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Introduction and Disclosures | Hits and Misses: An Interactive Mortality and Morbidity Session
Introduction and Disclosures | Hits and Misses: An Interactive Mortality and Morbidity Session
2017AVIRcharlesclevelandhepatocellularinteractiveinterventionaloncologyradiologysessionunresectable
Complication Management and Low Risk SIR Guidelines | Hits and Misses: An Interactive Mortality and Morbidity Session
Complication Management and Low Risk SIR Guidelines | Hits and Misses: An Interactive Mortality and Morbidity Session
2017AVIRchapterembolifull videojvirmoderateparacentesispiccspneumothoraxprettyproceduresriskthoracentesisunintendedvenous
Dose of Contrast | Hits and Misses: An Interactive Mortality and Morbidity Session
Dose of Contrast | Hits and Misses: An Interactive Mortality and Morbidity Session
2017AVIRcontrastcreatininedosingnephropathypediatricreactionsrenalvenography
Route of Elimination | Hits and Misses: An Interactive Mortality and Morbidity Session
Route of Elimination | Hits and Misses: An Interactive Mortality and Morbidity Session
2017AVIRbowelcauschapterexcretionfull videoinsufficiencyrenal
Possible Complications | Hits and Misses: An Interactive Mortality and Morbidity Session
Possible Complications | Hits and Misses: An Interactive Mortality and Morbidity Session
2017AVIRchapterfull videoliterpatientspneumothoracesremoveremovedsuboptimalultrasoundvasovagal
Technique | Hits and Misses: An Interactive Mortality and Morbidity Session
Technique | Hits and Misses: An Interactive Mortality and Morbidity Session
2017AVIRchaptercolordopplerfluidfull videopicturetube
Complications of Ultrasound Guidance  | Hits and Misses: An Interactive Mortality and Morbidity Session
Complications of Ultrasound Guidance | Hits and Misses: An Interactive Mortality and Morbidity Session
2017AVIRchapterfull videohemorrhagehypogastricmedialpatientrectustrauma
ESLD | Paracentesis and Embolization | 59 | Female | Hits and Misses: An Interactive Mortality and Morbidity Session
ESLD | Paracentesis and Embolization | 59 | Female | Hits and Misses: An Interactive Mortality and Morbidity Session
2017abdominalanesthesiaapneaascitesAVIRbleedcatchcatheterizationchaptercompartmentdiseasedistensiondosingembolizefluidfull videokidneyliverpatientperineumprettyretroperitoneal
Cirrhosis ES Ovarian Cancer and Ascites | Paracentesis | 71 | Female | Hits and Misses: An Interactive Mortality and Morbidity Session
Cirrhosis ES Ovarian Cancer and Ascites | Paracentesis | 71 | Female | Hits and Misses: An Interactive Mortality and Morbidity Session
2017ascitesAVIRbilateralchapterchestcontrastdoseeffusionsfluidfull videopatientpleuraltube
Renal Biopsy and Complications | Hits and Misses: An Interactive Mortality and Morbidity Session
Renal Biopsy and Complications | Hits and Misses: An Interactive Mortality and Morbidity Session
2017AVIRbiopsybleedingchapterdiastolicfull videokidneyoptimizedpatientrenalsystolicultrasound
Liver Biopsy | Hits and Misses: An Interactive Mortality and Morbidity Session
Liver Biopsy | Hits and Misses: An Interactive Mortality and Morbidity Session
2017AVIRbiopsiesbiopsychapterfull videokidneylabsliverminimizeoptimizedpathologistultrasound
Transcript

Hey guys. Welcome back from lunch. We're gonna get started. So our next speaker is Hits and Misses: an interactive mortality and morbidity session with Dr. Charles Martin. Dr Charles Martin received his medical degree from Case Western Reserve University School of Medicine. He then

completed his radiology residency with University Hospitals of Cleveland and his vascular and interventional fellowship with New Haven Hospital. He currently serves as an assistant professor and clinical director of radiology at

Cleveland Clinic. Dr.Martin is also involved with oncology research and actively involved in trials for patients with unresectable hepatocellular carcinoma. Today Dr.Martin will lead an interactive M&M session with us...so we

encourage questions because this works when you have questions. Thank you. Ok good afternoon. Ok so as far as the session goes the cases are just gonna be relatively... pretty pretty common things. We have a

monthly M&M session in Cleveland and I kind of am one of the people who are under the opinion that anything could happen to anyone at anytime. And it's usually kind of the the run-of-the-mill things that kind of when they go

sideways that's usually kind of the ones that you really have to kind of figure out kind of what to do and how to kind of handle. So here we go. And then anytime somebody has questions just shouting them out come up to one of the

microphones let's keep it really kind of free form and low key. So there's my disclosures. I'm my part of a medical

advisory board. And so to kind of start things. You know as I kind of mentioned

there's so many procedures that IR does that you touch and it's so varied depending on the institution where you work. And you know when people come in off the streets I kind of feel like there's

...there should be some way that you can kind of figure out kind of where where things are going to go. I'm sure we've...everybody in this room you know you...whether it's your kind of in the middle of the night and you

kind of come in for a GI bleed or if it's a kind of middle of the day and you're right there for a for a pretty standard central venous access. There are certainly there are times when you you actually know like things might go

go a little south but there are other times when you you really want to kind of make sure that you have the full understanding of the entirety of the procedure. So you know most of our

procedures when we when we perform them

most of things we're looking at or trying to kind of avoid the big things. We never going to want to give anybody any medications that have any issues with allergies no issues with bleeding risk you

really want to make sure that labs are optimizing and the patient is optimized for whatever the procedure is. And then you start looking at a procedural planning. You know essentially looking at kind of how you're going to do the procedure

what could potentially go wrong what potentially could go right and understanding the entirety of what of

what is. And you know I kind of feel like the great majority of what we do these are kind of the...some of the big the big

hitters and the things that you really probably should look out for one way or the other. You know pretty much anytime you break the skin there's always a risk of excessive bleeding pneumothorax especially with all the things we're

doing in the in the chest cavity air emboli and injuries to adjacent structures or unintended structures. Those are kind of the big categories of I guess as you could say there's people who are kind of lumpers

and splitters I'm kind of a lumper just to kind of give And you know I still actually have this hanging in my office. I always give a copy of this to every fellow in the

beginning of the year and then we always revisit it at least two to three other times during the year. I find that it's really really helpful just to kind of... this is a paper from several years ago in JVIR but it pretty much lists

all procedures and it kind of stratifies it into low moderate and high risk. And what's really nice about this is that when you when you really start to look at the list it just kind of helps you to kind of get a picture in your head as to

as to what you what you want to do for the procedure and you know the potential for things to to kind of go bad. And it really can also kind of help in the discussions with just the patient as well as the family. And then just to

kind of set the set the mood in the room as you know there's the low risk procedures things usually pretty low-key but for the high-risk procedures everybody's pretty you know that things could get pretty intense in

the room. But it you know its many times it's the it's the moderate risk ones where... those are the ones that you really have to watch out for. And you know just to actually go back here for just one

moment. When you look at the list right here you know you have the procedures that I think everybody are doing your your filters your PICCs your paras thoras. You know everybody kind of discounts those procedures and...oh

it's just a kind of....it's going to be a quick paracentesis it's going to be a quick thoracentesis going to be quick central line. I could probably fill up a day just showing case after case after case of how those cases can really

really turn bad and unfortunate. And very much the same way with this moderate risk category. You know you have you venous.... your venous interventions and then you start to get into your non vascular procedures like

your biopsies. A lot of the solid organ biopsies are going to have it their own their own list of issues that will get kind of get into just a little bit. And then obviously you're high-risk procedures.

These are the ones that you know pretty much everybody knows everybody kind of... I hate to say it...but almost you kind of expect that things can kind of get hairy kind of in the procedure. And you know it's really one of those things that

even as high-risk as these procedures are kind of understanding that the... what you know kind of what's going on in the room to make sure that the patient's kind of aware of the of the severity of the situation the complexity of the

procedure I think that can go a really long way toward an optimal outcome.

And so this is one thing that you know unfortunately at our institution we've had we've had a couple of these relatively recently. And it was when

Kristen had asked me to have a talk I have started putting together a some slides of our M&M and after we had a couple cases of kind of contrast allergies it was something I kind of felt like it would

be really really helpful just to kind of review really quickly. Because I mean contrast is pretty good we use it on just about every procedure and it's not without its own risk. So it's just something to kind of think

about. You know you obviously have multiple brands of contrast multiple formulations but you know you always want to kind of keep an eye on the patient as to what's going on. And you know I got to tell you I recently

had a contrast allergy and it was actually my tech who had picked it up just because you know the patient was literally covered you know it in their entirety other than like a little circle right here at their neck. And she had you

know kind of looked on the other side and just saw like a few hives and she's like I think the patients having a an allergy. And it was it was huge it was very very helpful. And they were someone who you

know we have taken those precautions. They had they had previously had contrast they had a history of asthma for which they hadn't been taking any medications and we were using actually an isoosmolar contrast. As I look

through this this list are there...you know are there any things that people see when you're thinking about contrast that you kind of come to mind as far as kind of the common threads. And it is..anyone?

Reactions. Yeah a lot of the reactions and it will also be due to just kind of any history of contrast administration. Yes. Absolutely. And that's... that goes right to

that other point about prep. You know really making sure that you know kind of where their creatinine is. And not just looking at one day's creatinine kind of looking at the kind of their their trends. You know one of our contrast reactions

was purely due to a patient who they did they had actually had contrast induced nephropathy and it was just secondary to the fact that the primary service had been tee-ing this patient up for so so long and giving them lots of IV lasix and you

know they're creatinine and was kind of....it had kind of bottomed out. It was at a reasonable range for us proceed but over the next couple days when you start looking at the entirety of medications that they were on as well as their

trend they were you know certainly an area where we should have exercised I think a little bit more of a little bit more concern. And you know for the most part we do take you know kind of contrast

dosing for granted you know except...and happily....except in the pediatric population. Everybody seems to always be aware of the other concerns with dosing of contrast in kids. And it's very strictly

weight base which is great but you know at the same time with adults it shouldn't be something that's kind of looked over. We've had multiple cases where as we look at things patients have had....had come in after

you know acute MIs. Things like that they were they were in the cardiac cath lab all night they had large amounts of contract and unfortunately due to their underlying clinical condition the contrast load they now needed a tunnel

dialysis catheter. Well they had a history of either chronic renal failure and stage renal disease and sometimes they would require things like a venography or other procedures and you start you start really looking at their

total contrast load and you start kind of figuring out how you can kind of best manage that. So this is a something that I still kind of hold pretty

close. And this just kind of get into some of the roots of elimination of

contrast. It's something that still probably every year maybe every other year certainly you know we'll have a CT scan where all of a sudden we'll see like hyper enhancement of the bowel and or kind of persistent excretion of the

kidney through some of the extra renal routes kind of list the here in the liver or the bowel wall. And it's actually quite quite striking. And you know some of some of...here's just an additional kind of issues with reaction.

And you know these are kind of the real big areas right here. You're where you know patients with end-stage renal disease. The renal insufficiency with or without diabetes. Dehydration is a really big one

you know a lot of times we'll look over the fact that these patients are NPO for sometimes longer than 24 hours that they have a whole litany of test that they're getting. I mean you could you could really....you know what without even

knowing it...really kind of caus a pretty significant bump in their creatinine...you know pretty quickly. Now obviously some underlying conditions. I put sickle cell disease because it's usually one of the more common ones but

there's a whole history or a whole list of the blood discrasias that

you can kind of get into there. And you know these are just kind of some of the some of the things we could do. You know what I would argue that this is

probably one of the one of the biggest issues right here. Minimizing patient anxiety. You know we we always report the contract reactions but I would argue that there's probably ten times more cases where a

patient comes in the room they're just wickedly anxious about the procedure they're you know getting close to hyperventilating and you know that can really kind of make... it can muddy the waters. And you know I

gotta tell you my technologists at the clinic...and I love them to death...is there's been multiple times where they can you know they can kind of sniff that out. Even after I've kind of consented and talked with that out with them and felt like I had like a

pretty good rapport but then they're the ones that are kind of getting the patient on the table and while they're...you know kind of prepping the patient the room they just kind of get a sense of well this patient's a little bit

more anxious than normal and that's really kind of when...that kind of those discussions and kind of taking that extra time has really kicked in kind of help us out more than once. And you know

just some of the some of the

things that you can do to kind of minimize contrast whether it's a you know kind of hydrating the patient making sure your minimizing their diuretics making sure they're optimized for their CHF and your kind of keeping

keeping an eye on some of those diabetes medications. And just you know some of the adverse effects here. You know you're obviously your're full blown anaphylaxis with your hives and stridorr but this is certainly something

that you have to kind of keep an

eye on. And then our ABCs which is which is always kind of very very necessary. Keeping an eye out for bronchospasm anaphylactic reaction with use of epinephrine or even convulsions heaven

forbid requiring diazepam. Now you know our technologists back at the clinic are...many of them are need....due to I guess kind of changes in some of our hospital policies there. Many of them are studying for the

that VIR exam. And this is one area that they you know...many whom have either taking the test or who are studying for it it tends to be like a an area that they have noticed that it's quite quite popular.

And you know it has really been something that we've gone over multiple times and you know we've found pretty helpful. And you know this is just kind of our...these are our guidelines that we use for just the kind of the

contrast induced nephropathy. Our patients will wind up seeing about a bump in their about one-half or 0.5 to one milligram of um...that's when we'll start to get concerned. And just here's some incidents just some epidemiologic

fact...okay. So quick question. Anybody

have any thoughts kind of using those initial guidelines that I popped up beofre. I'll give you guys a second to kind of read the question.

I probably should've put an ABCD down there...I just kind of used the bullets. What's that? I think I heard it. C. The correct answer was C. When you when

you kind of look here...it's the heparin. And then you know the renal biopsies are your high-risk procedures. We do them quite often and I'll get into that in just a little bit but you know it's one of those things where we always

try to kind of optimize the INR. We personally for our high-risk procedures at a minimum.... even our TIPS... you know unless it's incredibly emergent and we'll start we

potentially with an INR less than... excuse me....platlets less than 50. But they are actually actively in getting platlets FFP and everything else infusing. It is one thing that you know its kind of happening for every procedure.

Ok this is another area that as of recently at our institution this was something that I think for many reasons...practice patterns financial incentives...there were multiple areas across our hospitals that had been

performing many paracenteses and thoracenteses in addition to IR. And unfortunately due to some unfortunate event we're actually starting to see an uptick in the number of such procedures. And you know this is kind of

another area when Kristin and I were kind of talking about it earlier that I kind of want to harp on because this is probably a procedure that...I mean how many people are doing you know more than two to three paracenteses or

thoracenteses a week. Show of hands. Yeah. Now the places that are doing or not doing them or not doing them what are some of the reasons. You're doing them in ultrasound. Ok so does body IR guys or

the vascular IR guys but ok so the body guys. Is it.... body guys? Okay. And are they using...they're using image guidance? Like an ultrasound or something CT? Okay good. Believe it or not these are still

done in many places by many people just kind of blindly which and I think that's perfectly reasonable to some degree. But you know there are multiple studies that show that will in and of itself just using image guidance will

decrease the risk. It's something that we we hold multiple courses that at our institution just to kind of promote the use of image guidance for procedures like this because it's a very easy way that you cannot kind of limit

your complication rates to your hospital. So you know when you kind of

hospital. So you know when you kind of look at you know those numbers and it kind of gets into that. I don't know if it's projecting very well. But I mean you'll go from...there could

be a significant increase in pain many times just because people are using multiple sites to stick if you're not doing this under ultrasound guidance. Or you're doing it under ultrasound guidance and it's either a suboptimal ultrasound

or you're just not in the kind of the ideal pocket. You know... Oops. Let me go back here... pneumothoraces shortness of breath cough vasovagal reactions. Now when you guys are doing...let's say we'll start with

thoracenteses. What's... how much are people most people removing. 1500. Perfect. Ok you know unfortunately you know that that's that still doesn't seem to kind of be out there as much. So we've seen

several several patients who they're removing two three liters. And patients will you know kind of getting to get into some issues you know right there either you know with them or shortly after.

you know another thing that we do at our institution is the post procedure like if we do remove that you know full liter and a half in the department you know we will make sure that we communicate with the service but the entirety of the

fluid that could be removed within 24 hours has been removed and please don't remove any more'n whole thing's kind of equilibrate so that's another kind of another area that I'd probably recommend a kind of a evaluating if you happen to

see patients who have a tour event and

this is just kind of a quicker a couple of light shone kind of technique here you just kind of a ride that ride the top of the rib and there we were usually do them under ultrasound guidance many

if not most of our patients to kind of sitting up you know or if the patient is unable to will just kind of have them kind of supine of like and you know kind of going for the for that largest pocket I don't know for that projecting well

for the Lightning you with you I got ok with that up there ok

great okay so I'm would you mind just lowering a life in the back I don't know how his condition and everybody hated ok so on you know usually a you can you can kind of feel like a little bit of rib here Rick shadow and you know you could

do like a nice a nice large pocket of a of fluid right here with a pretty depreciation amount of soft-tissue alright sweet is it a little bit of a better picture sweet effect cool so here's kind of a little bit of rib we

have from shadow kind of coming down you kind of see it kind of parallel there and kind of but you are a popular fluid right here and very very much in the same way you could kind of you and catch up some music on someone right down

there with ok alright here's just a another quick picture that kind of shows much of the same we have long years of their diaphragm right here we always try to acquire like a picture with the you use

of color doppler just too and just kind of concerned that there are no army lon you know best was kind of running in that in in your state now you are most people performing the you know I can similarly like sitting up to pine

alright so and here's just because i might go a little bit of a quick discussion kind of the step-by-step just kind of showing kind of a you know going so far too kind of place the catheter and then go ahead and place a chest tube

and using we use the skaters just because we find it pretty easy to kind of convert either from a reasonable amount amount of fluid to we just have to go through a chest tube it it'll it'll accommodate a 35 wire and there we

go right there and this is just one of

our one of our phantoms that get a week we kind of have our team kind of practice on and our technologies who start with us we kind of will bring the Phantom's we have a simulation area and

we'll just kind of run through a couple features and and let them now I kind of gotta get an idea of where things are and where things look like kind of a real time and we found that to be tremendously helpful

alright here's the kind of the same thing for powerful pc you feel like a ton of the bowels down here here's our societies and I'm just a little bit of the little bit of soft tissue patient with a lot better than that last patient

for the flora and you know one of the things that we as i mentioned we're seeing quite quite a bit more of our arm and unfortunately unfortunately bleed due to go in a little bit to a little bit to medium you know these you can

kind of happened and unfortunately the patient can be pretty significantly before they know before they come back to attention and you guys are there are many people placing like the tunnel catheters as well and ok you got to

place them purely under ultrasound under ultrasound in the fluoro or ultrasound on floor oh ok we have a couple services that are at our place that are doing an entirely under ultrasound and unfortunately they've been coming back

in time to time just because there's that the to kind of shift a little bit the other thing is kind of the acknowledged of right right where the hypogastric vessels are and kind of a couple couples schematics and right here

I mean this is really kind of a pretty much you could put you know about a one to two fingers kind of just lateral to each humble itís you'll find the inferior epigastric artery and assures anything you know we probably see one of

these a month and its really kind of unfortunate because there's usually a ton of food and a ton of fluid as well as especially if you go further laterally you know those are those are always great places to to to him

and this is just kind of that the needle insertion technique where we just kind of pull down the skin and then we'll have a will have access and there how many people are also administering albumin during during that once in

awhile ok do over five years ok whatever your chronic patients who were your 10-15 indication that the much yeah they were havin tree

and it's completely fair i mean that we we want to giving album we use the 5 litre rule and it was pretty well we're we're pretty aggressive about making sure that there are patients will have a little bit extra kind of intravascular

you know kind of a osmotic hole

there we go now getting into some of the complications we're going to start to kind of show of you that a few of the pictures here as we kind of get into get into some of these arm now how many how

many uh people here in like that level one trauma hospitals wow nice name that's impressive what kind of future do you get mostly young man like you today how much time are you actually are you

get everything like a trauma nice ok we'll get into those little bit okay so here's just a couple pictures just kind of showing the hypogastric arteries like most ppl these days you can you know you can catch these vessels

are you know they literally run right next to the and all like the abdominal rectus much culture and you know when you want to do it once you kind of start seeing them you can you know kind of notice know the kind of avoiding there

they are a kind of traveling up and this is unfortunate patient who they literally kind of you'll see a track coming up but they went 14 medial and now there's a patient has a pretty pretty significant hemorrhage and all

kind of people party Mia and this is this is the NGO that kind of subsequently followed basically I could kind of go up and over and it kind of get into the hypogastric vessel which is kind of coming out here and we're

catching a bleed kinda right out there now here's here's another picture of it right there

and this is another patient and that things occurred kind of in a similar way this patient had end-stage liver disease

so she was the shoot regular pathak and you know these are the patients who why when we know we've been able to make pretty significant changes to our complication rates just by their kind of self-selecting patient population and

you know to that end how many how many people here are using anesthesia pretty consistently for four cases ok kind of here in there for everybody because that's all I think you're kind of losing down there but you know

unfortunately for us you know they were they were very very helpful in that you know they made a really a very reasonable argument and kind of change some of our practice policies that arm you know for for patients who you know

have the relatively short neck you know pretty significant sleep apnea morbidly obese everything else like that yeah we were there a lot quicker to contact anesthesia we kind of use that same argument with our with our

colleagues a DIC use it on the floors you know the patient has end-stage liver disease and kidney disease and they're going to go have a wagon opportunities you know instead of you guys doing those procedures send them down to us because

things just turn out kind of quickly and this is the CTA that you know that actually shows some pretty significant fluid here kind of the perineum and little bit more another kind of fun finding a kind of

getting back to our discussion earlier days anybody see anything also click really kind of a normal picture this you know this is the kidney here it's like screaming hyper again the patient actually had a cardiac

catheterization you have 30 just about 30 hours of prior and they're created because of the blood loss because of all kind of fluid ship their reaction was you know kind of getting high and at the outcomes that the outside hospital they

essentially this kind of dosing with korea toasting with the contract again and for us you know for fruit that to demonstrate the bleed but unfortunately the they hadn't even kind of clear that they previously had you can kind of see

that by this this kidney here just being way too down and you're just a little bit more and more fluid down here and fluid and there and there's are fighting right there he kind of catch you could kind of catch the bleep kind of coming

right off there they had a unfortunate kind of tried to perform a tourist in pieces in paris in pieces and bad things kind of happened could be kind of like one and then the other and the patient kind of blood for both and we're kinda

never we were kind of left holding the bag and here's here's a handy Graham right here we actually kinda had to perform a little bit of connect to different things but he kind of the autograph right here is a one-bar branch

kind of coming out right down here and then you catch the bleed kind of a kind of all the way out here there's just a little bit more of a persistent blush i hope its kind of projecting well enough another picture of it and it is again

and here's a kind of post future picture you can kind of catch the coil maps right there we we had to embolize that branch but unfortunately because of the the degree of zone distension this patient was actually developing an

abdominal compartment for your own so we want and we went ahead and place the catheter just to start to be compressed unfortunately grateful for this case we actually had a different patient who had had pretty significant ascites a similar

situation had pretty bad of abdominal compartment syndrome with a retroperitoneal bleed instead of an introvert nobly and because the Department of is that the pressure was so 10 the patient actually had to come

back to us on two different occasions and we were just symbolizes lumbar vessels because they were just kind of popping off the aorta from the level of pressure in the admin so well we just kind of when this one came around I just

prophylactically put it put a tube in just to kind of decompressed here it is again ok here's a here's

another case but before we kind of going to say many questions or softer kind of observations are things that they're

doing it they're at their institutions that they think that are you know that that that could be helpful to the group oh I feel you're saying so like if they you know post all that administration kind of what's that window where you're

going to still be okay yeah we're we're usually ok up to about six hours yeah I mean it's kind of ideal in that first few hours the other thing is that were stratified by the severity of the

contrast reaction like if it's a 60 Plus year old patient who has previously had a contrast the action more than likely was with some of your older contrast agent and it was more than likely the agent and not something that you know

kind of ahead occurred with respect to to them having some kind of anaphylaxis due to due to their own past medical history so we will kind of extend that range on to like six hours in a patient who has had a contrast or had had issues

a little more recently will actually come just bring it down to three but usually between 32 and we do cable for like three dosing and kind of figuring it out ok

you know that that also weight-based you know and then the other the other issue is you really shouldn't there's there are probably not always that kind of in two ways there's kind of two different patient populations you

know if there's if it's just really like a contrast reaction and you're doing kind of a you're more than likely referring to like floral procedures and relatively quick floor procedures whether using destiny

ok you know they're there is a calculation that's essentially kind of weight based didn't want to bore everybody with it but putting it on there and I could actually I'm more than happy to kind of

email it to you that was that will use but at the same time it's a it's kind of a picture of the cat kind of weak create and and a kind of a couple other factors and then you kind of determine that the dose it would be tough for me to say

that's like higher load is depending on the patient's body habitus you know renal function G of art that and that would all kind of play into a kind of visitors that the total dose you know especially I guess looking at there have

been more and more studies looking at kind of gallium metabolism there were a lot quicker to to kind of pull the trigger on that kind of co2 studies or on your kind of some other adjunctive mr technique and I know that kind of

getting time in a magnet might be tough but down you know you kind of use some of those techniques vs kind of giving a larger amount of Catalonia hi I have a question about thoracentesis I apologize if I mystics it came in a

little bit late Wow patients with large bilateral pleural effusions is it safe to do both at the same time or in the same day we we don't do them at the same time but we would we do you know from from time to

time we will perform them on the same day we typically don't try to remove that much fluid usually it'll be like a chest tube on one side and for some pieces on the other just that we can regulate the amount of fluid out you

know when patients have relatively large bilateral pleural effusions will try to drain the more symptomatic side first and then you know ideally kind of gets like one and a half out that they're significantly more consider putting a

chest tube in relatively small like a treasure chest tube or just put in chest tubes in both sides and just kind of sequentially draining them over a day or two to make sure that we're not going to kind of bottle mountain cause the ledge

pulmonary edema ok thank you from how many people are very good but practice in a similar way you doing bilateral Thoreau's or just kind of quickly press to do chest tube things

like that floral drain they're not whatever work wow that's has been that the new way to do it again kind of interesting okay that's what I like that you're good here's another patient the end in a

similar way relatively large amount of ascites and you know honestly this is someone that should read really really kind of tippy right off maybe you're going to see a ton of ascites that really kind of shrunken a kind of tiny

liver over here now you know that there's going to be some bad things going on and you probably proceed with caution and very much so in the same way this patient had a pretty large bleed you kind of hyper dense material back

here and here's another one of the bleeds right there there it is and kind of a little bit tougher to be on this one but the station also kinda had a kind of a powerful pieces come on

and you know we we tend to have kind of runs released the features you kind of catch the bleeding out here here now you know as far as the guy you had asked about trauma how many people are actually sharing a an interventional

sweet with cardiology vascular surgery or kind of crossing kind of with with both so that's the surgery is it a hybrid or or the day ok a floating floor mounted unit or beyond that and here just kind of been

posted images kind of showing that we're

going to kind of get into biopsies really quickly like especially kind of kidney biopsy and by the way anybody has any questions to stop because i don't want to run over on time but I want to

make sure everybody has all their questions answered you're getting into some of the complications you know renal renal biopsy struts are considered a kind of high-risk completing procedures

these are absolutely the procedures that going into them we really try to make sure that the patient parameters are you kind of optimized you know one of the other things that we will do is we also will

drive the blood pressure down you know that systolic less than a hundred and a diastolic list and 110 you know many were several of my partners who will use a diastolic less than a hundred even and you know who will kind of minimize the

risk of bleeding that way and here's here's a one patient right here now who's who here they're doing real universities anybody else's him and how many of those people who are raising their hands are doing them by ultrasound

CT CT isn't okay okay yeah you know it's a yeah there's there they're 17 of us who do I are armed and we're kind of split down the middle far like who's doing i'm at office on Tuesday under CT you know it's

kind of funny because when we do them under ultrasound you know that there's bleeding just not really seeing it as much as we do the mothers PT just always going to be bleeding and it's just kind of a little bit off-putting and you can

kind of catch that right down here this is a a patient who we had just performed a renal biopsy kind of went right down here toward the lower Pole and there's just a little bit of bleeding and you know you really want to just try to

track it over from from one hour to five hours and kind of keep an eye on the overall size of the you know the area and here it is again and now this is just another kind of a really pretty picture I've never actually had a had a

kidney for treem asking my colleagues so like I got this one from from from the web just kind of showing up pretty pretty nice active lead right there you

know some of the other things that we will do for our kidney biopsies that two

of our hospitals will actually have a pathologist present just to minimize the number of passes yeah we've done that really really helpful with a kidney biopsies are many people doing that others are you guys

have like some kind of internal check or economy people but they are kinda have a pathologist kind of presidential ok yeah and that's pretty much how we we will kind of go

about it as well many of our renal biopsy so formats well actually uh we just kind of will consider kind of treatment right there will still bring the pathologist in with the understanding that it's positive

we'll just kind of go ahead and treat and a blade what does and you know kind of liver liver biopsies this is another procedure that it's I got to put it on here because it can be done in a whole bunch

of different ways we have several services that are institutions who do it and some are still done by blindly yeah yeah yeah yeah I suppose so you guys like what yeah finally just kind of cabinet out

kinda been going right at it and we we will you know we will see some of these patients come back how many people here liver biopsy use ultrasound CT and I so that's just as well and you know we found that you know

kind of performing under ultrasound minimizing the potential for society making sure that the patient labs are in a reasonable range tom are you know those are just some of there are things that also make sure the patient's blood

pressures that are in a reasonable limit and then you know the other thing that you know where were pretty quick to do is if a patient's labs are not kind of optimized in any of those ways we'll just go right to transfer a liver biopsy

and then just kind of minimize minimize some of the issues and and here is just one of our patients who had a relatively large largely the Tennessee he kind of right there you can not without their risks and that was a

patient who didn't really have very much cited sources inside and lung biopsies

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