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Introduction- Nursing Management in Prostate Artery Embolization | Nursing Management in Prostate Artery Embolization
Introduction- Nursing Management in Prostate Artery Embolization | Nursing Management in Prostate Artery Embolization
Overview of BPH (Benign Prostatic Hyperplasia) | Nursing Management in Prostate Artery Embolization
Overview of BPH (Benign Prostatic Hyperplasia) | Nursing Management in Prostate Artery Embolization
Assessment of Symptoms | Nursing Management in Prostate Artery Embolization
Assessment of Symptoms | Nursing Management in Prostate Artery Embolization
Treatment of BPH | Nursing Management in Prostate Artery Embolization
Treatment of BPH | Nursing Management in Prostate Artery Embolization
The Process of the Prostate Artery Embolization | Nursing Management in Prostate Artery Embolization
The Process of the Prostate Artery Embolization | Nursing Management in Prostate Artery Embolization
Benefits of a PAE Procedure | Nursing Management in Prostate Artery Embolization
Benefits of a PAE Procedure | Nursing Management in Prostate Artery Embolization
Research on PAE | Nursing Management in Prostate Artery Embolization
Research on PAE | Nursing Management in Prostate Artery Embolization
Work-up for PAE | Nursing Management in Prostate Artery Embolization
Work-up for PAE | Nursing Management in Prostate Artery Embolization
Case 1 PAE | Nursing Management in Prostate Artery Embolization
Case 1 PAE | Nursing Management in Prostate Artery Embolization
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Case 2 PAE | Nursing Management in Prostate Artery Embolization
Case 2 PAE | Nursing Management in Prostate Artery Embolization
allergicbladderchapterciprocliniccontrastfoleyFoley catheterholderibuprofenimportantlyinducinginjectionipssmedicationsNonePAEpatientpatientsprostateSent home with a Foley catheter due to prostate volumesymptomstecniquetypicallyunknownurologist
Q&A- PAE | Nursing Management in Prostate Artery Embolization
Q&A- PAE | Nursing Management in Prostate Artery Embolization

so my name is Paul I'm one of the nurse practitioners from UCI Irvine healthcare and what am i one of our minerals in there is basically working on patients for consultations doing the patient rounds writing notes ordering labs etc we also have several clinics that we run

at UCI Medical Center involving patients needing consultations for Libra direct therapies ablations and so forth and one of the more recent clinic that we started running is basically treating patients with BPH and so what we would

know inspiration is basically treating and regarding their symptoms and the procedures pretty much called a prostate artery embolization so the main purpose of this patient excuse me the main purpose of this

topics is basically to provide the general information of what the procedures are about illustrating indications risk and to hopefully help our nursing staff to better take care of these patients sorry so first and

foremost I just wanted to thank my team UC Irvine for allowing me to take some time off of work and enjoying Austin and its many food and object and and allowing me to speak to you guys a little bit about prostate ammo on our

pitchers basically you can't I don't know laser printer but our physicians dr. Karen Nelson she's one of our chief of IR dr. Dan through Fernando dr. Nadine a bitch day and dr. James Castro thesis

he's got daughter Kat Reese is our main doctor that does most of our process embolization our excellent iron nursing team and of course my fellow nurse practitioners who is holding the fort back home Pamela and Takara and watch

and Lou sorry but so our objectives for discussions basically to illustrate the indications and benefits of prostate artery embolization we're going to go over the side effects and risk complications associated with this

procedure and also recognize the value of nursing care going starting from the workup leading to the proper process in trot process and post procedure care sort of a brief outline of what we're gonna be

talking about we're just gonna go over the basic fundamentals of BPH as well as the treatment for PAE and the second portion of this lecture is going over how we walk patients up in clinic what we tell patients and we're gonna go

through the proper care and drop care ask well ask the post-op care and we're going to go through a couple of cases in there it's just to describe to you guys how we care for these special population

so just to give you guys an example of a

typical patients that we would see in patient this example right here is a 71 year old guy as far as this urinary symptoms he has this long-standing history of lots or lower urinary tract symptoms so we call it lots for short

but basically has the symptoms of urgency hesitancy and sometimes I'm aware incontinence he's also been followed by our urologist and it was seemed to have a little great prostate cancer so at least at this time

it's not getting any treatment so it's just on close surveillance however though he was straight on flomax which is one of the alpha blockers would we'll briefly go over later he's not able to stay on those medications because of the

side effects he's having some dizziness hypertension and he's complaining that he cannot perform well at home so this is just a quick view this is an MRI to your right there is an MRI looking from the front side and so you can see the

hip bone so it's on the right but if you look in the middle there that's this prostate gland okay and the highlighted part is this bladder as you can see the process is compressing on the bladder and likely compressing the urethra air

obstructing urine flow and to your left there is the sagittal view of the MRI and you could also see that bladder compressing excuse me that the prostate compressing on a bladder now this process is measured to be about a

hundred and fifty six grams normally a male should have about thirty grams so he has like five times the normal of size of a normal guy so be pages a very common condition usually related to aging and then when they have and it's

causing the subscribe' symptoms and we call it lots basically so about thirty percent of men would be ph will have the symptoms and if you're above sixty you're gonna have at least like fifty percent of them and seventy or an older

you pretty much have the symptoms of let's just like recovery of an enemy patho of the prostate as we all know the prostate is doughnut shape glad that in circles the urethra it's just right below the bladder and above the base of

the penis is right in front of the rectum so on exam you're able to palpate the process easily the main function of the prostate is usually to make this fluid with the semen the lining of the prostate is filled with this alpha

receptors which is important to know especially with some of the medical therapy with prostate and it's activated by smooth muscle regulated by the our genetic nervous system just a quick review on the path though so be case you

really refers to this tissue going around the prostate and so this causes compression also there's a decrease in elastic fibers in the prostate you read her causing increased resistance and one of the more popular if delivery what we

think this is happening is this imbalance in testosterone that's converted into tht also called the hadass the hydro testosterone and this is converted by an enzyme called 5-alpha reductase it is

also important to know especially with some of the malko therapies that are being used with BPH and so once the DHT is formed within the prostate he undergoes this complex mutation basically causing prostate hyperthre

being so BPH basically is hyperplasia upto prostate tissue and this really common or two reasons why patients will have lots it's because of bladder obstruction and there's increased resistance within the prostate urethra

so a lot of patients will have symptoms of hesitancy extreme straining nocturia urgency or frequency and many transportation can be fully dependent due to the severity of their symptoms so many of these men that comes to our

clinic and we want test them they will come in jokingly talk about their symptoms but in reality a lot of the symptoms are really life-altering a lot of these patients are not able to sit through a meeting for a long time they

can take long trips without having multiple stops a lot of patients are also having to go to the restrooms multiple multiple times at night causing a sleep deep vibration so a lot of these patients are actually press and a lot of

another thing that's more important for this patient it actually causes sexual dysfunction which a lot of men are not very happy about so nearly half of them will have some type of sexual dysfunction when patient have a lots

associated with BPH and would be paged you know you could have also complications such as never your Yarilo Suzman huge early biases patients can have recurrent UTIs especially the ones who are fully dependent

and at force they can affect our kidney function so this is our questionnaires

called international prostate symptom score we call it IPS as in short it's basically a good way to measure how bad your symptoms are so it's the first

thing we do when we see the patient is hand this paper over it's gonna give us a good assessment of how bad the symptoms are and and see how well they can actually benefit or from the procedure that we're offering so it's a

series of basically seven questions it scored from a zero to five each question and it totals to zero to 35 and this questioner actually allows for classifications or how bad their symptoms are so for example if someone

had scored a seven they're considered mildly symptomatic give this card between eighteen to nineteen we consider modern students symptomatic and the ones that are twenty to thirty five there varies they're severely symptomatic the

less or questionnaire the eighth question has to do with the quality of life regarding to their urinary symptoms they also call this the butter term score and we actually considered this probably the most important questions

out of all the first seven questions there and it basically tells you if you were to spend the rest of your life with urinary condition just the way this now how would you feel about that and so zero is like the elided if you go all

the way to the end is terrible so a lot of patients that would come on to us it's gonna be at least three or higher so just moving over to treatment of BPH

so the first treatment is basically no treatment and a lot of this no

treatments basically for patients who does not want to or not ready to pursue a therapy or someone who is just mildly or maybe moderately asymptomatic from Luntz so a lot of patients will adjust or they can just be recommended to

minimize their fluid intake or just our fluid intake according to their lifestyle or their schedule you could also advise them to decrease caffeinated beverages or alcohol alcoholic beverages sometimes can

trigger a retention as well as color nergic medications as a matter of fact we have a lot of patients that would come to us that you know they would be on their medications they will go to a wedding

and have a few drinks and they couldn't urinate and end up having to the ER to get a Foley placed so the first line of therapy for BPH is usually medications and it's been like this at least since the 1990s and the more the more popular

ones that we're probably familiar are the alpha blockers the alpha 1 block excuse me and alpha the 5 alpha reductase inhibitor they also call that v a RI now the alpha blockers are had been made now to be more selective

meaning that is geared to cost less side effects however the patients still have with side effects with these type of medications including hypertension headaches or sexual dysfunction and it's

it's it's a function is to relax the smooth muscle to allow urine to flow a lot more freely the next popular one is the 5 alpha reductase inhibitors and this basically blocks the enzyme that we discussed earlier that can cost the

formation of DHT and really the goal is to shrink the prostate and it's known to to reduce the prostate about 32% volume however though you may take some time for this to actually work it doesn't work right away you may take about six

months or more for this to actually work or have some effects on the decreasing size decreasing size of the prostate again this medication has its side effects number one complaint with patients sexual dysfunction decreased

libido and also can cause gynecomastia and some of the small populations patients can also be in combination therapy other medications that are discussing literature are the beta-2 agonists and anticholinergics however

though unfortunately about 25% of men will discontinue the medications and usually because of the dissatisfied and from its side effects so despite medical therapy it'sit's been mentioned at least 30% of men will still require

some type of surgical procedure and the mainstay of therapy right now is well it's all we all know is the transfer urethral resection of the prostate also called Terp and it's usually meant for someone who has a prostate volume of 80

grams however though even though our turf procedures has gotten better compared to many years ago it still has this comorbidities associated with them so nearly half the patient or more than how the patient will have some symptoms

of exactly dysfunction bleeding bladder injury or incontinence other surgical therapies that are open there are the basically that total prosthetic t'me these are usually meant for someone who has a very large parts of volume more

than hundred grams and one of the newer one is called a prostatic urethra left this basically it's meant to be an outpatient procedure but it's meant to cost traction of those prostate lobes allowing you enter for - to flow freely

and basically getting rid of obstruction the you to live has been somewhat popular because it doesn't involve cutting of the nerves so it's been mentioned in literature that it can actually preserve a sexual dysfunction

percent of this sexual dysfunction unlike other surgical therapies so because of this because of the many comorbidities and sexual dysfunction associated with a lot of this or somewhat aggressive surgical procedures

a lot of them minimally invasive procedures have come up in the last several years briefly there's been some transurethral ablation therapy also they can use laser or heat where the doctors couldn't basically stick a special probe

near the urethra and burn the prostate costing obstructions along the urethra but well we're really going to be focusing about it the prostate artery embolisation the processor artery embolisation has been

first described at least back and or at least is being used at least in the 1980s and it's usually meant to control bleeding with patients who have bleeding from a recent processor procedure surgery any bleeding related prostate

cancer however the PAE and relates to be Patriot Lutz was first described by bleep I didn't married in 2000 where they actually embolized some guy who has a very large prostate I don't recall

what but they also know the obviously noted as hematuria has resolved but they also noted that his IPSS score has dropped from 24 to about 12 12 months after and they also noted this got to have a reduce prostate volume about 40%

and his PSA had dropped from I think 40 to about a four so how does the prostate

artery embolisation work so I'm going to cut through this like like fancy words so basically what happens is because an infarction of the prostate that

decreases a lot of this excuse me it did subsequent cost is shrinker prostate by decreasing tht and hopefully will she's a prostate he also has to do with the innervation and decreasing the sensitivity of the alpha-1 receptors

which actually does is actually smooth the muscle around a process allowing urine to flow freely so just to give you an example even though patient has a prostate volume 150 grams mute if we were to

shrink it just a little bit it doesn't mean that their symptoms would be relieved actually because the smooth muscle relaxation around the prostate a lot of the symptoms may actually get better so this this procedures indicated

for some of us who may be at high risk for any surgical procedure someone who's refractory to medical therapy or does not want to consume medical therapy or someone who obviously hat with a high IPSS score

the thing with PAE is obviously technically it's very challenging because as you go under proceed the artists get smaller and smaller so you have to consider the elderly who may have some atherosclerosis disease and

there's also risk of non-target embolization where we could potentially embolize the penis or the bladder or direct them as far as strict factors we want to consider patients age someone has diabetes chronic renal failure we

want to make sure that patient doesn't have any recent infection stones or any instrumentation regarding their neurological system so what are the

benefits of having a PAE well first of all Sam in a minimally invasive

procedure patient come in the same morning go on the same day basically all they'll just go home with a little puncture in ur going as we all know this is an angiogram procedure since we're not since it's a purely vascular

procedure we're not cutting any nerves so it's not super serve a sexual dysfunction so that's one of the number one page things that patient would ask with my sexual function get better there's no nothing the literature that

says PE will improve it however though since this spacious may eventually hopefully be weaned off with some nice medications their sexual function may actually improve so there's also that possibly of stopping their daily meds

and someone who is folk dependent there's always that chance that they could be fully independent and listed there are the adverse side effects complications which we should I go through in a little bit later when we go

to the clinic evaluation so this is

basically the longest study regarding prostate as we know it's done by doctor Pisco down in Brazil and they basically did more than 600 patients that has successful PA es and basically at five

years to follow-up at least 76% of them at least had clinical success rate and so one of the things that would ask patients with the patient would ask us in clinic is how successful is this and this is the

only data I think probably the best data available for us to first suggest a patient that you know patient will respond at least 75 to 80 percent at a time at least at five years follow oh excuse me so so what so their IPs is

have dropped so for example a lot of this patient would have IPSS score of say greater than 20 the clinical success rate was considered if their IPs has dropped for the last 15 and they call a lab score had dropped to less than 3 so

cost analysis there's been a study by dr. Pamela recently and in Ventura Nia and this might not reflect the cost in your hospital because he may different geographic Lee but obviously they found that PAE is a lot less costly compared

to doing a Terp the only thing that I think PA may be a lot more costly as the supplies that are used during at this procedure and more importantly as you can see the length of stay it's a lot shorter this is meant to be an operation

procedure for a patient as us for the most part goes home the same day

so we're just gonna like hop over to the clinic side and kind of discuss how we work up or what are the things we look for when we see the patients in clinic

so a lot of patients are referred to us by urologist so we have to have a urology on board to to better take care of this patient we can't treat this patient you know by ourselves so a lot of patients are referred to us by our

neurology team if they don't have a urologist we have to refer to them to erosions first before we can even work them up or PAE so we won't make sure that patient you know doesn't have any underlying cancer that we know of so we

want to make sure that we check their PSA levels because this high high patient can ask actually I predict a decent progression and actually our risk for acute urinary retention you want to make sure that you get

urinalysis a lot of patience wet with lots is not only due to pph you could also be secondary to UTI or if patient has some type of bladder tumor or bladder disorder so it's kind of good to know to understand some of the lingo

that urology uses so once they see the urologist they do some your dynamic studies and one of the popular ones are these non-invasive studies called euro flama tree and the post-void residual do you offer the Euro excuse me you heard

from a tree usually we will measure the flow rate and the volume of the patients so what they do is they they would pee in this special funnel and the final obviously they go in private but this final is connected to some machine that

can actually measures how fast and how much their voiding and so normally it's about 25 miles per second but if it's anywhere less than 13 to 15 it can suggest obstruction and use the obstructions usually due to BPH some of

us a very low flow rate such as like say less than ten or six you have you want to be a suspicious of some type of you to neutral structure after they do that usually what they'll do is they take a post void residual is basically scan so

they'll put that little probe above the bladder and they'll see how much is left in a bladder if it's 150 that she usually indicates in complete emptying someone who has greater than 200 that may suggest patients having some type of

bladder dysfunction so a lot of its patients to us at least woke up with some type of imaging and the ones that at least our physician selects is the MRI patient do get a CT angiogram which can also evaluate the pelvic Anatomy and

arteries however the process the mr process actually gives a better illustration of the prostate a tissue to see if there's any suspicious for cancer for example you can also display the president atomy and characteristic up

the gland so most patients do get MRI or at least we get them to get MRI to measure the actual volume in literature they will tell you that a patient can get a trance rectal ultrasound but I'm not sure how many

guys in here would like a probe stuck up their butt to get to get their prostate measured so unless you wanted to get pissed at you just supporter I am right so when we see the patient you obviously want to review their HMP more

importantly you'll want to check their comorbidities there's social history whether it is smoke or not because they're gonna that's gonna have an impact on how we stay patients and how you can predict their anatomies

obviously someone's died who is diabetic or who has a history of smoking you could expect for them to have a greater degree of atherosclerosis and again the first thing that we would get the patient why we walked in is we go in

that scoresheet the IPSS score and so that's gonna give us an idea of how bad this symptoms are so if they come in to us with a score of say you know they're mildly symptomatic I'm not sure how much to pee a procedure with would help them

because how much more lower can we get their scores down so a lot of patients we would treat are in the moderate to severe category and their quality of life score should be for the most part will be about three or higher you also

want to make sure the trusted results since this is Andrew Graham procedures you will make sure that they have a pretty decent renal function patients with lots a lot of them may have some degree of renal insufficiency so we have

to be careful make sure we watch that lab value so this is some of the screening criteria that a lot of us may use so patients who I have refractory to medications for the six months someone has a high IPSS core grain 13 or

qualifies score greater than three process volumes gotta be at least 40 grams we sometimes get patients with a high score but they're positive volumes around 30 we usually usually wouldn't treat those

patient because we can't basically treat or shrink the prostate any any lower than that you someone who has an abnormal urine Flo and someone who maybe refractor to medical therapy these are just a list of

exclusion criteria the ones that should my party set out someone who has prostatitis or current approximate infection you definitely want don't want to treat those patients chronic renal failure and relatively maybe coagulation

factors that could be patient dependent sometime sometimes we could optimize them to get this arteriogram procedure and prostate and bladder malignancy also this somewhat also relative we do treat patients with prostate cancer it just

depends on what course of treatment they're on currently so once we had screen the patients and and deemed them to be a candidate we reviewed the patient we review in detail the procedure with the patient so you want

to let them know that it's a our angiogram procedure that will go through the either the growing or sometimes the radio and the procedure itself you can take anywhere from one for one to four hours and sometimes longer depending on

how complicated their arteries feeding the prosthetist more importantly we want to educate them about the side effects okay we have to let them know that a lot of their symptoms might actually worsen during the first few days after the

procedure so if they have the Syria now urinary continence they actually may get really worse especially for the first few days okay we have to go over the complication with the patients that can include a public infection ischemia or

any vessel related complications that pseudoaneurysm or bleeding so we have to basically have a basic knowledge of how do we combat this side effects and these are just some of the list of side effects that

are mentioning or at least we also used a PI radium it helps I guess to numb up the prostate urethra we have to educate the patient that this can change the color of the urine so we always make a note to our patients that if you are

going to take this medication please call us that way we don't kind of shock you and we also know that the change of color is from the pair radium and not from anything else the tripping or oxybutynin

it helps reduce bladder spasm we would normally use it for a patient who go somewhere to Foley our patients would go some Foley tends to have a great degree of bladder spasm Coley's a lot of spatially get constipated for multiple

reasons being better that or they and she is soft and there's also the over-the-counter azem so this is just a sum of the standard medications that we would give all our patients all of them will get about cipro for seven days

we'll give them some type of anti-inflammatory Asia usually is ibuprofen were prescribed 800 a tid if needed anti-acids since it's just to protect your belly or their stomach from the ibuprofen minimum we'll get a stool

softener at least for the first three days or if they got developed loose toast and we would ask them to stop it and the medications for pain that we would get them as Norco just in case and I would say like more than half these

patients don't even need Norco at best they'll probably use ibuprofen you know just to minimize the inflammatory side effects that I get it also helps out with post embolization that sometimes we'll get and I believe so I don't I'm

not sure if I'm messing about post embolization syndrome patient do can get these symptoms and a lot of symptoms can vary they can get some body slug or fever malaise and the degree the symptoms were may bear from patient to

patient and a lot of symptoms are described kind of like a flu-like symptoms and we also want to reiterate a patient that the symptoms are temporary and it should get better over to at least at first week or so so patients on

warfarin we have a lot of patients on warfarin for whatever reason whether they had a recent cardiac intervention we want to assure that we stop those medications at least before the edge ground procedure so it's very important

that you have a good rapport or whoever and have prescribed him the coumadin whether it's a cardiologist or the surgical team and a lot of dissipation may need to be crossover outside like a short-acting

anticoagulation such as Lobo Knox at least in our practice we ask the patient to this condition discontinue your aspirin unless they're you know they have a recent cardiac intervention we may leave it leave them

on aspirin metformin as very important since we did it is a natural procedure we want to at least hold have the patient hold the metformin the morning of the procedure and maybe a couple of days after and someone who are

allergic to contrasts we will make sure that we're prepared to premedicate a patient and also be prepared in case there's a severe reaction and the pre medication as we know will give them some type of a standard metal prednisone

will they'll take it like twelve seven or one hour before and they also gets unbearable and preoperatively or one hour before the procedure and during the clinic we also determine the level of anesthesia so since this procedure

usually takes a long time we always get it with our anesthesia team is just more for patient comfort it's not really for pain okay I couldn't imagine laying a table for several hours at the time so we all shop anesthesia on board just

really for patient comfort so we're just

gonna kind of move over to kind of like a case scenario study give us an example we're gonna go back to that patient that we saw earlier so again this is a 71 year old guy he's

your hypertension he's your logical history basically consists of nocturia urgency incontinence he does have a low-grade prostate cancer which is currently on close surveillance so he's not getting

any oncological therapy at this at this point well we give them the IPS a score his score was at 29 so he was categorized as severely symptomatic he'd tried flomax he doesn't like him because he gets dizzy

and so his urologists had referred to us this to explore this minimally invasive procedure another thing i that i mention is it's important to have not a lot of urologists are on board with this procedure and so and that's maybe the

reason why patients are may not beginning referred to us so we're fortunate to have a urologist that believes in this procedure so that's not another important note so again this is this MRI that we took you could see that

prostate greatly compressing on the bladder causing you know lots so when we bring a patient and in the prototype area obviously we want to confirm all his labs okay particularly the kidney function

female in him adequate make sure their penis up the play list for at least from our Center you should be at least 50 and above and we want to make sure that these coagulation studies are optimized patient with diabetic we want to make

sure that you check their glucose or routinely monitor them according to your hospital protocol we will want to confirm their fasting status during pre-op and also important to reconcile the medications especially if they stay

overnight because we don't want to interfere some of the medications that there aren't especially if they're on some type of like anti epileptic or BP meds we don't want their a BP shouldn't up during the proactive area and more

importantly we want to assess for symptoms of UTI you don't obviously we're gonna induce inflammation or prostate so someone who has a UTI currently is we're just gonna make things worse and lastly we want make

sure that we have the correct consent for the procedure itself other things to look for vital signs we want to sure we got baseline make sure that kind of we're in set it around we normally insert Foley's to all our

patient is this is basically to provide an orientation of the prostate site and other structures related to the you know the prostate so usually we'll we'll put like some contrast to the balloon that way when the doctors did that Flores

said they could they could see where the prostitutes at but we've been doing it just with saline he they're still able to visualize it without putting the I denied contrast so they'll be under the eye our physicians discretion you want

to make sure you have fluids or patient we want to hide your time accordingly to whatever their current level yes so if it's be femoral access we will make sure we check our five piece right the pain

pallor paresthesias there's a couple more that I forgot but basically you want to make sure to palpate their their from their pulses and you'll mark the site and we always want to prep both growing's in case the boxes cannot

access the right we could always go to the left we also do patients Radle access and these are usually meant for patient who does not have any coronaries or risk of stroke so someone who's healthy doesn't have any coronary

disease may be a candidate for a radial access in addition patient has to be short like me someone who is six foot tall or higher they can't be a candidate for radial axis because the catheter just doesn't go that long so it's got to

be someone like 511 or shorter okay and in pre-op we also if we are gonna go radio we want to do our Allis tests where you include both ulnar and radial area simon squeeze and you know the the fingers becomes pallor and you let go of

the ulnar artery and they should go back up after five seconds five or ten seconds later another trick that that i learned is you could actually put the pulse ox on on the finger and do your Alan's tests and when you include both

arteries you would see that wave form flatten okay and then when you're at least two older artists you should see the way back up okay so that also tells you that you're bringing back oxygenation wants to release the older

answer so it's another kind of good way of doing it having some type of objective measure right in front of you so enter procedure real quick obviously we'll make sure that we did the proper time out it's important to monitor the

vowel signs throughout and really getting to know who your patient is paying attention to patient comorbidities like renal function diabetes or any outcome routes that they may have and if the patient is someone

awake you always want to provide a good therapeutic environment if you can imagine this patients lying out there may be someone awake and you have a whole group of peor people talking a lingo that the patient may not

understand so it's very important I provide them with type of therapy environment so his procedure kind of went well so our acts are went well I lasted for three hours tea right there is just a quick picture

of preamble ization you can see all that blush blood flow go into the prostate and after employing some microspheres coils they were able to stop much much much of the blood flow through prostate now there's never one of the questions

that would ask us can you fully infarct the prostate it's probably impossible because there's so much arteries that feeds the prostate maybe it would probably be good if you mark it because he will probably no longer grow or get

bigger but you can't fully infarct the prostate another thing too is with the PA is even though if this wasn't successful they could also get surgery so surgery this is not off the table when patient gets

PAE I said matter of fact you might actually make the surgery better because they they may have less bleeding because of the embolization that we perform so post procedure when a patient gets back to our recovery room you obviously want

to you know monitor the vital signs whatever our protocol is we always want to first assess the patient's sedation level and more opponent Lee with these patients would assess their ability to avoid okay and we could do that with the

use of a bladder scan so if a patient usually patient will go home after four hours but if they can't urinate after four hours we do bladders we haven't void we do a bladderscan if it's more than a 150 usually we would

suggest a patient to go home with a Foley catheter which a lot of them don't like and so these are some of the predicts predictors that patient may go home with a Foley or may become may develop urinary retention so someone

with a high PB are on baseline someone who has eye hype IPS asked or someone who is used to doing a routine self catheterization usually we would send those patient home with a Foley someone who has a big prostate so

so at least in our practice when a patient has the prospect of hundred fifty grams we automatically would send them home with a Foley catheter so patients are usually discharged from a beds at four hours after we have to make

sure that the tolerating they died well if they're unable to urinate we have to make sure that they have a Foley in place and we have to give them appropriate discharge instructions if they do go home with a Foley we have to

be prepared that the patient has have a follow-up at the urologist if they don't we had to be referred as a service to perhaps do the void and trollop remove the Foley's so it's important for at least our department to be somewhat

familiar how to discharge the Foley catheter so in this case our guy here he spent four hours in a recovery room he was enabled aboard he was getting really anxious we did PVR his PBRs 240 so went up discharging a Foley but he did go to

the urology clinic about a week later when he was able to disk in utero Foley and if if you if we're most of us in radiology are not familiar with this container Foley but how we would do it is why she did this in in our in our

suite one time because the patient did not want to go to urologist and want to come to us have his fully removed so basically you would instill about 150 to 200 ml of saline to the bladder or the patient feels that they're getting full

but usually about 150 ml s they're gonna feel I'm getting full and once I get full you clamp the Foley deflate the balloon and basically pull the Foley catheter and Amelie after you get the Foley catheter out you would have them

void it through a urinal or to toilet and once they void you to a better scan to make sure that your bladder is empty if it's not empty or if it's still 150 or more then we have to fully put the pulley back in

and we would only probably do this a case where they don't have a complicated Foley insertion there are some patients that we have to have scope by urologist just to put a Foley in place but so in those situations we would probably refer

them back to a specialist like the urology department so I always do a follow-up phone call with all these patients make sure that they're in compliance with their medications especially the cipro antibiotics a lot

of patients may need some education zhan what certain medication was for so for example they would be complaining of pain but yet they're not taking their pain medication ibuprofen so you want make sure that they're compliant their

medication I would also want to ask him about their angiogram site to make sure that there's no hematoma bleeding or anything going on with that and a lot of patients we would see about two to four weeks after the procedure and it takes

about a month for us to see some changes in her IPSS score so I so for the forward four so for this case number one we saw him about a month after he's angiogram Silex well yes if you remember his preoperative score was twenty six

and six a month after he was completely different man he he went down to ten and four so this is just a second case I

want to go over is we're gonna kind of fast forward but this is kind of like our record holder in terms of prostate

volume so this guy's six seven year old history of BPH for a long time obstruction he's been fully dependent for several months and so we can't he can't even fill up that IPS or Christa doesn't pertain to him is she's fully

dependent but his call it life is obviously very bad it's at six he has a lot of core abilities like diabetes hypertension he is on chronic pain medications due to some sciatica and he also has some unknown contrast allergic

reactions that we don't even know about and he's allergic to bactrim and his MRI showed at 306 grand process so this is so far he's our holder so this is just the idea of how biggest prostatitis

again tear white is to the frontal view of the process it looks like is basically compressing most of his bladder right there so who knows how much bladder or how much urine he's able to retain in that bladder and to that to

your left is the shuttle of you and you could see that fully basic line there and the base of his bladder so with this guy since he has some unknown conscious allergy he had had undergone eye referral to our allergist team it was

confirmed that he wasn't learning to contrast after also the several weeks for us to get that confirm the first time he went to our clinic he actually had getting he had the episode of UTI so when our nurses checked him he was I

believe he was taken some subtract zone injection because he couldn't get sipper because it was allergic to it so he's getting home health subtracts from an injection and so since he showed up to our pre-op with a current or of he's

getting treated for Kearny ty we had to postpone and rescheduled him so this guy was obviously because of his prostate volume was a grade 150 we had to be the stretch with a Foley we had to make sure that this patient gets followed up with

our urologist and because his allergic to cipro which is the medication said we would typically give a patient and we have to set up home health to make sure that he gets his four seven injections at least one week post procedure and all

the patients that are sent home with a Foley since they tend to have more symptoms of bladder spasms we would get on some oxybutynin so he's gone oxybutynin and some narco ibuprofen and the pp is and some colace as all the

other set orders prescriptions that we would typically prescribed for patients so with this guy upon a follow up when I call them a day or two later his main complaint was bladder spasm and again this is related to probably from the

from the inducing press inflammation or prostate are probably having the the catheter in place but so at once I call him when I have to reassure him that make sure he takes the oxybutynin to see if that'll help him

which he did and he was basically taking ibuprofen every eight hours for the first two days which helped most of his symptoms so a lot of its patience you just have to really reassure them and make sure they're compliant with the

medications and if they are having symptoms of post elbow station syndrome then he had to reassure them that those things should get better so when we see this guy on page so this patient we saw him in clinic he was seen by the

urologist two weeks after and he was able to have his Foley remove so he was totally happy he was actually able to fill up that IPSS car which is 15 however more importantly his koala life went from 6 to now - so just to kind of

wrap things up in conclusion you know PAE is safe and efficacious excuse me and effective I did at least based on short term follow-up it does how yield a high patient satisfaction I would say like more 80% or so patients are fairly

satisfied when we see my month or two later it is tecnique technically challenging is not performing a lot of IRS are programs and I think more importantly for our nurses is vital for us to be

knowledge of this procedure that way we can educate our patient better and also minimize any arrests and complications that are associated with with this PAE so just the close things up this is probably my favorite nursery code this

by mother Teresa it is not how much you do but how much love you put in the doing thank you

[Applause] I'm sorry said again oh so the thing with Mormon anytime you have or do

contrast that if you cause a contrast induced nephropathy or kidney failure and patients is on metformin it can cause some lactic acidosis yeah the risk is very low but but more Batali's high so it barely happens but

when it happens it can be deadly so we would yeah yeah but we normally don't check their credit lapis we just kind of hold have a holder for the first there so yeah I think yeah we should with 80% of the case are still being done a few

more oh so the the radial axis hasn't been a lot more proper so even so with interventional cardiology but at least Center five eight percent are still being done the different wall access no well that's that's a good question so

that's very important we're lucky enough to have a very good ear urologist that believes in this procedure so he anytime a patient hears about some of the surgical procedure and they don't want to do it he would have her first yeah

and some of the patients that come from the outside Madeline would tell us that you know that doesn't work or whatnot so but a lot of urologist world is not fully on board with it yet not not at least not in this case I mean

like when they had any lepers oh no no yeah we have not seen that so if a patient has like that the Europe platter is function usually there would not be a candidate for the PAE because shrinking or open up that ureter would

not benefit them if they have a blood is bladder dysfunction yes yes it depends so usually the nurses will just try the regular Foley but in a patient has a history of difficulty with full insertion they may strike a day if it's

really difficult then we have our urology our residents or team with put it in and that's actually a good question you may be basic to us nurses but a lot of our there so one case where we put in a Foley

the nurses saw a year in return and had thought that during a bladder inflated a balloon but they're in the urethra so so we have to make sure that we're in a bladder every time with enough Foley it sounds basic but it's one of those

fundamental things that we have to really watch for are usually just a normal I guess 60 yeah yes yes yeah it's like a question we that's like that's a very good question we have especially with the ones with severe

bladder spasm however at least in California and Orange County area this time there's not a lot of pharmacists that the carries belladona so as a matter of fact as a patient that we had thought that would benefit from

belladonna I called multiple pharmacies and a lot of unfortunately does not carry them even our own pharmacy so yeah yes yeah so this is one case we had we were yeah so one case we were able to dispense in patient but there's there's

a lot of barriers if you were to describe it as an outpatient there's a lot of authorization and and delivery method involved which takes several days and several days is a lot of time for a patient to was having bladder spasms yes

are usually in clinic usually if they have a negative year within 30 days we're good to go yeah so that's that's the more important thing if there aren't pre-op and a lot of patients have your recurrent UTIs so

they know what their symptoms are so you would want to assess them hey do you think you have a UTI have you had any change or in urine yeah P material or blood or pus in the urine so it's very important that we assess them

preoperatively to make sure that they don't have current UTIs oh yes there there's only one case that we actually give a patient a manual dose pack and it helped but a lot of times at least from my experience the degree of their

posterization is not as bad as for example who someone's getting like a key mobilization or taste or or y9e so it's usually a mild degree of a post amble syndrome but yes yeah and usually for the most cases as far as proposed post

amble syndrome ibuprofen the anti-family would suffice in terms of managing their symptoms all right thank you [Applause]

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