Chicago SGNA

Fall into GI 2013 A Special "Hands-On" ERCP Clinic Station Objective Handouts

Chicago SGNA Education Committee 11/9/2013

OBJECTIVES FOR STATION #1

DESCRIBE THE ROLE OF THE RN/GI TECH IN PREPARING THE

ENDOSCOPY SUITE

Position carts and monitors in the room for easiest viewing of

monitor and fluoroscope screen by MD and assistive personnel

Work top organization should include and organizer with pockets

or clips to hold various equipment (wires tend to be long), gauze,

sterile water, normal saline and alcohol pads (to clean sticky

contrast agents off gloves)

Equipment preferences of the MD.

PPE equipment including gowns, gloves, masks, lead aprons with

thyroid collar, X-ray badges, and X-ray in use warning signs, X-ray

protective goggles

RN RESPONSIBLE FOR

drawing up and proper labeling of all medications

used during procedure, including

contrast agent 1/2 strength and full strength with

no air bubbles

Normal saline and or sterile water drawn up in

20ml syringes

glucagon available

simethicone available (not used in all institutions)

sedation used during procedure (unless general

anesthesia)

reversal meds readily available

IDENTIFY VARIOUS TYPES OF ERCP EQUIPMENT INCLUDING CANNULATOMES AND WIRES

HANDS ON DEMONSTRATION AND RETURN DEMONSTRATION OF ERCP EQUIPMENT- including

cannulatomes and wires

E ndoscopic - Looking inside with a scope

R etrograde - Backwards

C holangio - Biliary

P ancreatography – Pancreas –

using radiographic examination

Cholelithiasis: Gallstones in the

gallbladder

Cholangitis: Inflammation of the

common bile duct, often

secondary to bacterial infection

or choledocholithiasis

Cholecystitis: Inflammation of

the gallbladder secondary to

gallstones

Choledocholithiasis: Gallstones,

which have migrated from the

gallbladder to the common bile

duct

We discussed the SGNA position statements-

Ergonomics in the Gastroenterology Setting

Radiation Safety in the Endoscopy Setting

Available at www.sgna.org

OBJECTIVES FOR STATION #2

Describe the role of the RN Pre-procedure/patient assessment

RN needs to completely assess the patient prior to the procedure, and accurately

document all nursing measures, including the following:

Date/time of arrival

History obtained from

Who is accompanying the pt/who is driving home?

Ambulation

Indications for procedure- (evaluation of s/s of malignancy, acute/recurrent/chronic

pancreatitis, CBD stones, unexplained chronic abdominal pain, jaundice, possible bile

duct disease, pre or post cholecystectomy stone removal, ampulla and bile duct

manometry

Pt ID and Allergy/other Alert Bands

Previous sedation problems

Medical and surgical history

Metal implants/ICD for grounding pad placement

Current Medications

Current Physical exam including- vital sign, lungs sounds, bowel sounds, Ht and wt,

pregnancy status

NPO status

Dentures

Advanced directives

Belongings

Current Lab results

Start or check for patent IV line

Assess knowledge deficits for patient education related to ERCP

length of procedure

Positioning

use of flouro

sedation and monitoring

indications

recovery expectations

Ensure any preoperative MD orders are implemented

Identify various types of ERCP equipment including those to facilitate access and opening of the ampulla

such as a needleknife, dilators and biliary balloon dilators

HANDS ON RETURN DEMONSTRATION OF ERCP EQUIPMENT including those to facilitate access and

opening of the ampulla such as a needle knife, dilators and biliary balloon dilators

We discussed the SGNA Standards and guidelines

Guidelines for Documentation in the Gastrointestinal Endoscopy Setting

Available www.sgna.org

OBJECTIVES FOR STATION #3

Describe the role of the RN Intra-procedure, including proper positioning and possible complications of

poor positioning of the ERCP patient

Goal is to position for patient comfort with the least chance for complications

usually prone or slight left lateral (prone is best anatomically)

if pt is to be intubated, done supine and then turned prone with a minimum

assist of 4 people

preserve cervical spine and body alignment

pad under bony prominences

pad or pillow under shins will prevent foot drop

ask ladies if their breasts are comfortable, men if their scrotum is

comfortable

arms should never be >90 degrees at the shoulder

Potential Complications from poor positioning

nerve damage (axillary, radial, ulnar, peroneal or tibia nerves)

vessel compression

pressure ulcers

compartment syndrome (straps too tight)

V/Q mismatch (one lung perfusing, one lung oxygenating)

atelectasis (shallow breathing due to pressure on chest)

corneal abrasions

Identify various types of ERCP equipment for stone retrieval

Hands on return demonstration of ERCP equipment- including stone retrieval balloons and baskets

PRONE POSITIONING SHOWING PROPER PADDING UNDER BONY

PROMINENCES

POSSIBLE NERVE DAMAGE

DUE TO CHEST COMPRESSION

V/Q MISMATCH

A VQ Mismatch in respiratory pathophysiology is a problem with either the Ventilation (air

going in and out of the lungs) or the Perfusion (Oxygen and Co2 diffusion at the alvioli and

the pulmonary arteries). VQ ratios compare the amount of air reaching the alveoli to the

amount of blood reaching the alveoli.

Ventilation Problems include: inadequate rate or tidal volume during respiration. For

example, the person has an adequate rate of respirations (say, 18 breaths per minute), but

the tidal volume is insufficient). This would be considered a V/Q mismatch relating to a

problem with the V side of the equation.

Alternatively, you may have a perfusion problem. For example, excess pulmonary dead

space,such as: emphasema, bronchitis, pneumonia, atelectasis, low pulmonary artery

pressures, RVF, lack of haemoglobin availability (as a result of haemorrhage or Carbon

Monoxide Poisoning).

OBJECTIVES FOR STATION #4

Describe the roles of the RN or GI tech during ERCP, intra-procedure

One RN to be considered the "circulating" RN

liason between the outside and the procedure room

administer and monitor sedation (unless general or MAC)

be responsible for accurate and thorough documentation of all nursing

measures

be able to retrieve equipment, troubleshoot, and carry out MD orders

during procedure

One RN or tech to be considered the "scrub or assist" role (some institutions may use GI techs during

ERCP)

has to be extensively familiar and competent with ERCP equipment to work with the MD

Circulating RN role

RN responsibility of accurate documentation of the following:

re-verify Pt ID and procedure during time out

verify consent form signed

all personnel involved in case

scope ID used

events or occurrences

vital signs per protocol

any specimens retrieved

therapeutic devices used (cautery, balloons, dilators)

grounding pad placement and evaluation of skin

IV fluids

fluoroscopy time

if pt was shielded

contrast media(amount and strength)

RN is responsible for monitoring of the sedated patient

medications and reversals used during endoscopic sedation

indications for and levels of sedation

sedation policies and guidelines

airway management

continuous monitoring of the sedated patient

risks and complications including cardiac, respiratory and paradoxical, precautions during

pregnancy, pediactric and elderly, difficult to sedate pt, sleep apnea.

Identify various types of ERCP equipment - including biliary and pancreatic stents

HANDS ON RETURN DEMONSTRATION OF ERCP EQUIPMENT- including biliary and pancreatic stents

SEDATION SCALE (CHECK YOUR INSTITUTION GUIDELINES)

www.medscape.com

Dosage Guidelines for Adults Table 1. Commonly Used Drugs for Procedural Sedation and Analgesia in Adults(Open Table in a new window)

Drug Adult Dose Onset

of

Action

Duration

of Action*

Comments

Midazolam

(Versed)

0.02-0.1 mg/kg IV initially; if further

sedation is required, may repeat with 25%

of initial dose after 3-5 min; not to exceed

2.5 mg/dose (1.5 mg for elderly persons)

and 5 mg cumulative dose (3.5 mg for

elderly persons)

1-2 min 30-60 min Respiratory depression or hypotension may occur, particularly when rapidly

administered or combined with fentanyl (may need to decrease midazolam dose); does

not provide analgesia; action reversed by flumazenil

Fentanyl 1-2 mcg/kg slow IV push (over 1-2 min);

may repeat dose after 30 min

1-2 min 30-60 min May cause chest wall rigidity, apnea, respiratory depression, or hypotension; elicits

minimal cardiovascular depression; may cause dysphoria, nausea, vomiting, or EEG

changes; action reversed by naloxone

Etomidate

(Amidate)

0.1-0.2 mg/kg slow IV push over 30-60

sec

< 1 min 3-5 min Commonly causes myoclonus, pain upon injection, adrenal suppression (typically no

clinical significance unless repeated doses are used within a limited time span); may

cause nausea, vomiting, and lower seizure threshold; does not alter hemodynamics;

causes a slight to moderate decrease in intracranial pressure that only lasts for several

minutes; does not cause histamine release; useful for patients with trauma and

hypotension

Propofol

(Diprivan)

0.5-1 mg/kg IV loading dose; may repeat

by 0.5-mg increments q3-5min

< 1 min 3-10 min Provides rapid onset and recovery phase, and brief duration of action; has

anticonvulsant properties; can rapidly cause deepening sedation;

causes cardiovascular depression and hypotension

*Duration of action based on normal drug elimination (ie, nonelderly adult with normal renal and hepatic function)

OBJECTIVES FOR STATION #5

Describe the role of the RN in ERCP related complications.

frequent assessment intra and post procedure

Perforation-can be from guidewire, sphincterotomy, or luminal

increased chance with a hx of bilroth 1 or 2

s/s can include-

sudden or worsening pain

changes in body temperature

rigid abdomen

loss of bowel sounds

formation of crepitus (prepare for possible x-ray with gastrograffin)

Hemorrhage from sphincterotomy (prepare for possible injection with epi, cautery or clips)

pancreatitis- (usually occurs 2-4 hours post procedure, monitor for fever, chills, abd pain, nausea

or vomiting)

compromised airway-( watch head and neck angle, scope can occlude airway, make corrections)

respiratory depression (adequate oxygen, and prepare for reversal of medications)

cardiopulmonary- hypoxemia can lead to cardiac arrhythmias

Identify various types of ERCP equipment- including brushes, and emergency handle

HANDS ON RETURN DEMONSTRATION OF ERCP EQUIPMENT- including brushes, and emergency handle

Sphincterotomy bleed with clips

www.medscape.com

Post-ERCP Pancreatitis: Presentation and Management

Typically, if a patient is going to develop post-ERCP pancreatitis, the

probable diagnosis becomes apparent within a few hours of the procedure.

It is characterized by;

severe abdominal pain

frequently, back pain

nausea (with or without vomiting)

mild fever

Unfortunately, the usual 1-hour observation period after ERCP is often

insufficient for post-ERCP pancreatitis to declare itself. If the patient can be

kept under observation longer, or returns with symptoms, a 2-hour serum

or urinary amylase level (> 1000 IU/L) is highly predictive of evolving post-

ERCP pancreatitis

Patients presenting with post-ERCP pancreatitis should receive:

adequate (narcotic) analgesia

treatment for nausea (if present)

copious intravenous fluids (starting with a 1-2 L bolus of Ringer's

lactate solution and continuing with 250-300 mL/hr)

A nasogastric tube should be placed only if the patient has unrelieved

nausea or vomiting.

Urine output should be monitored and charted, with the aim of at least

50 cc/hr of urine output (100 cc/hr is better). In patients unable or

unwilling to spontaneously pass urine, placement of a urinary catheter is

necessary to monitor urine output.

Patients should be watched for signs of severe inflammatory response

syndrome, which includes:

fever (> 38˚ C)

tachycardia (> 90 beats/min)

tachypnea (> 20 breaths/min)

and low or high peripheral white blood cell count (< 4000/mm3 or >

12,000/mm3).

SGNA.ORG- SEDATION AIRWAY MANAGEMENT

Go to SGNA.org

Go to issues tab, then under that tab is ‘sedationfacts.org’ – Read all about sedation and patient

management there.

Reversal Agent Indication Adult Dose Pediatric Dose Comments

Naloxone (Narcan) Reverses

opioid

agonists

Postanesthetic or

opioid dependent:

0.1-0.2 mg/kg IV;

may repeat q2-3min

prn

Opioid overdose:

0.4-2 mg IV; may

repeat q2-3min prn

Postanesthetic reversal:

0.005-0.01 mg/kg

IV/IM; may repeat q2-

3min prn

Opiate intoxication:

0.01-0.1 mg/kg dose

IV/IM; may repeat

every min; not to

exceed 2 mg/dose

Onset of action for IV is 1-3 min vs

10-15 min for IM; rebound sedation

may occur; if used in patient with

chronic opioid use, will precipitate

acute withdrawal and abrupt

sympathetic discharge possibly

leading to acute pulmonary edema

www.medscape.com- Commonly used reversal agents.

Flumazenil

(Mazicon)

Reverses

benzodiazepines

Partial antagonism

(for sedation

reversal): 0.1-0.2

mg IV infused over

15 sec; may repeat

after 45 sec and

then every min; not

to exceed total

cumulative dose of

1 mg

Complete

antagonism (for

overdose): 0.2 mg

IV infused over 30

sec; may repeat

with additional

doses of 0.5 mg

over 30 sec at 1-

min intervals; not

to exceed a total

cumulative dose of

3 mg

0.01 mg/kg/dose

IV infused over 15

sec; not to exceed

0.2 mg/dose; may

repeat every min;

not to exceed total

cumulative dose of

0.05 mg/kg or 1

mg (whichever is

lower)

Rebound sedation may occur; if

used in patient with chronic BZP

use, will precipitate acute

withdrawal; may precipitate

seizures unresponsive to BZPs

OBJECTIVES FOR STATION #6

DISCUSS CASE STUDY – BILIARY STRICTURE

New onset jaundice associated with solitary biliary strictures in the elderly is concerning for a malignant

stricture such as cholangiocarcinoma.

Patient, 70 year old male

Symptoms- Painless jaundice

Labs-

His bilirubin was 7.0 mg/dl

alkaline phosphatase was 294 U/L

Ultrasound and CT scan were normal

ERCP- revealed a biliary stricture below the bifurcation of the right and left hepatic ducts, concerning for

cholangiocarcinoma – a stent was placed

Biopsies and brushings were negative

CEA and CA 19-9 were normal

One month later, repeat ERCP and cholangioscopy revealed that the stricture had resolved.

Ampullary biopsies revealed infiltration with IgG4 plasma cells

Liver function tests returned to normal

Nine months later, the patient represented with painless jaundice

Labs-

bilirubin was 8.1 mg/dl

alkaline phosphatase was 282 U/L

CT scan was normal

2nd ERCP- revealed a new stricture in the distal bile duct- concerning for a malignant stricture. The

previously seen proximal biliary stricture remained resolved.

Biopsies and brushings were negative.

Repeat CEA and CA 19-9 were normal.

Endoscopic ultrasound- revealed a mass surrounding the biliary stricture

He was treated with prednisone 20 mg, and a slow taper

His liver enzymes returned to normal

Repeat ERCP showed resolution of the biliary stricture. His liver enzymes have remained normal after

10 months of follow-up

DISCUSSION-

IgG4-Related Sclerosing Cholangitis (IgG4-SC) is a rare condition which can cause biliary strictures

mimicking malignant strictures. It is most often seen in association with autoimmune pancreatitis,

which our patient did not have.

It can also be associated with IgG4-related lymphoplasmacytic infiltration in other organs. We report a

rare case of IgG4-SC causing metachronous biliary strictures responsive to medical therapy.

This is an important differential diagnosis to consider, particularly to avoid drastic unnecessary surgery

or chemotherapy in benign disease.

DESCRIBE VARIOUS EQUIPMENT USED TO CANNULATE THE COMMON BILE DUCT

Cannula: Catheter used to gain access to CBD and/or PD. Can have

multiple lumens for injection and guide wire usage.

Guide wire: Wire placed into the CBD/PD. Can be used for cannulation.

Left into the duct to maintain access while devices are exchanged over

it.

HANDS ON DEMONSTRATION AND RETURN DEMONSTRATION OF ERCP EQUIPMENT- including

cannulatomes and wires

Biliary stricture

Source- http://openi.nlm.nih.gov

OBJECTIVES FOR STATION #7

Discuss Case Study- Primary Sclerosing Cholangitis

52 year old with history of Htn and hyperlipidemia

Current symptoms-

Progressive fatigue

Pruritis

Labs- rising bilirubin

Tests-

Diagnosis of PSC typically does not require ERCP

ERCP is reserved for treatment of dominant stricture or sampling to rule out

cholangiocarcinoma

Can be diagnosed with MRCP

ERCP was performed with stent placement in hepatic stricture

Liver biopsy performed to confirm “onion skin” or fibrosis in hepatic tissue

Considerations with PSC

Consider in patients with IBD, unexplained cholestasis, and normal MRCP

6% overlap with autoimmune hepatitis

ERCP is done for patients with PSC and worsening

symptoms to evaluate for dominant main duct disease→ concern for cholangiogram

Dilation or dilation + stenting are both effective to treat strictures

dilation + stenting associated with more infectious complications

No randomized control trial comparing dilation to dilation + stenting Risk of cholangiocarcinoma

is 1-2% per year

As with all indeterminate biliary strictures, yield of brushing is poor. Slightly improved with

biopsy, however, overall sensitivity is still suboptimal

DESCRIBE VARIOUS EQUIPMENT USED FOR OPENING AND ACCESSING THE COMMON BILE DUCT

SPHINCTEROTOME: Catheter used to gain access to common bile duct (CBD) and/or pancreatic

duct (PD) and perform sphincterotomy. Can have multiple lumens for injection and guidewire

usage.

DILATION BALLOON: Balloon catheter used to open the ampulla. Commonly done following a

sphincterotomy. Dilation balloon can also be used to open up strictures within the CBD and PD.

NEEDLE KNIFE: A slender surgical knife with a needle point, used to gain access of the CBD.

Needle is advanced into the tissue, heat is applied to cut through mucosa and gain access.

HANDS ON DEMONSTRATION AND RETURN DEMONSTRATION OF ERCP EQUIPMENT including

those to facilitate access and opening of the ampula such as a needleknife, dilators and biliary

balloon dilators.

OBJECTIVES FOR STATION #8

Discuss case study- choledocholithiasis

35 year old with no past medical history

Current symptoms

epigastric abdominal pain

nausea and vomiting x 48 hours

Labs-

liver enzymes elevated 2x ULN

bilirubin 2.0

Lipase is normal

Ultrasound is ordered which reveals dilated intra and extrahepatic ducts with no stone in

the CBD.

Choledocholithiasis is suspected on the basis of clinical symptoms and initial laboratory

evaluation

Normal liver enzymes have a negative predicitive value of 97% for choledocholithiasis

RUQ ultrasound has a sensitivity of 22-50% for choledocholithiasis

Guidelines from ASGE-The Role of Endoscopy in the Evaluation of

Suspected Choledocholithiasis

Gastrointest Endosc 2010;71:1-9 1. We recommend that the initial evaluation of suspected choledocholithiasis should include serum liver

biochemical tests and a transabdominal US of the right upper quadrant. These tests should be used to

risk-stratify patients to guide further evaluation and management.

2. We recommend that patients with symptomatic cholelithiasis who are surgical candidates and have a

low probability of choledocholithiasis proceed to cholecystectomy without additional biliary evaluation

3. We recommend that patients with an intermediate probability of choledocholithiasis undergo further

evaluation with preoperative EUS or MRC or an IOC. In this group of patients, we suggest that ERC be

deferred unless EUS, MRC, and IOC are unavailable, given the less favorable risk profile of ERC.

4. We recommend that patients with a high probability of choledocholithiasis undergo an evaluation of

the bile duct with therapeutic capability, generally preoperative ERC. When available, laparoscopic bile

duct exploration can serve as an alternative to ERC.

5. We suggest that EUS or MRC be considered in the diagnostic evaluation of postcholecystectomy

patients suspected of having choledocholithiasis when initial laboratory and US data are abnormal yet

nondiagnostic.

6. We recommend against early ERC in the evaluation and management of patients with mild ABP in the

absence of clear evidence of a retained stone.

7. We recommend early ERC in patients with acute biliary pancreatitis and concomitant cholangitis,

given the observed benefits in morbidity and mortality.

8. We suggest that patients with acute biliary pancreatitis and clinical evidence of biliary obstruction be

considered for early ERC. We cannot recommend for or against early ERC in patients with predicted

severe acute biliary pancreatitis in the absence of overt biliary obstruction or cholangitis, given the lack

of consensus in the available data.

9. As patients with acute biliary pancreatitis are at least at intermediate risk for choledocholithiasis, we

suggest pre-operative EUS or IOC be considered for these patients when cholangitis or biliary

obstruction are absent.

Patient had cholecystectomy without complications.

Identify and describe various equipment used during ERCP for stone retrieval

RETRIEVAL BALLOON: catheter with a balloon on the end. Balloon is inflated in the proximal CBD and

pulled through the duct to remove stones. Device can be placed into the duct over a guidewire and can

have an injection port.

RETRIEVAL BASKET: catheter with a basket on the end. Basket is opened and closed by manipulating the

handle. When opened inside the duct the basket can grasp stones. Stones can be crushed inside the

duct or pulled out. Baskets can be used with or without a guidewire and may have a lumen for injection.

HANDS ON DEMONSTRATION AND RETURN DEMONSTRATION OF ERCP EQUIPMENT- including stone

retrieval balloons and baskets

OBJECTIVES FOR STATION #9

Discuss Case study- Bile leak

48 year old with intermittent RUQ pain presents with fever and severe RUQ pain.

Ultrasound reveals acute cholecystitis.

The patient is taken to the OR for cholecystectomy where dense adhesions are noted. Laparoscopic

procedure converted to open and only partial cholecystectomy was able to be performed.

Bile leak is a common surgical complication

Laparoscopic > Open

Severe inflammation and adhesion is also a risk factor.

Bile leak is suspected with pain post cholecystectomy with imaging revealing biloma

If JP drain is placed, bilious output is diagnostic

HIDA scan can make diagnosis, but does not provide detailed anatomic information

Therapy for bile leak involves

percutanous drainage of the existing leak

ERCP to prevent further leak

Goal of ERCP is to reduce the transpapillary pressure gradient → not necessary to “bridge” the

leak for simple leak

Stenting is better than sphincterotomy alone, however, unclear if stenting plus sphincterotomy is

better than stenting alone

ERCP with CBD stent was placed, pt symptoms resolved over time

Identify and describe various equipment used for stenting the common bile duct and pancreatic duct.

BILIARY PLASTIC STENTS: a plastic tube that is inserted into a bile duct to relieve narrowing of the duct (also called bile duct stricture). Comes in center bend, duodenal bend & double pigtail shapes. Can be placed in CBD or PD BILIARY METAL STENTS: a metal tube that is inserted into a bile duct to relieve narrowing of the duct (also called bile duct stricture). Can be fully covered, partially covered, or uncovered. Design can be open or closed cell

HANDS ON DEMONSTRATION AND RETURN DEMONSTRATION OF ERCP EQUIPMENT- including biliary and pancreatic stents

Source- American Journal of Gastroenterology- www.nature.com - Am J Gastroenterol 2010; 105:100–

105; doi:10.1038/ajg.2009.546; published online 22 September 2009

Assessment of Need for Repeat ERCP During Biliary Stent Removal After Clinical Resolution of Postcholecystectomy Bile Leak

OBJECTIVES FOR STATION #10

Discuss case study- Pancreatic head mass

58 year old with history of CAD presents with progressive jaundice, weight loss and anorexia.

CT reveals a 3.9 cm pancreatic head mass with associated biliary dilatation and pancreatic duct

dilatation.

EUS confirmed a 3-4cm mass in the head of the pancreas. Portal vein was not involved and

the mass was not adjacent to splenic artery.

EUS-FNA revealed adenocarcinoma

ERCP with brushings of pancreatic duct

Pt referred for whipple procedure due to no evidence of metastasis found on CT scan

Since surgery couldn’t be done immediately, a pancreatic stent was placed

From The American Society For Gastrointestinal Endoscopy

The role of endoscopy in the evaluation and treatment of patients with pancreaticobiliary malignancy

Identify and describe various equipment used during ERCP for collection of cells for diagnoses

Cytology Brush: catheter with a brush on the end. Brush is operated by opening and closing the handle

of the device. Used to collect cells from the CBD/PD to diagnose diseases.

SpyGlass Cholangioscopy: Four way steering catheter with four lumens allows for direct visualization of

the duct. EHL and laser probes can be passed to fragment large stones. Biopsy forceps can be passed for

direct visualization biopsies

Hands on demonstration and return demonstration of ERCP brushes and possible Spyglass probes

Note- pancreatic head mass is usually diagnosed through EUS/FNA. This case study was put at

this station randomly, not because brushings or Spyglass is used as a primary method for

diagnosis.