Statements & Guidelines

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QUALITY CONTROL IN ENDOSCOPY

The SAGES Committee again confirms that it accepts the Conscious Sedation Clinical Guidelines SAMJ - A 1997 : 87 (4) 484 - 492 Conscious Sedation Working Group MASA

SAGES does not agree with the SA position statement regarding conscious sedation combining analgesia and sedation (Sedo-analgesia). This will be discussed with Professor David Morrell before the final SAGES Conscious Sedation Clinical Guidelines are published.


ENDOSCOPIC PROCEDURAL SAFETY

SAGES wishes to remind the members of the increasing complexities regarding the medico-legal aspects of endoscopic practice.

Recognition and accreditation of Gastro-enterology Subspeciality training requirements and programmes have resulted in the Certificate of Gastro-enterology, College of Medicine of South Africa. This structured curriculum is applied by the academic units and the detailed curriculum will be available on the SAGES website. This may also be obtained from the Heads of Departments at the relevant academic units.

Problems may arise when medico-legal questions are directed at SAGES regarding the training and competence of the endoscopist or aspects regarding procedural safety e.g.


POTENTIAL DETERMINANTS FOR PROCEDURE SAFETY

• WHAT
  procedure is performed
  - diagnostic versus therapeutic
  conscious sedation or anaesthesia is used
  benzodiazepine alone versus with narcotic
  bolus versus titration
  level of monitoring is employed
  personnel (gastrointestinal nurse) assisting
  electronic equipment (oximetry, ECG) use
  resuscitation equipment available
  
• WHO
  undergoes endoscopy young versus elderly medically fit versus unfit consultation versus checklist performs endoscopy training and experience competence
• WHY
  endoscopy is performed indicated versus contra-indicated
• WHERE
  endoscopy is performed
  fully staffed hospital endoscopy unit versus small hospital versus clinic or office
  elective (endoscopy unit) versus emergency (ICU or other hospital ward)
• HOW
  the patient is recovered the outpatient is discharged.

SAFETY DURING THE PROCEDURE

It is recommended that continuous intravenous access should be used and available when sedation is employed, no matter how quick or short the procedure is anticipated to be.

Universal monitoring is encouraged. An understanding of the limitations of pulse oximetry is necessary. Continuous ECG and blood pressure monitoring are open to a wider interpretation and an algorithm approach is difficult.

Current practice favours the selective use of supplemental oxygen. There is a theoretical concern that carbon dioxide retention could be masked. Supplemental oxygen is, however, cheap, relative to the procedure and universal use could be argued.


NURSING SUPPORT

Many societies feel that one assistant was required in addition to the endoscopist for diagnostic endoscopy and colonoscopy and that two were required for more complicated procedures.


POST-PROCEDURAL SAFETY

Flumazenil could be used for routine reversal of Benzodiazepine-induced sedation if post-procedural monitoring and throughput are under pressure. End points as to when monitoring should cease have been defined i.e. the patient has stable vital signs, is able to speak clearly, is understanding and able to sit up and be independently mobile, where appropriate.

Post-procedural instructions, discharge requirements and precautions remain the responsibility of the endoscopist.


THE ENDOSCOPIST, THE SEDATIONIST AND THE LAW

In examining endoscopic practice internationally it seems anomalous that in France the endoscopist does not act as a sedationist and an anaesthesiologist must be present throughout the whole procedure, but this was not so for other parts of the world. In Germany nurse sedationists are permitted and in the United States conscious sedation is managed by nurse-anaesthetists.

SAGES is not aware of any position statement in South Africa with reference to the different arenas of clinical endoscopy in our country.