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MySpine Value Proposition
MySpine Value Proposition
Pharmacology- Benzodiazepines | Procedural Sedation: An Education Review
Pharmacology- Benzodiazepines | Procedural Sedation: An Education Review
What's ahead for PE | Pulmonary Emoblism Interactive Lecture
What's ahead for PE | Pulmonary Emoblism Interactive Lecture
Pre-procedure Assessment | Procedural Sedation: An Education Review
Pre-procedure Assessment | Procedural Sedation: An Education Review
Renal Ablation | Interventional Oncology
Renal Ablation | Interventional Oncology
Practice Guidelines | Procedural Sedation: An Education Review
Practice Guidelines | Procedural Sedation: An Education Review
Background on Interventional Oncology | Interventional Oncology
Background on Interventional Oncology | Interventional Oncology
Pulmonary Ablation | Interventional Oncology
Pulmonary Ablation | Interventional Oncology
Pharmacology- Opiods | Procedural Sedation: An Education Review
Pharmacology- Opiods | Procedural Sedation: An Education Review
Pharmacology- Versed | Procedural Sedation: An Education Review
Pharmacology- Versed | Procedural Sedation: An Education Review
Where We Are Now | Pulmonary Emoblism Interactive Lecture
Where We Are Now | Pulmonary Emoblism Interactive Lecture
Indirect Angiography | Interventional Oncology
Indirect Angiography | Interventional Oncology
Just Culture Concept | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
Just Culture Concept | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
Why is Staging Important | Interventional Oncology
Why is Staging Important | Interventional Oncology
Administration | Procedural Sedation: An Education Review
Administration | Procedural Sedation: An Education Review
Muscoskeletal Ablation | Interventional Oncology
Muscoskeletal Ablation | Interventional Oncology
Airway Assessment | Procedural Sedation: An Education Review
Airway Assessment | Procedural Sedation: An Education Review
Human Factors Engineering- What is it? | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
Human Factors Engineering- What is it? | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
Bland Embolization | Interventional Oncology
Bland Embolization | Interventional Oncology
Ablative Radioembolization | Interventional Oncology
Ablative Radioembolization | Interventional Oncology
Cone Beam CT | Interventional Oncology
Cone Beam CT | Interventional Oncology
ablationanatomicangioarteriesarteryartifactbeamchaptercombconecontrastdoseembolicenhancementenhancesesophagealesophagusgastricgastric arteryglucagonhcchepatectomyinfusinglesionliverlysisoncologypatientsegmentstomach
How Do I Approach Submassive PE Today? | Pulmonary Emoblism Interactive Lecture
Pharmacology- Antagonists & Additional Medications | Procedural Sedation: An Education Review
Pharmacology- Antagonists & Additional Medications | Procedural Sedation: An Education Review
Radioembolization | Interventional Oncology
Radioembolization | Interventional Oncology
Why Interventional Oncology | Interventional Oncology
Why Interventional Oncology | Interventional Oncology
The Ablation Concept | Interventional Oncology
The Ablation Concept | Interventional Oncology
Intraprocedure | Procedural Sedation: An Education Review
Intraprocedure | Procedural Sedation: An Education Review
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

know the difficulty with placement pedicle screws and despite the fact we all think we're we're good at it and

we're experienced at it we also know that screws are occasionally misplaced and this technology should allow the safer placement of screws more accurate placement screws for patient safety but also it should increase the speed the screws

are actually placed for operative workflow.

we know try to make this painless but I think it's kind of interesting

so metabolism is just talking about converting a medication into a less or more active form and that gets converted into what we call metabolites within metabolism you have your cytochrome p450 system which is responsible for

metabolism of a lot of the drugs that we give and essentially that's just a family of enzymes that are responsible for metabolism properties are going of the drug are going to influence the duration of action and the half-life of

your medication so for instance of a pee if a drug is highly protein bound what it does when you administer it is it binds to the protein molecules and slowly dissociates so you have a longer duration of action

because when it's bound to the protein it's in active half-life again any properties that increase the duration of action are going to be something we want to pay attention to and how is the drug excreted you can have excretion through

the bile feces renal system a big thing I think for us and IR is drugs that are really excreted benzodiazepines are the mainstay in providing the sedative component a procedural sedation it's going to enhance the inhibitory effect

of the gaba neurotransmitter in the central nervous system why do we care about that does anyone know have something to do with our reversal so our gaba neurotransmitter is responsible for inhibiting the activity

in the brain so if we didn't have a gaba neurotransmitter we would have seizures all day patients who have seizure history of seizure disorder are sometimes on benzodiazepine therapy at home if you sedate them and they require

reversal and you give them flemeth know you can potentially precipitate a seizure so it's just something you want to keep in the back of your mind it doesn't mean you're not going to reverse them you just want to be prepared to

handle a seizure if that occurs versed is our number one drug that we use onset of action and peak effect or seen in 3 to 5 minutes the antagonist as I mentioned is flumazenil and the half-life is three

hours typically in our department we give one milligram depending on the patient's physical condition and what they require and how anxious they are we may give 0.5 or up to two in one dose now you're gonna see and an Aaron says

this to in their procedural sedation guideline that you shouldn't exceed five milligrams I don't complete and that means overall in one case I don't completely agree with that I'll explain more why later but I think patients are

really complex and there can be a lot of drug interactions that are occurring that may cause them to require more sedation than a typical patient so it's not so cut and dry you could look at five milligrams and go that's kind of

more than the norm and maybe I need to look at is the sedation not working but you may have a patient that could take 10 11 12 milligrams of versed and be

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

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

different applications renal ablation is very common when do we use it

high surgical risk patients primary metastatic lesions some folks are actually refused surgery nowadays and saying I'll have a one centimeter reno lesion actually want this in lieu of surgery people have

familial syndromes they're prone to getting a renal cancer again so we're trying to preserve renal tissue it is the most renal parenchymal sparing modality and obviously have a single kidney and a lot of these are found

incidentally when they're getting a CT scan for something else here's a very sizable one the patient that has a cardiomyopathy can see how big the heart is so it's you know seven centimeter lesion off of the left to superior pole

against the spleen this patient wouldn't have tolerated bleeding very much so we went ahead and embolized it beforehand using alcohol in the pide all in a coil and this is what it looks like when you have all those individual ice probes all

set up within the lesion and you can see the ice forming around I don't know how well it projects but in real time you can determine if you've developed your margin we do encompass little bit of spleen with that and you can see here

that you have a faint rim surrounding that lesion right next to the spleen and that's the necrotic fat that's how you know that you got it all and just this ablation alone caused a very reactive pleural

effusion that you can see up on the CT over there so imagine how this patient would have tolerated surgery pulmonary

so my name's Heather I'm a nurse in interventional radiology at NYU Langone health in New York and I am the clinical resources for our department so what that means is I'm responsible for individualizing our education to meet the needs of our department and one of

the first things I wanted to look at when I took on the role was our procedural sedation practices and how we can improve by enhancing our knowledge this presentation includes many of the lessons and concepts that I learned

along the way that I think are really important to understanding how to effectively administer procedural sedation so our learning objectives are going to be a review of the guidelines pre-procedure assessment components

including airway assessment pharmacology of the medications that we give and intra procedure assessment so this is the 2018 AAS a practice guidelines for a procedural sedation by non anesthesiologist has everyone seen this

good great as so this is especially important because as you'll see the American College of Radiology and Society of interventional radiology were involved in its development so this is our guideline and I think it's really

important to look at this look at the practice recommendations and see how they align with your own practice and if there may be some changes you need to make first thing you always want to look at when you're reviewing any sort of

literature whether it's evidence-based guidelines or maybe just a review article is you want to look at the methodology that the author used to create the guideline so anybody know why that's important you just shout it out

so if I want to write a guideline for procedural sedation I could find a bunch of studies or review articles that fit my point of view and use them throw them at the bottom and that would be that but even if I use for an demise control

trials which are considered the gold standard of experimental research those randomized controlled trials could be poorly constructed randomized controlled trials so they may have introduced bias at some point into the study

that's skewed the outcome and the findings so you really want to make sure that the authors of the guideline that you're looking at appraise the research that they're using to support their recommendations and that's what the

aasa' task force did so they used randomized control trials and observational studies and then they categorize the strength and the quality of the study findings so as you're going through you'll see that statistically

significant was deemed a p-value of less than 0.01 and outcomes were designated as either beneficial harmful or equivocal equivocal meaning this findings were not significant one way or the other and then they also used

opinion based evidence from experts so they surveyed members of their task force and they did take into account some informal opinion from message boards and letters to the editor so I think a good example here is one of

their recommendations about capnography so they did a meta-analysis of randomized control trials that indicated that the use of continuous and title carbon dioxide monitoring was associated with a reduced frequency of hypoxemic

events when compared to monitoring without capnography and then you'll see at the end of the recommendations this category so for this particular recommendation they labeled it as category a1 - B evidence and what that's

telling you as category a means it was a randomized control trial which is great it was a level one meaning it's a high level of strength and quality and B is telling you that there was statistically significant findings that demonstrated

benefit to the patient now another recommendation that you may see as you're reading through would be the NPO guidelines so if you look at any of the literature about NPO recommendations it's really all expert

opinion because all of the evidence has shown equivocal findings so for example one of the studies they looked at compared the outcomes of patients who had clear liquids one hour prior to the procedure versus two hours and they

found no change in the outcome I think it's important when you're a provider and you're looking at that because you're gonna base your judgment calls on the evidence so you may have a patient come in who had tea up until one hour

prior to their procedure and you have to make a decision whether or not you want to cancel or proceed and you could look at the findings of the literature that shows that there really hasn't been a proven difference in outcomes so you may

decide to just do the procedure versus capnography there's very strong evidence showing it's beneficial to the patient always so I think this is a real big take-home point of why we do everything we do about procedural sedation all of

our assessments and enhancing our practice as a sedation is a continuum and practitioners intending to produce a given level of sedation should be able to rescue the patients whose level of sedation becomes deeper than initially

intended pre-procedure our assessment

no thanks to the avir we really wouldn't be able to do anything that we can without y'all so I take great great pride in sharing things from our perspective said you folks can start contributing your own thoughts your own opinions and your own vision during

these cases I think it's certainly something that I've appreciated since the first day of doing invention where do you all do so having said that we're just a smidge in the behind side so we'll try to focus today is mainly a

survey to stimulate everyone in terms of what's actually happening on the other end of the catheter with respect to the patient why are we doing these things where's our role and I think that's gonna add hopefully some value the next

time you folks step in on one of these cases alright so as you know dr. daughter first was able to visualize the inside of a blood vessel and find a stenosis and a lady who had limb ischemia and then was able to use a

dilator to fix that so obviously that gave birth to interventional radiology so we started taking pictures of tumors just to diagnose tumors back in the day before we had actual imaging and what we found

was well if tumors have a high demand for blood just like anything else what happens if we take away that blood and this is a 1975 image of renal cell carcinoma is to call them hyper and if Roma's back then but basically the

concept of interventional ecology was born the moment you could do something to make the environment for the tumor less hospitable and to try to palliate patients if they weren't subject to the the gold treatment standards like

resection in this case so fast forward to 2016 there was a huge study was International where they looked at over 3 000 patients who have primary liver cancer or her pata cellular carcinoma and what they found was that regardless

of where but if you sum all the treatment decisions that are related to those patients about 70% will see treatment by an interventional radiologist as you know that was a astounding amount

so si are listened to a lot of these types of messages even outside of obviously oncology basically we realize that there's a tremendous responsibility and the best thing to do is to dedicate ourselves fully to that and that's why I

think with IR now is a separate medical specialty we're going to start seeing more of the clinical involvement of this and certainly think the caseloads going to go up so why interventional oncology

blasian it's well tolerated and folks with advanced pulmonary disease there's a prospective trial that showed that

there are pulmonary function does not really change after an ablation but the important part here is a lot of these folks who are not candidates for surgical resection have bad hearts a bad coronary disease and bad lungs to where

a lot of times that's actually their biggest risk not their small little lung cancer and you can see these two lines here the this is someone who dr. du Puy studied ablation and what happens if you recur and how your survival matches that

and turns out that if you recur and in if you don't actually a lot of times this file is very similar because these folks are such high risk for mortality outside or even their cancer so patient selection is really important for this

where do we use it primary metastatic lesions essentially once we feel that someone is not a good surgical candidate and they have maintained pulmonary function they have a reasonable chance for surviving a long

time we'll convert them to being an ablation candidate here's an example of a young woman who had a metastatic colorectal met that was treated with SPRT and it continued to grow and was avid so you can see the little nodule

and then the lower lobe and we paste the placement prone and we'd Vance a cryo plugs in this case of microwave probe into it and you turn off about three to five minutes and it's usually sufficient to burn it it cavitate s-- afterwards

which is expected but if you follow it over time the lesion looks like this and you say okay fine did it even work but if you do a PET scan you'll see that there's no actually activity in there and that's usually pretty definitive for

those small lesions like that about three centimeters is the most that will treat in a lot of the most attic patients but you can certainly go a little bit larger here's her follow-up actually two years

that had no recurrence so what do you do when you have something like this so this is encasing the entire left upper lobe this patient underwent radiation therapy had a low area of residual activity we followed it and it turns out

that ended up being positive on a biopsy for additional cancer so now we're playing cleanup which is that Salvage I mentioned earlier we actually fuse the PET scan with the on table procedural CT so we know which part of all that

consolidated lung to target we place our probes and this is what looks like afterwards it's a big hole this is what happens when you microwave a blade previously radiated tissue having said that this

was a young patient who had no other options and this is the only side of disease this is probably an okay complication for that patient to undergo so if you follow up with a PET scan three months later there's no residual

activity and that patient actually never recurred at that site so what about

So question. I do have a wonderful group of nurses, an excellent group that I get the chance to work with

and they have asked 100 questions and they've listened to me talk a few hundred times. Anyway, hopefully, they have helped to make this a clear presentation. One of our EP physicians looked over the information and he and a device nurse also agreed

and they were wonderful. I do have the samples here, the Medtronic grip Trip Walker gave me. Anyway, you're welcome to come up and take a look at them. But before I do, do you have any questions? Yes.

- [Woman] So our Medtronic rep comes and does whatever he does, we never really know. We think you said (distant indistinct muttering) okay, they're sent to eight. We sit there with pulse ox on, they get scanned. We reset to whatever they were before and they leave,

so clearly I'm going to up it a little bit after seeing this talk. But he doesn't always stay. I know. So we don't have a device nurse. It's just this Medtronic rep.

Would that be-- - And how would you access him if you had an emergency? - [Woman] I don't know. That's what I'm going to work on-- - Totally. - [Woman] He has left the building before.

(indistinct chattering) I know! (distant indistinct muttering) - No, he shouldn't-- (distant indistinct muttering) - [Woman] So if he has the rest of these slides somehow, I mean, I got most of these but (mumbles) I got three pages here but the other things

that say like (distant indistinct muttering) stuff like that. - I don't, but it's going to be on the web or whatever they do, and it will all be there. distant indistinct muttering) Mm-hmm, mm-hmm. And your physicians, our docs know on the morning

of the procedure that all the devices that are going to happen, hopefully they will have reviewed that. - [Woman] This is how it works. Our scheduling calls the MRI, MRI says okay (mumbles) pacemaker.

An MRI technologist calls Medtronic. Medtronic or the other (mumbles) companies says yay or nay, this is our device. (distant indistinct muttering) Other than the ordering doctor, there's no doctor that knows that patient's there.

The cardiologist knows-- (overlapping dialogue) - According to this consensus statement, and it's all highlighted, you know, that if you're saying, "Hey, where are our guidelines "and how are we doing this and where does this come from?"

you have a really strong statement that is a little bit confusing. They've written a very concise guideline. It doesn't say a whole lot of information about much of anything actually in my opinion. But this statement is 50-some pages.

It has clinical studies and it has information about caring for these patients and how they should be assessed and programmed. (distant indistinct muttering) It is. And it's on the back actually of your paperwork too, the name of that study.

Mm-hmm? - [Woman] Just a question about traditional and nontraditional pace. Right now we only do, yeah, they did an x-ray (distant indistinct muttering). - You can't tell that from an x-ray.

- [Woman] Right, but I mean, the look of the model just to see if it's MRI compatible (distant indistinct muttering) just the actual pacer (distant indistinct muttering) and then we have, the EP comes down, (distant indistinct muttering) nurse that comes down and interrogates

and shuts the pacer, puts them in a certain mode before we do it, but I'm just concerned about the difference between traditional and nontraditional (distant indistinct muttering) - So she's questioning about conditional or nonconditional.

You can't tell by looking at the device. You need to have information from the programmer itself telling you what the device is and if there's a lead that matches it. Like I said one time we had recently had a patient that had a nonconditional lead,

but the device was deemed conditional. But it really would then made it a nonconditional system. And that has those extra requirements according to this guideline. Now it doesn't say this is the way it has to be. It says, your institution needs to adapt

or to make their own very clear protocols so that when you go into the scanner and you're taking responsibility for that patient, you know that they have been thoroughly, you're safe, as safe as can be. (distant indistinct muttering)

Nonconditional is a device that is not FDA approved. Conditional is FDA approved, whoops. And I think we're at about a couple seconds here, so if you have questions I'm glad to answer them. Back there too, but hmmm? (distant indistinct muttering)

She's been back there since the beginning. (distant indistinct muttering) I don't know that an LVAD would be compatible by any stretch of the imagination. Reveals or those monitors are actually, are MR compatible. There's also a single or a lead-less system

that is MR compatible. I have those up here too so if you want to take a look at those, you can. They're really cool little gadgets. But LVAD would not be. Whoops.

Sorry. - Just to keep on time because we have another like her starting. If we can just step out in the hallway and have her finish addressing your questions and getting the answers.

And to reiterate, just watch for your emails coming from ARIN and you'll have access to her lecture, her slides. So for people who want to make practice changes, it'll be available. - And I did put my contact information on those papers

that I handed you. If you have any questions, please let me know. (audience applause drowns out dialog) Thank you.

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

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 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

to talk about is indirect angiography this is kind of a neat trick to suggest to your intervention list as a problem solver we were asked to ablate this lesion and it looked kind of funny this patient had a resection for HCC they

thought this was a recurrence so we bring the comb beam CT and we do an angio and it doesn't enhance so this is an image here of indirect port ography so what you can do is an SMA run and see at which point along the

run do you pacify the portal vein and you just set up your cone beam CT for that time so you just repeat your injection and now your pacifying the entire portal vein even though you haven't selected it and what to show

well this was a portal aneurysm after resection with a little bit of clot in it the patient went on some aspirin and it resolved in three months so back to our first patient what do you do for someone who has HCC that's invading the

heart this patient underwent 2y 90s bland embolization microwave ablation chemotherapy and SBRT and he's an eight-year survivor so it's one of those things where certainly with the correct patient selection you can find the right

things to do for someone I think that usually our best results come from our interdisciplinary consensus in terms of trying to use the unique advantages that individual therapies have and IO is just one of those but this is an important

lesson to our whole group that you know a lot of times you get your best results when you use things like a team approach so in summary there are applications to IO prior to surgery to make people surgical candidates there are definitive

treatments ie your cancer will be treated definitively with curative intent a lot of times we can save when people have tried cure intent and weren't able to and obviously to palliate folks to try to buy them time

and quality of life thermal ablation is safe and effective for small lesions but it's limited by the adjacent anatomy y9t is not an ischemic therapy it's an ablative therapy you're putting small ablative radioactive particles within

the lesion and just using the blood supply as a conduit for your brachytherapy and you can use this as a new admin application to make people safer surgical candidates when you apply to the entire ride a panic globe

thanks everyone appreciate it [Applause] [Music]

culture concept so the single greatest impediment to err prevention in the

medical industry is that we punish people for making a mistake we should learn right we should really learn so what comes to mind when you think about it the term just culture right she's being able to

report something and not having having punitive actions from that Lane free fair open and honest trustworthy supportive nice place to work yes so two nurses select the wrong medication from a dispensing system

one dose reaches the patient causing him to go into cardiac arrest and the other is caught at the bedside before causing harm do we treat these nurses in the same way no we should but oftentimes we don't right

right right so an active failure versus more the latent failure right so upon further investigation it showed that the two vials that these nurses pulled were very similar the vials was very similar to something that wears a different

medication so we needed some separation from pharmacy so so a little systems intervention right in our Omni cells so and maybe you know maybe there's some human factors that were involved there too that you know one nurse caught it

and the other one didn't but rather than punishing we need to work on consoling and supporting and look at the system and find what's happening what's going on what's the root cause a nurse loses custody of yet an unlabeled specimen but

chooses not to report the incident at a fear of discipline do we fur grit forgive the breach given the nurses fear no no so we really can't but we shouldn't come down on her like a hammer you know or on them doesn't have

to be heard on them because this can actually be a sentinel event if if you have to go back and get another sample that's a set a little bit so that's a Joint Commission never event so that that's not that's not a good thing plus

it's an extreme inconvenience to the patient and also we're opening that patient up to further harm because we have to get another sample so you have to ask why did the nurse behave this way why did she choose not to report it

honest honest disclosure without fear of retribution that's an important characteristic of the just culture hmm yes it does doesn't it that's an excellent point thank you very much for

sharing that excellent point certainly she said that you also have to look at leadership because a lot of times leadership has favoritism so you've got to work on the favoritism so it has to be fair and that's also part

of the just culture and that's a very good point as a learning experience and we're gonna cover some of that too so we have a radiology team that defends skipping the timeout on the basis that no adverse event occurred

so do we condone this no no no so we we don't condone it and it is it is a Joint Commission requirement but and although this incident didn't end in an adverse event we could certainly see where it might so again we need to engage our

leadership we need to engage people at the bedside including our physicians as to you know why we blew right through the timeout so a fair and just culture is is a culture that refers to values supportive model with shared

accountability um it's also an integrated pattern of individual and organizational behaviors based upon shared beliefs and values that continuously cease to minimize patient harm that may result from the processes

of care delivery so culture is the outcome of how our organization responds it's the outcome so if we have a just culture we will have people who will report those events those near misses and will work and not hide them and do

what's right that's why we need it because if we don't have it only two to three percent of errors would be reported most hospitals would be unaware of what errors they had health care workers would report only what they

could not hide and airs as viewed by hospital workers and the media are indicators of carelessness which is not true in fact it's farthest from the fact

so why staging important well when you go to treat someone if I tell you I have a lollipop shaped tumor and you make a lollipop shape ablation zone over it you have to make sure that it's actually a lollipop shaped to begin with so here's

a patient I was asked to ablate at the bottom corner we had a CT scan that showed pretty nice to confined lesion looked a little regular so we got an MRI the MRI shows that white signal that's around there then hyperintensity that's

abnormal and so when we did an angiogram you can see that this is an infiltrate of hepatocellular carcinoma so had I done an ablation right over that center-of-mass consistent with what we saw on the CT it

wouldn't be an ablation failure the blasian was doing its job we just wouldn't have applied it to where the tumor actually was so let's talk about

timing of a minute administration is that you need to know the drugs time of onset peak response and duration of action and titration of drug to effect is an important concept so you need to know whether the drug you just gave hit

its peak effect before you start Rideau seing them that concept is called Li and C to peak drug effect and all that's saying is that you just want to make sure that you're hitting the peak effect before you redose if you don't you can

have dose stacking which can put the patient at risk for toxicity and latency to peak drug effects can be changed by the physical physical chemical properties like we just discussed so how much it provides to protein is it lipid

soluble it's basically talking about how quickly it can get to the site of action and do what it needs to do pharmacokinetic and pharmacodynamic variability is basically just telling you that I could give one person a

milligram of versed and then give the next patient a mil a milligram of versed and they can have completely different responses and some things we can predict ahead of time and other things are we're just not going to know I mentioned the

cytochrome p450 system there are patients that have genetic variances of those enzymes that can change the way they metabolize the drug there's no way that we're going to know that beforehand the way that you deal with this or

tackle this problem is you start small assess and adjust we all know this you learn this in nursing school it's easy to add more it's always going to be worse to try to take it back you won't be able to take it back

I like this chart just because it kind of talks about the different variables that you may encounter so we already talked about the pharmacokinetic variabilities but some of the pharmacodynamic variabilities are going

to be your drug receptor status genetic factors drug interactions and tolerance when I look at drug receptor status I'm thinking methadone buprenorphine if you have a patient on buprenorphine and that receptor is occupied by the

buprenorphine it's going to cause competition for the next opioid you try to give like fentanyl we've had some problems patience in our department with this drug as far as titration is concerned

you want to administer each component individually to achieve the desired effect now this was a change for us when I first started talking about this because we used to give versed and fentanyl together every single time but

with the AFA recommends is that you give the drugs individually monitor the response and then assess accordingly this is an algorithm I found on up-to-date it's just a suggestion obviously it's not going to fit every

patient but it's just describing how you would start out with midazolam first give that time to hit the peak effect which again remember is gonna be 3 to 5 minutes and that can feel like a long time NIR so it's a little painful to do

this but it is going to I think lead to a better outcome for you and for the patient as far as their experience then if necessary give fentanyl I usually give that for the access because really I think for the most part most of the

things we do aren't overtly painful there may be painful parts of the procedure but it's not just two hours of pain or it shouldn't be and then you want to observe the patient if you gave fentanyl you really want to wait five

minutes and then redose from there so usually I just give the one dose of fentanyl and then I stick with my versed by eliminating that that double dose every time you're going to be able to go higher on your versed or your fentanyl

depending on what you need to give so that makes sense to everybody we were we were giving we call it one round versed in fentanyl one round and then by the fourth round nurses were understandably going oh good I the

patient needs more but I feel really uncomfortable and a CRNA said to me one day why are you guys giving fentanyl and versed every time it's great for the synergistic effect but you're going to hit that feeling a lot faster than if

you just give small incremental doses of versed to get them through the procedure and leading into synergistic interactions so giving a benzodiazepine and opioid together elicits a synergistic interaction you can think of

it as 1/2 plus 1/2 equals 4 in the city and that's a lot of what we were seeing we were seeing this you know give the fence alone verse said okay they're really sedated and then they're not anymore and then they're really

sedated and then they're not anymore versus this really nice steady maintenance of sedation during the procedure intra procedure you want to be

ablating things in the bones well musculoskeletal blasian we're fortunate within our practice that we have a doctor councilman Rochester who's

a probably one of the biggest world's experts on this and these are his cases that he shared but you can see when you have small little lesions and bones that are painful you can place probes in them and you freeze them the tumor dies and

musculoskeletal things remain intact what about when you have cases like this where there's a fracture going through the iliac bone on the left with an infiltrate of malignancy well you can cryo blade it and what's cool about is

you can using CT guidance do percutaneous cannulated pins and screws and a cement o plasti ver bladed cavity and when you're done the patient who initially couldn't walk now can and whose pain scale went down to one so I

think that's that's very important to realize the potential of image-guided medicine this is something that previously would have had to been done in the orthopedic lab so you know I think this is extending options where

otherwise it would have been difficult same thing applies to the spine you can ablate and fill them with cement so

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

get into human factors engineering so James riesen who were going to talk a little bit more about said we can't change the human condition but we can change the conditions under which humans work and this is the discipline that is

human factors engineering so it's a discipline that takes into account human strength and limitations in the design of interactive systems that involve people tools and technology and work environments to ensure safety most

notably or most recently they were involved in the restructuring or re-engineering of anesthesiology machines so you may remember a time when anesthesiology machines didn't even have a monitor a

patient monitor on him they were just the machine and they had the bellows on them on top that would go with the patient respirations so since that time they've been written a re-engineered to include a patient monitor further

reengineering took in human factors which is is the human condition and I'm going to get into some of those human factors a little bit later but we they took a look at the monitor to make it more clear and intuitive for the

anesthesiologist they also took a look at the alarms of these anesthesia machines to make sure that they were accurate and had a better range to prevent alarm fatigue and then lastly they put in some automation into those

machines human factors engineering is also used outside of healthcare in aviation automobiles so the backup camera that we enjoy at our cars that came from human factors engineering and also a Three Mile Island they used human

factors engineering when they looked at that accident that nuclear accident that took place those many years ago and they used what they learned from Three Mile Island to design much safer patients say sorry nuclear power plants so it's it's

not only used in healthcare but throughout all of our industries so

we're gonna move on to embolization there a couple different categories of embolization bland embolization is when

you just administering something that is choking off the blood supply to the tumor and that's how it's going to exert its effect here's a patient with a very large metastatic renal cell lesion to the humerus this is it on MRI this is it

per angiogram and this patient was opposed to undergo resection so we bland embolized it to reduce bleeding and I chose this one here because we used sequentially sized particles ranging from 100 to 200 all

the way up to 700 and you can actually if you look closely can see sort of beads stacked up in the vessel but that's all that it's doing it's just reducing the blood supply basically creating a stroke within the tumor that

works a fair amount of time and actually an HCC some folks believe that it were very similar to keep embolization which is where at you're administering a chemo embolic agent that is either l'p hi doll with the chemo agent suspended within it

or drug eluting beads the the Chinese have done some randomized studies on whether or not you can also put alcohol in the pie at all and that's something we've adopted in our practice too so anything that essentially is a chemical

outside of a bland agent can be considered a key mobilization so here's a large segment eight HCC we've all been here before we'll be seeing common femoral angiogram a selective celiac run you can make sure

the portals open in that segment find the anterior division pedicle it's going to it select it and this is after drug living bead embolization so this is a nice immediate response at one month a little bit of gas that's expected to be

within there however this patient had a 70% necrosis so it wasn't actually complete cell death and the reason is it's very hard to get to the absolute periphery of the blood supply to the tumor it is able to rehab just like a

stroke can rehab from collateral blood supply so what happens when you have a lesion like this one it's kind of right next to the cod a little bit difficult to see I can't see with ultrasound or CT well you can go in and tag it with lip

Idol and it's much more conspicuous you can perform what we call dual therapy or combination therapy where you perform a microwave ablation you can see the gas leaving the tumor and this is what it looks like afterwards this patient went

to transplant and this was a complete pathologic necrosis so you do need the concept of something that's ablative very frequently to achieve that complete pathologic necrosis rates very hard to do that with ischemia or chemotherapy

alone so what do you do we have a

them so my particular area of interest is a blade of radium ization and what we'd like to do is to break the liver

down into a bunch of little tiny perfused volumes off of a single vascular pedicle or what we call angio zones and those are those allow us to segment out if you only have small volume disease for example like here in

segment three why do I have to treat the entire left to paddock low I can actually treat just that small portion just like it what it tastes only now I'm administering y9t but since it's expendable liver I

can administer doses that are way higher orders of magnitudes higher than what I could if our infusing into the liver just on its own so here's an example of that if you look at this lesion in the right of panic lobe you'll see these

little lines over them what we want to achieve is around a 205 GRA threshold for these lesions that's the red line everything that's south of red in terms of color orange Holly to blue is not cold enough to kill tumor so if we

administer a dose of a tea grade to the lobe we get this coverage which is to be a partial response if I administer 150 grey suddenly that red line gets larger what happens when you administer 400 grey now you've officially covered the

entire lesion and so you're going to lose the adjacent liver at those kind of doses and as well - what what the real question then is not sort of how much dose you give it's you give what you need to to ablate the tumor in its

entirety and you see what the patient's left with if someone's left with anatomically a lot of remnant liver because of how you've segmented out that lesion then go ahead and dose extremely high and that's essentially what we've

seen in pathologic results it's one of the highest things of high school pathological crosa rates you can achieve with a trans arterial therapy it's highly competitive with thermal ablation in the correctly selected bleezin

so this is an example of what it looks like when you segment out a little lesion like this and this patient ultimately went to resection and this was a complete pathologic necrosis but as you can see even it was a cirrhotic

patient we chose a very small volume of liver that we felt the patient would tolerate so that's a blade of vernalization let's take a look at what looks like in real time so we have a little capsular lesion we felt that

ablating this patient who was a potential transplant candidate we felt we can probably with a blade of radium realization so you go in and this is the comb beam CT that looks at a complete enhancement of the lesion within the NGO

zone this is what the MAA looks like when we administer it you can see how it tends to cluster within the tumor but you can see what the adverse territory is the liver adjacent to it this is what the engine room looks like how highly

selective it is the day of and this is what the wine ID actually looks like is the wine 90 doing its job and you can see how conformal it is there's no risk whatsoever to the liver that's adjacent outside of that field of

a maximum of around 11 millimeters and this is a patient at one month with a complete imaging response and this patient never developed a recurrent to the site and what's actually sole mode of treatment for this person's liver

cancer this is how you get complete pathologic response if you look at those little tiny grey dots in there those are actually the spheres within tiny little vessels within the tumor sometimes they go even to the portal branch but you can

see how they're not clustered uniformly but when you make them super hot that allows them to give range where otherwise they would be fine a little bit short so this also applies to the whole lobe this was a patient that had a

very unusual presentation of colon cancer that was invading the portal II we weren't sure what to do with this patient no one was because a very rare occurrence so we said well we would like

to resect him but there's not enough liver and we're not sure if this person's gonna survive because we've never seen portal cancer invading the portal vein so we said let's treat it with the radiation lobectomy and what's

cool here is if you look at the the arteries even though the tumor is invading the portal vein it's bringing arterial supply along with it like a vagabond and that's the conduit that allows us to treat these patients so

when we saw that we felt this patient we good candidate for irradiation lobectomy which is applying an ablative dose of y9t to the entire low not just a small segment in patients where otherwise cannot because of the anatomy the tumor

or if you're trying to shrink that lobe to get that person ready for surgery why because if you look at the size of the lobe on the left from this first image and compare it here you can see how much larger it got what happens is that part

that the surgeon ultimately tens on resecting in volutes over time and becomes completely vitalized and turns into scar tissue so we know that if a surgeon goes in afterwards to cut it out it's going to not result in liver

failure and that level of security allows people to have sir who otherwise wouldn't this patient is not going to have metastatic disease because we followed their blood level markers let me see how low they are and

is going to have enough liver remnant so the patient went to resection and this is the pathologic specimen and this was also a complete pathologic necrosis so I

know we're running a bit short on time so I want to briefly just touch about

some techniques with comb beam CT which are very helpful to us there are a lot of reasons why you should use comb beam CT it gives us the the most extensive anatomic understanding of vascular territories and the implications for

that with oncology are extremely valuable because of things like margin like we discussed here's an example of a patient who had a high AF P and their bloodstream which tells us that they have a cancer in her liver we can't see

it on the CT there but if you do a cone beam CT it stands up quite nicely why because you're giving levels of contrast that if you were to give them through a peripheral IV it would be toxic to the patient but when you're infusing into a

segment the body tolerates at the problem so patient preparation anxa lysis is key you have them exhale above three seconds prior to that there's a lot of change to how we're doing this people who are introducing radial access

power injection anywhere from about 50 to even sometimes thirty to a hundred percent contrast depends on what phase you're imaging we have a Animoto power injector that allows us to slide what contrast concentration we like a lot of

times people just rely on 30% and do their whole the case with that some people do a hundred percent image quality this is what it looks like when someone's breathing this is very difficult to tell if there's complete

lesion enhancement so if you do your comb beam CT know it looks like this this is trying to coach the patient and try to get them to hold still and then this is the patient after coaching which looks like this so you can tell that you

have a missing portion of the lesion and you have to treat into another segment what about when you're doing an angio and you do a cone beam CT NIT looks like this this is what insufficient counts looks like on comb beam so when you see

these sort of Shell station lines that are going all over the screen you have to raise dose usually in larger patients but this is you know you either slow down the acquisition speed of your comb beam or

you raise dose this is what it looks like after we gave it a higher dose protocol it really changes everything those lines are still there but they're much smaller how do you know if you have enhancement or a narrow artifact you can

repeat with non-contrast CT and give the patient glucagon and you can find the small very these small arteries that pick off the left that commonly profuse the stomach the right gastric artery you can use your comb beam CT to find

non-target evaluation even when your angio doesn't suggest it so this is a patient they have recurrent HCC we didn't angio from here those arteries down there where those coils were looked funny even though the patient was

quote-unquote coiled off we did a comb beam CT and that little squiggly C shape structures that duodenum that's contrast going in it this would be probably a lethal event for the patient or certainly would require surgery if you

treated that much with y9t reposition the catheter deeper towards the lesion and you can repeat your comb beam CT and see that you don't have an hands minh sometimes you have these little accessory left gastric artery this is

where we really need your help you know a lot of times everyone's focused and I think the more eyes the better for these kind of things but we're looking for these little tiny vessels that sometimes hop out of the liver and back into the

stomach or up into the esophagus there's a very very small right gastric artery in this picture here this patient post hepatectomy that rides along the inferior surface of the liver it's a little curly cube so and this is a small

esophageal branch so when you do comb beam TT this is what the stomach looks like when it enhances and this is what the esophagus looks like when it enhances you can do non contrast comb beam CTS to confirm ablation so you have

a lesion this is the comb beam CT for enhancement you treat with your embolic and this is a post to determine that you've had completely shin coverage and you can see how that correlates a response so the last thing we're going

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

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

think we mentioned some of them we need our we need our Huddle's right we need Huddle's we need our department meetings to include a patient safety event or it

doesn't have to be an event but a patient safety item you can wrap all kinds of things around that for your department meetings you know you can you can make it a contest for your staff you know for which patient safety item you

want to bring forward for your staff meeting you know giv yo suggestion involves staff directly in

problem solving processes and really take a look at your current disciplinary processes not only from leadership departmental wise but but organizationally you've really got to be a voice it's got to start somewhere so

you've got to be a voice so risk is everywhere it could be perception it can be absolute and it's not essentially bad so if you remember most of us are taught to drive at 10:00 and 2:00 but we slide our hands down to that 9 and 3 position

and my car was in the in the in the repair shop and I had a loaner and this loaner had a steering wheel warmer and my hands definitely went down to nine and three because it was right during the heart of so that Chicago winter that

we have so but normally I'm driving at 8:00 and coffee so I mean Mike so ah but I'll tell you during a blizzard I don't I'm not holding that coffee my hands are back up at ten and two

because I understand the risk so we there's risk in many things that we do in health care it's fraught with risk but we do that because and you hear the physicians talk about you know that risk benefit and we way that you know risk

benefit so we do a lot of risky things in health care but it's okay because there's a lot of good things that come from that in taking care of our patients but we need to recognize those human factors that come into play we need to

be aware of our surroundings so that situational awareness when we're taking care of our patients and affect patient safety manage and support our values of our organization and each other

patient like this you have a very large left lateral HCC that's invading the left the patek vein and extending into the heart since when we get into things like radioembolisation if you have

multifocal liver disease if you want to apply radiation therapy to that's very difficult to do that because it actually requires more radiation dose to kill HCC than it does the adjacent normal liver the liver is actually that ready

sensitive so you can do things like SBRT and pick an individual lesion you can do things like a imrt which is you know survey 8 non focus generalize low dose but what's interesting Malaysian is that if you administer

particles they only shoot about two millimeters worth of the raishin field around it so of what used is that with one not much but if you put eight to forty million of them within the bloodstream they Auto sort themselves

based off of the vascular flow preferential that exists with tumors tumors actually emit hormones pull in blood supply that you weren't born with and that actually tends to pull beads from the bloodstream preferentially

towards it so this is an example where you stain a tumor with two types of wax one the portal that's blue one the artery that's red and you can see how much that preferential exists so what ends up happening is these spheres

cluster within the tumor and then provide local dose radiation that's very hot where the tumor is and low elsewhere so here's an example of that this is a patient with metastatic neuroendocrine disease multifocal liver lesions you can

see that vascular flow preferential this is what it looks like on the maa when we jecht a protein particle surrogate that has a technician I should have assigned to it just as a visualization of how the particle is

going to sort out and the post y9t bremsstrahlung CT is over there and you can see how intense the necrosis is within the tumor and how much it's spared the normal liver however you do get some radiation damage they don't

live a regardless that's why choosing the timing of when you're gonna do this is important this is a patient that was treated with tastes above and one session of y9u beneath so you can see that they do have different types of

therapeutic mechanisms they're not the same even though they look very similar in terms of when we're administering

the traditional three pillars are

surgical medical and rad honk which actually was once part of radiology and separated just like interventional radiology has and where is the role for this last column so many patients are not medically operable so if you set the

gold standard you know that the cure for someone has a primary liver mass well about 20 percent of patients who present can undergo resection what you do for the remaining portion so Salvage is what we offer when someone has undergone

standard of care and it didn't work how do we hop back in and try to see how much these folks it's low-risk it's not very expensive at all as compared to things like surgery and the recovery is usually the same date so

this concept here of tests of time is kind of interesting a lot of times when we look at a tumor let's say it's 2 centimeters it's not really the size of the tumor but it's how nasty of a player it is and it's

difficult to find out sometimes so what we do is we'll treat it using an IR technique and watch the patient and if they do well then we can subject them then to the more aggressive therapy and it's more worthwhile because we've found

that that person is going to be someone who's likely going to benefit you can use this in conjunction with other treatments and repeat therapy is well tolerated and finally obviously palliation is very important as we try

to focus on folks quality of life and again this can be done in the outpatient setting so here's a busy slide but if you just look at all the non-surgical options that you have here for liver dominant primary metastatic liver

disease everything that's highlighted in blue is considered an interventional oncology technique this is these the main document that a lot of international centers use to allocate people to treatments when they have

primary liver cancer HCC and if you see if you see at the very bottom corner there in very early-stage HCC actually ablation is a first-line therapy and they made this switch in 2016 but it's the first time that an

intervention illogic therapy was actually recommended in lieu of something like surgery why because it's lesions are very small its tolerated very well and it's the exact same reason why your dermatologists can freeze a

lesion as opposed to having to cut everything off all the time at a certain point certain tumors respond well and it's worth the decrease in morbidity so

the ablation concept in general is to provide an environment that is

completely hostile to tumor minus 40 degrees Celsius 150 degrees Celsius 500 gray which is a radiation dose we say it's very hard for it's about anything to survive but so why is it that it doesn't always work well that's a

function of all those parameters that you see there we got to make sure we pick the right patients we got to make sure that we treat tumor where we think it is and avoid trading things that don't need treatment avoid causing

damage to collateral structures and getting a reasonable margin where we actually get some of the tumor that's microscopic there are a lot of ablation modalities radiofrequency alternates electrical current very rapidly so that

generates friction within the lesion and causes heat it looks like this a lot of times you see these little times that stick out so that you can increase the size of your blasian zone and here's a one of those deployed in a patient who

had a colorectal Curren after hepatectomy cryoablation freezes things and it pushes a gas that once it goes through a pin hole tends to expand and cause rapid freezing he can also push another gas right through it and cause

rapid heating but this is just bringing tumors to that minus 20 degree minus 40 degree threshold the nice part about cryoablation is that you can visualize your ablation zone so we're right up against the bile duct here and it tends

to be a little more respectful of tissues so that's why cryoablation is chosen every once in a while we're do frequency ablation is an excellent tool we have lots of data for it but likes it sometimes it's difficult determine where

the ablation zone is interprocedural e microwave ablation there was just a randomized study that came out that compared microwave ablation to radiofrequency ablation and the results are very similar

it was a very very experienced institution doing it but the whole point here is that a lot of these tools work pretty well there's no clear superiority on them but one thing that microwave offers it's very fast so generates

temperatures to boiling within the tumor in about five minutes and so it's certainly very fast as compared to radiofrequency and you can see boiling happening within this tumor that's been accessed eventually there that gas is

actually literally fluid that is boiling away from the tumor couple of cool ones this one's reversal expiration what we do here is we place probes throughout the lesion and we pulse it to confuse the membrane on the cell to think that

it's a it has holes in it that it cannot close and so what is happening is the contents inside the cell leave and that's pretty much consistent with not being able to survive the nice part is we can accomplish all that without

thermal ablation what do we mean that we don't go over about 40 degrees Celsius so if something is involving a bile duct or involving a critical structure like the ureter it's not actually going to damage it it just basically tells all

the the cells within there to stop stop undergoing the cellular mechanisms responsible for life it's a little more finicky to place you have to place these little parallel probes here's one we did that was directly write on the

bifurcation of the main bile ducts and you can see here afterwards is an immediate post contrast scan how that whole area is ablative it does not take up contrast and this patient never developed biliary strictures that side

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

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

if we had less blame we'd have more patient event reporting and from there

we can do more to look at our systems in our organizations and really affect patient care it helps so increased reporting helps to prevent future patient harm it provides an indication of human and system performance so again

we're working on the system not the person it guides performance improvement and it also provides an opportunity to identify risks it also provides a culture of safety so we go from blaming the equipment and the other person to

looking at owning some of our own air and then ultimately when we know that we have not followed a policy as we should have because we know that we're gonna our leadership is going to look at that and find out why we didn't do what we

were supposed to according to policy sometimes those policies are written by people who aren't at the bedside or they're so old that they're not up-to-date they don't have best practice in them and so we'd need to be conscious

of those so you know every three years we're supposed to be updating our policies and procedures and that includes our departmental ones too and we need to be looking at best practice and listening to our staff to really

prevent patient safety errors so if you look at your system design and behavioral choices if you spend 80% of your son time there you could really reduce your human errors in your adverse events that's

what a just culture and a culture of safety brings you but in order to do that you have to have organizational trust so management needs to be trusted management needs to trust the staff and staff needs to trust management so all

that is cyclic elana just culture you would have that so how do we get there I

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