WEEK 3 – PATIENT CARE

ICV 113 Interventional Neuroradiology

Objectives

Week 3– Patient Care Discuss the potential neurologic complications

of Cerebral/Spinal Angiography Discuss the potential nonneurologic

complications of Cerebral/Spinal Angiography Discuss premedication for patients with

contrast reactions Discuss hydration and the Diabetic patients Discuss prevention of contrast-induced

nephropathy Discuss the importance of postprocedural

patient care

Patient Care: Remember the Following!!!

Professional Attitude

Team confidence Limit extraneous

conversation Communicate with

the patient Minimize patient

stress Never leave patient

unattended

“TIME OUT” (Correct patient? Procedure?)

Make sure pre-cath orders were followed

Allow patient to wear glasses and dentures if possible

Check for Signed Consent

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What if You Were the Patient?

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One of the most common complaints from patients is concerning the staff’s non-professional behaviour.

Always keep in mind the “Golden Rule” and put yourself in the patient’s shoes.

How would you like to be treated?

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Dr. Morris is quoted as saying, “Many or most complications can be avoided by a methodical and systemic execution of all diagnostic studies with consistent use of simple, uncompromising, and unhurried routines.”

TWO KEY WORDS FOR ICV: ANTICIPATION AND CONSISTENCY

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The text points out the importance of quick recognition of any problems before they become larger.

Always be aware of the patient and their environment, not what happened on TV last night.

Possible Causes of Complications

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Below is a list of some potential causes of complications. One should look for these “red flags” prior to, during and after the angiogram.

Patient population (age, gender,etc.)

Type(s) of disease the patient has

Who referred the patient (is this procedure appropriate or would CT/MRI be better?)

Experience level of the Physician (and staff!!!)

Risk Factors for Cerebral Angiography

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Patients that have/are:

History of Stroke or TIAs (Transient Ischemic Attacks)

50-70% stenotic disease in cerebral vessels

Older than 70 yrs. of age

Angiograms which require a higher volume of contrast

Angiograms that last 60 to 90 minutes or require multiple catheter exchanges

Systemic hypertension (HTN) or renal impairment

Referred for subarachnoid hemorrhage (SAH) or who are immediately postoperative

Other Procedure - Related Risks

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The following are some procedure-related risks (complications) that the Physician and staff must constantly be aware of during the procedure itself.

Neurologic Complications:

Microemboli

Microbubbles

Aneurysm Rupture (if applicable)

Neurologic Complications

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Neurologic complications result when pieces of plaque or other debris become dislodged from the vessel wall and travel up into the blood vessels of the brain.

Air bubble come from syringes and/or pressure-bags that have not been carefully connected so as not to have any microbubbles within the system.

Aneurysm rupture comes from careless handling and pinning of the wire(s) being used.

An Ounce of Prevention…. The Telfa Pad

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Microbubbles and the Syringe

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Microbubbles and the Syringe

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Pressure Bag Set-Up

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Other Procedure - Related Risks

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• Major Nonneurologic Complications:

Hematoma formation Dissection of artery Pseudoaneurysms MI (myocardial infarction) Cardiac Arrest Angina Pectoris Allergic Reactions

Pseudoaneurysm

Dissection with Thrombosis

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Aneurysm Rupture

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If in the unfortunate event an aneurysm is ruptured, the first course of action may be to reverse any Heparin that may have already been given.

What drug reverses the effects of Heparin?

Answer: __________?

Neurologic Complications

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Minor Nonneurologic Complications:

Nausea or vomiting Bradycardia Extrasystoles Fainting Delayed hematoma after discharge from

hospital

Premedication of Patients

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Many times, questions arise concerning the patient’s medications they are taking. Should they or should they not take them prior to a Cerebral Angiogram?

It’s best to refer the question to the Physician

The next slide will answer many of those questions based on many Physicians decisions.

Patient Preparation and Prescription Drugs Prior to Angiogram

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Diet and Hydration (NPO prior to most procedures) Medications

1. Insulin (may take- at lower dosage)2. Glucophage (48 hrs. prior and post)3. Antihypertensives (yes)4. Diuretics (Lasix)- no5. Heparin (stopped 2-6 hrs prior)6. Warfarin (stopped 5-10 days prior)7. Lovenox ( 5-10 days by most) 8. Aspirin9. Ativan (pre-procedure sedation)

Patients with Impaired Renal Function

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Prevention of Contrast-Induced Nephropathy1. Mucomyst2. Corlopam3. Sodium Bicarbonate infusion (? Under debate)4. Theophylline

Pre-Procedure CareOther Possible Issues to Address

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Prophylactic Antibiotics (Possible Infection) Within 2 hours of procedure

Correction of Coagulopathies (Bleeding Disorders)

Vasovagal Response

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A response generated from fear or nervousness.

Characterized by pallor, diaphoresis, nausea, and hypotension, which is frequently preceded by, or accompanied by bradycardia.

TREATMENT: fluids, Atropine, patient in Trendelenburg

Intra-Procedure Care

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Hypertension (Labetalol) Bleeding (Increase Fluids ? CT) Contrast Reactions Hypoglycemia (Check Blood Sugar level) Dysrhythmias (“PULL BACK!!!”) Sepsis (Antibiotics) Seizures (Valium) Air Embolism –Use extreme caution and watch

pressure lines for any bubbles CARDIAC ARREST (Start CPR –Call Code!)

Intra-Procedure Care

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Reaction to Sedatives and Analgesics

1. Nausea and Vomiting (Compazine)2. Decreased Resp. or BP (Narcan or Romazicon)

Post Procedure Care

Achieve Hemostasis Monitor puncture site Vital signs should be

monitored every 15min for 1 hour

Give post procedural instructions for closure devices (varied due to type)

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References

Morris, P.P. Practical Neuroradiography, 2nd Edition, 2007

Osborn, A.G. Handbook of Neuroradiology, 2nd Edition, 1999

Bontrager, K.L. TEXTBOOK of Radiographic Positioning and Related Anatomy , 5th Edition, 2001

Snopek, A.M Fundamentals of Special Radiographic Procedures, 5th Edition, 2006

Tortorici, M.R. Fundamentals of Angiography, 1982

Various other Internet sources