question
Research Question
  • Will new colon prep two 10oz Mg citrate (1 day apart) & 4 liters PEG solution improve diabetic prep over original prep 10oz Mg citrate and 4 liters PEG solution?
method
Method
  • Design: Experimental design
  • Randomized controlled trial
  • Double blinded: physician-nurse team and patient
conducted at gidc
Conducted at GIDC
  • University-affiliated VA Medical Center
  • IRB approval form University of California and VA Research Committee
  • 200 subjects
procedure
Procedure
  • Consent
  • Randomization: random table of numbers
  • Blinded procedure staff
  • Patient drinks one of two preps: experimental or standard
instruments
Instruments
  • Demographic Information
    • Age
    • Sex
    • Use of narcotics
    • Years of being diabetic
    • Signs of peripheral or retinal neuropathy
    • Serum creatinine
instruments37
Instruments
  • Patient Questionnaire
    • Which prep consumed?
    • How much was consumed?
    • How long it took to consume ?
instruments38
Instruments
  • Colon cleansing scale
    • Used by GI staff since 1998
    • Adams et al., (1994)
    • Scale of 1 to 5
      • 1 = very clear of feces
      • 5 = solid stool, aborted procedure
      • Colon rated at cecum, consensus between nurse and endoscopist
inclusion criteria
Inclusion Criteria
  • Outpatient colonoscopy
  • Diabetic
  • English speaking
exclusion criteria
Exclusion Criteria
  • Dementia
  • Psychosis
  • Prior colon surgery
procedures
Procedures
  • Recruitment: all diabetic outpatients being scheduled for colonoscopy
  • Consented patients
  • Select randomizedenvelope (table of random numbers)
procedure42
Procedure
  • Give prep and instructions: standard or experimental
  • All patients received verbal and written instructions from GI RN
procedures continued
Procedures Continued
  • Day of procedure: admitting nurse completes demographics
  • MD and patient (blinded):

completed colon prep evaluation during colonoscopy

study results demographics
Study Results: Demographics
  • Mean age 62 years
  • Men 187; women 8
  • IDDM = 53; NIDDM = 143
  • Demographics not significantly different between the two groups
study results
Study Results
  • Good colon prep:
    • Diabetic (experimental) prep = 70% Standard prep = 54%
    • Chi-square = 5.14
    • P = 0.02
    • Diabetic patients who used Diabetic prep had significantly cleaner colon
conclusion
Conclusion
  • Diabetic patients having a colonoscopy will get better colon cleansing if given 10 oz Mg citrate two days prior to procedure then 10 oz Mg citrate and 4 liters PEG the day prior to procedure
  • Other GI procedure units could confidently implement this prep for diabetic patients
practice change
Practice Change
  • Diabetic prep routinely for all diabetic patients scheduled for colonoscopy
  • Expanding the use of this prep to patients with constipation and those who had inadequately cleans colon on past colonoscopy
diabetes serious common problem in us
Diabetes Serious & Common Problem in US
  • 2008: 8% (24 million)
  • 2010 increase to 15%
  • Veterans 20% in 2000
  • Most are 60 years and older
safety of mg citrate
Safety of Mg Citrate
  • There were no adverse events in study
    • No clinical evidence of:
      • Hypovolemia
        • Electrolyte imbalance
patient tolerance to mg citrate
Patient tolerance to Mg Citrate
  • No patient in study voiced complaint
    • Flavor tolerated
    • Comfort

Significant fewer repeat colonoscopy

limitations of study
Limitations of Study
  • Small number of women in study
  • Question concerning constipation not effective
strengths of study
Strengths of Study
  • Large sample size
  • Experimental design
  • Double blind
  • Hence finding are generalizable
goal is clean colon
Goal is Clean Colon
  • When prepping patient consider:
    • Bowel habits
    • Medical conditions
    • Difficulty swallowing
    • Lack of mobility

Above may warrant change is colon prep

nursing research
Nursing Research
  • Effects the nursing culture
  • Nurse involved in research are likely to:
    • Develop innovations
    • Find best practices to improve patient care