Endoscopy during a missile attack: a military dilemma for civilians

In modern warfare, civilian populations may find themselves under immediate personal danger with very little warning. While there are ways to minimize this danger, there is a paucity of literature discussing this modern dilemma, and it is therefore important to try to address these situations in advance both logistically and ethically. Discussion of this case includes several relevant ethical principles.

[Experience of an interdisciplinary anesthesiology and nursing team for providing anesthesia outside the operating room]

OBJECTIVE

To report on the creation and development of an interdisciplinary anesthesiology and nursing team to provide anesthesia outside the operating room.

MATERIAL AND METHODS

We describe the creation of an interdisciplinary team and preanesthesia evaluation protocols for using nurses specializing in anesthesia for procedures outside the operating room. We analyzed the anesthetic procedures performed outside the operating room, the rate of suspensions due to failure of the procedure, and their impact on the rate of associated complications, from October 2006 to October 2007.

RESULTS

Since the start of the project, 586 procedures outside the operating room have been performed. No suspensions or delays were observed that were due to comorbidity not detected in the preanesthesia evaluation carried out by the nurses. The incidences of complications and inadequate sedations were comparable to those reported for other similar interdisciplinary groups in this area.

CONCLUSIONS

The creation of an interdisciplinary team of anesthesiologists and specialized nurses for providing anesthesia outside the operating room optimizes resources and improves routine clinical practice. It has allowed for universal preanesthesia evaluation, improved the distribution of resources, and proven a stimulus to the care-giving process.

Postoperative nursing care of the endoscopic nonsyndromic craniosynostosis surgery patient

Craniosynostosis affects 1 in 2,100 children. The current methods for the treatment of craniosynostosis at Rady Children's Hospital, San Diego, are open cranial vault remodeling and the minimally invasive endoscopic technique. The primary advantages of the minimally invasive endoscopic technique are decreased operative time, blood loss, swelling, incision size, and inpatient hospital stay. Postoperative helmet therapy is a necessary part of the treatment for the refinement of the surgical result. The purpose of this article is to present current inpatient and outpatient nursing management considerations in the care of infants undergoing the minimally invasive endoscopic technique for the treatment of craniosynostosis.

Reducing admission times in the endoscopy unit

Pre-procedural admission of outpatients to a day-case endoscopy facility is time-consuming. Collecting and recording routine but necessary information distracts nurses from spending time that could be used to counsel patients. This study assessed whether patients can record some pre-procedural details and whether such self-recording quickens nurse admission times. A new admission document was devised and posted to patients. Patients completed personal/administrative details and information about drugs and allergies and brought the document with them when attending for outpatient endoscopy. Endoscopy nurses anonymously timed 100 admissions, 50 using the new admission form and 50 using the old admission form. Overall, the median (range) time to admit using the old form was 6 (3-15.5) min. Using the new form, the median time to admit was lower at 4 (0.5-10) min. No patient completing the new form reported any particular difficulties. An admission document that patients partially complete at home leads to a faster pre-procedural admission in the endoscopy unit. This allows more nursing time to discuss patients' anxieties and answer patient queries, helps to prevent delays and facilitates increased capacity in the endoscopy unit.

Finding an alternative endoscope disinfectant to glutaraldehyde

Glutaraldehyde poses an occupational health hazard or risk for staff, with up to 15% of UK hospitals using it as their first-choice endoscope disinfectant. One NHS trust yielded unexpected additional savings by introducing a safer alternative in a bid to reduce potential health, safety and environmental risks.

Guidelines for performing fiberoptic flexible nasal endoscopy and nasopharyngolaryngoscopy on adults

This article presents guidelines for performing two diagnostic skilled examinations; adult fiberoptic flexible nasal endoscopy and nasopharyngolaryngoscopy. These guidelines help to address the paucity of nursing literature on this subject. These procedures previously have been the unique purview of otolaryngologists, but now are being performed by nurse practitioners in otolaryngology specialty practice, as well as by other healthcare providers. All healthcare providers are accountable for seeking appropriate learning resources and clinical supervision in acquiring new procedural skills after graduation and licensure. This article guides learners in acquiring upper airway endoscopy skills, and describes one nurse practitioner's path to gaining institutional sanction for expanding her scope of practice.

Gastro-oesophageal reflux disease

Part two of this article on GORD examines investigations and treatment options once the initial diagnosis of the condition has been made and focuses on the role that nurses can play in helping patients with this condition.

Propofol or Process

Due to increased public awareness, the number of endoscopic procedures performed per year is rapidly increasing. In lieu of expanding endoscopy units, current practices are being reviewed to improve unit efficiency without compromising patient care. Changing from a traditional medication regimen of demerol/versed or fentanyl/versed to propofol for moderate sedation is currently controversial. Studies using propofol are being conducted to measure recovery times, safety of administration by healthcare providers other than anesthesia providers, cost/benefit ratios, and patient satisfaction. In order to measure the benefits of propofol versus a traditional medication regimen, a retrospective review of 1,056 charts was conducted to evaluate the difference in procedure and post-procedure time between sedation groups before and after a process change. In this study, the use of propofol was associated with a statistically significant shorter mean procedure time (p <.001) and nonsignificant post-procedure time (p =.056) than a traditional regimen; however, a statistically significant reduction in mean times was demonstrated by changes in process (p <.001). The use of propofol demonstrated an actual total time savings of 5.3 minutes per case after the process change. This difference was not large enough for the authors to change current practice of traditional medication for moderate sedation when all other issues related to propofol were taken into consideration.

Review article: registered nurse-administered propofol sedation for endoscopy

Propofol has several attractive properties that render it a potential alternative sedative agent for endoscopy. Compared with meperidine and midazolam, it has an ultra-short onset of action, short plasma half-life, short time to achieve sedation, faster time to recovery and discharge, and results in higher patient satisfaction. Shorter times to achieve sedation enhance efficiency in the endoscopy unit. Multiple studies have documented the safe administration of propofol by non-anaesthesiologists. Administration by registered nurses is more cost-effective than administration by anaesthesiologists. However, the administration of propofol by a registered nurse supervised only by the endoscopist is controversial because the drug has the potential to produce sudden and severe respiratory depression. More information is needed on how training nurses and endoscopists should proceed to give propofol, as well as the optimal level of monitoring to ensure the safety of nurse-administered propofol.

Endoscopic strip craniectomy: a minimally invasive treatment for early correction of craniosynostosis

Traditionally, surgical correction of craniosynostosis involves calvarial remodeling, large blood losses necessitating transfusions, hospital stays of several days, and less-than-satisfactory results. In this study, outcomes from a minimally invasive technique called endoscopic strip craniectomy, along with a postoperative molding helmet, to correct craniosynostosis in young infants were evaluated. The endoscopic strip craniectomy was performed on 185 patients with clinical signs of craniosynostosis, with the following distribution: 107 sagittal, 42 coronal, 37 metopic, and 7 lambdoid, for a total of 198 sutures. The mean blood loss was 29.4 cc, and only two patients underwent intraoperative blood transfusion. Fourteen patients underwent postoperative blood transfusion; none was life-threatening. There were no deaths, complications, neurological injuries, or infections. All but six patients were discharged on the first postoperative day. A majority of the patients achieved or approached normocephaly, and there were no complications. Neuroscience nurses need to be aware of this technique when they discuss treatment options with the families of infants with craniosynostosis.

Endoscopic facial surgery

Endoscopy is a surgical technique involving the use of an endoscope, an instrument with a tiny camera inserted through very small incisions designed to project images of the body's internal structures onto a video monitor. In aesthetic surgery, endoscopic technology is a solution to the scarring problems that have long frustrated patients and surgeons alike.

Nurse-led direct access endoscopy clinics: the future?

BACKGROUND

Many studies have shown that rectal bleeding is a good indicator of underlying colorectal pathology, and that ost of the lesions in patients presenting with rectal bleeding lie in the left side of the colon [1, 5, 9, 12, 23, 26]. The recent acceptance of the nurse-practitioner by the National Health Service may allow the use of nurse-endoscopists to develop throughout the United Kingdom. This study aimed to audit a unique nurse-led direct-access nurse-endoscopy service with regard to its efficacy and cost effectiveness, and to monitor patient satisfaction and direct referrals from the primary health sector.

METHODS

A nurse-led open-access flexible sigmoidoscopy (OAFS) service for patients reporting fresh rectal bleeding was established at our center in February 1996. A prospective audit of sigmoidoscopic findings and a retrospective analysis of referral patterns from local general practitioners were conducted. A questionnaire survey of both patient and general practitioner satisfaction also was conducted at the same time.

RESULTS

Since February 1996, 706 patients have been referred to our service. Rectal bleeding was by far the most common cause for referral, representing the dominant symptom in 92% of the referrals received. Although 99% of the patients underwent a complete sigmoidoscopic examination, 16% of these examinations were limited because of several factors combined. A cause for bleeding was identified in 91% of the patients, with 24% of them experiencing subsequent significant pathology. Of the patients surveyed, 99% were satisfied with the service provided. The results also show nurse-led OAFS to be a more effective use of financial resources, costing $90 less per patient than general practitioner referrals sent to a consultant for further action.

CONCLUSIONS

Rectal bleeding is a good indicator of underlying colorectal disease. Most of the significant lesions presenting with this symptom are found in the left side of the colon. A nurse-led OAFS is safe, effective, and acceptable to patients. It also is more cost effective than a consultant-led service.

Endoscope reprocessing: taking the mystery out of high-level disinfection

Flexible endoscopes used in otolaryngology are often unable to withstand heat sterilization. An acceptable alternative to heat sterilization for these devices used to examine the aerodigestive tract is high-level disinfection. A review of otolaryngology (ORL) nursing clinical practice indicates that there is confusion regarding the recommended disinfectant solutions to use and the proper manner in which to use them. This article describes a method that is useful in determining the level of risk of infection posed by ORL endoscopy, a description of appropriate levels of disinfection, points to consider for achieving high-level disinfection, and appropriate personal protective measures.

Transumbilical breast augmentation

Surgical augmentation has been performed since 1899, with varying results. Recent developments in endoscopic instrumentation have enabled surgeons to perform many types of procedures through small incisions located at a distance from the surgical site. The transumbilical breast augmentation (TUBA) has advantages over other methods, including a quicker recovery, less pain, and lower chances of complications. This article familiarizes perioperative personnel with TUBA and how to care for the patients who undergo this procedure.

Practical points in spinal endoscopy

This article presents an overview of spinal endoscopy, including history, indications, and contraindications, along with the anatomy and physiology of the spine. A description of the procedure is provided, complications are identified, and nursing considerations are highlighted.

Twenty-five years revisited

In May 1998, we celebrated the 25th anniversary of the Society of Gastroenterology Nurses & Associates (SGNA). It was in 1974 that a group of dedicated people met in San Francisco under the leadership of Marna Harmon Schirmer to found an organization dedicated to the professional needs of health care providers working in the gastroenterology diagnostic and treatment setting. Through the efforts of these dedicated people and those who followed them, this organization has grown into the recognized specialty SGNA is today. SGNA has its roots in the historical development of clinical gastroenterology practice and the diagnostic tools made possible through advances in technology. Throughout the years, these changes continue to affect not only the delivery of patient care but also the specialty of gastroenterology nursing. This article explores the history of GI nurses--how we began, where we are now, and what we can expect in the future.

Lost gallstones--a small but real complication

Retained gallstones are considered a complication of cholecystectomies. If stones can be removed using minimally invasive procedures (i.e., laparoscopically), patients' recovery time may decrease and satisfaction may increase. Correct and immediate diagnosis of this complication at the time of the procedure often is the determining factor between patients' full recovery and their potential chronic illness. This article describes diagnostic tests and techniques used to surgically correct this complication and presents two case studies depicting patients' experiences from a few months to nine years postoperatively.

A new approach to an old and vexing problem: subfascial endoscopic perforator surgery

Chronic venous insufficiency with venous hypertension causes leukocyte trapping, lipodermatosclerosis, and finally, skin ulceration involving the lower extremity. Perforator vein incompetence has been identified as an important contributing factor to ulceration when abnormally elevated pressure is transmitted to areas of affected skin, usually at the ankle medially. Surgical techniques for ligation of incompetent communication veins were first popularized by Linton and Dodd from 1940 to 1950. Early techniques used extensive longitudinal incisions for subfascial ligation through indurated skin. These procedures were plagued with wound complications: delayed healing, skin necrosis, and infection. Techniques continued to evolve that used minimally invasive incisions and avoided zones of affected skin. With the availability of endoscopic, fiberoptic, and laparoscopic advances in surgery, instrumentation has been developed for minimally invasive endoscopic approach to accomplish subfascia endoscopic perforator surgery (SEPS) under direct vision. SEPS is now used alone and in combination with other venous interventions to reduce transmission of venous hypertension to affected skin areas. The SEPS procedure, its indications, and the history of surgical treatment of perforator vein incompetence are discussed. Unique problems related to short hospital stays and postoperative care are outlined. This review will help the vascular nurse understand the rationale and techniques of SEPS. This comprehension will enable provision of accurate information to the patient and a knowledge-based plan of care.

Guideline for the use of high-level disinfectants and sterilants for reprocessing of flexible gastrointestinal endoscopes. Society of Gastroenterology Nurses and Associates, Inc

Glutaraldehyde, 0.2% peracetic acid, 7.5% hydrogen peroxide, and 0.08% peracetic acid/1% hydrogen peroxide are cleared by the FDA for reprocessing flexible gastrointestinal endoscopes. Each product has advantages and disadvantages. All require adherence to published reprocessing protocols to maintain the integrity of equipment while providing the public with endoscopic instruments that are safe and effective. All chemicals must be handled with respect. Selection of a product must be weighted against the needs of a particular setting, taking into consideration factors such as compatibility, toxicity, environmental controls, and cost.

Defensible documentation using the endoscopy pathway

Complete, defensible documentation in a busy endoscopy unit can be elusive. Quick turnaround time, impatient physicians, and add-on and emergent cases all contribute to chaotic days. The endoscopy pathway provides a guided path for succinct documentation by the healthcare worker. A scoring system is initiated on admission. Assessment parameters clearly define scores for vital signs, level of consciousness, abdominal status, pain, safety, and mobility. Scores can be scanned quickly and compared by the nurse to identify significant changes in each patient. Documentation is timely, communicative, and complete. The endoscopy pathway is illustrated by a case study. It reflects patients' progress throughout their stay in the GI unit from admission to discharge. The implementation process of this innovative chart form is presented.