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Biliary intervention; sedation and analgesia. Is it good enough?

Biliary intervention; sedation and analgesia. Is it good enough?. Dr CKL Cook Interventional Radiologist Weston General Hospital and Bristol Royal Infirmary No conflicts of interest. Overview. Background of patients and pathology, and imaging The procedure The risks

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Biliary intervention; sedation and analgesia. Is it good enough?

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  1. Biliary intervention; sedation and analgesia. Is it good enough? Dr CKL Cook Interventional Radiologist Weston General Hospital and Bristol Royal Infirmary No conflicts of interest

  2. Overview • Background of patients and pathology, and imaging • The procedure • The risks • Survey of IR across SW UK • Conclusions

  3. Overview • Background of patients and pathology, and imaging • The procedure • The risks • Survey of IR across SW UK • Conclusions

  4. Biliary intervention;patients/ pathology • Biliary obstruction; carcinoma pancreas, cholangiocarcinoma, Lymph nodes/ adjacent tumours, hepatic metastases, benign causes. • Elderly, chronic ill-health, near end of life

  5. Presentation • Painless jaundice • Obstructive; pale stool, dark urine • Weight loss • Abdominal or back pain • Other indicators of primary or secondary disease

  6. Investigations • Ultrasound • CT for evaluation, and full staging • Magnetic resonance cholangiography (MRCP)

  7. Investigations • Ultrasound • CT for evaluation, and full staging • Magnetic resonance cholangiography (MRCP)

  8. Investigations • Ultrasound • CT for evaluation, and full staging • Magnetic resonance cholangiography (MRCP)

  9. Overview • Background of patients and pathology, and imaging • The procedure • The risks • Survey of IR across SW UK • Conclusions

  10. Intervention for biliary obstruction • MDT; Surgical, palliative, or best supportive care • Planning for intervention • ERCP- Endoscopic retrograde cholangio-pancreatography and stent. 1st line • PTC- percutaneous transhepatic cholangiography/ drainage/ stent. 2nd line, unless known duodenal compression or proximal lesions.

  11. Percutaneous biliary intervention • Percutaneous drain or stent • U/S and flouroscopic guidance; in Radiology Dept • Hydration, antibiotics, clotting, preliminary U/S to confirm extent of duct dilation • WHO/ RCR pre IR checklist

  12. Metallic biliary stent • Wall stent (Boston Sci) • Zilver (Cook Medical)

  13. Overview • Background of patients and pathology, and imaging • The procedure • The risks • Survey of IR across SW UK • Conclusions

  14. High Risk • Percutaneous biliary interventions are high risk procedures, with data suggesting immediate mortality of between 0.6 and 5.6% (1-4) • The UK Percutaneous Biliary Drainage Audit (2012) showed mortality at 30 days in the region of 19%*. • *British Society of Interventional Radiology: Biliary Drainage and Stenting Registry (BDSR) Cardiovasc Intervent Radiol (2012) 35:127-138

  15. High risk stratification* Immediate • Albumen less than 30 • Ascities • WCC greater than 14, CRP greater than 50 • Hb less than 11 Early Urea greater than 12 Bilirubin greater than 300, and ALT greater than 150 . *Eur Radiol (2011) 21:1948-1955

  16. Summary • Patients, pathology, imaging • MDT planning • Types of intervention • High Risk

  17. Overview • Background of patients and pathology, and imaging • The procedure • The risks • Survey of IR across SW UK • Conclusions

  18. Regional Survey • Regional survey of Interventional Radiologists across the South West of the United Kingdom • Approx 60 interventional Radiologists, and 40 IR nurses • Southampton – Oxford – Bristol – Plymouth – Cardiff • CIRSE; Cardiovascular and Interventional Radiology Society Europe, Lisbon 2015

  19. % patients Patient pain

  20. 2.The % of patients that appear to experience MORE than moderate pain, or move during procedure

  21. % Respondents Overall level of analgesia and sedation

  22. Comments/ Conclusions • Although a small number of both IR nurses (28%) and interventionalists (16%) feel that an anaesthetist is unnecessary for these procedures, 57% IR nurses, and 64% of interventionalists felt that patients experience moderate to severe pain, and 72% of nurses felt that an anaesthetist would improve the patient experience. • 37% of interventionalists stated they never had an anaesthetist but would like one, and more than 50% said they did not due to a difficulty to organise at short notice (and small case load). • 50 % of IR teams have never had formal training in sedation. • Only 5% of teams routinely have anaesthetic support.

  23. Qualitative responses • IR nurses… • Procedure often poorly tolerated • PTC patients deserve and require better pain relief • We are aware of occasions when a patient will be in a lot of pain • Radiologists… • Difficult to predict • Highly variable • Sedation and analgesia is somewhere between poor and satisfactory • I strongly believe anaesthetic cover should be the norm • Not normally a problem • Pain can be severe, and difficult to control

  24. Anaestheticrole • Pre-intervention clinical review • Maximise pre-operative state; renal, hydration, cardiac, infective • Sedation and analgesia • Patient relaxed, reassured, pain free, and still • Post operative care

  25. Overview • Background of patients and pathology, and imaging • The procedure • The risks • Survey of IR across SW UK • Conclusions

  26. Conclusions Benefits; (based on medical rationale and quality of care) Second opinion for IR team Maximise pre-operative state Analgesia – per and post operative Properly trained in sedating, and monitoring analgesic levels Problems; (issues of management and logistical limitations) Short notice Small and un-predictable caseload number

  27. Biliary intervention; sedation and analgesia. Is it good enough? Dr CKL Cook Interventional Radiologist

  28. Biliary intervention; sedation and analgesia. Is it good enough?No, not without an anaesthetist Dr CKL Cook Interventional Radiologist

  29. References • 1. Mueller PR, van stonnenberg E, Ferrucci JT Jr (1982) Percutaneous biliary drainage: technical and catheter-related problems in 200 procedures.  AJR Am J Roentgenol 138:17-23 • 2. Yee ACM Ho CS (1987) Complications of percutaneous biliary drainage: benign vs malignant diseases.  AJR Am J Roentgenol 148:1207-1209 • 3. Clark RA, Mitchell SE, Colley DP, Alexander E (1981) Percutaneous catheter biliary decompression.  AJR Am J Roentgenol 137:503-509 • 4. Carrasco CH, Zornoza J, Bechtel WJ (1984) Malignant biliary obstruction: complications of percutaneous biliary drainage.  Radiology 152:343-346 • 5. Uberoi R, Das N, Moss J, Robertson I. British Society of Interventional Radiology: Biliary Drainage and Stenting Registry (BDSR) Cardiovasc Intervent Radiol (2012) 35:127-138 • 6. Tapping CR, Byass OR, Cast JEI Percutaneous transhepatic biliary drainage (PTBD) with or without stent complications, re-stent rate and a new risk stratification score. Eur Radiol (2011) 21:1948-1955

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