1 / 72

Interventional Radiology

Interventional Radiology. North Shore Medical Center. The “Ins and Outs”. Needles Catheters Guide Wires Tubes Ya-Da-Ya-Da-Ya-Da!!!!. Introduction.

butch
Download Presentation

Interventional Radiology

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Interventional Radiology North Shore Medical Center

  2. The “Ins and Outs” • Needles • Catheters • Guide Wires • Tubes • Ya-Da-Ya-Da-Ya-Da!!!!

  3. Introduction • Purpose: to discuss a brief history of Interventional Radiology, the current interventional procedures done at the NSMC, the radiology nurse’s role and the impact on patient care in the Radiology Department • To educate floor and recovery room nurses about the pre and post care of the IR patient • Joyce Silvano, RN, ANM Radiology

  4. Topics of Discussion • Definitions and Brief History • Vascular and Non-Vascular Interventional Radiologic Procedures • Pre, Intra, and Post Procedure Nursing Care • Follow-up Care

  5. Definitions • INTERVENTIONAL RADIOLOGY (IR) • minimally invasive procedures and targeted treatments using image guidance • small instruments guided through the blood vessels or other pathways to treat diseases percutaneously

  6. Definitions • INTERVENTIONAL RADIOLOGIST • medical doctors who specialize and are board certified in performing procedures using medical imaging • assume responsibility for the patient’s care before, during, and after the procedure • INTERVENTIONAL RADIOLOGY NURSE • critical care RN who provides continuous quality care for the patient requiring an interventional procedure

  7. Interventional Radiology Nurse • Patient advocate • Patient educator • Responds to medical emergencies within the entire department 1. Contrast Reactions 2. Seizures 3. Vasovagal Reactions 4. Cardiopulmonary Arrest • Liaisons – communication between radiology and patient care floors, referring facilities, or doctor’s offices • Long-term Goal: continue to provide educational opportunities to our fellow nurse’s

  8. Brief History • 1967, Dr. Alexander Margulis coined the phrase “interventional diagnostic radiology” • Mid 70’s: Improved radiologic imaging and development of tools Balloon Catheters Wires • Interventional Radiologists pioneered coronary angiography, invented angioplasty and catheter-delivered stents

  9. Brief History • 1992: AMA officially recognized IR as a medical specialty • 2001: Society of Interventional Radiology (SIR) adopted the following definition: “Interventional radiology is the medical specialty devoted to advancing patient care through the innovative integration of clinical and imaging-based diagnosis and minimally invasive therapy.”

  10. Vascular Interventions • Angiography/Angioplasty/Stents • venous and arterial • Fibrinolytic Therapies • venous and arterial • Embolization Therapies • IVC Filter Insertions (mostly retrievable) • Venous Access Device Insertions • Implanted VAD • Dialysis Catheters: Temporary and Permanent • PICC and CVC insertions

  11. Non-Vascular Interventions • Biliary Interventions • Percutaneous Cholangiograpy and Biliary Drainage Catheter Insertion • Cholecystostomy • Biliary Stone Removal • Biliary Strictures: Dilitations and Stent Insertions • GI Interventions • Percutaneous Gastrostomy/Gastrojejunostomy • GI Strictures: Dilitations and Stent Insertions • GU Interventions • Antegrade Pyelogram/Nephrostomy • Nephroureteral and Ureteral Stent • Renal Stone Manipulation

  12. Non-Vascular Interventions Cat Scan and Ultrasound • Biopsy and/or Fluid Aspirations • Thoracic (lung, pleural, and mediastinal) • Retroperitoneal Lymph Nodes • Hepatobiliary ( liver: focal abnormality/targeted or for liver medical disease, increased LFT’s or Hep C) • Pancreas • Spleen • GU (renal: focal abnormality/targeted; medical renal disease; bladder, urethra, prostate) • Soft Tissue (superficial or deep) • GI Mesenteric • Adrenal • Peritoneal • Muskuloskeletal (bone, joint, muscle) • Neuro-spinal • Thyroid

  13. Drainages Abscess/Infections • Thorax – empyma • Retroperitoneal • Intraperitoneal • Visceral/Organ • Superficial Non-Infected • Pleural (effusion, pneumothorax) • Mediastinal • Retroperitoneal • Intraperitoneal (ascites) • Visceral/Organ (cyst aspiration) • Superficial

  14. Drainages (continued) Sclerosis • Thoracic • Retroperitoneal • Intraperitoneal • Visceral • Pain Management • Neuro-blockade • Vertebroplasty

  15. Interventional Radiology Nursing Care

  16. Pre-Interventional Procedures • Labs: BUN, Creat, eGFR, E-Lytes; Coags, CBC, FSBS on arrival if not done at home; urine HcG; fibrinogen and type and screen for fibrinolytic therapy; type and screen for RFA and medical renal biopsy; EKG for all PVD patients and patients receiving anesthesia • Consent/History & Physical • Nursing Assessment with Medication Reconciliation • Procedural Teaching • Pre-procedure instructions for outpatient (telephone screening if no consult) • Renal agram patients: Hold long acting antihypertensives if renal angioplasty is likely • eGFR < 60: Mucomyst 600mg twice a day 24 hours prior and on the day of the contrast and/or Bicarb drip 3 ml/kg for 1 hour prior to contrast exposure and 1 ml/kg during exposure and for 6 hours post contrast • Prior contrast reaction: Pre-medicate with prednisone and diphenhydramine • Anticoagulants: Coumadin, Heparin, Lovenox, Fragmin • Antiplatelet therapy: ASA products, Vitamin E, the 3 G’s, Fish Oil, Plavix • Site marking and patient identification outside of the procedure room

  17. Intra-procedure care • Procedural Sedation when indicated • Circulator for anesthesia cases • Monitor patient continuously during procedure • Report any abnormal changes in vital signs or patient condition to the interventional radiologist • Reassure patient, explain what will happen next • Reassess patient frequently for pain, change in condition and intervene as appropriate

  18. General post-procedure care • Post-procedure instructions: patient, family member if procedural sedation used • Maintain IV access until discharged • Monitor puncture site, wound, etc. until patient transferred to nursing unit or discharged home • Reassess condition, vital signs, pain as above • Document assessments and discharge criteria on flow sheet • Handoff report to accepting floor or outside facility • Discharge instructions given to and reviewed with patient and family member (may be done prior to procedure by IR RN)

  19. IR Procedures at NSMC

  20. Diagnostic Imaging Procedures • Lumbar Puncture • 2 hour recovery • Flat x1 hour • Pre procedure - No dietary restrictions; Post procedure - encourage caffeinated fluids if no contraindication • Outpatients may drive home • Myelogram • 2 hour recovery • Flat x 1 hour • Pre procedure - light breakfast then clear liquids; Post procedure – same as lumbar puncture • Patient requires ride home • Discharge instructions to include time frame and symptoms of post puncture headache (slow leak may take up to 3-5 days to exhibit symptoms nausea and vomiting; unable to lift head off of pillow) • Arthrogram

  21. Renal Artery Angiogram/Angioplasty/Stent Insertion

  22. Next Steps Peripheral Vascular Angioplasty/Stents

  23. Uterine Artery Embolization

  24. Post-UAE Pre-UAE

  25. Other Indications for Embolizations • Arterial bleeding d/t tumor erosion • Epistaxis • AVM/Cerebral Aneurysms • Uncontrollable post-partum bleeding • Inadvertent arterial injury during surgery

  26. General Post Angiography Care • Arterial puncture site • Femoral stick: lower extremity extended and still x 2-4 hours with closure device; x 6-8 hours manual compression, may log roll side to side • Axillary stick: keep arm in sling and still for 6-8 hours and assess for brachial plexus injury • HOB 30 degrees • Monitor puncture site(s) for hematoma • Apply direct pressure to puncture site and call IR • Retrograde stick – Index finger on and two fingers above puncture site • Antegrade stick – Index finger on and two fingers below puncture site • CONFUSED? Middle finger on the puncture site with one finger above and one below • Monitor vascular status of the extremity distal to puncture site to include pulse checks, csm and temperature assessments • Venous puncture site • Extremity still for 2-4 hours • Monitor for signs of bleeding • Encourage oral fluid intake for those patients able to drink to help excrete contrast and prevent nephrotoxicity • DO NOT ADMINISTER PROTAMINE SULFATE FOR REVERSAL OF HEPARIN TO ANY PATIENT THAT HAS RECEIVED NPH (neutral protamine Hagedorn) INSULIN. This may percipitate an anaphylactic reaction… • Give smoking cessation information to any patient with peripheral vascular disease that continues to smoke • Encourage patient to exercise regularly • Discharge Instructions: NSMC Clinical Med Rec Froms

  27. Specific Angiographic Potential Post Procedure Complications • Renal angioplasty +/- stent insertion • Hypotension especially if patient takes multiple antihypertensive medications and long acting drugs have not been discontinued • Worsening renal function or failure with peripheral renal emboli (not immediately evident) • Embolization procedures • Ischemic pain distal to embolization: UAE, iliac artery (pre endo graft repair of AAA) • Misembolization

  28. Endovascular Stent Grafts

  29. Indications, Goals, Complications • Combined IR/OR procedure in OR suite • Emergent or Elective • Known or suspected rupture or rapidly expanding rupture • Less invasive alternative for low risk patient decreasing procedural morbidity & mortality; post procedural pain and complications; decrease in hospital stay (2 days low risk patient and 4 days high risk patient) • Provides treatment to high-risk patients who are not surgical candidates and would have no other therapeutic options • Major Complications • MI, CHF, Hypertension, DVT, Stroke, GI and RP hemorrhage, HIT, limb ischemia +/- amputation, pseudoaneurysm, renal failure, infection, surgical conversion

  30. Venous Access Devices • PICC/CVC • Implanted VAD • Dialysis Catheters/Temporary and Permanent • Hickman Pheresis Catheters

  31. Biopsies

  32. Post Biopsy Care • Lung Biopsy • Usually FNA’s (Fine Needle Aspirations) only • CXR 1 hour and 3 hours post biopsy • Immediate CXR for chest pain, dyspnea, decreasing sats • Biopsy side down x 3 hours (may sit up to eat after 1 hour CXR) • NPO until 1 hour CXR read and is okay • Blood tinged sputum is to be expected, large amount of hemoptysis contact IR MD • Pneumothorax: Continue supplemental O2 • May transfer to recovery with small, stable ptx • PTX may be aspirated prior to transfer • Abdominal/Organ biopsy • Biopsy site down x 3 hours (liver/renal) • Liver biopsy – always core sampling for non targeted biopsy • Stretching of the liver capsule may cause moderate to severe pain • Pain may radiate to the shoulder • Advance diet as tolerated • All Biopsy patients • Up to 4 hour recovery time • Assess for signs of hemorrhage or infection – Non targeted renal biopsies (core) stay 23 hours to monitor HCT’s • Discharge Instructions NSMC Clinical Med Rec Froms

  33. Percutaneous Nephrostomy PCN – External drainage of the renal collecting system • Ureteral obstruction causing a hydro or pyonephrosis; tumor, pregnancy, stone. • Tract creation for lithotripsy with guide wires left in place • Urinary diversion to allow healing of ureteral leaks or fistulas • May be short term; tract for lithotripsy, decompression from infection, pre and post stent insertion (safety catheter) • May be long term; maintain drainage in patients with malignant tumors compressing the collecting system, uni or bilateral.

  34. Nephroureteral Stent & Ureteral Stent

  35. Post PCN Care • Observation for up to 4 hours • Monitor for signs of retroperitoneal bleeding • Vital sign changes • Severe flank pain • Drop in HCT without hematuria • Monitor for hematuria • Blood tinged urine output expected for the first 48 hours • Gross hematuria – call MD • Forward flush catheter with 10 ml NS • Maintain catheter patency - no kinks • Observe for drainage around catheter at skin site • Decreased urine out put • Bladder Spasms • Discharge Instructions NSMC Clinical Med Rec Forms

  36. Vertebral Augmentation - Vertebroplasty

  37. Vertebral Augmentation Kyphoplasty

  38. Post Vertebral Augmentation Care • Flat for 2 to 4 hours • Advance diet as tolerated • Watch for signs of complications • Chest pain/hypoxemia – pulmonary cement embolus • Neurological changes – CNS cement embolism • Loss of bowel or bladder control • Lower extremity weakness • Fractured Rib • Temporary worsening of pain may occur

  39. TIPS –Transjugular Intrahepatic Portosystemic Shunt • Reroutes blood flow to reduce complications from portal hypertension and varices • Reduces portal vein pressure by creating a decompression channel between a hepatic vein and an intrahepatic branch of the portal vein • Usually done emergently because of hemorrhage from varices • May be performed electively for refractory ascites • Stent placed from portal vein directly through liver to hepatic vein • Lasts 1-4 hours • Usually done under general anesthesia Potential Complications • Encephalopathy: toxic substances in the bloodstream are ordinarily filtered out by the liver. The TIPS may cause too much of these substances to bypass the liver filtration, so a patient who already has encephalopathy because of their liver disease may not be a good candidate for the procedure. • bleeding into and around liver • occlusion or stenosis of stent • pulmonary edema from elevated cardiac output, cardiac index and RA pressures (especially in acutely bleeding patient receiving fluid resuscitation)

  40. Radiofrequency Ablation (RFA) • Minimally invasive procedure under CT or US guidance • Special needle electrode placed in a tumor • Most often primary liver or colon met to liver, can be done for renal, lung and bone lesions • Effective treatment in patients unsuitable for surgery, failed chemotherapy, recurrence after surgery, multiple lesions • Treated in one or more sessions, minimal discomfort, outpatient procedure • Radiofrequency current passed from generator through the electrode to heat the tumor tissue near the needle tip destroying cancer cells and a small rim of normal liver tissue • Closes small blood vessels, minimizing risk of bleeding

  41. Radiofrequency Ablation (RFA) • Risks of liver RFA include brief shoulder pain, inflammation of gallbladder, damage to bile ducts with resulting biliary obstruction, thermal damage to bowel or adjacent structures • “Post-ablation syndrome” flu-like symptoms that appear 3-5 days post procedure, lasting about 5 days, treated with acetaminophen

  42. What’s on the Horizon? . . . .

More Related