Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Public health genomics wikipedia , lookup
Dental emergency wikipedia , lookup
Epidemiology wikipedia , lookup
Maternal physiological changes in pregnancy wikipedia , lookup
Seven Countries Study wikipedia , lookup
Epidemiology of metabolic syndrome wikipedia , lookup
1 Peripheral Arterial Disease and Acute Arterial Occlusion John Miller Peripheral artery disease (PAD) Primary risk factors o Atherosclerosis Narrowed peripheral arteries with impaired blood supply. Femoral and popliteal aneurysms o Diabetes o Smoking Secondary risk factors o Lower limbs more susceptible to arterial occlusion Disease or embolism usually occur in bifurcations. Most common areas: aortoiliac bifurcation and femoral bifurcation o Claudication symptoms more in men, at 60-70 years o Almost 50% with claudication have coronary artery disease. o Increased incidence for women after menopause. Anti-smoking PSA - Heart Issues, StopSmoking4Life, http://youtu.be/DoIZCnp_Wp8 Associated diseases Coronary artery disease (CAD), myocardial infarction Atrial fibrillation Carotid stenosis, stroke Renal failure Hypertension Hyperlipidemia (hypercholesterolemia) Causes of acute occlusions Embolism o Atrial fibrillation, atherosclerosis (atheroma), tumor Thrombosis o Obesity o Sepsis o Hypotension, low cardiac output o Aneurysms, aortic dissection o Bypass graft o Atherosclerosis (atheroma) Trauma Vasospasm Edema Pathophysiology Collaterals arterioles develop slowly in response to low oxygen levels. Vasodilation has a limited effect Anaerobic metabolism causes lactic and pyruvic acid build up Lack of flow causes pain (intermittent claudication) when muscle is forced to work without adequate blood supply. Acute or chronic o Three layers include intima, media, and adventitia. o Vasoconstriction, vasodilation 2 Assessment Can be asymptomatic. Diminished or absent pulses Intermittent claudication o Calves or buttocks o Sharp cramp or burning sensation o Does not occur with sitting or standing Rest pain Pain worsens with leg elevation. Elevation pallor o Elevate foot 12 inches o Pallor within 1 minute o Put in dependent position, color takes more than 10 seconds to return. Paresthesias Arterial steal: arterioles in muscle steal from cutaneous and peripheral nerves, resulting in coldness and pins and needles sensation Numbness, decreased sensation Patterns of claudication in distal tissues Aorto-iliac occlusion o Gluteal and thigh pain Femoral occlusion o Calf pain Popliteal / tibial occlusion o Calf or foot pain Leriche syndrome o Impotence is caused by occlusion. Arterial versus Venous problem comparison Arterial o Decreased to absent pulses o Pale with dependent rubor o Thick toenails if fungal infection is present o Edema usually absent o Cool. Absence of hair; thin, shiny skin o Muscle mass reduced o Decreased sensation o Ulcers Small, painful Points of trauma Between toes Distal most point: lateral malleolus or toes Venous o o o o o o Decreased pulses from edema Brown discoloration, dependent cyanosis Normal toenails Edema worse at the end of day No change in temperature or may be warmer Muscle mass not reduced 3 o o Pruritus Ulcers Broad Shallow Slightly painful ulcers of ankle and lower leg Surrounding skin is brown and fibrotic Ankle-brachial index Supine position, take both arm BPs Regular BP cuff applied to leg just above malleolus Doppler used to find dorsalis pedis and posterior tibial pulses Ankle-brachial index (ABI)= systolic ankle pressure / higher systolic BP of arm (example 60/120=0.5) o 1 or more is normal o 0.5-0.8 experience claudication o 0.4 or less experience rest pain o ABI falsely elevated in diabetes, so use toe-brachial index instead Complications Gangrene Extremity amputation Infection Sepsis Search on YouTube, which has examples and amputations. Lab tests Elevated Tests (normal range) o Hgb (40-54 men, 36-46 women) o BUN (3-20) o Cr (0.5-1.2 men, 0.4-1.1 women) o Na (135-145) o Lipids LDL (less than 100) HDL-C (greater than 39 men, greater than 40 women) Total cholesterol/HDL ratio (less than 5) Triglycerides (less than 150) o Total homocysteine Diagnosis Segmental pressure measurements: Cuff pressures on different limbs and places on limbs. Stress testing: Treadmill or exercise stress test monitoring ECG and for pain. Duplex Doppler ultrasound: Ultrasound to assess flow in arteries. Transcutaneous oximetry: Measure SpO2 in skin of affected limbs. Magnetic resonance angiography (MRA): Uses MRI. Angiography Multi-point Segmental Blood Pressure Test - How it Works - Blue Ridge HealthCare https://youtu.be/g77EgNWBIZg 4 Exercise stress testing Purpose o Measure severity of claudication o Measure the degree which claudication interferes with patient’s lifestyle Treadmill o 1.5-2 mph, 10-20 degree elevation, o Mild symptoms if can walk 5 minutes before pain o Severe disease if can walk only 1 minute Stress test patient preparation Preparation o Comfortable clothing, two pieces, top removed o No powder or lotion o Nothing to eat or drink 2 hours before except clear liquids not containing caffeine. o Provider may have beta blockers held prior. o Takes 1-1.5 hours. o Dobutamine may be given if cannot exercise, so the heart is stressed. Increases heartrate and force of contraction. During test: Life threatening dysrhythmias or chest/leg pain can occur. Post test: No special limitations. What to Expect from an Echocardiogram or Stress Test | IU Health Heart & Vascular Care https://youtu.be/JVNSIVE347c VASCULAR #2 Arterial Doppler and Imaging (Duplex Doppler) https://youtu.be/XykKUrw-SQ4?list=PLdVvae0BQcKztVN9VICTi25bXgmseXc0I Transcutaneous Oximetry - Part 1 - What We Are Measuring https://youtu.be/Y9xIELtCJ1Y Transcutaneous Oximetry - Part 5 - Predicting Benefit from HBO Therapy https://youtu.be/K6VfW6mr8lM What is a Magnetic Resonance Imaging (MRI) scan? https://youtu.be/Qbnz4_qed9Q Femoral Angiogram/Angioplasty with OEC Hybrid OR https://youtu.be/le0tB8jc1nE Angiography Preoperative or intraoperative Performed in a vascular (cath) lab with xrays o Sterile conditions o Catheter inserted through sheath (introducer) Local anesthetic Contrast injected Fluoroscopy to check catheter position Angiography preprocedure care Informed consent NPO 2-6 hours Mild sedative Prep femoral site Assess renal function, BUN and Creatinine o Poor renal function will not clear the contrast dye from the body. 5 Angiography postprocedure care Frequent vascular assessment o Vital signs o Neurologic function o Distal pulses, distal color o Puncture site for hematoma Bed rest 6-8 hours o Affected extremity straight alignment, without flexion Crystalloid IV fluid for 6-8 hours to flush out contrast, encourage oral intake o Check BUN and creatinine levels the next day More Angiography postprocedure Resume all orders, except heparin until hemostasis is evident Manage pain with mild analgesics, severe pain may be a hematoma Report any vascular changes immediately Complications o Allergy to contrast, thrombi, emboli, artery perforation, renal failure, pseudoaneurysm FemoStop Gold Product Demonstration Video https://vimeo.com/150287535 Angio Seal https://youtu.be/TbTRH5VquIE Cardiac Cath and/or Peripheral Angiography -Preprocedure Version (Orders) http://orders.benefis.org/ordersdoc/Cardiology/Cardiac%20Cath%20and-or%20Peripheral%20AngiographyPreprocedure.pdf Physician Orders ADULT Order Set: RAD Arteriogram (Femoral) Post Procedure http://www.methodistmd.org/dotAsset/584d19ce-f4f4-4347-8d9f-dcc6cf79e042.pdf Interventions Medications Exercise and dietary changes o Control diabetes and hypertension o Lower cholesterol levels o Weight loss Skin and foot care Smoking cessation Medications Antilipemics Anticoagulants o Heparin, warfarin o Direct thrombin inhibitors o Antiplatelets Medications: Antilipemics Antilipemics o HMG CoA Reductase Inhibitors (Statins) o Cholesterol Absorption Inhibitor o Bile-Acid Sequestrants o Niacin 6 o Fibrates HMG CoA Reductase Inhibitors (Statins): Atorvastatin Class: Antilipemic, HMG CoA Reductase Inhibitor-Statin Therapeutic effect: Reduce LDL, VLDL. Increase HDL. Increase vasodilation. Decrease plaque inflammation and thromboembolism. Use: Hypercholesterolemia, angina-MI, CVA Adverse effects Liver toxicity: Check AST level and stop medication if elevated. Check for hepatitis: anorexia, N&V, jaundice. Myopathy: Muscle pain, check CK and stop medication if elevated. May progress to myositis or rhabdomyolysis. Atorvastatin Contraindications/Precautions o Pregnancy risk X o Contraindicated in liver disease (hepatitis). Interactions o Fibrates increase risk of myopathy. o Erythromycin and ketoconazole increase statin levels. o Grapefruit juice increases statin levels. Do not drink more than one quarter daily. Take tablet in evening. Cholesterol Absorption Inhibitor: Ezetimibe Class: Antilipemic, cholesterol absorption inhibitor Therapeutic Effect: Inhibits cholesterol from food and bile. Use: Lower cholesterol with or without statin and modified diets Adverse effects o Liver toxicity: Check AST level and stop medication if elevated. Check for hepatitis: anorexia, N&V, jaundice. o Myopathy: Muscle pain, check CK and stop medication if elevated. May progress to myositis or rhabdomyolysis. Ezetimibe Contraindications/Precautions o Pregnancy risk X o Contraindication in moderate to severe liver disease, especially when taking statin. Interactions o Bile acid sequestrants interfere with absorption. Take 1 hour before or 4 hours after bile sequestrants. o Statins can increase liver dysfunction and myopathy. o Fibrates can increase risk of cholelithiasis and myopathy. o Cyclosporine increases ezetimibe levels. Bile-Acid Sequestrants: Colesevelam Class: Antilipemic, bile-acid sequestrant Therapeutic effect and use: Adjunct with statin to lower LDL. Adverse effects: Constipation, eat high fiber and drink fluids. Contraindications/Precautions o Pregnancy risk B o Contraindicated in pancreatitis caused by high triglycerides and bowel obstruction. o Caution with gall bladder disease, diabetes mellitus. 7 Interactions o Interfere with: levothyroxine, glipizide, vitamins A,D, E, K, oral contraceptives. Take these four hours before colesevelam. Antilipemic: Niacin Class: Antilipemic Therapeutic effect and use: o Lower LDL and triglycerides, raise HDL. (Niacin trade drug Niaspan only) o Patients at risk for pancreatitis and with elevated triglyceride levels Niacin Adverse effects o GI distress: Take with food. Time release take in evening. o Facial flushing, warmth, tingling of hands and feet: Take aspirin 30 minutes before. o Hyperglycemia: Monitor glucose. o Liver toxicity: Check AST level and stop medication if elevated. Check for hepatitis: anorexia, N&V, jaundice. o Hyperuricemia: Monitor renal function (BUN, Cr, I&O). 2-3L H2O intake. If uric acid elevated, take allopurinol. Contraindications/Precautions o Pregnancy risk C o Contraindicated in liver disease or gout. Fibrates: Gemfibrozil Class: Antilipemic, fibrate Therapeutic effect and use: o Increase HDL levels. o Decrease triglyceride (VLDL) level for those unable to lower level with lifestyle modification or other antilipemics. Adverse effects o GI distress: Oral and 30 minutes prior to meals. o Myopathy: Muscle pain, check CK and stop medication if elevated. May progress to myositis or rhabdomyolysis. o Liver toxicity: Check LFTs and stop medication if elevated. Check for hepatitis: anorexia, N&V, jaundice. Gemfibrozil Contraindications/Precautions o Pregnancy risk C o Contraindicated in those with liver, gallbladder, or renal disease. Interactions o Warfarin: Concurrent use increases bleeding. Monitor INR and for active bleeding. o Statins: Concurrent use should be avoided because increases muscle pain. Anticoagulants: Direct Thrombin Inhibitors: Dabigatran Class: Anticoagulant, direct thrombin inhibitor Therapeutic effect: Inhibits thrombin, preventing thrombus. Use: Prevent stroke or embolism in Atrial Fibrillation not caused by valvular disease. Adverse effects o Bleeding Stop before surgery. No antidote. Dialysis or recombinant factor VIIa may help. 8 o GI: N&V, reflux, ulcer Take with food. May need PPI or H2 antagonist. Dabigatran Contraindications/Precautions o Pregnancy risk C o Contraindicated in active bleeding o Caution with liver disease, who are prone to bleed. o Caution with renal disease. Interactions o Rifampin decreases dabigatran levels. Antiplatelet: Aspirin Class: Antiplatelet and arterial vasodilator Therapeutic effect: Inhibit platelet aggregation (clumping) preventing clotting. Use: Prevent MI and additional episodes. Prevent ischemic CVA. Adverse effects: Dyspepsia, N&V o Take with food. o Use enteric coated tablet. Do not crush. o Take PPI or H2 antagonist to reduce acid. o Hemorrhagic CVA o GI bleed, thrombocytopenia o Tinnitus, hearing loss Aspirin Contraindications/Precautions o Pregnancy Risk D o Contraindicated for those with bleeding disorders and thrombocytopenia. o Caution with peptic ulcer, severe renal or hepatic disease. o Do not give to children or adolescents with fever or recent chickenpox. Interactions o Concurrent anticoagulants or NSAIDs increase bleeding risk. o Ammonium chloride may increase aspirin levels. o Beta blocker therapeutic effect may be reduced by aspirin. o Corticosteroids may reduce aspirin levels. o Caffeine may increase aspirin levels. Antiplatelet: Abciximab Class: Antiplatelet and arterial vasodilator Therapeutic effect: Inhibit platelet aggregation (clumping) preventing clotting. Use: Acute coronary syndrome (MI) intervention in cardiac cath lab Adverse effects: o Hypotension, bradycardia o Bleeding, thrombocytopenia Abciximab Contraindications/Precautions o Pregnancy Risk C o Contraindicated for those with bleeding disorders and recent surgery. o Caution with peptic ulcer, renal or hepatic disease. Interactions o Concurrent anticoagulants and NSAIDs increase bleeding risk. 9 Antiplatelet: Clopidogrel Class: Antiplatelet and arterial vasodilator Therapeutic effect: Inhibit platelet aggregation (clumping) preventing clotting. Use: Acute coronary syndrome (MI) intervention in cardiac cath lab Adverse effects o Bleeding, thrombocytopenia o Diarrhea, gastric symptoms of belching, heartburn, etc. Clopidogrel Contraindications/Precautions o Pregnancy Risk B o Contraindicated for those with bleeding disorders. o Caution with peptic ulcer, renal or hepatic disease. o Do not breastfeed. Interactions o Concurrent anticoagulants and NSAIDs increase bleeding risk. o PPIs decrease clopidogrel levels. Antiplatelet: Pentoxifylline and Cilostazol Class: Antiplatelet and arterial vasodilator Therapeutic effect: Inhibit platelet aggregation (clumping) preventing clotting. Use: Intermittent claudication, oral Adverse effects of pentoxifylline o Dyspepsia, N&V Take with food. Do not crush. Increases theophylline level. Monitor drug level. Pentoxifylline Contraindications/Precautions of pentoxifylline o Pregnancy Risk C o Contraindicated for those with bleeding disorders. Interactions of pentoxifylline o Concurrent anticoagulants increase bleeding risk. Monitor PT and INR. Exercise Walk 45-60 minutes per day. Stop at onset of pain. When subsides, continue. Promotes o Increased collateral blood vessels to send blood around the blockage. o Higher HDL levels o Lower LDL, triglyceride, and blood glucose levels o Greater insulin sensitivity o Lower body mass index Exercise recommendations American Heart Association Recommendations for Physical Activity in Adults http://www.heart.org/HEARTORG/HealthyLiving/PhysicalActivity/StartWalking/American-HeartAssociation-Guidelines-for-Physical-Activity_UCM_307976_Article.jsp#.VxQQyTArKHs See slide for details. 10 American Heart Association Dietary Guidelines Variety of fruits and vegetables Whole grains o Fiber (women 25 GMs, 21 if over 50 years) (men 38 GMs, 30 if over 50) Fat o Polyunsaturated, monosaturated (olive, avocado, nuts), omega 3 oil (fatty fish) o Skinless poultry and fish, low fat dairy, nuts and legumes o Non-tropical vegetable oils. Palm is a tropical oil. o Limit transfats - also known as partially hydrogenated oil (in most processed food) o Limit added sugar in foods. Sodium (limit to 2,500 mg, 1,500 is even better), potassium Alcohol in moderation: 2 drinks each day men, 1 each day women. Detailed diet: DASH diet The American Heart Association's Diet and Lifestyle Recommendations http://www.heart.org/HEARTORG/HealthyLiving/HealthyEating/Nutrition/The-American-Heart-AssociationsDiet-and-Lifestyle-Recommendations_UCM_305855_Article.jsp#.VxQSkTArKHs Managing Blood Pressure with a Heart-Healthy Diet http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/PreventionTreatmentofHighBloodPressure/ Managing-Blood-Pressure-with-a-Heart-Healthy-Diet_UCM_301879_Article.jsp#.VxQURzArKHs Obesity High risk waist size: men greater than 40 inches, women greater than 35 (diabetes risk increases also) Body mass index goal: 18-25. 30 or higher is considered obese. Loss of at least 10-20 pounds will reduce risk. Alternating pattern of weight gain and loss is higher risk for CHD and PAD. Obesity Information http://www.heart.org/HEARTORG/HealthyLiving/WeightManagement/Obesity/ObesityInformation_UCM_307908_Article.jsp#.VxQYOTArKHs Calculate Your Body Mass Index http://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm Diabetes Diabetics have a much higher risk of PAD and CHD, occurs earlier and is more accelerated. o Monitor Hgb A1C Diabetes 6.5% and higher Pre-diabetic: 5.7-6.4% Skin care Good shoes that protect and allow air flow Avoid elastic support hose 6 inch shock blocks under the head of bed (reverse Trendelenburg) Fleece boots, heels floated off the bed, heel protector, bed cradle Keep warm, reduce stress, legs below heart level Avoid crossing legs or standing in one place for a long time. Lotion avoided between toes. Keep feet dry, cotton socks Elevate feet slightly if swell. 11 About Peripheral Artery Disease (PAD) http://www.heart.org/HEARTORG/Conditions/More/PeripheralArteryDisease/About-Peripheral-ArteryDisease-PAD_UCM_301301_Article.jsp#.VxQaFzArKHs Endovascular Interventions in Catheterization Lab Local anesthesia, quick recovery, with angiography o Angioplasty (PTCA) with stent placement o Atherectomy Treatment of Critical Limb Ischemia with Balloon Angioplasty and Stents https://youtu.be/UOXQbF3K56g Atherectomy [www.keepvid.com] https://youtu.be/wTrYH9_jFx4 Arterial bypass o Aortoiliac blocked Usually aortobifemoral bypass graft is performed, synthetic material. o Femoral-popliteal graft Saphenous vein is used (SVG). o Complication Clots in graft causing an acute arterial occlusion o Anticoagulants (ASA, heparin, LMW heparin) o Fibrinolytics if stable after surgery Minimally Invasive Vascular Surgery https://youtu.be/gsM8k0sLT0k?list=PLdVvae0BQcKztVN9VICTi25bXgmseXc0I Vascular Surgery: Aorto Bifemoral Grafting for Complete Aorto-Iliac Block https://youtu.be/J-eQF97FnYc?list=PLdVvae0BQcKztVN9VICTi25bXgmseXc0I Aorto Bi-femoral Grafting.wmv https://youtu.be/3GnFRCj-tFs?list=PLdVvae0BQcKztVN9VICTi25bXgmseXc0I Aortobifemoral bypass surgery by Cal Shipley, M.D. https://youtu.be/f3wmmPo6Rs0?list=PLdVvae0BQcKztVN9VICTi25bXgmseXc0I Preoperative Interventions Pulses with doppler, marked Assess for other atherosclerosis problems such as with heart, brain, kidneys. Reverse malnutrition. Clean wounds. Resolve all infections, especially if synthetic graft (Gortex, PTFE) is used. Postoperative Interventions Adequate vascular volume o Stable BP, good u/o, skin warm, intake = output, stable Hgb and Hct o Keeps graft patent. Supine position Pain meds for 48-72 hours Avoid flexion at the operative site. ROM, ambulation Avoid tape on legs Assess pulses, neurological status of extremities 12 Complications of surgery Hemorrhage o Disrupt suture line o Pseudoaneurysm Clotting of graft Infection (if synthetic graft it must be removed) Compartment syndrome o Causes loss of nerve and motor function, acute tubular necrosis. o Signs: severe pain, tense swollen leg, pain with passive stretching, decreased sensation, rusty brown urine (myoglobinuria) Carotid Endarterectomy Similar care postop as with other arterial surgery Distal pulses checked include temporals. Assess neurological function. UCLA Vascular Surgery - Carotid Endarterectomy Procedure 2 https://youtu.be/Z-2wsztt3bA?list=PLdVvae0BQcKztVN9VICTi25bXgmseXc0I Thromboangitis Obliterans Also known as Buerger disease Occlusive vascular disease Pathophysiology and course o Inflammation and spasm in small and midsize peripheral arteries, causing clots to form o Intermittent with dramatic exacerbations and marked remissions Assessment Manifestations o Pain in affected extremities o Claudication and cramping o Rest pain o Skin is thick and shiny; nails thickened. o Distal pulse is hard to locate o Painful ulcers and gangrene Incidence and risk factors Men under age 40 who smoke More prevalent in Asians, people of eastern European descent Cigarette smoking is most significant cause. Diagnosis o o o History and physical examination Doppler studies Angiography and MRIs Buerger's Disease Interventions https://youtu.be/K2P4FWFGObM?list=PLdVvae0BQcKztVN9VICTi25bXgmseXc0I 13 Interventions Promotion of Arterial Circulation Prevention of Prolonged Tissue Hypoxia Smoking Cessation Support Relief of Acute Manifestations Surgical Interventions o Sympathectomy o Arterial bypass graft Raynaud Disease Disease and phenomenon Pathophysiology and manifestations o Episodes of intense vasospasm in the small arteries and arterioles of fingers and toes o No identifiable cause; can occur secondary to another disease Raynaud's Disease https://youtu.be/pjar6pXxQ34?list=PLdVvae0BQcKztVN9VICTi25bXgmseXc0I Assessment Pathophysiology and manifestations o Primarily affects young women o Manifestations "The blue-white-red disease" o Diagnosis History and physical examination Raynaud's Phenomenon in real time https://youtu.be/NSn8PTJndBA?list=PLdVvae0BQcKztVN9VICTi25bXgmseXc0I Interventions Medications o Vasodilators (prostaglandin): Iloprost o Sustained-release calcium channel blockers: Nifedipine Interventions Keep hands warm Measures to avoid injuries Smoking cessation Stress reduction measures Diet Exercise Maintain normal body weight Acute Arterial Occlusion Occurs by thrombus or embolism Risk for necrosis and gangrene 14 Pathophysiology o Arterial thrombosis Thrombus Blood clot that adheres to vessel wall o Arterial embolism Sudden obstruction of blood vessel by debris Thromboembolus Assessment Six P’s (Use for all arterial problems previously mentioned.) o Pain o Pulselessness o Poikilothermic (coldness) o Pallor –can progress to mottled and cyanotic o Paresthesias Numbness, tingling, pins and needles Loss of position sense Cannot detect pressure or pin prick. Cannot tell whether toes are flexed or extended o Paralysis o Muscle spasms Interventions Surgical embolectomy o Limited amount time to prevent permanent damage. o Local anesthesia o Anticoagulant medications To allow time to do embolectomy. Fibrinolytic medications Acute, Complete Occlusion of the Leg Arteries https://youtu.be/tttaSS9Z8hk?list=PLdVvae0BQcKztVN9VICTi25bXgmseXc0I