Download Patient Preparation

Patient Preparation
Dr Richard Tippett
IR Consultant
Dorset County Hospital NHS Trust
IRTB 2013
Objectives
• Understand the principles relating to:
– Anticoagulation
– Antibiotic prophylaxis
– Sedation / Analgesia
– Local anaesthesia
MINIMIZE RISK!
LOCAL VARIATION
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Other considerations
• Radiation protection
– You
– Allied staff members
• Dose reduction
• Patient
• Scatter
• Aseptic technique / Skin preparation
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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.
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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
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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
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High risk
• TIPSS, biliary, renal interventions and biopsy
• Check everything
• INR / APTTR <1.5
• Plts >50
• Stop aspirin / clopidogrel 5 days
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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?
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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.
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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 during
Vascular and Interventional Radiology Procedures
© 2010, Society of Interventional Radiology
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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?
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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
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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
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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
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Sedation / Analgesia
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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
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Fentanyl
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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.
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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 400600 mcg)
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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)
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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.
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Administration
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Use smallest needle possible for the skin.
Always aspirate before injecting.
Inject slowly.
Ultrasound guided administration – encase
the target.
• Overdose – give IV lipid emulsion
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Summary
• Understand the principles relating to:
– Anticoagulation
– Antibiotic prophylaxis
– Sedation / Analgesia
– Local anaesthesia
MINIMIZE RISK!
IRTB 2013