Patient Preparation Dr Richard Tippett IR Consultant Dorset County Hospital NHS Trust IRTB 2013.
-
Upload
tamsyn-richard -
Category
Documents
-
view
217 -
download
3
Transcript of Patient Preparation Dr Richard Tippett IR Consultant Dorset County Hospital NHS Trust IRTB 2013.
Patient Preparation
Dr Richard TippettIR Consultant
Dorset County Hospital NHS Trust
IRTB 2013
IRTB 2013
Objectives
• Understand the principles relating to:– Anticoagulation– Antibiotic prophylaxis– Sedation / Analgesia– Local anaesthesia
MINIMIZE RISK!
LOCAL VARIATION
IRTB 2013
Other considerations
• Radiation protection– You– Allied staff members
• Dose reduction• Patient• Scatter
• Aseptic technique / Skin preparation
IRTB 2013
Anticoagulation
• Warfarin / Antiplatelets / Heparin
• Elective / Urgent / Emergency• Patient co-morbidities• Risk of haemorrhage
Consensus Guidelines for Periprocedural Management of Coagulation Status and Hemostasis Risk in Percutaneous Image Guided Interventions
© 2012, Society of Interventional Radiology.
IRTB 2013
Low risk cases
• Venous access, drain insertion, drainage tube exchange, IVC filter insertion
• No need for pre-procedural coagulation tests (unless on warfarin / heparin)
• INR<2.0• Continue aspirin / clopidogrel
IRTB 2013
Moderate risk
• All angiography, most of everything else
• Pre-op clotting req’d, no platelet assessment
• INR<1.5• Platelets >50• Stop clopidogrel 5/7, continue aspirin
IRTB 2013
High risk
• TIPSS, biliary, renal interventions and biopsy
• Check everything
• INR / APTTR <1.5• Plts >50• Stop aspirin / clopidogrel 5 days
IRTB 2013
Warfarin
• Ideally INR < 1.5
• Emergency reversal– Vitamin K: 500mcg – 2mg often gets INR to
acceptable level. 10mg can cause problems with re-warfarinisation.
– Prothrombin complex concentrate –Beriplex.– FFP?
IRTB 2013
Anti-platelets
• Aspirin, Clopidogrel, Dipyridamole.• Single agent regime- No indication to stop for
most IR procedures.• Dual agents- stop one (e.g. Clopidogrel) for
5/7.• Patients with drug eluting stent/carotid stent.
IRTB 2013
Antibiotic prophylaxis
• World wide attention on drug resistant bugs• Most guidelines/ reviews extrapolate from surgical
data.• Some evidence specific to IR.• Helpful to categorise into:-– Clean– Clean contaminated.– Dirty.
Practice Guideline for Adult Antibiotic Prophylaxis duringVascular and Interventional Radiology Procedures
© 2010, Society of Interventional Radiology
IRTB 2013
Clean
• If the gastrointestinal (GI) tract, genitourinary (GU) tract, or respiratory tract is not entered
• Inflammation is not evident• No break in aseptic technique.
• Routine diagnostic angiography.
• No prophylaxis required.• Stent-grafts?
IRTB 2013
Clean contaminated
• If the GI, biliary, or GU tract is entered• Inflammation is not evident• No break in aseptic technique.
• Nephrostomy tube placement in a patient with sterile urine. Also UAE
• 1gm Cef
IRTB 2013
Dirty
• If it involves entering an infected purulent site such as an abscess, a clinically infected biliary or GU site, or perforated viscus.
Prophylaxis is mandatory, adjunct to existing therapy. WATCH FOR SEPSIS
IRTB 2013
When to administer?
• Optimal timing is within 2hrs of the procedure.
• If the AB is given 3 hours pre/post, the infectious complications are 5X greater.
• If clean, clean contaminated 1 dose lasting 6-8 hours is adequate.
• Contact your friendly Microbiologist.
Classen DC, Evans RS. Pestotnik SL. Ct al.The timing of prophylactic administration of antibiotics
and the risk of surgical wound infection.N Eng/J Med 1992:326:281-286
IRTB 2013
Sedation / Analgesia
IRTB 2013
Sedation / Analgesia
• Get good at it and give it!• Need to be monitored- Not by you!• Need to be fasted for 6 hours (solids + Milk)
2Hrs (Clear fluids)• Give Analgesia first then sedative 5-10
minutes later- Synergistic effects.
• PCA in complex / embolisation cases
IRTB 2013
Fentanyl
• Particularly useful- Onset within 1-2 minutes.• Short duration of action.• Repeated doses have a longer duration.• Dose 50-200 mcg then 50mcg as required.• Does not accumulate in renal failure.
• Naloxone- 400mcg to 2mg.
IRTB 2013
Midazolam
• Conscious sedation– Responds to non-painful stimuli.
• Maximum onset 10-15 minutes.• Dose- 2mg/ 0.5-1mg in the elderly.• Paradoxical excitement/aggression.
• Flumazenil- 200mcg over 15 secs then repeated doses of 100mcg (usually need 400-600 mcg)
IRTB 2013
Local anaesthesia
• Topical:-– Amethocaine (Amitop) better than EMLA.– Needs to be put on at least half an hour prior to
procedure.• Injectable– Lignocaine (Lidocaine)– Lignocaine + Adrenaline (Xylocaine)– Bupivicaine (Marcain)
IRTB 2013
Doses
• Lignocaine:-– 4 mg/KG– 1% = 10mg/ml– 28 mls of 1% for 70Kg patient.
• Xylocaine:-– 7mls/KG– 53mls of 1% for 70 Kg patient.– Anaesthetists will give more
• Marcain– Max 60mls using 0.25% solution.
IRTB 2013
Administration
• Use smallest needle possible for the skin.• Always aspirate before injecting.• Inject slowly.• Ultrasound guided administration – encase
the target.
• Overdose – give IV lipid emulsion
IRTB 2013
Summary
• Understand the principles relating to:– Anticoagulation– Antibiotic prophylaxis– Sedation / Analgesia– Local anaesthesia
MINIMIZE RISK!