PTU-134 Algorithm for management of iatrogenic perforation – a quality improvement project

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Abstract

Introduction

Iatrogenic perforation of the gastrointestinal tract related to diagnostic or therapeutic endoscopy is a rare but severe adverse event, associated with significant morbidity and mortality. Because of the lack of high quality studies mainly due to the rarity of these adverse events, there is no universally accepted management strategy. The clinical management of perforation can be challenging as it warrants multiple specialist input i.e surgical/radiology/medical team and need to co-ordinate and accomplish a number of tasks within a short time.

Aim

Why do this project?

Aim

Although perforations are uncommon, a predetermined plan of action can streamline patient management particularly in that stressful environment. To develop a management algorithm for our trust following two recent incidents of iatrogenic perforation in our endoscopy unit at Llandough hospital.

Methods

The need for a perforation algorithm was discussed in our gastroenterology departmental meeting.

Input from gastroenterology

A preliminary algorithm was reviewed and amended by our consultants. It included stepwise initial general measure like securing iv access, bloods, iv fluids, analgesia as well as endoscopic closure guidance if expert help available. The algorithm instructs SpRs or nurse endoscopist to contact consultant immediately in the event of a perforation.

Input from radiology

The radiological investigations that is required following endoscopic perforation was discussed and agreed with the GI radiologists and department in our health board. This was included in the algorithm as per site specific perforation management. For eg: CT Thorax arterial phase with oral omnipaque was adviced for oesophageal perforation and to specifically scan from skull base down if suspected high oesophageal perforation.

Input from microbiologists

We discussed with our microbiologists and agreed on a ‘regime’ of antibiotics to be used in these circumstances thereby avoiding any delay in administering the medications. For eg: amoxicillin+gentamicin+ metronidazole+fluconazole in colorectal perforation.

Input from surgeons

The algorithm was reviewed and agreed with the surgeons in trust endoscopy users group meeting. The surgeons preferred to be contacted and made aware of all patients including those who had endoscopic closure for perforation.

Main algorithm

Owing to site specific differences, four flow charts were created specifically for oesophageal, gastric, duodenal and colorectal perforations. The final algorithm was implemented and posted in our endoscopy unit.

Outcome

High degree of satisfaction was expressed among endoscopy staffs and endoscopists for having clear pathway to guide in a step wise fashion.

Conclusion

We provide an algorithm of perforation management to coordinate patient management and increase the environment of safety and communication among health-care providers.

Conclusion

All the 4 algorithms with general measures algorithm are detailed below:

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