Patient Care in the Interventional Suite
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1 Patient Care in the Interventional Suite October 3, 2015 Peter O. Simon, Jr MD Vascular and Interventional Specialists Charlotte Radiology
2 Outline 1. Pre-procedure Assessment 2. Basic Intraprocedure Management (medications) 3. Common Emergencies 4. Postprocedure care 5. Q&A
3 The storm is coming whether you re aware of it or not, and whether you re prepared for it or not. Jarod Kintz
4
5 Essential Elements: Physician / Practitioner Planned Procedure Expected Course Most Common Risks / Benefits / Alternatives Opportunity for questions Informed Consent
6 Personnel Roles and Responsibilities
7 Situational Awareness
8 Preoperative Patient Clinical Evaluation Airway Neurologic Cardiac Pulmonary Organ System Specific: Arterial, Venous, Hepatobiliary, Genitourinary, etc
9 ASA Physical Status Classifications
10 ASA levels of Sedation
11 Preoperative Lab Evaluation - Coagulation
12 Preoperative Lab Evaluation - Coagulation
13 Preoperative Lab Evaluation - Coagulation
14 Preoperative Lab Evaluation
15 Preoperative Lab Evaluation Renal Function
16 Premedication for previous contrast reaction
17 Prophylactic Antibiotics
18 ASA levels of Sedation
19 Basic Requirements of Sedation
20 LEMON Airway Assessment Look at anatomy Small mandible, large tongue, obese neck Evaluate Loose teeth Mallampati Obstruction Secretions, stridor, etc Neck Mobility RA, Ankylosing spondylitis, Cspine precautions
21 Local Anesthetic Agents
22 Common Sedative Agents - IV
23 Reversal Agents
24 CO2 Capnography
25 Special Medication Considerations Heparin UVA VIR Fellow s Manual 2011
26 Special Medication Considerations: Nitroglycerin UVA VIR Fellow s Manual 2011
27 TPA Tissue Plasminogen Activator Mechanism Activates plasminogen Typical dose rate: mg / h Many protocols minimizing dose to 24 mg / 24h UVA VIR Fellow s Manual 2011
28 TPA Tissue Plasminogen Activator Mechanism Activates plasminogen Typical dose rate: mg / h Many protocols minimizing dose to 24 mg / 24h
29 Special Medication Considerations Aspirin and Plavix Mechanism: irreversible cox-1 and txa2 blocker T ½ 6-12h New plts have to form to return function Bleeding time returns to normal approx. 5 days after stoppage Mechanism: adenosine diphosphate inhibitor on plt T ½ 6h Prolongs bleeding time Contraindications: Bleeding and sensitivity
30 Special Management of the Pediatric Consent Airway Metabolism of sedative agents Weight based medication dosages (abx / pain meds) Hypothermia Bronchospasm / Vasospasm Radiation precautions (ALARA) Patient
31 Specific Emergency Scenarios
32 Specific Emergency Scenarios
33 Get Help!
34 BLS
35 Diagnosis: Hypotension, bradycardia, nausea, diaphoresis Vasovagal Reactions Treatment: Leg elevation, fluids, atropine UVA VIR Fellow s Manual 2011 Nursingconsult.com
36 Over-Sedation Diagnosis: Hypoxia and Respiratory depression Treatment: Monitoring, airway support, reversal agents, help
37 Air Embolus Left lateral decubitus position (minimize RVOT path) Oxygen therapy Supportive care Aspiration? J. Cardiothorac Surg Sep 15;10
38 Anaphylaxis Recognition Prompt, aggressive Rx Supplemental Oxygen IV fluids Epinephrine (1:10,000 IV) Supportive care
39 Pneumothorax / Hemothorax
40 Oxygen Monitor IV Morphine ASA Nitrates Diuretic / Dialysis Definitive Care MI / CHF
41 Stroke OMI Source? CT! Definitive care Time is Brain Can I get it out?
42 Code Scenarios Bradycardia Vtach / Vfib Asystole PEA *If you have a wire in the heart, expect an arrhythmia*
43 Post Procedure Care Catheter Removal Patient Monitoring Management of Acute Complications Discharge and Follow up
44 Catheter Removal Catheter Removal / Closure / Loss of Access Suitable? Anatomy, ACT, size of access Reversal Agent? Protamine Tract embolization? Time to discharge? Ability to lie flat?
45 Patient Monitoring / Disposition Patient Monitoring Access site and pulses q 15 min Observation following sedative minutes Discharge times vary (arterial / venous, extend of intervention). Hand off of care / Communication Post procedure orders
46 Management of Acute Complications Rapid Assessment (Importance of pre-op exam) Puncture site bleeding (compression / reversal) Arterial Occlusion (back to angio) Distal embolization (heparin + / - back to angio) J Korean Neurosurg Soc Jul;48(1):88-90.
47 Discharge and Follow up Printed DC instructions Activity Diet Wound / Dressing Mgmt Medications Follow-up Contact Info
48 Summary Outline 1. Pre-procedure Assessment 2. Basic Intraprocedure Management (medications) 3. Common Emergencies 4. Postprocedure care 5. Q&A
49 References and In-Depth Reading
50 Head on a Swivel
51 Vascular and Interventional Specialists Peter O. Simon, Jr. MD CHS-NE: Concord V&V Clinic:
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