Diabetic Colon Preparation for GI Procedure

2. Diabetic Colon Preparation for GI Procedure Ann Hayes BSN, RN, CGRN Marti Buffum DNSc, RN, PMHCNS-BC Joyce Hughes MS, RN, CGRN Veterans Affairs Medical Center San Francisco

3. Background • Colon cancer second leading cause death from a cancer in North America • 150,000 colon cancer diagnosed per year • Totally preventable

4. Colonoscopy • Increasingly used for screening • Adequate bowel prep significant for GI units and patients

5. Clinical Problem • Inadequate colon preparation means repeat procedure • Colonoscopy has potential risks • Bleeding and perforation • Sedation complications: • Cardiac • respiratory

6. Required bowel cleansing • Day prior to procedure • Wide variety of colon preps • Patients often complain about prep

7. Preventing repeat procedure • Decreases availability of colon screening • Maximizes patient safety • Ensures organizational efficiency

10. Clinical Problem in GI unit • 1997 Survey of 64 patients colonoscopy preps 19% had good preps 81% poor prep means repeat exam • GI nursing staff began QI project to improve patient care by improving colon preps

11. Nursing Interventions to Improve Colon Preps • Improve patient education • Phone call week prior to procedure

12. 2001 Survey • 50 colon preps = 79% good to excellent • But diabetic colon preps = only 63% good New finding!!

13. Prep Survey • Suggests diabetic patients having more difficulty attaining adequate colon prep • Needs to improve / change the way diabetic patients are prepped

14. Are diabetics different? • Need to do a literature review • Found no colon prep studies with diabetic

15. Literature review • Nakahara et al., (2002) • Gastroparesis: slow emptying of stomach • Well known in medicine • Causes nausea and often vomiting

16. Literature • Taylor & Schubert (2001) diabetic patients prepped significantly less effective prep • Using PEG solution for colonoscopy • 17 of 45 diabetic patients had inadequate colon prep

17. Literature • Fincher et al (1999) : preps for sigmoidoscopy less likely to be adequate • Study of 299 • Regardless of which 3 preps used, diabetics less likely to have adequate prep

18. Literature review • Study by Maleki et al., (1998): significantly slower colonic transit times • Ascending and transverse colon slower • Study by Celik et al., (2001) • Constipation a problem for 2/3 diabetics

19. Special Needs of Diabetic • Approach to colon prep in diabetic patients needs to be different • Need to change standard prep used

20. PEG Solution • Polyethylene glycol-based isotonic salt solution • Davis et, al 1980 • Safest and most commonly used

21. Sodium Phosphate Solution • Low volume, strong laxative • Associated with dangerous fluid & electrolyte shifts • FDA issued a warning

22. Magnesium Citrate (Mg) • Study by Berkelhammer 2002 showed Mg citrate milder, low volume laxative • Minimizes electrolyte imbalance, dehydration & aphthous ulcers • Sodium phosphate solution = 5.5% ulcers • Mg = 1% ulcers • Significant finding: p< 0.01

23. Mg Citrate • Aphthous ulcers lead to diagnosis confusion • Could be: IBD, ischemic colitis or infection

24. Mg Citrate • Available over the counter & low cost • Minimal fluid and electrolyte shift • Fewer incident aphthous ulcers

25. Mg Citrate & Electrolytes • Sharma et, al 2001 study showed: • No significant shifts in BP, pulse and electrolytes • Mg citrate safe & effective for colon cleansing

26. Usual Reaction to failed colon prep • Repeat colonoscopy • Double PEG = 8 liters

27. Double Prep Problem • Diabetics have slow gastric emptying • Would have difficult consuming large volumes • Possible vomiting and non adherence

28. Constipation Problem • Large percentage of diabetic are constipated • Need to correct this prior to starting colon prep

29. Decision Process • Conferred with Dr McQuaid, Chief GIDC • Tried new prep on small group with good success

30. Standard Colon Prep • Clear liquids day prior to colonoscopy • Late afternoon: • 10 oz Mg citrate • 4 liters PEG

31. New Diabetic Colon Prep • All patients have clear liquid diet day prior • Diabetics: two days prior to exam 10oz. Mg citrate • All patients: day before test, 10oz Mg citrate and 4 liters PEG

32. Research Question • Will new colon prep two 10oz Mg citrate (1 day apart) & 4 liters PEG solution improve diabetic prep over original prep 10oz Mg citrate and 4 liters PEG solution?

33. Method • Design: Experimental design • Randomized controlled trial • Double blinded: physician-nurse team and patient

34. Conducted at GIDC • University-affiliated VA Medical Center • IRB approval form University of California and VA Research Committee • 200 subjects

35. Procedure • Consent • Randomization: random table of numbers • Blinded procedure staff • Patient drinks one of two preps: experimental or standard

36. Instruments • Demographic Information • Age • Sex • Use of narcotics • Years of being diabetic • Signs of peripheral or retinal neuropathy • Serum creatinine

37. Instruments • Patient Questionnaire • Which prep consumed? • How much was consumed? • How long it took to consume ?

38. Instruments • Colon cleansing scale • Used by GI staff since 1998 • Adams et al., (1994) • Scale of 1 to 5 • 1 = very clear of feces • 5 = solid stool, aborted procedure • Colon rated at cecum, consensus between nurse and endoscopist

39. Inclusion Criteria • Outpatient colonoscopy • Diabetic • English speaking

40. Exclusion Criteria • Dementia • Psychosis • Prior colon surgery

41. Procedures • Recruitment: all diabetic outpatients being scheduled for colonoscopy • Consented patients • Select randomizedenvelope (table of random numbers)

42. Procedure • Give prep and instructions: standard or experimental • All patients received verbal and written instructions from GI RN

43. Procedures Continued • Day of procedure: admitting nurse completes demographics • MD and patient (blinded): completed colon prep evaluation during colonoscopy

44. Study Results: Demographics • Mean age 62 years • Men 187; women 8 • IDDM = 53; NIDDM = 143 • Demographics not significantly different between the two groups

45. Study Results • Good colon prep: • Diabetic (experimental) prep = 70% Standard prep = 54% • Chi-square = 5.14 • P = 0.02 • Diabetic patients who used Diabetic prep had significantly cleaner colon

46. Percent of Patients for Whom Colon was Easily Visualized Chi-square = 5.14, p=0.02

47. Percent of Patients Who Drank 4 Liters of PEG as Directed p=.96, NS

48. Conclusion • Diabetic patients having a colonoscopy will get better colon cleansing if given 10 oz Mg citrate two days prior to procedure then 10 oz Mg citrate and 4 liters PEG the day prior to procedure • Other GI procedure units could confidently implement this prep for diabetic patients

49. Practice Change • Diabetic prep routinely for all diabetic patients scheduled for colonoscopy • Expanding the use of this prep to patients with constipation and those who had inadequately cleans colon on past colonoscopy

50. Diabetes Serious & Common Problem in US • 2008: 8% (24 million) • 2010 increase to 15% • Veterans 20% in 2000 • Most are 60 years and older