SAGES Magazine

THE SOUTH AFRICAN GASTROENTEROLOGY REVIEW 2022 | VOLUME 20 | ISSUE 3 | 43 ERCP | A GUIDE FOR NURSES AND ASSISTANTS | Re-printed with permission Midazolam is a sedative. This means it relaxes the patient to the point where they may fall asleep but it is not the primary purpose of giving the medication, which is to relieve anxiety. It has no analgesic (pain-killing) properties. Midazolam takes approximately 2 minutes to work, and in that time patients may become disinhibited; talking or trying to remove their mouthguard. Gentle reassurance is required at this point. A particular bugbear of mine based on observations over the years comes into play here: My wife is a heavy sleeper and often nods off during movies irrespective of dramatic music or explosions. If I whisper her name, however, she immediately wakes up. So it is with sedated patients, and I ask the nurse or assistant guarding the airway to avoid using the patient’s first name when giving instructions or reassurance as it is unlikely that they will return to their sedated state afterwards, and this may shorten the time available or even prevent the procedure being completed. Fentanyl and Pethidine are both opiates, that is to say powerful analgesics. They have a sedating effect as well and are used in conjunction with Midazolam to keep the patient comfortable. Fentanyl works faster and lasts a shorter time than Pethidine. Operators have their own preferences and neither choice is incorrect. In excessive doses, particularly if given too quickly or in conjunction with sedatives, opiates may cause respiratory depression and a fall in oxygen saturation. This usually responds to gentle stimulation, but if prolonged then an antidote to the sedation ( Flumazenil ) is given first, followed by an antidote to the analgesia ( Naloxone ) if this is ineffective in rousing the patient. This is because reversal of analgesia is extremely unpleasant for the patient, (although preferable obviously to prolonged respiratory depression) and reversal of sedation is usually adequate. Buscopan is a smooth muscle relaxant. It is used to temporarily halt contractions in the duodenum that may make cannulation of the ampulla difficult. It causes a temporary tachycardia, and is associated with triggering closed angle glaucoma , and so is not used where there is a history of severe cardiac problems or glaucoma. In these cases Glycogen is used, but is not as effective in my experience. 17