INTRODUCTION TO INTERVENTIONAL RADIOLOGY

Transcription

1 INTRODUCTION TO INTERVENTIONAL RADIOLOGY JAMES CHEN INTRODUCTION TO RADIOLOGY JULY 29, 2014 GOALS AND OBJECTIVES Overview of interventional radiology (IR) Fundamental tools Major types of procedures Provide practical advice for IR rotation Resident role on the team Key resources General workflow Tips for consults 1

2 FIELD OF IR: BASIC OVERVIEW WHAT IS INTERVENTIONAL RADIOLOGY?" 2

3 TOOLS: IMAGING TOOLS: BASIC EQUIPMENT SHEATHS CATHETERS WIRES 3

4 TOOLS: CATHETERS AND SHEATHS Catheters and Sheath Size: French (Fr) 3 x Diameter (Slightly < circumference) in millimeters OUTER DIAMETER: CATHETERS INNER DIAMETER: SHEATHS TOOLS: CATHETERS NONSELECTIVE: SELECTIVE: PIGTAIL STRAIGHT COBRA SIMMONS BERENSTEIN 4

5 TOOLS: WIRES Wire size Diameter (inches): i.e , Length (cm) Other wire properties Stiffness: floppy (Bentson), stiff (Amplatz) Tip: shape and stiffness TOOLS: DEVICES, TUBES, ETC. STENTS OCCLUSIVE DEVICES/AGENTS DRAINS OTHER DEVICES 5

6 PROCEDURES: BREAD & BUTTER Venous access Lines i.e. PICC, tunneled dialysis catheter Tubes/drains GI: PEG GU: Nephrosotomy, nephroureteral stent Abscess/collection drainage PROCEDURES: VASCULAR Restoring flow Dialysis fistula/graft Peripheral vascular disease Stopping flow (embolization) Trauma GI bleeding Varicose veins Vascular malformations 6

7 PROCEDURES: ONCOLOGY Oncology Chemoembolization and radioablation: hepatic tumors Thermal ablation: renal tumors Pre-operative embolization PROCEDURES: FIBROIDS Uterine artery embolization 7

8 BASIC PROCEDURAL SKILLS Ultrasound guidance Vascular access (MILESTONE) Fluid drainage (MILESTONE): paracentesis, abscess drainage Putting wires in catheters and catheters over wires Flushing catheters Filling syringes with contrast and saline Surgical knots IR ROTATION OVERVIEW 8

9 IMPORTANT RESOURCES Penn IR Website: User: pennir Password: ponsky Contains PDFs for all consents HI-IQ: database for tracking cases (fellows do all data entry) User: res Password: res Texts: Vascular and Interventional Radiology the Requisites Resident and Fellow Manual (on PennIR site) DAILY SCHEDULE 7:00 am: Resident/Fellow Conference 8:00 am: Film rounds (review cases from previous day) If on VA or Presby, leave after film rounds 8:30 am: Board rounds (review cases of coming day) 8:45 9:00 am: Cases begin 5:00 6:00 pm: Sign out to on-call fellow 9

10 AM CONFERENCE SCHEDULE Check schedule in work room and/or ask fellows Monday: Chief rounds (Work room) Tuesday: Didactic lecture (Baum/Donner) Wednesday: 6:30 am Chief rounds (Work room) Thursday: Sometimes coding conference/journal club (Baum) Friday: Liver (2 Dulles), Dialysis access (Work room) conferences ROTATION BREAKDOWN Cases Assigned with fellow to 2 rooms (fairly flexible if you are not on with many more trainees) HUP 1 rms 5/6 ( High-end cases tend to be done here) HUP 2 rms 3/4 HUP 3 rms 1/2 Consult days Paired with fellow or senior resident 10

11 CASES OUTPATIENT PREPROCEDURE WORKUP 1. Pre-procedure note 2. Nursing sheet 3. Informed consent 4. Review prior imaging 5. Review HI-IQ 11

12 NURSING SHEET NURSING SHEET: ASA STATUS American Society of Anesthesiologists Physicial Status Classification 1. Normal healthy pt 2. Mild systemic disease 3. Severe systemic disease 4. Severe systemic disease that is constant threat to life 5. Moribund pt not expected to survive without operation 12

13 NURSING SHEET: AIRWAY Mallampati Score 1. Soft palate, uvula, tonsils 2. Soft palate, uvula, 3. Soft palate, base of uvula 4. Hard palate GETTING READY FOR A CASE 1. Review preprocedure note and imaging 2. Introduce yourself to tech and RN 3. Put your gloves out (double gloving recommended) 4. Put on: Lead, hair cap, eye protection 13

14 TO SCRUB OR NOT TO SCRUB Versus Scrub cleanser or Purell: Nontunnelled lines Tubes Chembo UAE Full 3 minute scrub: Tunneled lines Ports Covered stents CASE STARTS! 1. Your role dependent on fellow/attending experience/comfort 2. Common portions of procedure you will be involved in: Venous access Helping pin wires, exchange devices over wire Filling contrast and/or saline (Bubbles are bad!) Tying down lines, closing skin incision for ports 14

15 SEDATION MEDS Midazolam (Versed) 1 mg IV Fentanyl 50 mcg IV 1 round Versed 1 mg + Fentanyl 50 mcg CASE IS DONE! Post-procedure (Responsibilities shared between you and the fellow): 1. Write down medications and fluoro time 2. Write postprocedure note 3. Place postprocedure orders in Sunrise 4. Dictate case (section macros, leave in draft) 5. Add case to your CASE LOG 15

16 INPATIENTS 1. Sign-out to on-call fellow at the end of the day 2. AM pre-rounding (coordinate with your fellow) Get sign-out from on call fellow See pt and write SOAP note Discuss plan with fellow/attending 3. * Note: PAs see pts with tubes/drains so you don t have to CONSULTS 16

17 CONSULTS Act as point of contact for IR Work with fellow or senior resident Get to know Danielle IR coordinator! Schedules all cases Extremely helpful resource CONSULTS: KEY QUESTIONS Phone rings! Interventional radiology, this is Key info before any details: Name Callback number Pt s name Pt s rm number Which part of hospital What procedure is being consulted for?" Overview of clinical situation? 17

18 CONSULTS: KEY QUESTIONS Labs? INR Platelets Creatinine Consentable? If NO, who consents? Contact #? NPO?" Is order in Sunrise? CONSULTS: LABS INR Platelets Heparin Arterial interventions Nonvascular procedures (except para/thoracentesis) TIPS Port placement Port removal Tunneled catheters Transjugular liver biopsy IVC filter Dialysis access interventions Paracentesis Thoracentesis Nontunnelled catheters Tunneled catheter removal (without cutdown) ,000 Off 2 hours pre-procedure 2 25,000 Off 2 hours (tunnelled cathethers) Off at sunset (remainder) None None Off at sunset 18

19 CONSULTS: LABS CREATININE < Proceed Renal sparing protocol Consider alternatives Renal Sparing protocol Mucomyst: 3 ml 20% N-acetylcysteine PO q12h, 4 doses Bicarbonate protocol Use < 10 ml Isovue CO 2 for central venous imaging CONSULTS: NOW WHAT? Stay in work room until ~ 10 am (unless urgent consult) Take additional consults Look up history, imaging, HI-IQ Start filling out pre-procedure forms Organize consults by location and urgency Paperwork to bring Pre-procedure note Consent form 19

20 CONSULTS: SEEING THE PATIENT 1. Introduce yourself 2. Talk about procedure, risks/benefits 3. Examine patient 4. Get informed consent 5. DO NOT tell patient or team procedure will be done at specific time CONSULTS: DISCUSS 1. Run cases by attending (before and/or after you see patient) 2. Call consulting physician to let him know the plan 3. Call/talk to Danielle so she can add case to scheduling board 20

21 COMMON CONSULT: TDC Tunneled Dialysis Catheter Indication Pt requiring hemodialysis Physical Examination Pulses, arm swelling, chest/neck collaterals Other points NO INR or platelet requirement NO sedation so NO NPO order needed COMMON CONSULT: PICC Peripherally Inserted Central Catheter Indication Need for IV medications/tpn long term (> 2 wks) Contraindication Creatinine > 3: venous access preservation Other points NO INR or platelet requirement NO sedation so NO NPO order needed 21

22 COMMON CONSULT: SBCC Small bore central catheter Indication: as PICC Benefit: venous preservation Technique Inserted into internal jugular vein Tunneled subcutaneously in chest wall TIME FOR A TOUR! Questions? 22