Diabetic Colon Preparation for GI Procedure

Diabetic Colon Preparationfor GI ProcedureDiabetic Colon Preparationfor GI Procedure

Ann Hayes BSN, RN, CGRNAnn Hayes BSN, RN, CGRN

Marti Buffum DNSc, RN, PMHCNS-BCMarti Buffum DNSc, RN, PMHCNS-BC

Joyce Hughes MS, RN, CGRNJoyce Hughes MS, RN, CGRN

Veterans Affairs Medical CenterVeterans Affairs Medical Center

San FranciscoSan Francisco

BackgroundBackground

 Colon cancer second leading cause deathfrom a cancer in North America Colon cancer second leading cause deathfrom a cancer in North America

150,000 colon cancer diagnosed per year150,000 colon cancer diagnosed per year

Totally preventableTotally preventable

ColonoscopyColonoscopy

Increasingly used for screeningIncreasingly used for screening

Adequate bowel prep significant for GIunits and patientsAdequate bowel prep significant for GIunits and patients

Clinical ProblemClinical Problem

Inadequate colon preparation meansrepeat procedureInadequate colon preparation meansrepeat procedure

Colonoscopy has potential risksColonoscopy has potential risks

Bleeding and perforationBleeding and perforation

Sedation complications:Sedation complications:

•Cardiac•Cardiac

•respiratory•respiratory

Required bowel cleansingRequired bowel cleansing

Day prior to procedureDay prior to procedure

Wide variety of colon prepsWide variety of colon preps

Patients often complain about prepPatients often complain about prep

Preventing repeat procedurePreventing repeat procedure

Decreases availability of colon screeningDecreases availability of colon screening

Maximizes patient safetyMaximizes patient safety

Ensures organizational efficiencyEnsures organizational efficiency

Clinical Problem in GI unitClinical Problem in GI unit

 1997 Survey of 64 patients colonoscopypreps 1997 Survey of 64 patients colonoscopypreps

19% had good preps19% had good preps

81% poor prep means repeat exam81% poor prep means repeat exam

GI nursing staff began QI project toimprove patient care by improving colonprepsGI nursing staff began QI project toimprove patient care by improving colonpreps

Nursing Interventions to ImproveColon PrepsNursing Interventions to ImproveColon Preps

Improve patient educationImprove patient education

Phone call week prior to procedurePhone call week prior to procedure

2001 Survey2001 Survey

50 colon preps = 79% good to excellent50 colon preps = 79% good to excellent

But diabetic colon preps = only 63% goodBut diabetic colon preps = only 63% good

New finding!!New finding!!

Prep SurveyPrep Survey

Suggests diabetic patients having moredifficulty attaining adequate colon prepSuggests diabetic patients having moredifficulty attaining adequate colon prep

Needs to improve / change the waydiabetic patients are preppedNeeds to improve / change the waydiabetic patients are prepped

Are diabetics different?Are diabetics different?

Need to do a literature reviewNeed to do a literature review

Found no colon prep studies with diabeticFound no colon prep studies with diabetic

Literature reviewLiterature review

Nakahara et al., (2002)Nakahara et al., (2002)

Gastroparesis: slow emptying of stomachGastroparesis: slow emptying of stomach

Well known in medicineWell known in medicine

Causes nausea and often vomitingCauses nausea and often vomiting

LiteratureLiterature

Taylor & Schubert (2001) diabetic patientsprepped significantly less effective prepTaylor & Schubert (2001) diabetic patientsprepped significantly less effective prep

Using PEG solution for colonoscopyUsing PEG solution for colonoscopy

17 of 45 diabetic patients had inadequatecolon prep17 of 45 diabetic patients had inadequatecolon prep

LiteratureLiterature

Fincher et al (1999) : preps forsigmoidoscopy less likely to be adequateFincher et al (1999) : preps forsigmoidoscopy less likely to be adequate

Study of 299Study of 299

Regardless of which 3 preps used,diabetics less likely to have adequate prepRegardless of which 3 preps used,diabetics less likely to have adequate prep

Literature reviewLiterature review

Study by Maleki et al., (1998): significantlyslower colonic transit timesStudy by Maleki et al., (1998): significantlyslower colonic transit times

 Ascending and transverse colon slower Ascending and transverse colon slower

Study by Celik et al., (2001)Study by Celik et al., (2001)

Constipation a problem for 2/3 diabeticsConstipation a problem for 2/3 diabetics

Special Needs of DiabeticSpecial Needs of Diabetic

Approach to colon prep in diabetic patientsneeds to be differentApproach to colon prep in diabetic patientsneeds to be different

Need to change standard prep usedNeed to change standard prep used

PEG SolutionPEG Solution

Polyethylene glycol-based isotonic saltsolutionPolyethylene glycol-based isotonic saltsolution

Davis et, al 1980Davis et, al 1980

Safest and most commonly usedSafest and most commonly used

Sodium Phosphate SolutionSodium Phosphate Solution

Low volume, strong laxativeLow volume, strong laxative

Associated with dangerous fluid &electrolyte shiftsAssociated with dangerous fluid &electrolyte shifts

FDA issued a warningFDA issued a warning

Magnesium Citrate (Mg)Magnesium Citrate (Mg)

Study by Berkelhammer 2002 showed Mgcitrate milder, low volume laxativeStudy by Berkelhammer 2002 showed Mgcitrate milder, low volume laxative

Minimizes electrolyte imbalance,dehydration & aphthous ulcersMinimizes electrolyte imbalance,dehydration & aphthous ulcers

Sodium phosphate solution = 5.5% ulcersSodium phosphate solution = 5.5% ulcers

Mg = 1% ulcersMg = 1% ulcers

Significant finding: p< 0.01Significant finding: p< 0.01

Mg CitrateMg Citrate

Aphthous ulcers lead to diagnosisconfusionAphthous ulcers lead to diagnosisconfusion

Could be: IBD, ischemic colitis or infectionCould be: IBD, ischemic colitis or infection

Mg CitrateMg Citrate

Available over the counter & low costAvailable over the counter & low cost

Minimal fluid and electrolyte shiftMinimal fluid and electrolyte shift

Fewer incident aphthous ulcersFewer incident aphthous ulcers

Mg Citrate & ElectrolytesMg Citrate & Electrolytes

Sharma et, al 2001 study showed:Sharma et, al 2001 study showed:

No significant shifts in BP, pulse andelectrolytesNo significant shifts in BP, pulse andelectrolytes

Mg citrate safe & effective for colon cleansingMg citrate safe & effective for colon cleansing

Usual Reaction to failedcolon prepUsual Reaction to failedcolon prep

Repeat colonoscopyRepeat colonoscopy

 Double PEG = 8 liters Double PEG = 8 liters

Double Prep ProblemDouble Prep Problem

Diabetics have slow gastric emptyingDiabetics have slow gastric emptying

Would have difficult consuming large volumesWould have difficult consuming large volumes

Possible vomiting and non adherencePossible vomiting and non adherence

Constipation ProblemConstipation Problem

Large percentage of diabetic areconstipatedLarge percentage of diabetic areconstipated

Need to correct this prior to starting colonprepNeed to correct this prior to starting colonprep

Decision ProcessDecision Process

 Conferred with Dr McQuaid, Chief GIDC Conferred with Dr McQuaid, Chief GIDC

Tried new prep on small group with goodsuccessTried new prep on small group with goodsuccess

Standard Colon PrepStandard Colon Prep

 Clear liquids day prior to colonoscopy Clear liquids day prior to colonoscopy

Late afternoon:Late afternoon:

10 oz Mg citrate10 oz Mg citrate

4 liters PEG4 liters PEG

New Diabetic Colon PrepNew Diabetic Colon Prep

All patients have clear liquid diet day priorAll patients have clear liquid diet day prior

 Diabetics: two days prior to exam 10oz.Mg citrate Diabetics: two days prior to exam 10oz.Mg citrate

All patients: day before test, 10oz Mgcitrate and 4 liters PEGAll patients: day before test, 10oz Mgcitrate and 4 liters PEG

Research QuestionResearch Question

Will new colon prep two 10oz Mg citrate(1 day apart) & 4 liters PEG solutionimprove diabetic prep over original prep10oz Mg citrate and 4 liters PEG solution?Will new colon prep two 10oz Mg citrate(1 day apart) & 4 liters PEG solutionimprove diabetic prep over original prep10oz Mg citrate and 4 liters PEG solution?

MethodMethod

Design: Experimental designDesign: Experimental design

Randomized controlled trialRandomized controlled trial

Double blinded: physician-nurse team andpatientDouble blinded: physician-nurse team andpatient

Conducted at GIDCConducted at GIDC

University-affiliated VA Medical CenterUniversity-affiliated VA Medical Center

IRB approval form University of Californiaand VA Research CommitteeIRB approval form University of Californiaand VA Research Committee

200 subjects200 subjects

ProcedureProcedure

ConsentConsent

Randomization: random table of numbersRandomization: random table of numbers

Blinded procedure staffBlinded procedure staff

Patient drinks one of two preps:experimental or standardPatient drinks one of two preps:experimental or standard

InstrumentsInstruments

Demographic InformationDemographic Information

AgeAge

SexSex

Use of narcoticsUse of narcotics

Years of being diabeticYears of being diabetic

Signs of peripheral or retinal neuropathySigns of peripheral or retinal neuropathy

Serum creatinineSerum creatinine

InstrumentsInstruments

Patient QuestionnairePatient Questionnaire

Which prep consumed?Which prep consumed?

How much was consumed?How much was consumed?

How long it took to consume ?How long it took to consume ?

InstrumentsInstruments

Colon cleansing scaleColon cleansing scale

Used by GI staff since 1998Used by GI staff since 1998

Adams et al., (1994)Adams et al., (1994)

Scale of 1 to 5Scale of 1 to 5

•1 = very clear of feces•1 = very clear of feces

•5 = solid stool, aborted procedure•5 = solid stool, aborted procedure

•Colon rated at cecum, consensus between nurseand endoscopist•Colon rated at cecum, consensus between nurseand endoscopist

Inclusion CriteriaInclusion Criteria

Outpatient colonoscopyOutpatient colonoscopy

DiabeticDiabetic

English speakingEnglish speaking

Exclusion CriteriaExclusion Criteria

DementiaDementia

PsychosisPsychosis

Prior colon surgeryPrior colon surgery

ProceduresProcedures

Recruitment: all diabetic outpatients beingscheduled for colonoscopyRecruitment: all diabetic outpatients beingscheduled for colonoscopy

Consented patientsConsented patients

Select randomized envelope (table ofrandom numbers)Select randomized envelope (table ofrandom numbers)

ProcedureProcedure

Give prep and instructions: standard orexperimentalGive prep and instructions: standard orexperimental

All patients received verbal and writteninstructions from GI RNAll patients received verbal and writteninstructions from GI RN

Procedures ContinuedProcedures Continued

Day of procedure: admitting nursecompletes demographicsDay of procedure: admitting nursecompletes demographics

MD and patient (blinded):MD and patient (blinded):

completed colon prep evaluation duringcolonoscopycompleted colon prep evaluation duringcolonoscopy

Study Results: DemographicsStudy Results: Demographics

 Mean age 62 years Mean age 62 years

Men 187; women 8Men 187; women 8

IDDM = 53; NIDDM = 143IDDM = 53; NIDDM = 143

Demographics not significantly differentbetween the two groupsDemographics not significantly differentbetween the two groups

Study ResultsStudy Results

Good colon prep:Good colon prep:

Diabetic (experimental) prep = 70% Standardprep = 54%Diabetic (experimental) prep = 70% Standardprep = 54%

Chi-square = 5.14Chi-square = 5.14

P = 0.02P = 0.02

Diabetic patients who used Diabetic prep hadsignificantly cleaner colonDiabetic patients who used Diabetic prep hadsignificantly cleaner colon

Chi-square = 5.14,p=0.02

Percent of Patients for Whom Colon was Easily Visualized

Percent of Patients Who Drank 4 Liters of PEG as Directed

p=.96, NS

ConclusionConclusion

Diabetic patients having a colonoscopy willget better colon cleansing if given 10 ozMg citrate two days prior to procedurethen 10 oz Mg citrate and 4 liters PEG theday prior to procedureDiabetic patients having a colonoscopy willget better colon cleansing if given 10 ozMg citrate two days prior to procedurethen 10 oz Mg citrate and 4 liters PEG theday prior to procedure

Other GI procedure units could confidentlyimplement this prep for diabetic patientsOther GI procedure units could confidentlyimplement this prep for diabetic patients

Practice ChangePractice Change

 Diabetic prep routinely for all diabeticpatients scheduled for colonoscopy Diabetic prep routinely for all diabeticpatients scheduled for colonoscopy

Expanding the use of this prep to patientswith constipation and those who hadinadequately cleans colon on pastcolonoscopyExpanding the use of this prep to patientswith constipation and those who hadinadequately cleans colon on pastcolonoscopy