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How Do I Approach Submassive PE Today? | Pulmonary Emoblism Interactive Lecture
Pre-procedure Assessment | Procedural Sedation: An Education Review
Pre-procedure Assessment | Procedural Sedation: An Education Review
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The Dashboard Implementation | Innovation and Application of Real Time Nursing Dashboards
The Dashboard Implementation | Innovation and Application of Real Time Nursing Dashboards
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Background to the Project- Challenges | IR Lean Sigma Team Improves Patient Experience and Throughput
Background to the Project- Challenges | IR Lean Sigma Team Improves Patient Experience and Throughput
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What's Next | AVIR CLI Panel
What's Next | AVIR CLI Panel
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Project Interventions & Improvements- Intake | IR Lean Sigma Team Improves Patient Experience and Throughput
Project Interventions & Improvements- Intake | IR Lean Sigma Team Improves Patient Experience and Throughput
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Definitions in PE | Pulmonary Emoblism Interactive Lecture
Definitions in PE | Pulmonary Emoblism Interactive Lecture
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Pharmacology- Antagonists & Additional Medications | Procedural Sedation: An Education Review
Pharmacology- Antagonists & Additional Medications | Procedural Sedation: An Education Review
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Compassion | Gold Medal Lecture - Health of Technologists and Nurses and the Role of Compassion in an AI Focused World
Compassion | Gold Medal Lecture - Health of Technologists and Nurses and the Role of Compassion in an AI Focused World
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Pharmacology- Versed | Procedural Sedation: An Education Review
Pharmacology- Versed | Procedural Sedation: An Education Review
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Organizational Strategy | Innovation and Application of Real Time Nursing Dashboards
Organizational Strategy | Innovation and Application of Real Time Nursing Dashboards
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Massive PE | Pulmonary Emoblism Interactive Lecture
Massive PE | Pulmonary Emoblism Interactive Lecture
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Radiation Protection | Gold Medal Lecture - Health of Technologists and Nurses and the Role of Compassion in an AI Focused World
Radiation Protection | Gold Medal Lecture - Health of Technologists and Nurses and the Role of Compassion in an AI Focused World
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Pathophysiology | Pulmonary Emoblism Interactive Lecture
Pathophysiology | Pulmonary Emoblism Interactive Lecture
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Intraprocedure | Procedural Sedation: An Education Review
Intraprocedure | Procedural Sedation: An Education Review
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The Ways to Recanalize the Below the Knee Vessels | AVIR CLI Panel
The Ways to Recanalize the Below the Knee Vessels | AVIR CLI Panel
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Submassive PE | Pulmonary Emoblism Interactive Lecture
Submassive PE | Pulmonary Emoblism Interactive Lecture
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The Case that Launched the Cornell PERT (PE Response Team) | Pulmonary Emoblism Interactive Lecture
The Case that Launched the Cornell PERT (PE Response Team) | Pulmonary Emoblism Interactive Lecture
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IR Outpatient Delays | IR Lean Sigma Team Improves Patient Experience and Throughput
IR Outpatient Delays | IR Lean Sigma Team Improves Patient Experience and Throughput
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Why Do We Need Different Directions For Occlusions? | AVIR CLI Panel
Why Do We Need Different Directions For Occlusions? | AVIR CLI Panel
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Q&A- Procedural Sedation | Procedural Sedation: An Education Review
Q&A- Procedural Sedation | Procedural Sedation: An Education Review
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Where We Are Now | Pulmonary Emoblism Interactive Lecture
Where We Are Now | Pulmonary Emoblism Interactive Lecture
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The Last 5 Years in PE | Pulmonary Emoblism Interactive Lecture
The Last 5 Years in PE | Pulmonary Emoblism Interactive Lecture
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Clinical Implementation | Respiratory Compromise: Use of Capnography During Procedural Sedation
Clinical Implementation | Respiratory Compromise: Use of Capnography During Procedural Sedation
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Where do we go from here for submassive PE | Pulmonary Emoblism Interactive Lecture
Where do we go from here for submassive PE | Pulmonary Emoblism Interactive Lecture
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The Landscape of PE | Pulmonary Emoblism Interactive Lecture
The Landscape of PE | Pulmonary Emoblism Interactive Lecture
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Prospective CDT Trials | Pulmonary Emoblism Interactive Lecture
Prospective CDT Trials | Pulmonary Emoblism Interactive Lecture
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Pharmacology- Opiods | Procedural Sedation: An Education Review
Pharmacology- Opiods | Procedural Sedation: An Education Review
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What's ahead for PE | Pulmonary Emoblism Interactive Lecture
What's ahead for PE | Pulmonary Emoblism Interactive Lecture
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Airway Assessment | Procedural Sedation: An Education Review
Airway Assessment | Procedural Sedation: An Education Review
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Transcript

sub massive PE is an unknown entity so we still have these patients coming to us how do I approach it today

well those patients that are high-risk sub massive so high risk intermediate just like that ESC slide who look like they're about to Crump or look bad like they have an elevated lactate even if they don't meet the criteria for

hypotension those are patients that I'll almost always try to repr fuse and and that can be reproducing with any technique it could be surgical unbel ectomy it could be systemic thrombosis it could be Katherine directed therapy

but that's where the PERT concept where you bring together multiply multiple disciplines in a relatively short time and and make a consensus life decision that is thought to be the added value of the pert these other ones are getting

less and less common in terms of intervention so I used to intervene on a lot of these patients but as the data has come out and I've noticed that with the tincture of time 24 hours of heparin actually gets these people out of the

danger zone I've actually made my practice a little more conservative than it used to be and low risk sub massive Pease should pretty if if you're frequently doing this it's probably a time to re-examine your practice because

it may not be based on evidence or truth

includes an interview of the patient abnormalities of major organ systems like cardiac status do they have a reduced ejection fraction do they have coronary artery disease I want to know

if they have an EF of 10% because if they become hemodynamically unstable and I want to give them fluids I'm not going to bolus a patient with a very low ejection fraction with two liters of fluid you're gonna cause

pulmonary edema and you're going to worsen the situation renal status is huge a lot of our patients are renal e impaired and that can affect the way that they clear the sedation medications that we're giving pulmonary status do

they have COPD asthma or sleep apnea sleep apnea is major in procedural sedation neurologic status do they have a history of seizures endocrine status hyper or hypo metabolism of medications can occur if they have a thyroid

disorder we want to know about adverse experiences with sedation in the past do they have a history of a difficult airway for us at NYU if they have been already been identified as a difficult airway that automatically means we're

doing the procedure with anesthesia current medications potential drug interactions is very important we'll go over that a few slides drug allergies and herbal supplements that they're taking tobacco alcohol or

substance use and frequent or repeated exposure to sedation agents is just going to increase their tolerance of the medications physical exam vital signs auscultation of heart and lungs and then their airway assessment sorry excuse me

do they have any Strider snoring or sleep apnea advanced RA they're gonna have a hard time tilting their neck back if they have cervical spine disease or they have rheumatoid arthritis chromosomal abnormalities like

trisomy 21 patients with Down syndrome can have an enlarged tongue that can impair your ability to manually ventilate them if respiratory depression wants to occur body habitus if they have significant obesity especially of the

head and neck areas and head and neck limited neck extension short neck decreased ornamental distance which is basically just looking at how far back they can tilt their head any neck mass and then again cervical spine disease or

trauma do they have a c-spine collar are they on c-spine precautions that's not a patient we're going to be able to manipulate their airway and then mouth opening we do use Mallampati and I'll review

that in a couple of slides so the AFC classification is a categorization of the patient's physiologic status that can be helpful in predicting operative risk it is recommended by the AFA that if a patient is an Asaf or that that

should prompt an evaluation by an anesthesiologist I will tell you at NYU we will still get procedural sedation to some patients who are in Asaf or but we like to identify it ahead of time because if they have significant

comorbidities that will potentially increase their likely hurt likelihood of having an adverse outcome we then have a lower threshold for activating a rapid response or a code if something was to happen if we got concerned about

something so the airway assessment is

so are you ready here's the final project product tada that's what our d-h radiology nursing dashboard looks like today so as Tommy mentioned the goal of

our dashboard is to help the frontline objectively understand their performance and be proactive about making decisions to help their run day their day run smoothly all of these metrics on the dashboard work together to achieve those

goals so for example at the top right here the procedural workup pending and calls pending help to see the volume of pending workup and phone calls that need to be completed over the next few days another exam

well here on the bottom left the nursing case volume that's another it helps us to sort of see the different levels of nursing resources needed by hours of the day the dashboard is not just for nurse managers and for supervisors but for the

frontline users as well we had to teach your nurses how to use this information in real time what we have learned that by using actual data to drive decision-making nurses are able to deliver patient care more consistently

and in compliance with standard practice they are also able to manage variation and optimize utilization of resources the dashboard proves to be an easy tool to apply and capture meaningful metrics around the radiology nursing workflow

this is the framework we use to educate the frontline nurses on the real-time application of the dashboards we broke it down into four simple steps look so looking at the data interpret and gain insight 3 apply and maybe take action

and for what are the results and how are we assessing those results the next few slides will look at some specific components of the indicators on the dashboard and demonstrate how we use this model look interpret apply and

assess to increase the utilization of the frontline staff in their everyday work this is one of the dashboard components that you saw on the dashboard called buffer time the buffer time is the amount of time left till the patient

scheduled appointment time so for example the patient's appointment time is at 12:00 you can see the check-in time generally what we have found that it takes about 60 minutes from the time the patient checks in to get them into

the procedural room so based on that we have the appointment time at 12 12 o'clock the patient checked in at 10 11 and we have a buffer time you have 21 more minutes to go until there a scheduled appointment

time so let's use the look interpret apply and assess model to help better understand how this dish board indicator works so look as you can see we have multiple patients that have checked in interpret we have three patients

highlighted in red that indicates their past their appointment time and then we have four patients in green indicating time left till scheduled appointment time so what action can we take on this well first I'd look at the red patients

since they're late and I would determine next steps there's an ir case in room two that's nine minutes late and then we have an MRI our nurse that is also nine minutes late and it looks like we have a CT case that has nineteen minutes late

oftentimes I know this just because it's our area but if I was to look at this in our nurses too we would confirm that the CT three case really needed a nurse and generally we don't do procedures in our CT room three as far as the green

patients are concerned we would look at the we'd look at both these two twenty one minute buffer times and say and confirm that the pre-work is on track that we're ready to go and we're going to be able to get those patients in as

far as these two patients you can see they checked in way early then there's 60-minute time and at this point I wouldn't do anything else for that and then as far as assessing generally that's done sort of like later in the

day to discuss in the huddle future actions that needed to be taken maybe to prevent this okay let's try another component of it of our dashboard this here is our procedural patient workup turnaround time so here the first box is

the time in which it takes the RN to do her workup so that might be checking the patient in verifying labs vital signs placing an IV etc and then this middle box is the total workup time which includes the fizz

since time as well so a si and Malley mallampati assessment consent that kind of thing and then the third box is the total time the patient was in the pre room so let's apply our model again so as we can look the RN pre workup is

taking 22 minutes on average the pre procedural workup time total is taking 39 and the total patient time 65 so what can we gather from that as I mentioned earlier we give about us it's about 50 minutes generally when we've done a lot

of audits but we give a 60 minute window so that's why we asked our patients to come in 60 minutes before their before their actual scheduled appointment time so what can we interpret from this so as I'm looking the RN process time is

within 30 minutes so we're good there the total workup time was is in within the 50 minute expectation and we still have our 10 minute buffer remember however the total time in pre exceeds the 60 minute expectation so what action

might we take as a frontline either charge nurse or the any of the nurses say what should we do next so here what I might do is talk to the charge tech who sort of does all the orchestrating of the rooms and say so what's the

possible bottleneck because we've got our patients ready to go within 39 minutes to gain on time start but however it looks like we're stuck I will tell you that there is some of those variations like we had a stroke come in

or a trauma that actually bumps cases we get that piece but why are the rooms running what can we do can we maybe make a person that was scheduled going to room to go into our overflow room in five if say a power authorities like are

less acuity room so those are type of things that we can talk about in real time to get patients moving and so we don't continue to have late start delay so we'll move on to the next one

on our IR department at Hopkins we have 11 procedure rooms all combined we see roughly 350 patients per week that includes everything outpatient

procedures inpatient procedures our bedside service and all of our consultation clinics so what prompted our project well there were two issues patient delays and patient complaints so for patient delays we were not always

starting our outpatient procedures on time we had three put problems we had some bottlenecks in prep and patio and we had patient complaints so patients are understandably not usually happy about being delayed for a long time

so we wanted to make improvements and we knew we needed to quantify the problem how many delays did we have how long were they but we had huge challenges with this that were not easy for this team to figure out so what were these

challenges there were three basic challenges one on I don't know about everyone else's schedule but on our EMR schedule we were not able to see the delays in real-time the patients were on this schedule but it just there was no

real visual or alert when patients were delayed so in the busy environment of the day the fact that mr. Jones is running two hours late could easily fall off our radar secondly we struggled with how we

were going to quantify the delays we knew we wanted automated data we were extremely determined to find a way to get that we knew we didn't want to use paper we have a lot of patience so we ran a report and that's what we often do

right we want some data we go to our EMR system and we run a report however it turned out we couldn't use the report and why was that well the report was wrong so why does this happen well what happens is let's say mr. Jones is

scheduled in room 6 at 10 o'clock room 6 starts running behind so we just sort of drag mr. Jones over into room 8 and say at 12 o'clock so he hit 2 hours too late when we run the report later this is not reflected because the act of dragging

mr. Jones from room 6 to room 8 on our schedule resets or reschedules his time in the EMR so the EMR system thinks that mr. Jones was scheduled for 12 o'clock start all along when in actuality he was 2 hours delayed we'll imagine running a

report with you know a thousand two thousand patients totally wrong so we weren't able to use that so we had to really get inventive third issue return rate for our patient surveys our old surveys were the paper type the type

that the patients needed to mail back to us and we would get maybe one a month I don't know how your returns are but we had very little virtually no patient feedback or any feedback was really mainly verbal incidental feedback from

the patients or maybe if there were severe delays from the patient relations department so this was really a challenge and this team was really determined to figure this out

after having these two cases one in our institution and one at University of North Carolina Chapel Hill that we would then basically upsize our particles to

100 micron and we have not seen that and we're doing a second clinical study and I'm not seeing that as either we had about a 70% reduction in pain so if you look at our visual analog score out to six months and if you look at our

disability it actually paralleled this exactly which is pretty impressive considering mostly patients had bilateral knee pain so out to six months very good results 90% of patients were responders so two

out of our twenty patients did not really respond one patient didn't respond at his one-month follow-up but did respond at his three and six so I still consider him a clinical failure because we expect

these patients to respond by one month here's just an example of a baseline MRI before and after and you can see all that joint effusion there the white that decreases just even after a month how much it decreases and we looked at this

in terms of synovial thickness and distension and even on MRI you can object objectively count calculate synovitis scores and we calculated that they actually statistically decreased this is another patient on the left the

image shows diffuse white enhancement if you will of the synovium of the lining on the right it shows the fluid this is an image just of embolization and I show this image because it's really shocking and this is actually one of our nurses

who's enrolled in a clinical study is this is before this is all we did we embolized the medial aspect of the knee this is one month later 30 days in fact somebody just asked me this when I was in the booth over at the meeting across

the street and basically I said listen I don't know why this happened so quickly I have no idea we didn't tap renu-it into anything else if you look at this premium post it's pretty dramatic so clearly there's an inflammatory process

that we are arresting or stopping in such a short period of time so is there a future for this I don't know it may just we may just fall down and find out that there really is in a great future but so far we know it's at least

technically successful it's the results are positive in the short term long term we're not so sure yet we do need to better understand these risks and I think in my opinion in the long term it'll probably be really really good for

this 40 to 65 year old patient population who's not yet ready for knee replacement surgery this is the algorithm for our clinical study which were almost done enrolling right now it's a randomized control study against

placebo so it's two to one randomization which means one third of the patients actually get a sham procedure so we do an angiogram on their leg they're asleep they have no idea for embolizing they're genetical it arteries or not we wake

them up I think about the table and we follow them up if they're no better they're allowed to cross over and get the treatment the other 2/3 of the

morning thank you Andrew hi everybody my name is Monique Dawson and I'm an RN patient care coordinator in the PCC

office here is a list of our team interventions and we implemented many many interventions for this project our team selected what we thought were some of the most important valuable interventions to share with you so what

is a patient care coordinator well the patient care coordinators our nurse known as a PCC that works in the intake Center and this intake Center is a central hub for the I our department I mean it literally sits in the center of

the department we have the prep and PACU on one side with the I our procedure lab on the other the intake Center houses nurses schedulers and insurance presearch staff the nurses responsibility is to include which

includes outpatient procedures we manage a variety of triage calls we lead rounds with the physicians in the teams for the next day we also make pre-op phone calls we do a lot of patient teaching and we see patients in the IR consult clinic

several times a week with our attendings and our pas the intake center I would say is fairly unique I call it the one-stop shop which makes it convenient for providers and patients to give you an idea of the intake center workflow

the clinician or provider calls the PCC directly they request an outpatient procedure so say for instance its patient were Marie who needs a single meda port placement for chemotherapy because she has breast cancer so we then

take this information and we confirm that we have a correct order in the system we also complete any clinical screening questions which would include labs any blood thinners

airway issues we're able to decide upfront at the patient needs general anesthesia or sedation we also get calls from the patients directly like my tube fell out or my tube is leaking which I'm sure some of you can relate to when the

nurse finishes the clinical piece we then hand off to the scheduler who verifies the demographics the insurance and does all the non nursing scheduling tasks and one of the things we really love about our own insurance presearch

staff is that they are experts in explaining indications for procedures to the insurance companies which then helps get things approved and on a short notice so so some of the improvements that we did and implemented in the

intake center just to mention a few was the pregame Huddle's so it's a PCC and the text would get together every week and talk through the next week schedule as indicated that's myself and one of the techs named John going through the

weekly schedule we look at case length equipments and resources that are needed and this helped us learn from each other and to schedule more effectively the other super exciting thing that we implemented was to stop using requiring

tons of labs unnecessary labs for the pre-op labs and to introduce and to tell you more about that I like to bring up dr. hardy Singh who's going to elaborate on our lab reduction initiative thank you

clicker okay hi so first I'm gonna do a

that's background let's talk about what I mean when I say massive sub massive low risk high risk intermediate risk low risk all these definitions they're

actually pretty precise and so I think we need to be on the same page for that so when you see this what do you call it saddle saddle is a reasonable one large because there's I'm not sure automatically did that but would you

call it a massive PE how many would say yes this should be called a massive PE okay how many no okay it's not a big deal I'm not remembering faces but this is not necessarily a massive P I'd be surprised

if it wasn't but it's not necessarily because I haven't given you a key piece of information the hemodynamics massive PE is all about hypotension so what does that mean so this is from the American Heart Association in 2011 a massive PE

is an acute PE with sustained hypotension meaning a systolic blood pressure of less than 90 millimeters of mercury for greater than 15 minutes or requiring inotropic support okay so doesn't matter where the clot is

doesn't matter how much clot there is if you're hypotensive for greater than 15 minutes then you fit in the massive category okay sub massive PE okay you have a normal blood pressure but your right ventricle is dysfunctional so

either by echo CT biomarkers such as BNP or troponin your EKG shows right heart strain basically your right ventricle shows some measure of duress but it has not totally decompensated to the point you're starting to get hypotensive and

I'll give you a pathophysiologic explanation in a couple slides low risk basically means that you have no hypotension no RV dysfunction no myocardial necrosis so you have clot in your pulmonary arteries absolutely but

your right ventricle is acting normal and you have no issues with hypotension that's 60% of pease that present to the hospital fortunately sub massive about 25% and massive five to ten percent okay why do we care about this categorization

is there any functionality this yes massive PE carries about a 25 to 65 percent mortality so it's a coin flip whether these patients are gonna live or die that's how severe this disease is sub massive PE you know these are the

patients that are compensated from a blood pressure standpoint but have RV dysfunction these patients have a three percent mortality or so in the most recent randomized now back in the late 90s and early 2000s

the mortality seemed to be higher on the order of 10% but I think we're settling around a 2 to 4 percent mortality for this group now these patients do have a higher rate of clinical deterioration than the low-risk group meaning they can

progress from the sub massive category to the massive category that's that 5% number there so this this group is a little bit that's why I said in yellow and the top group is in red low-risk patients anticoagulate them they'll be

fine so that was the eh-eh-eh in 2011 well the Europeans have to had to have their own version in 2014 and they said you guys you Americans are not doing this quite right so that's where they I'm sorry I can't put two pointers at

the same time that would be pretty cool but I'll start on this side if I can everybody over there see that all right so this intermediate group here is the same as the sub massive category I'm gonna walk you through this just because

it's you know we're more and more going towards the European Society guidelines so they break down this sub massive category into intermediate high and intermediate low and the reason they did that is they're saying that not all sub

massive pease are the same and that's probably true there's some some sub massives that are really not looking good and going towards massive and sub some some sub masters that are just rock solid stable and beside a little bit of

RV dysfunction they're probably gonna do just fine and just you know go towards the low-risk with a little bit of anticoagulation so what how do they break this down well both of them have this positive especi or pecci I'll show

you on the next slide what that is basically it's a pulmonary embolism severity index okay so you have to have that being abnormal or positive for you to fit in the intermediate category but then this is where it differentiates so

if you have an imaging test such as a CT or an echocardiogram and you have your laboratory biomarkers such as a troponin or BMP being elevated or abnormal then you fit into this intermediate high-risk category but if you have only one of

them or neither of them being positive in the intermediate low-risk category so what's the big deal why does that matter well but we don't really know frankly but what the European guidelines recommend

is if you're in this intermediate high category you should be watched because you have a risk of clinical deterioration and if you're going towards that they say consider reperfusion reperfusion could be

anything it could be systemic thrombolytics it could be catheter directed lytx or it could it could be surgery that's that's the way they put it if you're in the intermediate low-risk category you can be discharged

pretty early this is that pesi score and you can see why they tried to simplify it the s pesky because you have all of these factors and they're all assigned these points the more points you have the worse you are but let's focus on the

simplified pesky scale if you have a score of one or more of these then you're considered to have a 10% mortality in the next 30 days so that's these are what they thought were the highest impact issues in a patient

presenting with PE it doesn't tell you that just because you have a positive s peso you should intervene it just says that this is what may happen with these circumstance and we'll go through the first set just for a second here so age

greater than 80 years that's a that's an issue if you have cancer if you have heart failure or pulmonary disease a heart rate greater than 110 the systolic blood pressure less than 100 or an arterial oxygen saturation off of nasal

canula or supplemental oxygen less than 90% you get a point okay all right are we ready for the first question 65 year old man blood

interesting to grapefruit if a few YP three a-four inhibitor so I always remembered from nursing school they said

don't give grapefruit but I never really knew why but that's why it's just inhibiting the enzyme that's required for metabolism flumazenil is the reversal agent for benzodiazepines your initial dose is going to be 0.2

milligrams over 15 seconds what's important to note about flumazenil other than the seizures that I mentioned before is that the half-life is shorter for flumazenil than it is for versed so you can see a recitation effect which is

why you really need to monitor them for a good period of time after you're giving it and monitor to make sure they don't become reefa dated we're all familiar with narcan it's the reversal agents for opioid medications the

initial dose is 0.4 milligrams given over 30 seconds and you can repeat every one to three minutes to a maximum of ten milligrams other medications I think are useful to mention because you do see them and I are usually given by an

anesthesiologist propofol is a great drug onset of action is less than one minute but it's a potent drug so you can see significant hypotension and respiratory depression for us in New York it's not permitted for use by non

anesthesiologists Dex Mehta Tommy Dean is another interesting drug that's sort of getting into the kind of talk in the IR world so in the 2018 guidelines that I mentioned before they address sex medicine

and they said that it could be an alternative for versed in particular cases it's a highly selective centrally acting alpha-2 agonist with eggsy oolitic sedative and some analgesic effects

you usually administer it as a bolus over 10 minutes and then you start a continuous infusion however some of the very potent bradycardia that you can see can be mitigated by eliminating the bolus infusion or the bolus

administration rather and significant considerations with this are hypotension and bradycardia does anyone use pres iudex in their ir suite oh you do okay you guys give it cool we'll talk our our anesthesiologists are

a little territorial with it however the research does show that it does have a better safety profile in certain patients so it you know yeah so that's my experience with it but our particular anesthesiologist that oversees our

sedation committee and all of our sedation practices is concerned about us using in an ir because not all the practitioners have experience administering it there's not a reversal so if the patient became bradycardic you

would have to treat their bradycardia with fluids or atropine or other medications for your particular institution yeah right it yes yes always look at your state guidelines yes so the a what the a sa says about the

conversation about okay I am nearly at a time of 3 minutes compassion so I'm going to just summarize this basically

we've a whole focus on AI and how radiology is screwed and you know I don't believe that we still need to be compassionate to our patients there is a small group of people at Geoffrey Hinton and others who feel that I can be

replaced by an algorithm these are probabilistic algorithms that mathematically calculate the probability of something being X or Y if I was a diagnostic radiologist I would be worried yeah I think they've got a real

problem but those of us who do procedures who look after patients who know our patients name who hold their hand feel their pulse we will be okay we just have to manage the other aspects of what we do compassion is a basic human

need like Maslow's hierarchy of needs like water like air like food and we sometimes I think underestimate this I was very sick over the last four years and my son had a massive scoliosis repair and was quite unwell that a cord

injuries recovered but we learned during this that that most health care is delivered by the lowest paid people in the hospital the patient support worker and they've they're often first-generation Americans

first-generation Canadians they got you out of bed they wash you they change your gown they change your pillow they change your sheets they feed you and we don't pay them enough we don't look after the mo enough we don't educate

them enough we don't give them opportunities enough but this is what I learned from this this experience the other thing I learned is that this racial variation in how people wait if you're in the waiting area of a surgical

or you know there'll be one Caucasian son there will be like you know one Norwegian there'll be maybe five Hispanic or Portuguese people and that'll be like seven Indian families and they'll have food with them and

there's nowhere for them to reheat their food so we're still building our hospitals on a Caucasian model of health care that doesn't work certainly doesn't work in Canada I learned that there's some beautiful things

you know I saw vein physicians come out and talk to patients you are so lucky my gifted hands looked after your loved one you know and then we saw beautiful things this young neurosurgeon really remarkable I was very impressed so the

focus should be on the patient and the family and their major life event not the team not the operator certainly not the operator we are just tools that reassembles the 35 millimeter reel of that person's life and reattaches it and

keeps a plane this AI stuff medicine is not the science of healing but the art of wooing nature I don't have much faith in the ability of Amazon or Google or Microsoft or Facebook to be any more empathetic and compassionate to us if

they're delivering our health care then the way they manage us as potential consumers and I worry about their involvement in healthcare I'm going to skip all this physicians interesting you study art or more empathetic but most of

medicine still boils down to this you sit beside the patient you hold their hand you feel their pulse and you talk to them and you make eye contact and that's what you do and that's why I have such respect for what you do I'm out of

time so I'll stop now and I just wanted to thank you very very much for this [Applause]

fine versed is extensively metabolized by the liver so I mentioned the Cy p450

systems so the specific enzyme that metabolizes versed cyp3a4 now that sounds like way too much information but what's important about that is there are some drugs that are also metabolized by the same enzyme that are inhibitors of

this enzyme and one of them is verapamil so at my institution when you order verapamil and versed together a warning comes up that's telling you that the verapamil may potentiate the effect of the versed and that's because the

verapamil is inhibiting the metabolism of the versed which means it's sticking around longer it's a consideration because we give wrap a mill for our radial access cases for a Vizsla spasm prophylaxis and neural patients yes yeah

a lot of neural patients for a cerebral vasospasm properties it's 97 percent protein bound so that means if you have a patient who has low serum albumin you may see a more potent effect right away because they don't have as an

a lot of protein circulating so that drug won't have protein to bind to half life in patients with renal failure reduced elimination of an act of the active metabolite can cause drug accumulation and prolonged sedation and

I'll tell you why that's especially important in the next couple of slides and then considerations prolonged tap life and the elderly obese and reduce hepatic and kidney function I think most of us know this but I think it kind of

helps to drive at home if you know why why is it prolonged half life in reduced kidney function well it's because it's 97% protein bound and it needs to be excreted by the kidney and you have an active metabolite circulating around not

getting cleared opioids are the mainstay

so before we get into the dashboards which I know you're all interested in

hearing about I'm going to talk a little bit about organizational strategy and how it really does align with our frontline workers so we all know that senior leaders have a responsibility to create a vision and a strategy for our

organizations they do this using benchmarks cost margins revenue in order to position our organizations to deliver high-quality care but also to position ourselves in ever-growing markets which I'm sure you're all aware of so as

organizational leaders develop these strategies for future development it is really important that the front line that the mid-level leaders are able to take these strategies and translate them down to the front lines so when you read

a story or you watch a movie you just assume that the cast of characters and the plot are going to follow along and if they don't we lose interest or we become disengaged so in this case can you trace the CEOs sorry can you trace

the CEOs vision for his strategy and how he asks the mid-level leaders to take down to the front line probably not and this is what all organizations struggle with because we know that the whole is always greater than the sum of all the

parts so now we're going to show you some boxes and these boxes represent the front line the mid-level and the senior leaders let's have a show of hands today for how many of you in the audience consider yourself to be frontline staff

do we have any mid-level leaders great how about senior leaders great well today our dashboard presentation is going to mostly apply to the frontline staff so we know that when organizations build strategies and they ask our

mid-level leaders to take them down to the frontline staff that sometimes the translation of that information creates chaos and disruption at the front lines and an example of that is at Dartmouth our senior leaders had a strategy for

improving access for care for an underserved population of patients that had pacemakers and needed MRIs Fordyce diagnostic studies we felt we could take the volume so we embarked on imaging patients with pacemakers and what we

found is that the number of patients that had pacemakers was outpacing the resources that we had at the frontline and this created chaos and it made the good intention of the strategy lost on the frontline nurses so it's really

important that we not only take strategy down to the frontline but that the mid-level leaders take the reaction of the staff and how it affected their work back to the senior leaders so in 2013 at Dartmouth we began our journey to bridge

this gap and we did some process improvement projects and we soon found that the data that we were presenting wasn't really accepted or understood or trusted by the staff that we were working with we discovered

that at the front lines that sometimes perception is not always reality so our job was to help the staff objectively understand how to work on a daily basis how their work on a daily basis impacted our organizational strategy in 2015

you'll see we went live with the radiant product that epic has for radiology and when I began looking at the reporting metrics that epic presented I saw that it didn't really translate into radiology language and it really didn't

translate into nursing language at all so we needed some metrics and we needed a way to be able to give the nurses meaningful actionable information that they would be able to work on and that we could really turn them into

data-driven problem solvers so this is when I engaged with Thome our quality specialist and I asked her to help us develop a strategy for how we could empower the staff to become more data-driven problem solvers what we

decided was that we first had to build build competencies and understanding around data and how Thome decided to do this was to develop these monthly scorecards the scorecards our performance scorecards that the leaders

in the organization in our department can use to kind of measure their success so we first met with the leaders in each modality and this was the radiology directors it was our technologists lead our nurse's leads and Thome sat down and

said what would be meaningful for you to understand so that you can talk to your staff about the business that you are running so this is an example of one of the scorecards that Thome built and at the same time we decided that we would

align our organizational strategies and our department strategies with these scorecards this is an example of an IR scorecard and you'll see that they chose quality and safety operational excellence and

sustainability this was a way to look at what their monthly volumes were and when we were asking them maybe to move that needle a little bit and give us some more and they felt maybe that they couldn't because the staff was saying

that they were too busy we could show them that the utilization in one of their rooms was 65% and maybe there was indeed some opportunity to move that number a little bit after we were successful with the scorecards and we

felt we had built the competency on the department the section director level Thome began working on dashboards and these are real-time metrics that our frontline staff can use every day to see how well they're processing their

patients through our system we also developed daily Huddle's where they take these dashboards the charge tech nurse tech the radiologists staff if they're interested and we talk about what went well what maybe didn't go so well we

talked about action items opportunities for improvement and maybe some projects that we could start around things that they identify that are impacting their workflow so now I'm gonna turn this over to Tommy who's gonna talk to you about

how she used that data to get us to our dashboards thank you Chris all right so

about massive PE so let's remember this slide 25 to 65 percent mortality what do we do with this what's our goal what's

our role as interventionalists here well we need to rescue these patients from death you know this it's a coin flip that they're going to die we need to really that there's only one job we have is to save this person's life get them

out of that vicious cycle get more blood into the left ventricle and get their systemic blood pressure up what are our tools systemic thrombolysis at the top catherine directed therapy at the right and surgical level that what

unblocked me at the left as I said before the easiest thing to do is put an IV in and give systemic thrombolysis but what's interesting is it's very much underused so this is a study from Paul Stein he looked at the National

inpatient sample database and he found that patients that got thrombolytic therapy with hypotension and this is all based on icd-10 coding actually had a better outcome than those who didn't we have several other studies that support

this but you look at this and it seems like our use of thrombolytics and massive PE is going down and I think into the for whatever reason that that the specter of bleeding is really on people's minds and and for and we're not

using systemic thrombolysis as often as we should that being said there are cases in which thrombolytics are contraindicated or in which they fail and that opens the door for these other therapies surgical unblocked demand

catheter active therapy surgical unblocked mean really does have a role here I'm not going to speak about it because I'm an interventionist but we can't forget that so catheter directed therapy all sorts

of potential options you got the angio vac device over here you've got the penumbra cat 8 device here you've got an infusion catheter both here and here you've got the cleaner device I haven't pictured the inari float

Reaver which is a great new device that's entered the market as well my message to you is that you can throw the kitchen sink at these patients whatever it takes to open up a channel and get blood to the left ventricle you can do

now that being said there is the angio jet which has a blackbox warning in the pulmonary artery I will never use it because I'm not used to using it but you talk to Alan Matsumoto Zieve Haskell these guys have a lot of experience with

the androgen and PE they know how to use it but I would say though they're the only two people that I know that should use that device because it is associated with increased death within the setting of PE we don't really know you know with

great precision why that happens but theoretically what that causes is a release of adenosine can cause bradycardia bradycardia and massive p/e they just don't mix well so

about engagement so thoughts like those

two thoughts have a genealogy like a family 3 and you can trace the genealogy of an idea back to the original inventor and then who they thought and who they thought and you can follow it through tips why 90 peripheral vascular

intervention drug eluting balloons mathematics architecture and this will be the family tree for vertebroplasty but it's interesting to think that this ultimately despite AI boils down to humans telling other humans and helping

other humans to do something and despite the world of our internet we still need to do this this is a great example so this crazy physicist Schrodinger what it can show dangerous cat wrote this pamphlet saying that there was a

relationship between the wave form of physics and human DNA and this is a letter from 1954 from Crick and Watson to him saying we read your pamphlet from 1939 and it influenced us into this into their structure the figuring out the

structure of DNA so ideas have trickle-down effects like the tree falling in the forest or the wing of the butterfly that we underestimate okay now I'm going to talk about something really important I'm worried about the amount

of radiation we get I began this kind of work about six years ago this stuff doesn't happen overnight it's hours and hours of like rotating planets in your head and trying to make them into something that is real and tangible

so radiation shielding most of you probably wear your little badge but maybe not all the time I don't actually know where mine is currently and we've become so inured to the risks radiation that we underestimate the

damage it's doing to us and we don't all have an equal ability to repair radiation damage to our DNA some of us have mutations that prevent us repairing DNA damage we know the names of some of those B or C a B or one and two and

breast cancer ATM mutation there are known mutations that put a small at risk if patients are larger we get more scatter scatter is the main thing that we experience there are papers like this showing that double-stranded DNA breaks

occur in physicians after treating patients and that some physicians get more breaks than others lead is really really important in preventing this table side lead decreases the amount of dose skirts that

we get enormous ly using all the barriers is rare we make compromises we get rid of them the amount of lead that we wear varies from person to person the age of the lead that we wear varies light weight protective garments are a

problem we did some studies in a Mayo Clinic on this and only three out of 19 passed so you're trading off your protection for the weight of your lead led toxicity LED is one of the most toxic agents on the planet

60% of lead aprons have LED on the outside so something I'm gonna work on when I go home is lead levels in my staff this is a funny photograph a bunch of us figuring out that we had no hair on the outside of our left leg

this is radiation injury to us we know from the very beginning of radiology that people radiologists died right they sat in the field they lost fingers they lost nose noses etc and and they did badly so I had all the stuff in my head

and I came home and my mother-in-law who I like don't tell her came home from our Cancer Hospital Princess Margaret with the list of medications not to take prior to her radiation therapy I said Karen why did

they not want me to take these these are all my vitamins and I looked at them they're all antioxidants so I thought okay antioxidants if they prevent DNA damage from huge dose radiation could work for us and for our patients so go

outside to Ronan my son and the dog Cora and we went for a walk and Cora met another dog and that got you know playing together and the guy who owned the other dogs said to me what do you do and I said well actually I'm a doctor

I'm thinking about my research projects what's your research project of the wasana antioxidants to prevent DNA damage from radiation exposure and he said I make antioxidants and so this is like that letter you know this happens

and there's a certain state where it happens more frequently it's a weird thing like I'm a scientist but I believe that so I used his antioxidants and bunch of experiments on myself I drew my blood radiated it then took the

antioxidants may be slightly hypertensive cuz there was a lot of uric acid in it but I felt great and then I found I could decrease the number of DNA breaks I got this is the man Ivan D'Souza

and so I thought this could be good this certainly works I can decrease DNA breaks with antioxidants I went out as visiting professor to Dalhousie they grow a lot of apples out there red Canadian apples so why they make all the

apple pie I like pie and so I told them what I was working on they said we have extract from Apple skins that is a really powerful antioxidant so we added it to our formulation we license three patents I formed a company named after

the dog Cora Cora med and I studied the nature of DNA damage from x-ray exposure basically what happens is x-rays impinge upon water molecules which then break releasing free radicals which then bind to DNA and then

oxygen binds to that break site so you get an oxidative injury to your DNA antioxidants bind the oxygen and the free radicals and prevent that we are

okay pathophysiology right ventricular the right ventricle is everything when it comes to the pathophysiology of this disease I'm gonna lead you through this because I think it's interesting and important I'm gonna go to this side this

time be fair to both sides of the room so when you have a PE that increases your pulmonary vascular resistance normally the pulmonary vasculature is a very low resistance circuit but when you start putting clots in it it's restive

Gong its its resistance goes up it's kind of analogous to the left an electrical circuit what does that do to the right ventricle well it increases the after load on that right ventricle so what that does is it causes the right

ventricle to blow up like a balloon now by Laplace's law if you take a balloon and you blow it up the intramural pressure is higher in the balloon so if you can imagine that thin walled balloon if you took the pressure at each point

inside of the balloon because it still got a finite thickness the pressure is higher than if it's decompressed now the problem with that is that how does the right ventricle get blood it gets blood from the coronary arteries but if the

pressure inside the ventricle is higher than the pressure differential is less and what what what is Flo rely upon it relies upon a difference in pressure from point A to point B so if that starts to equalize your blood flow to

the right ventricle decreases okay that's why the right ventricle gets ischemic now when the right ventricle becomes ischemic it can't squeeze as hard so it gets hypokinetic when it dilates it also does

not seem to squeeze out as well because the muscle fibers aren't overlapping as well okay so both of those things lead to both so that the right ventricle is now not squeezing is hard and it's not getting blood forward to the left

ventricle so that results in LV preload reduction though LV is not seeing as much blood on top of that when the right ventricle dilates it starts impinging on the left ventricle so now the left ventricular cavity is smaller and it can

accept less blood your output is only as good as your input okay so that's where you start developing systemic hypotension because your left ventricle can't pump out as much blood what happens when your left ventricle can't

pump out as much blood you don't get as much blood into your coronary arteries you don't get as much blood into your coronary arteries you're not getting as much blood into your right ventricle this is the vicious cycle that leads to

right ventricular failure and the progressive death that you see with massive PE now if you were to draw a line like that everything above the line is sub massive PE everything below the line is massive PE okay this is a big

experiment I did we were trying to create sub massive PE we created a massive PE this used to be mostly the L the left-sided chambers and all of a sudden became the right-sided chambers to me this drove home how much the right

side can blow out and dilate that's the only point of this picture I hope I didn't cross you out okay so let's talk

checking on the patient periodically at least every five minutes and monitor the

response to verbal commands if a verbal response isn't possible come up with some technique with the patient ahead of time if they're gonna give you a thumbs up or thumbs down if they're gonna close one eye raise an eyebrow whatever they

want to do come up with that come up with that with them in advance and use that to guide their to their ability to maintain their airway because sedation is going to be the main indicator of eventual respiratory depression if

that's going to occur it's not going to be your respiratory rate or your other dimo dynamics it's going to be the level of sedation we we have this problem a lot one of the nurses came up to me the other day and said the doctor told me

not to talk to the patient during the procedure I said no that's just pull this up I always say pull up the guide line this is Society event you can say this is your Society they told me I need to assess the patient every five minutes

and assess their response to me there has to be some sort of verbal response the patient doesn't have to move their arms around or give you a hug it's it's really just saying I'm okay Richmond agitation sedation scale

this is what we use at NYU this is a scale essentially to measure the level of sedation our goal is to try to get patients into this negative three sometimes it's not always possible but we want to use this to determine whether

or not the patient is slipping into a deeper level of sedation and again that's important because this is going to tell us that the patient is then at risk for respiratory depression or apnea if they transition into a negative 4 or

negative 5 ventilatory depression and airway obstruction are two different problems I just think it's important to know this because it's gonna require two different rescue mechanisms although you will usually see both of these happening

at the same time I only saw one time where it was true ventilatory depression it was in the neuro suite does anybody do wadda tests yeah okay so I had only I've only seen this once but we gave the amytal and the patient had complete

depression of their respiratory center so she did not breathe at all we had to do really deep stimulation in order to get her to take a breath so we could have done all the airway maneuvers in the world it wasn't going to help her we

had to wake her brain up and tell her to take a breath if she didn't we would have had to have intubated her that would have been the only way to rescue her because as far as I know there's no reversal for the amytal that we give bag

mask ventilation this is the cornerstone of basic airway management it's not a skill easily mastered I think a lot of people will sometimes fly through this because you do this in ACLs if you worked in an ICU you did this a hundred

times but what's different between this and a sedation setting and in a code situation is the patient and the code is already dead the thing that's not going to save them is is you're good you know Ambu bag skills it's gonna be the CPR

what's going to save your patient who is respiratory depressed in a procedural sedation setting is effective airway skills because according to the H a ventilation via an Ambu bag may be just as effective as ventilation via an

endotracheal tube that's huge so you can buy your patients some time while you're getting the reverse or you're calling for an anesthesiologist to come and intubate them if you're not able to effectively

ventilate them and they progress to a CPA as I'm sure you're all aware that just is a major indicator for eventual poor outcomes the patient could experience some airway techniques that are helpful you can do the head tilt

chin lift or a jaw thrust in patients what you do want to be mindful of obviously if they're in c-spine precautions if you are doing the procedure with procedural sedation which I would caution against then you would

just go right to a jaw thrust you're obviously not going to manipulate their cervical spine and capnography I know everyone knows capnography I'm a huge huge fan of capnography I can't stress it enough I think does everyone use it

does anyone not use it you don't use it okay okay just know if you are having trouble getting your institution to provide the finances if that's their concern as I just showed you in the beginning of the presentation there is

very strong evidence showing that there it's a positive outcome for the patient if something was to happen one day with a patient and and maybe it was to go to litigation although guidelines aren't meant to be a

hard and fast rule likely it would be brought up in the litigation they would say why do all of these organizations recommend capnography but it wasn't used in your institution and then they may say well we haven't seen any cost

benefit and then they would say well but there is cost benefit it's level a one evidence so it's really really useful and most importantly pulse-ox is going to report an average saturation overtime so you are going to see some lag so it

could be one to two minutes before you actually see a change in the pulse ox and your patient may not have been breathing for those one to two minutes so once the pulse ox does go down it's going to go down real quick and also if

you want to look at some additional resources I think the air and capnography toolkit they did not ask me to say that but I do think it is actually really really great and it was put out

steer another thing I just want to say to make the capnography work for you I think in our institution we've been using it for a long time but it doesn't always work we use this nasal cannula that's supposed to have this nice little

reservoir but it's really not great because it's cold in the room so the plastic will stiffen and it flips up use some tape or I just put a simple mask over the nasal cannula and then you'll get your waveform you'll have the the

carbon dioxide captured I think there's some fancy masks out there I think Medtronic is may be releasing a mask that does a capnography which will be great but in the meantime just make it work for you and make it work in the

beginning of the procedure sooo as you're giving more and more sedation potentially you're not then worrying about futzing around with making the capnograph you work nonpharmacologic methods I think are really important so

we get this a lot Twilight are you giving me propofol it's the same as a colonoscopy right or you're gonna knock me out right right so these are really important conversations to have in the prep area when you're getting your

patient ready make them aware they're not going to have these things and be honest with them if they're adamant they want to be asleep they want the Twilight you reschedule there it's I have found it's not worth trying to convince them

to do something that they don't want to do because they're just gonna write a really nasty letter later and and I don't and I don't blame them because I think sometimes we're not honest and we think we're doing the right thing and

you know don't worry we'll get you through it were you gonna be really comfortable and sometimes patients aren't going to be comfortable and that's okay and if they're not okay with that then we have to do what we need to

do to make sure that we're meeting what their needs and that leads into setting realistic expectations I always tell patients you might not see me the whole time I'm gonna check on you at least every five minutes if you don't see me

it's because I'm right behind you tell me what you need every five minutes I'm going to say are you okay if you need to be a little bit more asleep if you're in pain you're having anxiety tell me and I'll give you more medication this is a

collaboration and I find that that really eases a lot of the anxiety especially them knowing you're right behind them the whole time if they can't see you like their tented you know without a halo I think yeah the covered

halo we were talking about before if they can't see you it gives them a lot of anxiety if they think no one's in the room and there's just a provider they can't see doing a procedure on them sedation scripts my attending left but

we had a little bit of a healthy argument about this so I talked to him about scripting the way that we talked to patients about sedation so we're all saying the same thing all the time and he said you know I'm an attending and I

I didn't do a residency and a fellowship to be a robot and all these things and you know it was and I he loves giving me a hard time about this stuff so it was kind of funny because he's doing he's currently engaged in a grant project

that's looking at our work flow throughout the institution and he has research assistants that are working on it with him and one of the things that they did was they went on the floor with some of our residents who are consenting

the patients for procedures and she the very next day in a meeting it was totally unrelated it said to him you know they're saying the wackiest things to the patients some of them are saying don't worry about it you'll be asleep

yeah yeah it's like whatever you had last time and they're really not setting them up with realistic expectations so when we get them at least our impatience when we get them down stairs for their procedure they're totally confused about

what they're gonna have done and then I think they feel very anxious because they're about to go right into the room and now we're telling them you're not going to be asleep you'll you'll be able to talk to me during the keys so you're

not saying everyone has to be a robot and say exactly the same thing but I you may want to talk to your staff about hitting the same take-home messages so that they're not hearing all different descriptions of sedation throughout

their stay all right thank you everyone

they travel together so that's what leads to the increased pain and sensitivity so in the knee there have been studies like 2015 we published that study on 13 patients with 24 month follow-up for knee embolization for

bleeding which you may have seen very commonly in your institution but dr. Okun Oh in 2015 published that article on the bottom left 14 patients where he did embolization in the knee for people with arthritis he actually used an

antibiotic not imposing EMBO sphere and any other particle he did use embolus for in a couple patients sorry EMBO zine in a couple of patients but mainly used in antibiotic so many of you know if antibiotics are like crystalline

substances they're like salt so you can't inject them in arteries that's why I have to go into IVs so they use this in Japan to inject and then dissolve so they go into the artery they dissolve and they're resorbable so they cause a

like a light and Baalak effect and then they go away he found that these patients had a decrease in pain after doing knee embolization subsequently he published a paper on 72 patients 95 needs in which he had an

excellent clinical success clinical success was defined as a greater than 50% reduction in knee pain so they had more than 50% reduction in knee pain in 86 percent of the patients at two years 79 percent of these patients still had

knee pain relief that's very impressive results for a procedure which basically takes in about 45 minutes to an hour so we designed a u.s. clinical study we got an investigational device exemption actually Julie's our clinical research

coordinator for this study and these are the inclusion exclusion criteria we basically excluded patients who have rheumatoid arthritis previous surgery and you had to have moderate or severe pain so greater than 50 means basically

greater than five out of ten on a pain scale we use a pain scale of 0 to 100 because it allows you to delineate pain a little bit better and you had to be refractory to something so you had to fail medications injections

radiofrequency ablation you had to fail some other treatment we followed these patients for six months and we got x-rays and MRIs before and then we got MRIs at one month to assess for if there was any non-target embolization likes a

bone infarct after this procedure these are the clinical scales we use to assess they're not really so important as much as it is we're trying to track pain and we're trying to check disability so one is the VA s or visual analog score and

on right is the Womack scale so patients fill this out and you can assess how disabled they are from their knee pain it assesses their function their stiffness and their pain it's a little

bit limiting because of course most patients have bilateral knee pain so we try and assess someone's function and you've improved one knee sometimes them walking up a flight of stairs may not improve significantly but their pain may

improve significantly in that knee when we did our patients these were the baseline demographics and our patients the average age was 65 and you see here the average BMI in our patients is 35 so this is on board or class 1 class 2

obesity if you look at the Japanese study the BMI in that patient that doctor okano had published the average BMI and their patient population was 25 so it gives you a big difference in the patient population we're treating and

that may impact their results how do we actually do the procedure so we palpate the knee and we feel for where the pain is so that's why we have these blue circles on there so we basically palpate the knee and figure

out is the pain medial lateral superior inferior and then we target those two Nicollet arteries and as depicted on this image there are basically 6 to Nicollet arteries that we look for 3 on the medial side 3 on the lateral side

once we know where they have pain we only go there so we're not going to treat the whole knee so people come in and say my whole knee hurts they're not really going to be a good candidate for this procedure you want focal synovitis

or inflammation which is what we're looking for and most people have medial and Lee pain but there are a small subset of patients of lateral pain so this is an example patient from our study says patient had an MRI beforehand

much more controversial so you it was pretty clear that we have to rescue

massive PD patients from death but with these statistics what are we supposed to do with sub massive PE well are we supposed to prevent mortality it's gonna be hard to do if the mortality is only 2 to 3% because you're trying to really

improvements of a very low statistic are you trying to reduce the rate of hemodynamic deterioration that's a possibility what about long-term disability if you remove clot upfront

will these patients do better six months one year or two years down the road frankly we don't know the answer to any of this and the reason is that the pytho trial made things quite difficult for us to interpret the pytho trial was the

trial that was going to answer all uncertainty this was a trial where it took some massive PD patients in that high-risk intermediate category and randomized them to receive a bolus of tenecteplase which is similar to TPA but

is not the same versus anticoagulation alone what did it show well it showed there was no difference in death between tenecteplase and placebo so they actually gave a placebo drug so that no it was a double blinded

study now if you look at the next line though a lot more patients decompensated if they receive the placebo than that's not to place this is not a bad thing you know it's not it's not great when you have to intubate somebody or initiate

pressors so if you can avoid that outcome that's it that's a pretty good thing so maybe it is the right thing to give systemic thrombolysis in the setting of sub massive PE problem was this the bleeding you look down here

there was an eleven percent rate of major bleeding in the tenecteplase arm there was a two percent rate of intracranial hemorrhage so now we've got this therapeutic window that's hard to interpret so we seem to be improving

outcomes from an efficacy standpoint but then we're also increasing the rate of bleeding so basically what we've sort of coalesced around is that systemic thrombolysis has a questionable risk benefit profile because the rate of

bleeding and the rate of really serious bleeding is makes us nervous so is that an opportunity for catheter director thrombolysis and I'll call this the poster child for Catherine throwing license if this is how it worked every

time we might have a homerun so this is gentleman looked terrible well still in the sub massive category but breathing at 35 times a minute hypoxic had his main PA systolic pressure of 60

millimeters of mercury you look over here and there's this large clot in the right upper lobe go to the left side and then there's all this clot in the left lower lobe as well so what do we do we put in bilateral infusion catheters this

can be an E Coast catheter it can be a standard catheter these areyou nafeez catheters have side holes starting from here and ending it's hard to see but there's another radiopaque marker somewhere down there on this side there

and somewhere over there and between those markers you have multiple side holes and those are put up inside the clot so you're dripping TPA at a rate of about 0.5 to 1 milligram per hour and you're getting it directly into the

clock that's the theory and so after 20 to 24 hours of that you know you're given 20 to 24 milligram of TPA that's compared to 50 or a hundred that you get was sitting with systemic thrombolysis you get something

that looks like this where the pulmonary arteries look pristine the PA still the systolic pressures come down the patient feels great now the skeptic would look at this and say well if you just tried some heparin and you just infuse saline

would you have the same result and frankly if you were to conduct the experiment you might find something interesting or not interesting but we never have conducted that experiment but you know I'll tell you a little bit

about the ultimate trial if I have time I don't want to go to overtime though

let me show you a case of massive PE

this launched our pert pert PE response team 30 year-old man transcranial resection of a pituitary tumor post-op seizures intracranial frontal lobe hemorrhage okay so after his brain surgery developed a frontal lobe

hemorrhage and of course few days after that developed hypotension and hypoxia and was found to have a PE and this is what the PE look like so I'll go back to this one that's clot in the IVC right there and

that's clot in the right main pulmonary artery on this side clot in the IVC clot in the right main pulmonary artery systolic blood pressure was around 90 millimeters of mercury for about an hour he was getting more altered tachycardic

he was in the 120s at this point we realized he was not going the right direction for some reason the surgeon didn't want to touch him still to this day not sure why but that was the case he was brought to the ir suite and I had

a great Mickey attending who came with him and decided to start him on pressors and basically treat him like an ICU patient while I was trying to get rid of his thrombus so it came from the neck because I was conscious of this clot in

the IVC and I didn't want to dislodge it as I took my catheters past it and you see the Selective pulmonary and on selective pulmonary angiogram here and there's some profusion to the left lung and basically none to the right lung

take a sheath out to the right side and do an injection that you see all this cast of thrombus you really see no pulmonary perfusion here you can understand why at this point this man is not doing well what I did at this point

was give a little bit of TPA took a pigtail started trying to spin it through aspirated a little bit wasn't getting anywhere he was actually getting worse I was starting to feel very very nervous I had remembered for my AV

fistula work that there was this thing called the cleaner I don't have any stake in the company but I said you know I don't have a lot to lose here and I thought maybe this would be better than me trying to spin a pigtail through

the clock so the important thing about the cleaners it does not go over a wire so you have to take the sheet out then take out the wire then put the cleaner through that sheath and withdraw the sheath

you can't bareback it especially in the pulmonary circulation the case reports are poking through the pulmonary artery and causing massive hemorrhage and the pulmonary artery does not have an adventitia which is the outer layer just

a little bit thinner than your average artery okay so activated it deployed it and you started to get better and this is what it looked like at the end now this bonus question does somebody see anything on this this picture here that

made me very happy on this side this picture here that made me feel like hey we're getting somewhere I'm sorry the aorta the aorta you start to see the aorta exactly and that that was something I was not seen before the

point being that even though this doesn't look that good in terms of your final image the fact that you see filling in the aorta and mine it might have been some of the stuff I had done earlier I can't I can't pinpoint which

of the interventions actually worked but that's what I'm looking for I'm looking for aortic blood flow because now I've got a hole in that in that clot that's getting blood flow to the left ventricle which starts to reverse that RV

dysfunction that we were concerned about make sure I'm okay with time so we'll

okay so what were those outpatient

delays once we figured this out so I'm going to be transparent here as we collected data using the app the delay dashboard app that I mentioned we discovered that 28% of our outpatients were delayed more than 60 minutes past

their scheduled start time so this was like oh my gosh unbelievable that was 28 percent of our patients sitting on a stretcher in the prep area delayed more than an hour past their scheduled start time just waiting and waiting so

honestly once we figured this out this was worse than we expected we were really pretty surprised and more determined so we decided to initially tackle patients in the 60 minute delay category it seemed like at 60 minutes

that's when patients are getting extra nervous maybe upset you know they're like it's been over an hour what's going on so we wanted to tackle that group first and we decided that our initial goal would be to reduce those delays by

50% and these are just some snapshots of the methods that we use to collect our data we used the app to calculate the number of minutes each patient was delayed that was our key metric we used secret shopping to obtain some

observation data we used our patient survey responses and the nuit surveys were fabulous by the way and we performed some financial analysis so why do we have all of these delays what are the reasons our team identified numerous

reasons for delays populated on this fishbone diagram we have finna ties them into six major categories and I assume you guys can relate to some of these reasons maybe labs need to be drawn at the last minute or the procedure before

wasn't scheduled for long enough gaps in the schedule creating an efficiency may be pakis getting full and we need to see a doctor before we discharge a patient under scrubbed in and as we discussed previously just a general awareness of

the delays was huge for us so as you can see by this Fishburne full of delay reasons there were many moving parts in our department and we felt that we had a fairly daunting task as we started to

tackle these delays so now I would like to introduce dr. Andrew Dahmer who will share more about our delay dashboard app

and you can see on this t1-weighted image that increased area of enhancement which is the area of synovial thickening you actually see this on MRI beforehand and there it is located over the lateral aspect of the knee on the axial image

and so what we're doing sorry in the medial aspect of the knee so what we're doing here on the angiogram is and you solve these leg angiograms where everyone doesn't really care about these Janicki lit arteries they're really

important when you have sfa or popliteal occlusive disease because they serve as a collateral source but otherwise and people have arthritis they can be a real pain and pain in the knee if you will so this is a this is the superior medial

genicular artery it always drapes over the femoral condyle and you'll see here on this image you don't really see very much once we get into the vessel look at this it almost looks like a small about a cellular carcinoma like when you're in

the liver you get this tumor type blush vascularity that's what we're looking for that corresponds to the patient's area of pain and then after embolization this is what it looks like takes a very small amount

of embolic we're using maybe 0.4 2.6 sometimes 1 CC at most of dilute embolic that we're injecting this is another case again before and after if you look here on the right and then on the left you don't really see much until you

select the vessel out once you get into that super medial vessel you can see how much enhancement there is so in our clinical study of 20 patients this is what we did you'll see on the bottom here we used embassy and 75 micron in 9

patients and 1111 patients got a 100 micron and I'll explain why we upsized our particles so initially we wanted to go very small because that's what dr. o Cano had done in Japan but then we wanted to actually up size our particles

and I'll explain this here in our complications so like all clinical studies the purpose of doing really good clinical research is because this is early and we don't know if they're going to be complications and it's always fun

when you're the first one to figure it out and you tell patients I don't really know what's gonna happen and this is what happens so 13 patients had this kind of skin discoloration over their knee now we knew this because we've been

doing knee embolization for about 10 years in bleeding patients not necessarily arthritic patients so we had seen this before but none of these patients in this clinical study went on to have any alteration of the skin and

it resolved in all patients there was some minor side effects from basically medications and one small groin hematoma but there were two patients who developed plantar numbness over their great toe so under their great toe

basically in the medial distribution of their tibial nerve they ended up getting plantar numbness and this is believed at least in our experience to probably be related to non-target embolization to the tibial nerve the tibial nerve

probably gets its blood supply from many of these generic arteries so we decided

are there any questions yeah yes that's a really good sure so the question was do you have any rules or guidelines in my institution about how long the procedure can be before you start

talking about anesthesia versus sedation is that right and positioning prone supine we did come up with a guideline with within our department we looked at a little bit of research but honestly was more expert opinion just best

practice and experience I in in general I would say if the procedure is 3 plus hours the patient should know they're going to be on the table not asleep for three plus hours and talk to them about what that means and if they're ok with

that I just think again that comes into setting realistic expectations that's one of the reasons actually that we're very interested in using Dex med otama Dean because that's going to be a better

drug for those longer procedures first was giving functional and versed for four hours it's just not it's not appropriate but you know and some people would say we'll just get an anesthesiologist them but a lot of these

patients are really thick so in our institution anesthesia is just really super regulated and they require all of these clearances for their involvement no matter what they're giving sometimes they'll require all these clearances and

they give exactly what we were going to give so you know it's it's really a juggling act I would say in our department we really just make sure the patient knows what the expectation is and then we'll usually say to the

provider to if if something goes like if anything looks a little concerning during the case we're stopping and they have to be ok with that and they are they really are but that took a lot of work to get everybody on board with that

type of communication yeah we don't know so they I know I think Sloane is anyone here from Sloane no I think Sloane has with dedicated anesthesiologists they work really closely with them and it's easier for

them to get cases scheduled they will give us they will assign us an anesthesiologist for the day but if we don't have any anesthesia cases they get reassigned somewhere in the o.r and it's a different analysis every time it tends

to be the same group some are stricter than others some will have a patient say I really want anesthesia and we can call up the provider and there they say no problem let me do a quick chart review whereas the next day the provider goes

no absolutely not send them for clearances that's a little tricky yeah right so what I showed you is from the american society of anesthesiology i am not affiliated with them at all i just think they bide non anesthesiologist

sedation so i rely heavily on what they say and they recommend waiting till peak effects so i would look at the pharmacokinetics so for versed it's 3 to 5 minutes so i would wait at least 3 minutes before your readmit a stirring I

think a good example with that is when diazepam with the sedative of choice the on the peak effect for diazepam is 1 minute so when midazolam came onto the market there were a lot of adverse outcomes

with patients because providers administering it weren't familiar with the pharmacokinetics and assumed that the peak effect for versed was the same for diazepam so in theory you could give a patient in 5 minutes 5 milligrams of

versed so by the time that fully hits them they could be in a negative 5 on your raft scale so you know just look at those pharmacokinetics look at that peak effect and I would use that to drive your dosing scheme Atlee that's what I

do and I think since we've done that we've seen better meet info cities and better safety outcomes yes okay yeah we don't do that we do one thing with uterine fibroid embolization swear they'll do a superior mesenteric block

but otherwise we don't do any other type of regional blocks but I have read about that I think that's really are the IR providers giving the block okay right I've seen two with uterine fibroid embolization we'll do an epidural in

advance some I think some institutions or some literature exists about that it's interesting it would be interesting if the IR providers could actually give it though I'm not sure if that's kosher in the anesthesia world but they're

certainly qualified to do it they they do already kind of do it really but so I mean that's certainly something interesting and if you have a provider that is comfortable taking that on and their institution I think it's worth

looking at because anything that's sort of I think mixes things up and and provides a different Avenue especially for high-risk patients is worth looking into definitely yes I believe it yeah

mm-hm right so I'll just repeat what she said so just jumping on the talk about blocks so in her institution they the providers to administer blocks and I think you said

coleus estas Tamizh and PTC's and biliary dream placements they'll use that and it will decrease the amount of sedation that's required sedation being versed and fentanyl that's required during the case which like yes like you

said is really great for patients who are already on opioids previously and habit aller ins yes [Music] something right so we again he left same provider though had a patient on Groupon

or Fein and it was our first experience within about a year ago and it was terrible and she did not have realistic expectations going in of how sedated she would be and she was very very unhappy

afterwards so we talked a lot about that and in that guideline I had mentioned that we made about when we involve anesthesia and when we don't there's a caveat about that that says that if a patient is on

methadone or buprenorphine that a discussion needs to take place making them aware that they will probably not feel very sedated but we will try our best and if they're not comfortable with that we reschedule the procedure with

anesthesia but they have to know going into it that they they may not feel completely sedated and we just keep that open and honest communication but we haven't really come up with a scheme of what's best we did actually try with her

we had her come in one day having taken her buprenorphine the day of the procedure and she seemed okay with that and then we tried having her go off of it so that the receptors wouldn't be blocked she was not happy with that

experience so that's really when a person like that probably would do great with propofol but we can't give propofol so you know if the and if the patient tells us no then we just reschedule with the anesthesia

right - hmm right right right you could at least if they're if they're on an opioid uh if they're on people nor Fein then in theory they should respond to the verse said you could go heavier hand it on the

versed just to get them sedated but they will probably still feel pain but it they hopefully won't remember it that's true I you know with the Richmond agitation sedation scale that's not going to fit every patient that's a

really good point I gave a patient seven of versed during an adrenal vein sampling and she was just talking my ear off I got I fed are you okay you know do you need me to give you anything else no no I'm good I'm good and then I wheeled

her out we got her in the recovery area and she goes sit over I said yeah she said wow I don't I don't remember anything the power of her said that that was like a true and music effect I hadn't seen that so strongly in a

patient before but if you if I had done you know I was documenting that she was a zero it looked like I wasn't doing much for her but then I was putting comments you know patient comfortable denying needing any more sedation so

won't fit every patient so it is good to look at that but yeah as far as the buprenorphine I mean it's it's it's tough yeah if they have an addiction specialist I would say talk to them and they might be

able to come up with a scheme that works for them and if there's a lot of pain expected afterwards those patients are gonna have to be on parenteral opioid therapy they'll probably have to stay you know if you're in a hospital they

would have to stay overnight so those are all things you have to consider yeah yes hmm yeah I'm like it so Adam and Alexa are nurse practitioners that we work with and I'm looking at Adam because

this is actually was a very hot topic for us in the last six months so we actually cheat we met with our sedation committee that's run by that in a physiologist who's blocking us from using pres of X and discuss with him

that in the protocol that guides our practice it's said that you did the timeout and then gave sedation but Ari anesthesiologists don't do that right so they intubate the patient and everything and then and they and then the provider

comes in and does the timeout right before the puncture or incision so we talked about to him about how well if we're gonna do the latency to peak effect it's not enough time right so we do now bring the patient in and start

sedation right away our orders are put in in advance I know some by the attending or the Li P so we have a PRN dose and with an a certain number of occurrences and a titrate to a certain Ross scale

yes yeah so and that our anesthesiologist mentions that our providers are present but it's it's a certain use of the language I think it might be like direct observation or immediately available and our providers

are immediately available it's up to your hospital so our profit our providers aren't like down the street on their way in to work with coffee and street clothes and we're sedating they're they're just down the hall maybe

or the way our department looks is we have a control area and it's like the you know the Central Station and you can see all of the rooms so they might be in the Central Station but just haven't gone in to do the time out yet that

being said I always talk to them before I bring the patient in and say what's the goal Rath and I address any concerns that I have and I think people think I'm a little kooky when I do that for every case but it I think it works really well

and I think the providers really like it so we just already start from the Gecko our line of communication I tell them the patient seems really anxious this is my plan what do you think agree disagree yes the procedural if does the procedure

list or the Lak but I've sedated the patient so the patient if you look at what Jayco describes in the universal protocol it's ideal if they can participate in the timeout however not required because then when they do the

timeout they're right there stabbing them with lidocaine so I like to you know I mean I would argue that by starting I would argue about that by starting at the sedation earlier and getting the patient into a comfortable

state you're more safe because you're doing the dosing appropriately according to the a sa yeah correct right right right

okay I think it's important to say though it's not about getting around Joint Commission this is what Joint Commission says you may feel uncomfortable with it and that's okay

but it is what our accrediting body says is okay we're also not intimating the patient and paralyzing them like an Asst the anesthesiologist is now having said that it's not like we walk the patient in and we go oh I think you're mr. Jones

we throw you on the table there is an initial timeout that's done with the nurse and the technologist and the other people in the room shaking his head yes as so the acceptable amount of time after reversal

yes so if it happens if it happens mid procedure you need to it's I believe the language the a sa uses that you have to have a discussion amongst the care team about whether or not you're going to proceed if it happens after the

procedure in the recovery area or it happens mid procedure and you abort then it has to be at least two hours before you discharge that patient or move them back to their unit where they came from because of that recitation effect and

because you can have really adverse effects from sedation like flumazenil can cause serious delirium I had a patient like that one time it was it was awful and it can cause serious cardiac arrhythmia so at least two hours if you

continue with the procedure I would just make sure everyone knows that you have to be really careful with recitation effects and and all of the adverse effects that you'd be looking at yes I think one more question I'm sorry

with hyperkalemia I have come across I want to say it was in perioperative guidelines when I was looking at the labs that we do cuz we do a lot of unnecessary labs in our department you guys might - I feel like we just really

overdo it I believe the perioperative recommendations are to check a serum potassium if the patient has a reason to have hyperkalemia however right if their hyperkalemic and

they develop a cardiac arrhythmia you know could hypoxia also precipitate that cardiac arrhythmia the results from the hyperkalemia maybe I just went in I wouldn't take an ounce

I would I would consider hyperkalemia severe hyperkalemia and unstable patient because that patient could go into a fatal arrhythmia so I would correct that before you bring them into an elective Percy what's often an elective procedure

so if you're doing a fistula gram you know right five point yeah why are we will go up to five point eight we personally will go up to five point eight because a lot of times they're hyperkalemic

because they're fish too less clothes now and we need to open it right so just again it I don't think there's ever going to be any hard and fast data that you see it's all about making sure everyone knows this patient has a serum

potassium of five point eight we're going to be really closely watching the ECG monitoring yeah thank you everyone thank you so much [Applause]

so where we are now these are my concluding slides massive PE is lethal systemic lysis should be used surgery should be discussed immediately in the ECMO which I didn't really get a chance

to talk about it's probably a game-changer because it's almost like a temporizing measure for any of these therapies patient comes in you immediately put them on cardiopulmonary bypass support and then you can decide

what to do should this patient get an embolectomy should this patient get a free directive therapy should we just wait and let the patient write it out and that is a right answer actually just keep them an anticoagulation so this

will be a game-changer for massive PE sub massive PE is dangerous to some of the patients risk benefit of systemic thrombosis is not favorable for most but for some it might be and CDT appears to be promising but we have a lot of work

to do so where we need to go from here is that I think for mass pe we need a prospective registry and we really need a randomized control trial for CDT for sub massive PE thank you very much guys thanks for your attention

individually into each one of these trials but I want to just point out to you how busy the last 5 years have been because it has really caused a

resurgence in our interest in both treating PE better and what the gaps are in our knowledge so I will point out in 2014 this was an inflection point for 10 years we didn't have a major trial actually more like 12 or 15 years we

hadn't had a major trial in in PE and pytho was a 1000 patient study that informed us about how systemic thrombolytics interact with sub massive P and I'll go through the data that same year

catheterized thrombolysis is everybody familiar with catheter at the thrombolysis for submasters before Pease that's totally off the grid okay good well this was the first time we had a randomized trial for catheter directly

thrombolysis with some with some massive PE only problem was it was 59 patients in Europe so and that's all we have as far as randomized trials for CDT this is my soapbox issue I'm sorry if you've heard me say this but that's that's my

big goal is to try to change that 2015 had some follow-on CDT trials 2017 this is when we started thinking about the long term effects of PE on patients both of these studies started to examine the issue where a year after the PE patients

are not normal if you did a for example this elope long term study almost 50% of patients had an abnormal cardio pulmonary function test one year later 2018 we started to experiment with the dosage that we're

administering during CDT that's the optimized trial and we saw the first trial completed for a mechanical device called the NRA flow trailer which I'll show you later in the talk as well so that was an exciting inflection point as

well the extract PE trial which uses the indigo cat 8 device to aspirate thrombus in pulmonary embolism we just completed enrollment this year the future is hopefully bright for generating more data the PERT consortium registry is up

and running and is hopefully going to help us aggregate data and make better decisions and then you have a couple more devices coming in and I'll tell you our efforts to try to really improve the knowledge base on what CDT for sub

massive P that's the P track trial that's the last bullet point there okay

all right so now here's what I want to

spend some more time digging a little deeper and talking about our clinical implementations this is where I get why I do a lot of these events and a lot of speaking with clinicians and this is where I'm gonna address a lot of the

questions that I get very frequently about using capnography and hopefully you leave with a little bit more knowledge and some troubleshooting tips so capnography traditionally when it first came out was used on intubated

patients right for establishing that they have a pain airway the endotracheal tubes in the right place and it's staying in the right place and that was placed in line with the endotracheal tube via adapter but now we're using

more and more capnography with patients who are spontaneously breathing and maintaining their own air and we have this breathing patients who are breathing between their nose in their mouth so they've developed

monitors where we can monitor patients who are exhaling through their nose and/or mouth we are looking at is again that non-invasive continuous plot concentration overtime of the co2 concentration that is being exhaled at

any given moment which is going to tell us instantaneously if there's any change in the patient's ventilation it just this is just a blown up view for those in the back saying if some of this can be difficult to see but what we have

here on the left side of the screen is an image and Michaels gonna start to hand out some of these just so you guys could put your hands on them and feel them and touch them because there's a lot of different advices that have come

out even in the last year that I haven't seen yet that I'm starting to see so we brought some samples that you guys can just touch and play with and such but what we have on the left is a sampling a filter line set which delivers oxygen

through in both nares both nasal you know prongs and also samples out of the nose but also out of the mouth and this is important because we all don't breathe just through our nose and mouth right we we we switch breathe Leone

where I'm talking I'm exhaling through my mouth sometimes I have a stuffy nose and I can't breathe through my mouth through my nose so sometimes when we're monitoring these things we can't if a patient is breathing just through one

air you're not going to get an adequate sample we're using capnography and I think it's more important to use capnography in the patients that have their own airway and our risk for losing their airway rather than ones that

already have an airway established and we're using it certainly in our sedation Suites we're using it pediatrics and neonates all the way up through adult right and we're using it more and more to with non-invasive ventilation with

our CPAP and our BiPAP patients that's another question I get a lot and we're gonna dig into that a little bit more but as you see on the picture on the right when we have patience with our non-invasive ventilation there's

different sampling sites that we can use we can have on the top there this patient is actually wearing a nasal and oral monitor underneath the mask there's also a mask port so a port that can be just plugged right into the

and then there's also ports that are on the circuit the mask ventilator connection which is a little bit more downstream so there's three places that you can attach capnography monitoring to and we're going to talk about the

differences with those as we go through here so let's look at physiology so why

massive PE well let's remember this at this point including all the trials that preceded the pytho trial almost 1 700 patients have been randomized into systemic lytic trials for some massive p yep all we have on the CDT side is the

ultimate trial of 59 patients non-us single was a single trial that's where this initiative is coming from to improve the data this trial called P track and I have preliminary information that we just made our first breakthrough

in fronting from the NIH so very excited that we have a planning grant to potentially get this thing moving so P tract is basically designed to be a randomized control trial of catheter directed therapy versus no catheter

directed therapy for sub massive PE to really try to answer this question just like the pytho trial tried to do for systemic thrombolysis in the setting of catheter Ida thrombolysis and this time we're not just using surrogate endpoints

we're not you the rvw ratio is probably not even gonna be calculated but what we want to know are these are patients doing better in one arm or the other and we're going to use outcomes that are important to both patients and providers

400 to 500 patients most likely looking at sites all across the so but we are still in this time when

I want this to be as instructive as possible I do have some multiple-choice questions that are peppered in there and hopefully you guys feel comfortable enough to shout out answers I really don't care if you get it right or wrong so but if I teach it right I hope it's

clear what the answers are okay so and and I know the title test says that I'm going to be talking about parts frankly I think there's a lot more to talk about about PE other than parts and I'm not going to be emphasizing that

but if there's time to ask questions or I'm happy to speak about that as well because I think the disease and the treatments are really the crux of PE at this point okay so I start with something called the landscape where are

we with pulmonary embolism well you know I don't know how many of you have seen PE in the IR suite or have dealt with these patients or even have friends or family that have had a PE but I don't think anybody who's interacted with this

disease would argue with the fact that PE is a big deal why do I say that statistically speaking well there are 900 000 VTE events per year that's DVT or PE that's a lot it's almost a million now the number of deaths from PE every

years quoted to be as high as 300 000 but is around 60 150 is what we think so quite a few this affects everybody you know you might have heard of Serena Williams getting a PE Chris Bosh and Serena Williams I think had a massive PE

which I'll tell you the definition of that later but it's a it's it's something that can affect a young person and kill that young person so that's what makes it a little bit tougher than some of the other diseases it's the

third most common cause of cardiovascular death stroke mi then PE ten percent are fatal within the first hour so a lot of these patients you're not even gonna see and when you do see them you've got a big task ahead of you

because they're you're trying to rescue them from death that's basically the same statistic now if you were to take every patient who comes into the hospital and you put an echocardiogram on them and you looked at the right

ventricle their right ventricle would show some evidence of dysfunction and so that's an interesting statistic because right ventricular dysfunction is you'll see on a subsequent slide is actually a pretty big deal and is actually at the

crux the pathophysiology of PE now if you were to do a VQ scan around six months after people got a PE you would find that 1/3 of those patients actually have residual thrombus so we think that you

know PE is a acute disease but what we're finding is that it's actually a cute disease that can become chronic and a lot of people and we're actually revealing unveiling the fact that maybe a year or two years after their PE these

patients aren't doing as well as we thought so that this is a burden it's a chronic it's a chronic disease that causes a burden on their lives so this is the disease and and you know as an IR you look at this and you say well that's

pretty exciting looks like we can intervene on something meaningfully but there are some caveats we should remember first most patients have low risk PE s I'll define that in a little bit but these patients don't need an

intervention they just need anticoagulation to the best of our knowledge that says all this this group needs sub massive PE I'll spend quite a bit of time on and it's a very controversial topic and there's a

lot of different attitudes between interventionalists and non interventionists about sub massive PE when you get a massive PE patient this is the patient that's crashing and burning most of them should receive

systemic thrombolysis which is an IV in the arm and a drug through their vein it's the fastest thing you can do and it doesn't involve corralling an IR suite the team for the IR suite or a surgical team and as I just said there's a wide

range of attitudes regarding treatment aggressiveness so I'm not going to go

these are our prospective CDT trials it's a lot to go through them so I'm not going to suffice it to say that the only one of these that is randomized is the

one in the top left the ultimate trial with 59 patients the rest of these are single set are single arm studies the optimized trial was randomized but the key arm it did not have was a control arm so all it did was vary the amount of

drug but there was no control arm to tell us how are people doing if they just get heparin well and I'll show you one result from these trials that is the most important result and that is up from the ultimate trial at 24 hours CDT

catheter to thrombolysis reduces the RV to lv ratio to a greater extent than heparin alone what does that mean so you saw all those pictures with the big dilated right ventricles our surrogate measure for right ventricular

dysfunction is the ratio of the diameter the inner diameter of the right ventricle to the left ventricle what we found in this study was that that ratio got reduced to a greater extent at 24 hours in the CDT arm compared to heparin

alone that means that CDT seems to reduce our V dysfunction faster than heparin now importantly 30 days later the echos looked identical so really it's a question of time which is not surprising what we've noticed in

our practice is that patients feel better faster okay I'm gonna go through the rest of this because I'm out of time but I want to give you a little bit of a sense of where we're going because there's bleeding associated with CDT and

maybe I'll show you this that in the Seattle to trial there was an 11% major bleeding rate now this was a pretty conservative definition but there were some serious bleeds and there were no intracranial

hemorrhages in this study but we have realized that CDT is not risk-free it's not like we've all of a sudden gained all of the advantages of systemic thrombolytics and none of the disadvantages now the rate of

intracranial hemorrhage seems to be about tenfold less but it does happen about 0.2 to 0.4% of the time the rate of major bleeding seems to be about 5% which is about half the rate of major bleeding that we see with system or

thrombosis so bleeding is still there it just doesn't seem to be as frequent so that's where some of these other devices are coming in then our a float Reaver the the the extra penumbra indigo cat 8 device and so the the float Reaver is

has actually gone through the full trial and the results are about to be published what is this thing well it's this pretty big hose which is about 20 French and it goes through the right heart and goes up there and it takes

this clot and literally aspirates it out and these are some of the things that will come out and that's sort of your post picture right there the data showed something similar to what we saw with the catheter directed thrombolysis

trials they had looked at 106 patients are vlv ratio was reduced again there's no comparator arm here so this is just the device on its own with a 3.8 percent adverse event rate and so now we're talking about mechanical devices that

don't use a clot-busting medication therefore you're gonna you can expect less bleeding but you're trading some of that off for a mechanical device that can cause injury to either myocardial structures or to the pulmonary artery so

that's something we have to be highly cognizant of as they're introduced into the market this is the penumbra cat 8 this is from Jim Benenati publication basically showing a couple things that's the separator that is the actual

catheter and that's the sheath back there so you've got poor profusion because of a clot in the inter lobar pulmonary artery and then at the end of it you have better perfusion for lung down there so we actually just completed

enrollment into the extract PE trial 120 sub massive PE patients the same efficacy endpoint you have to remember that has been established by the FDA as a way to get approval this is not the final

study nor should it be the final study when we evaluate these devices so to summarize sub massive PE what does the data not tell us CDT probably reduces the RV to LV ratio at 24 hours that is the main outcome that I want you

guys to remember from the ultimate trial it's associated you didn't see this data so don't worry about that we do see major bleeding and sometimes rarely but sometimes we see intracranial bleeding with CDT as well so what we're missing

from catheter directed thrombosis for sub massive PE is what are the clinical outcomes the RV to LV ratio is a surrogate outcome what about death what about clinical deterioration what about recurrent hospitalization what

about recurrent VTE how are people doing in the long term are they walking as well as they were before we don't know any of this none of the data right so far can tell us any of this information so where do we go from here for sub

in providing the analgesic component of procedural sedation they activate opioid receptors in the brain and spinal cord to inhibit transmission of painful impulses fentanyl is the main drug that

we use the onset of action is seen in one to three minutes and the peak effect is seen in five to fifteen the half-life is two to four hours and we typically give a dose of 50 mics to start again it's metabolized by that cyp3a4 what's

especially I think important to note is that it gets metabolized to inactive metabolites so I had a situation when I was a newer nurse I was working in the ICU I had an elderly patient it was my third night with her and she was

admitted for acute kidney injury related to her urosepsis so she really wasn't making a lot of urine and she lives in an incredible amount of pain she has been screaming for two nights and I finally said enough I went to the

resident so we have to give her something so she said let's give her some morphine you want to give her one milligram she's elderly can we at least start with 0.5 and see how she does with that she said that's fine I gave her the

point for five of morphine and she went to sleep maybe thirty minutes later and she looked really comfortable now we didn't we don't or at that time we didn't use capnography for non intubated patience in my ICU I was in but she did

have a pulse oximeter on and all the other monitoring I didn't really disturb her throughout the night I knew she hadn't slept in two days so I would go in and check on her and turn her and see how she was doing and she seemed really

asleep but comfortable I go and do my bedside handover with the day nurse in the morning we go to wake her up and she's not waking up and we do a really good sternal rub and all your nail bed pressure and all those tricks

and nothing's working and she's she's out so we called in the attending in the resident and pees and they ended up doing an arterial blood bath and her paco2 was 75 yes so they did give her narcan and thankfully it worked and she

didn't require intubation the nurse practitioner pulled me over afterwards when things had settled down she said you know I want to talk to you about what happened why did you decide to give her morphine and start a fentanyl and I

said well you know morphine of aura fentanyl rather is a hundred times more potent than morphine and I thought I was doing the right thing because she's an elderly patient I was worried about her cuz she's frail but then she explained

to me that morphine gets metabolized to several different metabolites and one of them is actually 2 to 3 times more potent than the original morphine that you're giving in the IV and because she was in acute renal failure she wasn't

excreting the drug so she had this two to three times more potent drug just circulating around her system all night which led to her respiratory depression and her hypercarbia with fentanyl you have metabolism to inactive metabolites

so it's considered to be more safe for patients who are in renal failure that was a real big aha moment for me because there's a lot that you have to know when you're a nurse especially if you're working in a critical care area and you

hope that you're the providers you're working with are thinking of these things but they're also very stressed so it's all of our responsibilities to know the way that these drugs work and I think it's great in IR because we we

don't give it a lot of medications we give a fair amount but they're pretty much the same medications over and over so we do have an opportunity to really take a better deep dive and really the mechanism of action and their

pharmacokinetic properties considerations you do want to consider renal e impaired patients because it can alter the kinetics meaning that there's decrease protein binding as I said for versed but there is they are slightly

less protein bound than versed and there is a black box warning for cyp3a4 inhibitors specifically for fentanyl just something to keep in mind when you're giving it though I think this is really more I'm talking about patients

that are going home with a fentanyl patch you want to make sure they're not taking inhibitors at home kind of

quo in 2009 looked at the data for this and basically unfortunately we do not have high with so strong level 1 data to tell us how to treat this disease but

this showed that we had an 86 and a half percent success rate at treating massive PE if that's the case this should be the first-line treatment from a soapie problems you look at the data and 500 of the patients actually came from

retrospective case series which really does not capture the full gamut of massive PE you're only going to report the cases that you're successful with that's just something we do so we there's a lot there's a lot more cases

that are excluded from this that we don't know what happened to them either with or without so where are we with the data for ass massive p/e we have these techniques from a catheter standpoint it can be

used if systemic lytx are contraindicated we don't know which one of these devices works the best we definitely don't know we probably won't know that on a comparative basis because massive P happens relatively rarely

whether it should be used in combination with other therapies and which patients should get this therapy and we should get surgery and we should get lytic sore which should get some combination and so where do we go from here for massive PE

I won't belabor this point but I think what we need is a is a massive PE prospective registry and hopefully something like the perk insertion will help us gather all the data from all the Centers it's just that you know we're

probably gonna see five to ten ten to fifteen massive pease per year per institution that's just not enough information to rapidly get up to speed with what's working so if Li if we can get all our resources together put it in

one place then we can develop algorithms around how to better treat massive PE but there's a lot of promise out there I'll give you that okay sub massive PE

all about effective bag-valve-mask it's the mainstay of airway management and procedural sedation but also in the o.r so you're gonna see if you're ever working with an anesthesiologist that

the first thing they want to see is how easily they can ventilate the patient with a mask and if they have trouble they know that's potentially going to be a patient that may give them difficulty later on when they're attempting to

intubate because when they go to intubate the patient if they're not successful they immediately stop and go back to bagging the patient they want to know that that's gonna be there their failsafe and that they have an

effective way of delivering breaths the difficult airway is going to be defined in terms of whether effective gas exchange can take place with an Ambu bag so at NYU we use the sorry we use the Mallampati so this classification system

attempts to grade the degree of airway difficulty the foundation of the assessment is that the tongue is the largest anatomical structure that can inhibit mask ventilation now again if you look at the research surrounding

this Mallampati used in isolation it's not useful you really want to look at all of the other airway assessment criteria that I just previously discussed because it's on our required documentation you know it can be

something that maybe providers get focused on just open your mouth cool and move on but it really is important to look at all the other components not to call out my attending sitting over there so this is a great mnemonic that I like

moans it's just a quick easy way to identify a patient that may give you a little bit of trouble when it comes to manual ventilation so M is for mask o for OB 3a for age and for no teeth and s for stiff lungs so you can see with this

patient here with the beard he has a lot of facial hair so that's a patient that you're gonna have a difficulty getting a good seal with and if you can see they actually covered his beard with Tegaderm in order to get an effective seal right

painful later but great for his airway um last thing yes at this point oh great this points you guys can still hear me okay so for this patient for for obese patients in general my biggest pain point I guess you could say is when I

see patients inappropriately position during procedural sedation and a nurse will call and say the patient's not really well sedated but his his capnography waveform looks all off he's occasionally having periods of apnea can

you come and help and the patient looks like this so a patient who's sedated is not going to be able to comfortably spontaneously mentally win their position like that you can see his airway is a little bit compressed here

he has to overcome extra body habitus in order to effectively take a breath so what you want to do is just ramp your patient and this is obviously extreme like if you're doing an angiogram you're not the providers gonna say what on

earth are you doing but what you can do is take that pillow out and put a little roll underneath the shoulders and you're gonna see the airway open up and if I get patients who come in and they can't be flat maybe they have congestive heart

failure so they have that pillow orthopnea you can position them like this give them the sedation and then take everything out that's what I always do you you want to make sure that you have

good positioning and that's going to set you up for success patients who are elderly or have no teeth are going to be what we call a dentist and they essentially just have loss of musculature in the face which is going

to correlate with surface area which means you're not gonna be able to get a good seal so what they did in this particular patient is they actually put gauze in to just increase that surface area and then patients with stiff lungs

are going to be patients who have a history of COPD or any other restrictive lung disease and they just may be difficult to ventilate Pharmacology and

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