Okay, this slide, are radiographic images, of an extravasation in the dorsum of the hand on the left, on your left side,
and on the antecubital fossa on your right. The image on your left shows us a large volume of extravasated contrast media in a small space, in the hand, and the image on the right shows us, a large volume extravasation in a larger space. So when you look at these two images,
which of the two do you think would be at most risk for complications? Yes, perfect, thank you. This is a perfect example of how volume and location impact patient outcomes.
In looking back, one thing that actually popped into my head is, we came, we saw, and instead of we conquered,
I actually thought it was we helped actually. We can help. And we didn't do anything novel at MGH. I wish we did. But what we're doing right there, is with that full time team,
we're making everything, we're mainstreaming all these nice studies that have shown anesthesia to benefit in patient care. So right now we're, there's these, just a couple studies that I pulled up. Five, and two on the left are just using
this very cool Jet ventilation, an advanced ventilation technique that was traditionally used in the operating room. And in was invented in 1960s, 1970s. And you see these papers are from 2011, and the other one I think is from 2012,
about using this ventilation modality for ablations. We're also doing paravertebral nerve blocks. And we talked about pain blocks for chronic pain. But these actually for acute pain for biliary drains we can actually use these paravertebral blocks that's been written about.
And was written about in 2011. So actually relatively, just, it's new. But nobody kind of got written up and kinda forgotten about. But now since we're there, we actually are bringin' these things back.
The newest paper that came out is using a block for, a brachial plexus block for fistulogram to enhance patient comfort. And actually that's what we're doin'. We are doin', peripheral nerve blocks for fistulagrams. Especially of the forearm.
We've noticed that those are actually very, very painful. So we actually go in and do a nerve block that lasts for four hours, something very, very short. And the patient's get still, they still need sedation.
But the pain is gone, and we find out that they actually, they don't need as much versed, or fentanyl, that they're much better satisfied. And this is where we're still doin' this. And we're still formulating this. We're also doing advanced,
right now we're doin' a Swan-Ganz catheter to measure cardiac output for percutaneous banding of these fistulas, where several patients have had issues with blood pressure, cardiac outputs increase with a fistula.
So the question is, if you actually band it, and you stop the blood flow, or decrease the blood flow, can it improve the cardiac performance. And we don't know that but we are able to place these lines, measure cardiac outputs.
We can actually compress, and you'll see actually right there in the bottom picture, over there I should say, where there's a tourniquet, and they're compressing the fistula, and we're actually shooting cardiac outputs
to see the decreased blood flow actually makes a difference. If it does make a difference in terms of decreasing cardiac output, the cardiac performance, they proceed with banding. And I think what we're gonna do next, in the future is, you know, in the anesthesia world,
we actually have this device that measures cardiac output non invasively, without a PA line. So I think we're gonna continue doing that to kinda guide our management. And this is anesthesia and IR working hand in hand, you know, applying novel ideas,
where existing, merging of actually two different technologies which exist down there, we just don't talk to each other. The other thing that's coming to light as well
Our next nursing consideration is our documentation of venous access site. We document the gauge and length of the catheter we use, and the location of the IV site.
We also document the attempts made by the nurse, because in our guideline, no more than two attempts should be made by one nurse, because multiple attempts would lead to delay in the study, it would give patients unnecessary pain, and of course, it limits the future venous access.
This is also the same documentation we use when we access Mediport for contrast media injection. We have to confirm the Mediport first, if it's power-injectable or not, and also we have to document the tip location. We also have to verify patency,
we have to make sure that the access flushes freely, the site is non-tender, and there's no signs of infiltration noted.
So what happens in acute compartment syndrome?
We have multiple compartments in our arm, forearm, hands, and wrists, and these compartments have a relatively fixed volume. During large extravasations, the compartment pressure increases to accommodate the extravasated fluid,
and that will lead to increase in venous pressure. So when the venous pressure is greater than the capillary perfusion pressure, the capillaries would collapse, and that would lead to decrease in tissue perfusion. When the capillaries collapse,
there's no blood supply going to the muscles and nerves, and that would lead to muscle and nerve ischemia. So what are the signs and symptoms of compartment syndrome? First sign is usually pain, pain that is progressive, pain that is greater than the... Pain that is progressive,
and pain that is greater than the initial injury. Paresthesia and poikilothermia, poikilothermia refers to the change in the temperature, so the affected extremity feels cooler compared to the unaffected extremity. Paralysis, pallor, and pulselessness
are all considered late signs. This means that there's no blood circulation going to the nerves and muscles.
Now we go to our nursing considerations when power-injecting through peripheral IV. First, we have to properly select the peripheral IV site, so Maria mentioned already earlier
regarding the high-risk sites, we avoid the dorsum of the hand, the wrist, for the risk of nerve damage, so we choose first the veins in the antecubital fossa. The catheter gauge, when selecting the catheter gauge, it is dependent on the patient's condition.
Elderly patients who have small veins, of course, we have to put in a smaller gauge. But sometimes, also dependent on the protocol, or the type of study. If it calls for a faster injection rate, of course, you have to put in a larger catheter.
We also ask, or allow input from patients, regarding which site is the best, because from previous experience, especially our cancer patients, they will be able to tell us which one is the best site for IV.
Next nursing consideration is to secure properly the site with transparent dressing to avoid premature catheter removal during injection, as well as to prevent dislodgement of the catheter, or any movement during injection. And we test inject it with normal saline
to verify patency, so note, if the patient complains of pain, if there's any evidence of infiltration or any swelling, you have to take that IV out right away and insert a new line.
Now we go to causes of port extravasation. So, first is when the Huber needle
is not inserted completely. We have to insert the Huber needle straight and perpendicular to the port's septum. We have to utilize a steady pressure until the needle stops at the base of the reservoir. We also make sure that there's no gap
between the skin an consider inserting a shorter Huber needle. Another cause of port extravasation is a catheter fracture or separation. The first sign is a pinch-off syndrome,
we can see it in the x-ray that the catheter is compressed or is indented as it passes beneath the clavicle. The catheter fracture usually occurs in the space between the clavicle and the first rib because the greatest amount of friction occurs here.
Another cause of port extravasation is a backtracking of fluid by fibrin sheath. Fibrin sheath formation occurs in all catheters within one week of placement, and initial sign that the fibrin sheath is present is a withdrawal occlusion.
So this means that you have no problems injecting the port, but you do not get good blood return. Persistent withdrawal occlusion would lead to catheter disfunction, low flow rate, and contrast media extravasation. In rare instances,
the fibrin sheath can detach from the vein wall and can embolize the pulmonary circulation, causing thrombotic complications. So in case of port extravasation, we have to stop the infusion right away, and we have to notify the doctor,
and the doctor will have to arrange for the port evaluation and sometimes, removal.
In a perfect world,
this is how the veins of all our patients should look like when they come to us. The area of the triangle there, is the most commonly accessed site for contrast injection. (clears throat) Excuse me. And also in that triangle,
you can see the veins that are also the preferred veins for IV cannulation, which is the cephalic vein, the median cubital, and the basilic veins. Why are they the preferred veins? Because they are accessible, they are visible, they are stable,
and they are large enough to accommodate large-bore catheters, and strong enough and large enough to withstand high-speed and high-pressure injections. How many of you here catch yourself unconsciously checking out other people's veins?
(audience laughs) Thank you very much (chuckles). I do that all the time in the subway. I make up stories in my mind how I can access that vein without a tourniquet and things like that. And I have come to realize that at this stage in my life,
diagnostic radiology and veins have become my thing. (audience laughs)
In case of severe contrast extravasation, we arrange for transfer to these patients to the emergency room for further monitoring and management.
And plastic or surgical consult is indicated in patients who has increased swelling or pain after two to four hours. Any evidence of altered tissue perfusion, and for all extravasation events, it needs to be documented.
So we have to document the medical team that was contacted, the interventions that we give to the patients, and the patient's response. And all extravasation events has to be entered into the patient reporting system.
is the effect of cancer recurrence and anesthesia. So the effect of anesthetics and cancer recurrence.
Do the anesthetics actually, can that impact cancer recurrence for these surgeries. You know can general anesthesia, do they you know, do they impair the immune system. And when you ablate, you know, if you impair the immune system
do you render the patient more susceptible for recurrence. If you start giving a lot of opioids, and there's evidence that opioids can actually cause or contribute to cancer recurrence. Is that an issue. So should we concentrate on decreasing opioids,
maybe avoiding general anesthesia, or certain anesthetics that are linked to cancer recurrence. Well that is a new thing that we're actually bringing, discussing. So we came up with, at MGH,
The superior hypograstric block is becoming kind of more commonly seen. In those practices that are doing it, a lot of uterine artery embolization, this is a really nice way to improve patients'
crampy abdominal pain or crampy pelvic pain that's related to uterine ischemia after uterine artery embolization. There have been authors that have proposed that to do UAE as an outpatient procedure, that we should couple the UAE procedure with this block.
It's good for pelvic pain, both uterine contractile pain, but also for cervical, vaginal pain, rectal, as well as bladder related pain. For those cancer patients, this is also a good block to consider. These are all palliative interventions
that are very simple to perform and can really improve patients' quality of life. Again, getting back to this really busy slide, if you target this lower hypogastric region, you're basically picking up the splanchnic nerves that innervate the large intestine,
the small intestine, the ovaries, the scrotum, the urinary bladder, and the perineum. On the right hand side, you can see the fluoroscopic guided way to do this, which is basically just to target the disc space between L5 and S1.
The other way that people do it is that during their uterine artery embolization, they'll take a catheter and put it up and over the bifurcation so that you basically then outline where the bifurcation is and then you just stick your needle right there in the V of your aortic bifurcation.
You take the needle just underneath the aortic bifurcation and dock it up against the vertebral body, pull your needle back, do your block, and you have a significant improvement in the patient's pain.
- I guess we can all agree that patient safety is paramount in the radiology department, in the vascular suite or otherwise. We're all very concerned about keeping the patient safe. That's why it's important to discuss
alternate contrast options. The use of contrast may present some safety concerns for certain patients, like the one we just talked about. Those with high risk for developing contrast-induced nephrotoxicity, and those who may have allergic reaction to contrast.
The American College of Radiology states in their manual on contrast media that patients who have had higher allergic- - [Audience Member] Can you speak into the microphone? - Sorry, is that better? - [Audience Member] Yeah.
- There's some background noise too. - According to the American College of Radiology, patients who have had a prior allergic or allergic-like reaction, or an unknown type of reaction, like those people who say that they're allergic to contrast but they can't articulate what that reaction may have been,
which I'm sure you have all run into, they're at a five times greater risk for having another reaction to contrast of the same type. So if they reacted to Omnipaque or Visipaque, something like that, they're at five times greater risk for reacting to contrast in the same category.
It's therefore conjectured that strategies to improve patient safety through the reduced risk of contrast-induced nephrotoxicity and anaphylactic reaction, while maintaining high quality images, includes the use of CO2 angiography.
So, competencies are really supposed to be meaningful. In our hospital, we had tons of competencies or an orientation skills checklist, and it was very lengthy,
and it was one-word statements, maybe just a couple phrases. I'm gonna list out every single thing that everybody needed to do. So I would like everybody to stand up. I know it's morning, we all had our coffee.
Everybody standup. You all get to sit down in a minute, I promise. Alright, so, if your organization has a competency or an orientation skills list and it's more than 20 pages, stay standing. Wow.
All right. Okay, so one more time, everybody back up. Sorry about that. Everybody back up. Alright, so now we're gonna do the reverse. If your organization has an orientation skills list
and it's more than 20 pages, go ahead and sit down. Alright, so if it's more than 15 pages, stay standing. So if it's, let's say if it was less than 15 pages, stay standing. If it's more than 15 pages, sit down.
- [Kristina] So, 15 to 20 range? - [Nikki] Yeah, 15 to 20. Alright, if your orientation skills checklist is less than 10 pages, stay standing. Wow, these guys are good. Alright, if your orientation checklist
is five pages or less, stay standing. My goodness, we need to find these people. - [Kristina] Well, honestly, to be really fair, a handful of them are my staff. (laughs) - [Nikki] Okay, so, next thing
if your orientation skills checklist is two pages or less, stay standing. Alright, so we need to find and talk with you at the end because that's what we need. And then everybody else in the room, you need to find them at the end.
Wow. Applause for you. - [Kristina] No, no, no. - [Nikki] Oh you don't have one. Oh, no, no.
Okay, I take the applause back. Alright, so we definitely need... - [Kristina] You need to find us, Kathy. - [Nikki] The other way around. So when we started this journey, our orientation skills checklist was reaching 23 pages.
And that, in my opinion, doesn't mean anything, it just means at some point or another somebody heard the topic during their orientation. They may have just a one-on-one discussion when they couldn't get through, and they just had to sign that off
in order to meet the joint commission requirements. So this is an example, very high level, of something that would be on one of our orientation skills checklist. So, if you read through there, does that tell you if I'm competent?
Does that tell you that I practice safely that I can do these things? It's more of a yes or no, but you don't know how to validate that, or you don't know how good I could really be at that. So this is an example of how we transform
those very long list into something that's a lot more meaningful. And if you notice, it went from seven lines of text down to four. So while it's more meaningful and gives more insight
as to how a practitioner could be deemed competent, it's also a lot shorter. All right. So how many of you in here know how to ride a bike or at least knew how to ride a bike when you were a kid.
Alright, me. So, I have not ridden a bike in a very long time, about 10, 15 year. And so, as I was teaching my son how to ride a bike, I was like, "Here, let me show you." So I got on the bike and I'm like, "Oh my goodness."
One, I'm a lot more scared and my fear factor has gone up, but number two, I was very shaky. But after about five, 10 minutes, you knew that you have to put your feet on the pedals, you knew you needed momentum in order to keep going,
and so I could then ride a bike. So I was very shaky. For all of your new hires to come in, at some point, they have passed some kind of licensure, they were deemed competent, they passed the boards, they took a fundamental or a transitions course,
they know how to take vital signs, they have a license. We need to give them credit for things that they should have already experienced. When I look around in this room today, everybody has a shirt one, your arms through the armhole,
at least I think so. Everybody has appropriate pants or skirt or dresses on. I don't need to have a 10-list page of can-put-shirt-on, can-put-pants-on. I'm assuming you have under clothes on. We'll add that on the list.
But what I can mostly say is that everybody is competent that you showed up here dressed appropriately today. Okay. So, just kinda just some other examples that we give.
Now, we have high-risk sites, which is the back of the hand, the wrist, the foot, and the ankle.
And we also have contra-indicated sites, which are the extremities that have evidence of phlebitis or infection. We have extremities with AV fistula or AV graft, extremities with lymphedema, and those extremities
that have had axillary lymph node dissection. On the screen is an algorithm that is part of our intravenous line placement and medication administration in patients who have had axillary surgery. There are two very important things to determine
before you proceed. First would be the type of axillary surgery. Was it a sentinel node biopsy? Or was it an axillary node dissection? Sentinel node biopsy is defined as the, is defined by the removal of one to four lymph nodes
on any given side. If a patient has had a sentinel node biopsy, that side can still be used for IV access and medication administration, as long as there is no evidence of lymphedema. Axillary node dissection, though,
is the removal of five to 30 lymph nodes on any given side. That side should be avoided unless it is an extreme emergency. There is a discussion between the LIP and the radiology team about risks versus the benefits, and also, we need an LIP order to use,
as well as the absence of lymphedema. When there's a lymphedema, no, we cannot use it.
is enhanced recovery after procedure. And is short term for ERAP for microwave ablations and our TACE procedures. So what we do there is we give, in the pre procedure area we give medications. Analgesics, Tylenol, Celebrex.
We do paravertebral blocks, or certain blocks for the patients who are in the procedure. And after the procedure we actually do, we use adjuncts to decrease the opioid consumption, increase patient satisfaction. And we've heard it before,
the previous speakers talking about how peripheral nerve blocks help. They do help. So they do enhance, patient's love it. And this is what we're doin' and it's actually very unique.
I think we're one of the first to do this, roll this out, is enhanced recovery. And this is what's been taken, we've been doin' in the operating room. So we went to the operating room. And I said okay why don't,
if we're already doing enhanced recovery after surgery, why don't we do it after a procedure. They're the same patients. They bleed, they have blood, they still have pain. And it's been getting a lot of traction. And this is just us doing a peripheral nerve block
in the IR suite, and you can see actually the IR tech and the nurses are in the background actually helping me do the nerve block. We have a little regional nerve, anesthesia regional nerve block that we've put downstairs, our offsite block.
Which is pretty neat.
So now we go to our nursing considerations when power-injecting central venous access devices. We have a lot of central venous access devices
already in the market that are power-injectable, such as our power-injectable PICC line catheters, our power-injectable Hickmans, and our power-injectable ports. So our first nursing consideration is to determine if this central venous access device
is power-injectable, so we can identify, if the device is power-injectable, by looking at the dictated procedure note, OR record, or outside facility documentation. The patient can also identify what type of device he or she has,
by showing us the implant identification card, ID bracelet, or key chain that was given to them after the procedure. Before accessing the central venous access device, documentation of a catheter tip location is required. So we can look for the catheter tip location in the chest x-ray or CT chest report.
For PICC lines inserted at that side using the 3CG device, we can look for the 3CG strip on the patient's chart. So what do we do in case the patient comes in with a non-power-injectable port for CT study? A risk versus benefit assessment has to made with the doctor.
We prefer inserting a peripheral IV, but if the patient doesn't really have good veins, then we can, with a doctor's order, and a verification of where the tip is located, we can use the port for a maximum rate of one ml per second. This would result in a lower image quality,
but we can use it in pediatric studies as well as studies that we can go at a rate of one ml per second. Prior to using the central venous access device, we also observe the head, neck, and thorax for any abnormalities. This is to rule out the presence of SVC syndrome
that is common in patients with malignancies. Clot-related SVC syndrome is directly associated in patients with central venous catheters. And also, prior to using the central venous access device, we inspect the catheter site for any signs of infection, such as if there's any redness, swelling,
or any drainage on the site, we do not proceed, we have to put in a peripheral IV. When using the port, we only use the power-injectable needle. It is designed to access the port to prevent coring the silicone septum.
And we aspirate for blood return for central venous access device. If there is no blood return, we cannot use it. And we vigorously flush it with 10 ml of saline, we note for any presence of pain, or if there's any signs of infiltration,
we do not proceed. While giving contrast media through the port, we closely observe the patient and the port site for any swelling or redness around the port or chest area. Any pain or burning sensation in chest, neck, or shoulder post-infusion,
those would indicate that there is port extravasation. After using the central venous access device for contrast media injection, we flush it per hospital policy, utilizing the push-pause method. We instill a third of the saline first,
pausing two to three seconds, we instill the second third of NS, pausing again two to three seconds, then we instill the remaining third. This is more effective in rinsing the catheter, preventing infection, and catheter disfunction
compared to the low-flow technique. And after using the PICC lines or Hickmans, we cover the needle-less connector with a disinfection cap to prevent infection.
This is just a little history of CO2 as a contrast agent.
In 1895 x-rays were discovered. Not that long afterwards room air was used with radiographs to visualize abdominal contents. Again, fairly soon after that, CO2 was introduced as a contrast agent. It was initially introduced to insufflate
the retroperitoneaum and CV structures and evaluate for masses. Room air was eventually abandoned as a contrast media because it became problematic. People were suffering air emboli. But CO2 remained viable.
In the '50s and '60s CO2 was used to visualize the right atrium to diagnose pericardial effusion. During the same period of time, animal studies demonstrated that CO2 was safe for venous injections and was generally well tolerated.
In the late '60s, CO2 was reported safe for injection into the IVC. Fast forward to the '80s and the development of digital subtraction angiography, CO2 becomes useful as a contrast media for vascular procedures.
So what do we do in case the patient comes in with a non-power-injectable port for CT study? A risk versus benefit assessment has to made with the doctor.
We prefer inserting a peripheral IV, but if the patient doesn't really have good veins, then we can, with a doctor's order, and a verification of where the tip is located, we can use the port for a maximum rate of one ml per second. This would result in a lower image quality,
but we can use it in pediatric studies as well as studies that we can go at a rate of one ml per second.
Now we go to power injections of lower extremity. We really tend to avoid using the veins in the lower extremity for power injections because of the increased risk of thrombophlebitis,
tissue damage, and ulceration. However, if no other options exist, again, we need to talk to the doctor for a risk versus benefit discussion. We need a doctor's order prior to insertion. It is only restricted to medical and nursing staff.
Hand injection is preferred. Distal location should be attempted first, and that documentation of the site is important.
Now, let's go to the risk factors of contrast extravasation. I've grouped them into three. First are the patient factors. In patient factors we have age,
the elderly and pediatric patients, because of their small, fragile veins, and their reduced ability to report symptoms. Then we have patients with altered mental status, because of their inability to communicate effectively. And, another is a history of extravasation.
This information is usually volunteered by the patient themselves, and believe me, they know exactly when it happened, which institution it happened, and even if the nurse did everything right and it was not her fault,
she is going to be the person responsible for the extravasation. Therefore, as clinicians, we should make every effort to try other sites first before that site of previous extravasation. And under patient factors,
we have comorbidities that further increase their risk. And first we have patients with vascular diseases such as Raynaud's, patients with diabetes, because of poor vascular circulation, and third, is very relevant to our institution, is cancer.
Memorial Sloan Kettering Cancer Center is a tertiary care cancer center. And the patients who come to us for cancer treatment require hospitalization, and surgeries with or without axillary node dissections. They also have to through multiple laboratory tests,
which equals multiple venipunctures. Frequent diagnostic radiology, diagnostic imaging studies, for diagnosing the extent of disease, or to evaluate the effectiveness of treatment. And that also equals multiple venipunctures
plus the injection of a vesicant, which is the radiologic contrast medias. They also go for radiation therapy and chemotherapy. Chemotherapy involves the administration of vesicant, sclerosing, and irritating agents through the patient's veins.
All of these factors result to what our patients love to call their chemo veins. What are chemo veins? Chemo veins are veins that are hard, they are scarred, they are sclerosed, and they move. And in very extreme circumstances,
you've got that vein but there's no blood return, nothing. Now let's go to the next group of risk factors that I love to call the contrast media factors. First is the type of contrast. Almost all contrast media are categorized as vesicants, and that goes for both iodinated contrast media
and the gadolinium-based contrast agents for MRI. We have the methods of administration, which is automated power injection, which allows for large volumes of extravasated contrast media in a short period of time. As opposed to a hand injection or a straight injection,
where the clinician injecting has absolute control over the administration of contrast. Third, larger volumes to be infused, and faster injection rates. These all contribute to increased risk of contrast media extravasation.
Having said that, iodinated contrast agents have a far greater risk of extravasation than that of gadolinium-based contrast agents. In terms of their method of administration which is power injection, the volume, which are larger volumes to be infused,
and the faster injection rates required within the protocol. So all of these factors are all associated to increased instances of contrast media extravasation.
Why are fast injection rates important? It is important because it allows for optimum enhancement of normal and abnormal structures in the body. It adds quality, value, and extent to the images.
At our institution, the maximum injection rate we currently use is 6 ml per second for CT angiographies. And when we are faced with the issue of image quality versus the risk of extravasation, I always remember what our favorite radiologist
always tells us: Maria, image quality is important, but patient safety comes first. There is a reason why we love him. But also, it depends on who you're talking to. Some radiologists would not even think of that. And here are studies that require fast injection rates
that we usually perform at our institution. And of all these studies, it is the liver and the pancreas studies that make up a large percentage of imaging that we perform at our institution. Now these are images of a CT of the chest
with IV contrast utilizing a one ml per second injection on your left, and a 2.5 ml injection on your right. You can see there is better enhancement, the blood vessels are clearer, the structures are clearer. And I have another slide
that will show us the CT of the abdomen with IV contrast utilizing a one ml per second injection versus a 2.5 ml per second injection. What can you see in the images on the right that you cannot see on the left? Blood vessels, yes, thank you.
You can see very clearly on the right, there are the normal structures, and you have the lesion on the liver, and there's something on the kidney that looks like maybe it's mets, or maybe it's just a cyst, hopefully.
And you see the spleen and the stomach, and there you can see, let me try this, right there, yay, okay, that is the main portal vein, and somewhere here is the hepatic artery, arteries. So having said that,
(laughs) I'm almost done. (Maria and audience laughing) Having said that, these images, oh, sorry, okay, these images clearly demonstrate that fast injection rates are essential
to achieve high quality diagnosis. However, as nurses, and as advocates for our patients, we should always remember that patient safety is still our priority.
I love this picture.
This illustration brings me to my third group of risk factors, which is, the healthcare professional's skills of IV insertion and assessment skills. Before I forget, I am so proud to be part of a group of nurses in my institution who are so good at what they do.
They cannot be here today, but they are so good at what they do. Now, this slide, what this slide means, is that the safe administration of contrast media depends on your skills as a nurse. In terms of your ability to identify the high-risk sites,
to choose the right location, to use the proper IV insertion techniques, and to assess previously placed IVs. Previously inserted IVs assessment should include the following: peripheral IV sites,
oops, sorry, peripheral IV sites that are greater than 24 hours of insertion. That IV site is at a greater risk for extravasation. Is the catheter power-injectable or not? Are there are multiple venipuncture sites
above, right above the site of injection? Are there dressings hiding the injection site, which prevents us from assessing the injection site before, during, and after the injection of contrast media. How many of you here have injected peripheral IV lines with contrast media which does not give us any blood return?
Anyone? We have a policy, not a policy but guidelines, for intravenous contrast administration via power-injection. It states that blood return is preferred but not essential, in the presence of an adequate flush, and a palpable thrill, because if there is a flush,
it flushes very well, and it has a palpable thrill, it is a good IV. And another thing I would like to mention. If you're assessing an IV site that does not have any blood return, it would be a good thing for you to inject that IV also.
Do not give it to your peers to inject and hope nothing happens. (audience laughs)
According to the ACR 2017 manual, the incidence of contrast media extravasation
related to power injection has ranged from 0.1%, or that is one out of 1,000 patients, to 0.9%, which is one out of every 106 patients. Peripheral venous extravasations are usually caused by a dislodged or malpositioned venous catheter. It could also be caused by the leaking of contrast media
at the site of the injection, or a newly venipunctured site above that site of injection, and it could also be caused by a rupture of the vessel wall.
Before we give the contrast, we perform a pre-procedure verification process, this is essentially the timeout.
How many of you guys perform timeout prior to giving contrast? So not everyone, okay. In MSK, we do a timeout prior to giving contrast. We properly identify patient using two patient identifiers,
the MRN, medical record number of the patient, or the full name of the patient. We also review the protocol and order for the contrast to make sure that we have the correct study. We verify that we have the right contrast, we have the right amount of contrast,
and, of course, the right rate. This is our verification form. Again, we confirm the patient's identity using at least two identifiers, we confirm the radiologic procedure to be performed, and we confirm the contrast type, amount, and rate.
So if the patient comes in for a double study, we do a second verification, like a second timeout. Part of our nursing consideration is also patient education. Of course we have to tell the patient
what type of contrast they are getting, what is the normal side effects, because the feeling of warm feeling, that metallic taste, can be overwhelming for some patients. And also, we have to also educate them regarding the signs of contrast complications.
Like hey, if you feel itchy, if you get short of breath, you let us know right away so we can intervene.
In conclusions, nurses play an important role in management of patients undergoing studies with power injection, extravasations can be prevented,
and that injury from extravasations should be minimal. Thank you, (speaks in foreign language).
Before we give the contrast,
it's our responsibility to warn the patients to report any unusual sensations at the IV site immediately, such as if the patient complains of any pain, like stinging or burning pain, any feeling of tightness or pressure in the IV site, that would indicate contrast extravasation already.
During contrast injection, we have to observe the IV site for at least the first 10 to 20 seconds of injection. We have to look for any redness, any swelling, and you have to palpate the injection site. So a strong, palpable thrill
would indicate a good contrast delivery. And if there's any sign of extravasation, we have to stop the injection of contrast right away.
So what do we do in case of contrast extravasation? First, of course, we have to assess the injection site. We have to note the amount of extravasated fluid,
we note the size of extravasation, as well as the patient's signs and symptoms. We elevate the affected extremity above the level of the heart, this reduces hydrostatic capillary pressure and promotes reabsorption of the extravasated fluid.
And of course, we have to notify the radiologist. We apply either hot or cold compress. There's no consensus as to which one is better, so cold compress promotes vasoconstriction, and helps with the pain and the inflammation, while the hot compress improves the blood flow
and also helps with the reabsorption of extravasated fluid. And we monitor patient closely for any complications, such as any sensory changes. Does the patient has any sensation of pins and needles in the affected extremity? Any motor changes,
can the patient move the affected extremity? Any vascular changes, such as decrease in capillary refill? Any change in the color or temperature of the affected extremity, or any presence of ulceration or blisters? And of course, we educate the patient
regarding signs and symptoms that would warrant further management. In case of severe contrast extravasation, we arrange for transfer to these patients to the emergency room for further monitoring and management.
And plastic or surgical consult is indicated in patients who has increased swelling or pain after two to four hours. Any evidence of altered tissue perfusion, and for all extravasation events, it needs to be documented.
So we have to document the medical team that was contacted, the interventions that we give to the patients, and the patient's response. And all extravasation events has to be entered into the patient reporting system. Because contrast media is considered a vesicant,
it has the potential to lead into blistering, ulceration, tissue necrosis, and acute compartment syndrome. So acute compartment syndrome is the serious complication that was directly associated with contrast media extravasation.
Following venous injection, CO2 is carried by the blood to the lungs and eliminated in a single pass. The cost of CO2 is much less expensive than iodinated contrast media. It's about 3 cents per 100 cc of CO2.
So now we go to nursing considerations when power-injecting contrast media.
First is assessment of patient's risk factors to contrast complications. We have to assess if patient is at risk for an allergic reaction, so for patients who had previous allergic reaction, we have to make sure that they are properly pre-medicated
before we give the contrast media. And for patients who have a diagnosis of active asthma, we have to be very vigilant when giving contrast media to these patients, because they can go into bronchiospasm. We also assess our patients,
if they are at risk for contrast-induced nephropathy, so for patients who are diagnosed with any kidney disease and diabetes, we have to check for their recent EGFR to make sure that their kidneys are functioning well before we give the contrast.
And of course, we have to assess our patients, if they are at risk for contrast extravasation. Maria already spoke to you earlier regarding the risk factors, patients who are elderly, patients who have history of contrast media extravasation,
and patients who have poor venous access, are all at risk for contrast extravasation.
- This talk is a brief one about what I think is an entity that we need to be aware of because we see some. They're not AVMs obviously, they're acquired, but it nevertheless represents an entity which we've seen. We know the transvenous treatment of AVMs is a major advance in safety and efficacy.
And we know that the venous approach is indeed very, very favorable. This talk relates to some lesions, which we are successful in treating as a venous approach, but ultimately proved to be,
as I will show you in considerable experience now, I think that venous thrombosis and venous inflammatory disease result in acquired arteriovenous connections, we call them AVMs, but they're not. This patient, for example,
presented with extensive lower extremity swelling after an episode of DVT. And you can see the shunting there in the left lower extremity. Here we go in a later arterial phase. This lesion we found,
as others, is best treated. By the way, that was his original episode of DVT with occlusion. Was treated with stenting and restoration of flow and the elimination of the AVM.
So, compression of the lesion in the venous wall, which is actually interesting because in the type perivenous predominant lesions, those are actually lesions in the vein wall. So these in a form, or in a way, assimilate the AVMs that occur in the venous wall.
Another man, a 53-year-old gentleman with leg swelling after an episode of DVT, we can see the extensive filling via these collaterals, and these are inflammatory collaterals in the vein wall. This is another man with a prior episode of DVT. See his extensive anterior pelvic collaterals,
and he was treated with stenting and success. A recent case, that Dr. Resnick and I had, I was called with a gentleman said he had an AVM. And we can see that the arteriogram sent to me showed arterial venous shunting.
Well, what was interesting here was that the history had not been obtained of a prior total knee replacement. And he gave a very clear an unequivocal history of a DVT of sudden onset. And you can see the collaterals there
in the adjacent femoral popliteal vein. And there it is filling. So treatment here was venous stenting of the lesion and of the underlying stenosis. We tried an episode of angioplasty,
but ultimately successful. Swelling went down and so what you have is really a post-inflammatory DVT. Our other vast experience, I would say, are the so-called uterine AVMs. These are referred to as AVMs,
but these are clearly understood to be acquired, related to placental persistence and the connections between artery and veins in the uterus, which occurs, a part of normal pregnancy. These are best treated either with arterial embolization, which has been less successful,
but in some cases, with venous injection in venous thrombosis with coils or alcohol. There's a subset I believe of some of our pelvic AVMs, that have histories of DVT. I believe they're silent. I think the consistency of this lesion
that I'm showing you here, that if we all know, can be treated by coil embolization indicates to me that at least some, especially in patients in advanced stage are related to DVT. This is a 56-year-old, who had a known history of prostate cancer
and post-operative DVT and a very classic looking AVM, which we then treated with coil embolization. And we're able to cure, but no question in my mind at least based on the history and on the age, that this was post-phlebitic.
And I think some of these, and I think Wayne would agree with me, some of these are probably silent internal iliac venous thromboses, which we know can occur, which we know can produce pulmonary embolism.
And that's the curative final arteriogram. Other lesions such as this, I believe are related, at least some, although we don't have an antecedent history to the development of DVT, and again of course,
treated by the venous approach with cure. And then finally, some of the more problematic ones, another 56-year-old man with a history of prior iliofemoral DVT. Suddenly was fine, had been treated with heparin and anticoagulation.
And suddenly appeared with rapid onset of right lower extremity swelling and pain. So you see here that on an arteriogram of the right femoral, as well as, the super selective catheterization of some of these collaterals.
We can see the lesion itself. I think it's a nice demonstration of lesion. Under any other circumstance, this is an AVM. It is an AVM, but we know it to be acquired because he had no such swelling. This was treated in the only way I knew how to treat
with stenting of the vein. We placed a stent. That's a ballon expanded in the angiogram on your right is after with ballon inflation. And you can see the effect that the stenting pressure, and therefore subsequently occlusion of the compression,
and occlusion of the collaterals, and connections in the vein wall. He subsequently became asymptomatic. We had unfortunately had to stent extensively in the common femoral vein but he had an excellent result.
So I think pelvic AVMs are very similar in location and appearance. We've had 13 cases. Some with a positive history of DVT. I believe many are acquired post-DVT, and the treatment is the same venous coiling and or stent.
Wayne has seen some that are remarkable. Remember Wayne we saw at your place? A guy was in massive heart failure and clearly a DVT-related. So these are some of the cases we've seen
and I think it's noteworthy to keep in mind, that we still don't know everything there is to know about AVMs. Some AVMs are acquired, for example, pelvic post-DVT, and of course all uterine AVMs. Thanks very much.
(audience applause) - [Narrator] That's a very interesting hypothesis with a pelvic AVMs which are consistently looking similar. - [Robert] In the same place right? - [Narrator] All of them are appearing at an older age. - [Robert] Yep.
Yep. - This would be a very, very good explanation for that. I've never thought about that. - Yeah I think-- - I think this is very interesting. - [Robert] And remember, exactly.
And I remember that internal iliac DVT is always a silent process, and that you have this consistency, that I find very striking. - [Woman] So what do you think the mechanism is? The hypervascularity looked like it was primarily
arterial fluffy vessels. - [Robert] No, no, no it's in the vein wall. If you look closely, the arteriovenous connections and the hypervascularity, it's in the vein wall. The lesion is the vein wall,
it's the inflammatory vein. You remember Tony, that the thing that I always think of is how we used to do plain old ballon angioplasty in the SFA. And afterwards we'd get this
florid venous filling sometimes, not every case. And that's the very tight anatomic connection between those two. That's what I think is happening. Wayne? - [Wayne] This amount is almost always been here.
We just haven't recognized it. What has been recognized is dural fistula-- - Yep. - That we know and that's been documented. Chuck Kerber, wrote the first paper in '73 about the microvascular circulation
in the dural surface of the dural fistula, and it's related to venous thrombosis and mastoiditis and trauma. And then as the healing process occurs, you have neovascular stimulation and fistulization in that dural reflection,
which is a vein wall. And the same process happens here with a DVT with the healing, the recanalization, inflammation, neovascular stimulation, and the development of fistulas. increased vascular flow into the lumen
of the thrombosed area. So it's a neovascular stimulation phenomenon, that results in the vein wall developing fistula very identical to what happens in the head with dural fistula had nothing described of in the periphery.
- [Narrator] Okay, very interesting hypothesis.
In order to understand CO2 angiography, you need to understand the properties of CO2. CO2 is an odorless and colorless gas. It occurs naturally in nature. It occurs naturally within the body. There's no concern for allergic reaction,
no association with renal or hepatic toxicity. Viscosity is a measurement of the extent to which a liquid or gas resists flow. CO2 is much less viscous than iodinated contrast media. It's 1/400 as viscous as iodinated contrast media, which allows for it to be delivered
through much smaller access. It can actually be injected through needles as small as 27 gauge. It can also be injected through a catheter with the wire still in place using a Y adaptor. It's useful during procedures where it's preferable
to maintain a wire access, or in which you have to have smaller access. The solubility of a substance is the ability of the substance to dissolve in the solvent. CO2 has a very high solubility. It's much more soluble than oxygen.
It dissolves in the blood within two to three minutes after injection. When it's mixed with water, it creates carbonic acid, which is dissociated into bicarbonate and hydrogen ions, and then it's carried by the blood flow to the lungs, where the lungs break down the product
and it's exhaled. The buoancy of CO2 is its ability to float on water, air, or other fluid such as blood. Typically a gas will rise to the nondependent surface of the vessel. If all the blood is not displaced from the vessel
it will readily demonstrate interior structures, but potentially demonstrate smaller image of the larger feeding vessel. So when you're using CO2, it's imperative to displace as much blood as possible to generate a comparable image as using standard contrast.
CO2 is a gas which displaces the blood. It does not mix with the blood. It absorbs less radiation than the surrounding vessel wall, and therefore it's considered a negative contrast agent. With DSA, the density of the gas and the vessel wall is apparent.
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