SAGES Magazine

THE SOUTH AFRICAN GASTROENTEROLOGY REVIEW 2022 | VOLUME 20 | ISSUE 3 | 42 ERCP | A GUIDE FOR NURSES AND ASSISTANTS | Re-printed with permission S E DAT I ON In many countries in the world, all ERCP’s are carried out under deep sedation with Propofol, or general anaesthetic. Most of us would rather have the procedure done this way, and having worked in places that do, I can see the advantages to the patients (who have significantly less anxiety about the procedure) the endoscopist (who is not limited by patient discomfort and can carry out ERCP in patients who are lying still and are not distressed) and the assisting staff (who are not required to comfort patients in distress or discomfort). Wheras I hope we will soon catch up with the places where this is normal practice, for now it is important to discuss and deliver the techniques required to carry out prolonged and invasive procedures with minimal discomfort and maximum safety. First and foremost it is vital to understand that sedation is not purely about giving drugs, but I will go through the medications most commonly used during ERCP, namely a local anaesthetic (Lignocaine), a sedative (usually Midazolam), an analgesic (usually Fentanyl, but sometimes Pethidine) and a smooth muscle relaxant (Buscopan, or Glucagon). There are many things that can be done to alleviate distress and anxiety for the patient that does not involve medication, what I like to call non-pharmacological sedation . A person in the right frame of mind hardly needs any medication at all - we have all seen patients undergoing colonoscopy unsedated without a murmur, and patients requiring heavy doses of sedation for simple and quick procedures. People feel things differently and their state of mind as they enter the theatre has a lot do do with it. Well-informed and meaningful reassurance and explanation will help the patient overcome their natural fear of the unknown. Visualisation (ie explanation of what the patient can expect to see and feel during the procedure, but also learning to imagine something they find pleasant during tense moments) and simple breathing exercises (eg practicing exhaling fully and counting to three before breathing in again, or taking a deep breath in and exhaling fully with a sigh “as if you’re bored…”) are other techniques that are used. A startled or ill-informed patient is unlikely to comply with or benefit from these methods. Lignocaine throat spray is not very pleasant and patients should be reminded that they cannot feel the air passing over their tongues which may cause anxiety. In these cases the patient should be encouraged to take a few reassuring breaths through their nose. It is useful in preventing gagging during intubation at the start of the procedure, even when sedated. 16