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Pharmacology- Benzodiazepines | Procedural Sedation: An Education Review
Pharmacology- Benzodiazepines | Procedural Sedation: An Education Review
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Education Strategies to Reduce Human Errors | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
Education Strategies to Reduce Human Errors | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
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Q&A PET/MRI  | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
Q&A PET/MRI | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
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DNA Repair | Gold Medal Lecture - Health of Technologists and Nurses and the Role of Compassion in an AI Focused World
DNA Repair | Gold Medal Lecture - Health of Technologists and Nurses and the Role of Compassion in an AI Focused World
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Practice Guidelines | Procedural Sedation: An Education Review
Practice Guidelines | Procedural Sedation: An Education Review
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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
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Factors Contributing to Hypoventilation | Respiratory Compromise: Use of Capnography During Procedural Sedation
Factors Contributing to Hypoventilation | Respiratory Compromise: Use of Capnography During Procedural Sedation
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Why is the Capnography Reading Abnormal- Assess for Equipment Issues | Respiratory Compromise: Use of Capnography During Procedural Sedation
Why is the Capnography Reading Abnormal- Assess for Equipment Issues | Respiratory Compromise: Use of Capnography During Procedural Sedation
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The Dashboard Implementation | Innovation and Application of Real Time Nursing Dashboards
The Dashboard Implementation | Innovation and Application of Real Time Nursing Dashboards
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Pharmacology- Antagonists & Additional Medications | Procedural Sedation: An Education Review
Pharmacology- Antagonists & Additional Medications | Procedural Sedation: An Education Review
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Overview of Respiratory Compromise | Respiratory Compromise: Use of Capnography During Procedural Sedation
Overview of Respiratory Compromise | Respiratory Compromise: Use of Capnography During Procedural Sedation
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Airway Assessment | Procedural Sedation: An Education Review
Airway Assessment | Procedural Sedation: An Education Review
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Intraprocedure | Procedural Sedation: An Education Review
Intraprocedure | Procedural Sedation: An Education Review
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Overview of Diagnostic Errors | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
Overview of Diagnostic Errors | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
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Why is the Capnography Reading Abnormal- Physiology | Respiratory Compromise: Use of Capnography During Procedural Sedation
Why is the Capnography Reading Abnormal- Physiology | Respiratory Compromise: Use of Capnography During Procedural Sedation
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Q&A- Procedural Sedation | Procedural Sedation: An Education Review
Q&A- Procedural Sedation | Procedural Sedation: An Education Review
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Pharmacology- Versed | Procedural Sedation: An Education Review
Pharmacology- Versed | Procedural Sedation: An Education Review
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Pre-procedure Assessment | Procedural Sedation: An Education Review
Pre-procedure Assessment | Procedural Sedation: An Education Review
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Q&A Bleeding Risks | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
Q&A Bleeding Risks | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
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Pharmacology- Opiods | Procedural Sedation: An Education Review
Pharmacology- Opiods | Procedural Sedation: An Education Review
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Normal Bleeding | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
Normal Bleeding | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
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Why is the Capnography Reading Abnormal- Getting a True Measure of End-Tidal Volume | Respiratory Compromise: Use of Capnography During Procedural Sedation
Why is the Capnography Reading Abnormal- Getting a True Measure of End-Tidal Volume | Respiratory Compromise: Use of Capnography During Procedural Sedation
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Research and Literature | Respiratory Compromise: Use of Capnography During Procedural Sedation
Research and Literature | Respiratory Compromise: Use of Capnography During Procedural Sedation
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Q&A- Respiratory Compromise | Respiratory Compromise: Use of Capnography During Procedural Sedation
Q&A- Respiratory Compromise | Respiratory Compromise: Use of Capnography During Procedural Sedation
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Administration | Procedural Sedation: An Education Review
Administration | Procedural Sedation: An Education Review
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Q&A Uterine Fibroid Embolization | Uterine Artery Embolization The Good, The Bad, The Ugly
Q&A Uterine Fibroid Embolization | Uterine Artery Embolization The Good, The Bad, The Ugly
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How We Established our Practice Guidelines | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
How We Established our Practice Guidelines | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
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Submassive PE | Pulmonary Emoblism Interactive Lecture
Submassive PE | Pulmonary Emoblism Interactive Lecture
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Transcript

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

strategies so some things that we have

in place right now our peer review Grand Rounds CPOE this is one of my one of my favorite process improvements is is making the right thing the easiest thing and you do that through standardization of processes so that's standard work so

that's your order sets that's the things pop-ups although you don't want to get into pop-up fatigue but pop-ups help our providers for little gentle reminders to guide them to what's right for the patient and to cover everything that we

need we need to cover to ensure the safety of our patient so recently in the fall of last year we had a TPA administration err that occurred it involved a 69 year old patient who two weeks prior had had some stenting in her

right SFA she presented to our clinic when our clinics with some heaviness in her leg and some pain and when she was looked at from an ultrasound standpoint it was determined that her stents were from Bost so she was immediately taken

to the cath lab and it was after angiography did indeed show that there was clot inside these stents they did start catheter directed thrombolysis in the cath lab they also did started concurrent heparin often oftentimes done

with CDT what's usual for our institution is that we have templates that pull in the active problem list for a patient in this case the active problem list or a templated HMP was not used had they

used the template at agent p they would have found that the second active problem on this patients list was a cerebral aneurysm so some physicians will tell you some ir docs will tell you that's an absolute

contra contraindication for TPA however the SI r actually lists it as a relative contraindication so usually we're used to when you when you start a final Isis case you know you're gonna be coming in every 24 hours to check in

that patient in this case we started the the CDT on a Thursday the intent was to bring her back on Monday the heparin many ir nurses will know that we will run it at a low rate usually 500 units an hour and we keep the patient sub-sub

therapeutic on their PTT although current literature will show you that concurrent heparin can also be nurse managed keeping the patient therapeutic in their PTT which is what was done in this case so what ended up the the

course progression of this patient was that so remember we started on Thursday on Saturday she regained her distal pulses in her right leg no imaging Sunday she lost her DP pulse it was thought that it was part of a piece of

that clot that was in the the stent had embolized distally so they made the decision with the performing physicians they consulted him to increase the TPA that was at one milligram an hour to 2 milligrams by Sunday afternoon the

patient had an altered mental status she went to the CT scan which showed a large cerebral hemorrhage they ain't we intubated to protect her airway and by Monday we were compassionately excavating her because

she me became bred brain-dead so in the law there's something that's called the but for argument so the argument can be made that this patient would not have died but for the TPA that we gave her in a condition that she should not have had

TPA for namely that aneurysm so this shows how standard work can be very important in our care of our patients and how standard work drives us down the right way making the easiest thing the safest thing so since that time

we've had a process improvement group that we've established an order set specifically for use and thrombolysis from a peripheral standpoint and then also put together a guideline that was not in place so it's some of that Swiss

cheese that just kind of we didn't have a care set we didn't have a guideline you know we didn't use our template so all those holes lined up and we ended up with a very serious patient safety event so global human air reduction strategies

oops sorry let's go back these are listed in a weaker two stronger and some of what we're using in that case is some checklists so we developed a checklist that needs to be done to cover the

absolute contraindications as well as the relative and it's embedded in the Ulta place order that the physician has to review that checklist for those contraindications and also there to receive a phone call from pharmacy

just to double-check and make sure that they have indeed done that that it's not somebody just checking it off so we have a verbal backup sorry so the just

I'm the FDG is have a radio pharmacy located on the second floor no New York State does allow nuclear medicine

technologist and nurses to inject the con the FDG isotope I know in other states one in particular is is New Jersey the the nurses are not allowed to inject isotope and the technologist has to do it also in addition certain

isotopes and certain scans the ducts have to inject the contrast like the the cervical Lin scintigraphy and some so my question has to do with discharge instructions so just like you give them that little card that they keep with

them so they trigger some radiation alarm and a bridge or on a highway do you give them discharge instructions about if there's small children at home that they're not sitting in their lap for extended period what kind of

instructions do you give on discharge after these patients so we when they come in coupled with the screening forms that they fill out we have some instructions attached to it and does that does have

the discharge instructions but we reiterate to them you know if they have small children or babies and pregnant women and just try to keep their distance for the next 12 to 24 hours just to until the really activity has

wear off so the FDG is like two hours almost for the half life FDA FDA has 60 minutes 116 minutes half life and usually by 12 hour by the 12 hour period they're mostly background radiation okay thank you

we had they have a written instruction like it's like a packet that we give into the market that we do to the patient and the patient have accessed to the web portal that they have and they can be the instructions from there

this is correct so betta bar is still investigational for the most part the only way you can build for it is two different scans you build for a pet and you build for our mr so you've got to get approval for both what you are not

going to get reimbursed for is the registration and that's where it gets a little bit challenging because then you need a radiologist who is both certified uncredentialed to read a pet and an mr so right now most institution bill it as

two different procedures so that's why you that's how we get the approvals just a little information on the side I went back to this case study because I forgot to tell you that in order for the PET CT to have as clear image as the pet MRI

the pet portion I mean the city portion and the pet city would have to be done diagnostically and that this would expose the patient to radiation three times that's why they prefer the pet MRI because yeah the reason why we do it if

we do it mostly for for for pediatrics and it's it and it's because of radiation because you know like our my team is saying you you are going to have this patient have constant follow-up so if you can reduce the amount of

radiation they have from a younger age as we all know it work in radiology DNA injuries occur when you're younger then more is more severe than than later our MRI the pet MRI injection they're all lined with lead and our MRI the pet

MRI room is actually lined with lead so we don't really have Needham let aprons we don't know we don't have wear aprons they are allowed to go to other appointments after they are pet MRI usually with the FDG most of the

radiation after the Tessa's finish is gone they're not more than what not more than radioactive than background radiation so they are are safe to be around people yes that's more for precautionary

measures yes no they go straight to the PACU so we our MRI table is detachable we have an area for where we keep our inpatient bay area we have a structured ready for them to go into right after the test and the

anesthesiologist and if they are Pediatrics the pediatric nurse is with them and they go straight to pack you do like probably like probably less than ten a week right now some weeks we are busy we do for how we do that much some

it varies like we'll do three or four but we are trying because the reimbursement that's one of the big issue our institution is actually eaten eating the cost for some of these to provide a patient with less radiation

especially or pediatric population we have one pet MRI machine for the whole institution three at the main campus we have two we have multiple and other regional sites so the yes

no less than 15 GFR except for the EU vist less than 30 then we notified the radiologists eeeh this is harder to so you this is the it's a linear contrast as opposed to the Catalan bettervest which is

macrocyclic so it's easier for the body to get rid of well there yes well they're only they're already getting dialysis so it's really not much of a harm yes we do patients on dialysis but we make sure the dialysis is done within

24 hours after receiving the contrast yes um sometimes you know you just have it to have it we don't require it for all the tests if you have it we have it we check if it's already in the chart we

acknowledge it you know we don't require for outpatient we don't require but in patients we do all right anything okay so Bernie pet/ct the scanning time for pet/ct is about 30 minutes to 45 minutes Patsy pet/ct is about 30 to 45 minutes

with the pet MRI sometimes they they order dedicated pet MRIs so that is a little longer you have to take note that we do a whole body scan whole body scans for even just for a regular MRI is at least an hour so we try to eliminate

just you know having them have to have to or point to different appointments and just one waiting room one waiting time so that cuts down the response for the patient themselves yes we do for adults it's 12 for the

whole body and then for the pet brain it's about 10 if I'm not mistaken and then plus or minus 10% and then the pediatric doses are cultured calculated base of their height and their weight and there are all protocol by a

radiologist because we have a lot of whole-body protocols we have the bone survey actually that's about 30 or 40 minutes and yes that's an hour and then we have longer whole body protocols diseases

specific and sometimes they try to depends on what the patient's diagnosis is we have whole body scans where they have to check the bone marrow and that needs to be from tips of the toes and tips of the fingers and that can be a

challenge especially if the patient is tall because that has to be in sequest sequestered and sequential patient and positioning is also a challenge alright thank you so much thank you thank you so much

[Applause]

increases now we all have certain repair mechanisms the key one is p53 it's called a guardian of the genome and there's another one called h2 alpha and

we can image these with immunofluorescence I can look at them when they're activated and I can count them and I can say this person had that much repair going on therefore they probably had that commensurate amount of

damage so when I did these experiments I measured those two areas p53 and h2 alpha in my lab and I did the initial work as a myself that would me top left and the the break that the dark bar is breaks prior to pre medication and the

bar behind that is the number of breaks the same dose caused after pre medication this is the formulation beta-carotene na C vitamin C quercetin alpha lipoic acid we did a prospective randomized study in people having bone

scans so they got technetium MDP bone scans we drew the blood in some measure their breaks injected the technetium the red line is where they got their there the increase in breaks from the bone scan dose and this is the group who we

pre-medicated this is one hour prior to radiation injection that's really pretty cool and so this is something I think we should take every day patients should take prior to procedures and passengers on long-haul flights should think about

doing it in the synchronicity in the Jungian sense of the weirdness of this whole thing like the dog meeting the other dog and the guy the antioxidant the weirdest thing is the company going to make this for me is

on Kirin Street in Quebec like this is really kind of gives you a chill you know okay so now in terms of breaks we don't all repair in the same way some of us repair better than others and I think we should be screened for DNA breaks

repair ability we should actually have our blood drawn and we should be evaluated to see if we have an impaired repair mechanism we don't do things like that we don't personalize healthcare like that for the employee but there's a

ton of references but 398 references on this area specifically in American radiological technologists and their cancer risks and the mutations which they have which increase their cancer risks so this is in the literature

Public Health the officials know this this is a public health issue it's an occupational health issue you shouldn't be unaware of this but also your department has a responsibility to you and when you wear your dld what happens

when your badge level goes too high you know do you do some diagnostic work for a while this this is something you need to be really cognizant of all of you as an organization there's a ton of data on this these are all peer-reviewed

publications in place it places like nature on the risks of radiation to people with certain types of mutations so we need to personalize our career choices based on our DNA repair ability and we can be screened for this there

are certain well-known ones brca1 and 2 p53 mutations ATM mutations and then mitochondrial mutations mitochondrial DNA is passed from mother to child there is no paternal DNA in mitochondria that's how people can say oh we were all

derived from women in Africa so you who are women past your mitochondrial DNA across generations so if you've imitation in that you can pass that across generations that's mind boggling

so screening it's a met its earthly complexed emotionally complex and it's worth having a well informed

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

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

some of the contributing factors to hypoventilation well certainly will we give sedation we give you know a benzodiazepine we give other medications we combine those with opioids right that

decreases our responsiveness to elevated co2 levels but we also have muscle relaxation certainly in patients with obstructive sleep apnea history undiagnosed or undiagnosed they lose their muscle tone in the airway patency

kind of diminishes very very quickly and they also have a decreased response to hypoxia all again creating that perfect storm of an adverse event waiting to happen and even patients that have don't normally have obstructive sleep apnea

can have it under our sedation so the key signs and symptoms you know clearly respiratory rate is one that we monitor but we also want to monitor the quality of ventilation right one look at patients tidal volumes and how much

they're expiring with each breath we want to look at their sedation scores whether you're using the rasp score or any of the other standardized scores spo2 less than 90 for at least thirty seconds that's pretty significant

hypoxia especially if somebody's on oxygen and hopefully you would detect somebody who's deteriorating much earlier than that but that certainly would be a terminal sign before they became bradycardic and you were pulling

out the code card but certainly using capnography you could tell breath by breath right instantaneous looking at those waveforms and look to see if the patient is not only taking enough breaths per minute but are they

taking quality ones so let's look at a little bit of a case study here we're gonna kind of look at this case study throughout so this is Jane Doe she's 39 years old she's being worked up for a nonspecific abdominal pain they've ruled

her out for gallbladder issues and appendicitis and they want to do an upper endoscopy in a colonoscopy she's treated with chronic pain medications gabapentin and oxycodone and she's had some surgeries in the past no allergies

to anything so concerns with this patient so what risk factors does this Jane Doe have for during for at risk for respiratory compromise during sedation possibility of undiagnosed OSA be a bio t mass index obesity high risk

comorbidities medical condition or advanced age there's more than one right answer so just make mental note here and these are the correct ones so she potentially has obstructive sleep apnea she does have an elevated BMI and she

has medical conditions she's sick acutely and she has pain medications as part of her chronic therapy so now let's look into solutions so again with our case studies after we give her some versed and a hundred Mike's of fentanyl

the patient develops the following pattern on the monitor so what should your first step be in this scenario nothing because her pulse oximetry is normal be stimulate the patient to take a deep breath perform jaw thrust and

place patient at a sniffing position to open the airway give a reversal agent or D intubate the patient good B you guys are all anesthetists now we have a bunch of positions open at Yale if you're

want to look at now third this is the area that I really wanted to get to today did we pass along out no yeah hand me up one if you don't mind

so third let's look for equipment issues anyone in here do yoga a couple hands okay so some of this is from a yoga exercise and it will play into what we're gonna discuss here but on the left here this is an example

of some of there's all different products out there so on the Left we have a nasal cannula that on one side is delivering oxygen and on the other side is monitoring our carbon dioxide so everyone just humor me if you're not

eating take your finger and plug your right nostril and just take a few breaths in and out through your left okay now let's do the other side so plug the other side it's supposed to be calming we do this in yoga anyone having

trouble breathing through one nostril over the other okay I see a quite a bit of hands so physiologically we have deviated septums we have nasal congestion we have you know our blood capillaries getting gorged on one side

you know I know if I sleep on one side I wake up all stuffed up I have to take a nap on the other side to even it out at least that's what I tell myself right but we preferentially breathe through different nostrils so if we have a

patient on a monitor there's only monitoring from one side do you think that's the most effective monitor we can use probably not just take notice right now who's breathing through their mouths because a lot of us breathe through our

mouths especially patients who are respiratory compromise under sedation or are sick and these are the patients we take care of so for monitoring just through the nose are we doing the best job of monitoring we could be doing no

and we found this out I mean there's all different products out there but what we have found that is most effective is using something that is delivering oxygen through both nares but also monitoring exhaled gases from both nares

but also from the mouth and evidence proves us so I'm not just making this up so we're looking at here is a study that was looking at the accuracy of non intubated capnography patients different sampling lines and what we see in the

navy blue on the left is the first is when they had patients just under a mer and then they put patients on a couple liters of oxygen per minute and you can see use the nasal canula with a scoop was pretty

accurate for both those patients who are breathing room air and supplemental oxygen when we look at two different other designs of nasal canula that just had like a little like a little port to kind of hung down the accuracy not as

great okay same patient group but what happens when we add oxygen to those nasal canula they just they dipped in their accuracy so I'm not saying not to use whatever you have you know if you may only have those kind of nasal canula

but just know that you might not be getting a full sample especially if you're adding oxygen if you're just using a nasal cannula port you follow so just knowing the limitations of your equipment so the monitor the little

machine can only evaluate the gas analyzer can only evaluate what's being delivered to it so if the sample line is not receiving an adequate sample it's going to give you an a waveform that is certainly not accurate so we want to

consider a few things are you connecting multiple tubes to get like multiple you know sampling lines together and connecting them with a stopcock yes no I see some nods of heads and sometimes we have to do what we have to

do right to reach the monitor to the patient but if you're connecting those sampling lines is the connector tight I've seen a number of times where I've seen abnormal waveforms and someone stepped on the stopcock that was

connecting two pieces of tubing and then you just correct the stopcock or tighten up the connection and then all of a sudden your waveform improves but also where the sampling port is located on the patient is important so remember

that picture I showed you of the non-invasive ventilation and the person had the oral and nasal scoop on and they also had the port on the mask and the port on the circuit three different locations we're gonna look at that a

little closer but where is the sampling port located doesn't it make sense to have the sampling port located right where the patient's exhaling especially for delivering oxygen and especially if we're delivering oxygen and kind of

higher flow rates right greater than 12 or greater than 8 and P because it's gonna do potentially dilute our samples and these are some of the challenges that when I talk to people that they are bringing to me like it

just doesn't seem accurate when I have patient on oxygen how can I know that it's accurate so that's what we're going to look at a little bit more here so the farther the sampling ports are from where the patient is exhaling the higher

the chance of your sample being diluted and not being completely accurate when you're looking at your exhaled gas and you may see something like this picture here so there's some challenges like I said we can do the exhaled co2 can be

diluted the masks we're passing around some masks here some of the masks may allow for rebreathing so when I started and you know in healthcare and especially in anesthesia and such and providing sedation we used to take a

non-rebreather put on the patient and then cut tubing and stick the tubing in one of the little holes okay see a couple of nods of heads here right we make our own and that's how we monitored air going in now but do you think those

non rebreather czar really allowing patients to exhale fully and to get all that co2 out where it's all that carbon dioxide going you you see the mask fog up right now they at risk for rebreathing co2 absolutely so we're

looking at all these challenges right and do you think that little like rigged up mask design was getting a really accurate sample really close to the airway not so much so and you guys are assuming do you guys do T E's and

things where you're putting mouth guards and patients yes no some their sampling issues with that right how do we sample when someone's working in the airway well there are bite blocks now that are integrated and I think we may even have

some here that we can actually capture an accurate sample so knowing the

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

there are some issues that impact human performance and you can substitute issues with human human factors and these factors that some of these factors

are present before an action takes place and those are fatigue stress and boredom dehydration and hunger there are some factors that are directly related to allowing us to make a decision and those are perception our memory our attention

our reasoning and our judgment and lastly there are factors that directly influence how a decision is executed and that's communication and the ability for us to carry out the intended action so a little bit about fatigue fatigue is the

easiest human factor to overcome but it's also probably the greatest human factor that interferes with our performance and our personality so fatigue affects us by reducing our decision making ability it prolongs

response time it increases lapses in attention and negatively affects short-term memory lessons the ability to multitask and it increases irritability moodiness depression and it also decreases our ability to communicate

part of what's built into us our mental shortcuts so we rely on these shortcuts in reasoning to minimize delay or cost or anxiety in our clinical performance you can imagine that if you everytime you had to run a fluid through an IV

line if you had to think back to when you were in nursing school about how you had to open the package take the line out straighten it out put it into the into the solution and run it through if you had to think about those steps every

time you did something or if you're in an ir procedure room if you had to think about every time you go to set up your patient if you had to actually think about those steps it would take you a very long time so we rely on mental

shortcuts however there are some things in our human condition our human factors that interfere with that and this is cognitive bias and hindsight bias so cognitive bias is a mistake in reasoning or evaluation and it often occurs as a

result of holding on to preferences or beliefs regardless of information in front of us and it's actually an attempt of our brain to simplify information processing hindsight bias works similarly but it calls upon experiences

that we've had in our past and we use them moving forward and what that does is it gives us cognitive dispositions to respond and those are jumping to conclusions seeing what's already expected whether it's actually there or

not it's a bias towards action versus non action so you may want to do something but really the better patient safety may be to wait and collect more information so that non action and assess get more of an assessment and

then there's an overconfidence bias these cognitive factors can contribute to diagnostic error in about 74 percent of cases

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

so reviewing the evidence in relation to respiratory depression and airway

compromise respiratory depressions been identified in ninety and ninety two claims of which seventy seven percent have resulted in severe brain damage or death eighty-eight percent of respiratory

depression events occur within 24 hours of a surgery or sedation related event and 97 percent of these were judged to have been preventable with better monitoring so where does capnography fit in with all of this with with your areas

well if you're starting capnography monitoring in your procedure and carrying that over into the post-operative or the post sedation care unit or in your own recovery units where you're recovering them before you send

these patients to the floor that could be part of a bigger picture they can continue on the capnograph even monitoring onto the floor and be monitored with that so that they are monitored throughout the entire time so

by starting capnography you may be actually implementing a monitoring strategy that hopefully could be carried through for that patient for the next 24-48 hours if they're receiving pain medications and such so when we look at

some of the factors for respiratory compromise we have patient factors right intrinsically they may have diagnosis that we do not know of like obstructive sleep apnea there hasn't been diagnosed polypharmacy some of the treatment

factors things medications that we give illnesses that they're coming in with or lying in bed developing atelectasis maybe have pneumonia they bring in their own illnesses and then the area of care factors right weather monitoring is

continuous or episodic in nature and certainly the interventions and you take all of these things together in this Venn diagram sometimes that can create the perfect storm for creating an adverse event related to either opioids

or sedative use and how do we monitor for that how do we figure out which patients we need to monitor there's so many complex factors we really need to anticipate the consequences right and monitor appropriately so moving on to

etiology and I keep the slide in here and I know it looks very basic oxygenation and ventilation oxygenation process of getting oxygen into the body onto the red blood cells and transported to these cells for cellular metabolism

and Krebs cycle whereas ventilation is removing carbon dioxide from the body these are two separate physiologic processes and sometimes these terms are used appropriately interchangeably they are

related to one another but they are separate processes we can oxygenate patients with ECMO with passive oxygen APNIC oxygenation High Flow oxygen but can we eliminate carbon dioxide without ventilation and the answer is no we need

to ventilate to get the co2 out and the co2 is a very important regulator of pH so how do we monitor ventilation and

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

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

campuses okay so now here's more of an introduction to our practice and to help you understand why we had to create these guidelines to use so within our

practice we have approximately 22 CT scanners we'll have 25 by the end of the year we have 40 M our scanners one of them being a 7 Tesla scanner currently we are doing head and knees on that scanner but yes it's open to clinical

patients it was really great bringing that in last May and then we have 50 ultrasound scanners we work amongst 78 CT technologists they work within the diagnostic imaging and procedural practice so our CT technologists go back

and forth 115 M our technologists and 90 scenographer 's we also have a hundred and sixty-five frontline nursing staff that work across our practice and 165 radiologists and procedure lists so understanding that concept is why we

needed to standardize this we could not accept our nurses to memorize what types of hold times or what types of medications each physician was concerned about here are some of the common types of

procedures note we do lots of other things but these are our big hitters this is what Kari and I are involved in most every day deep organ biopsies your liver kidneys pancreas drain placements intra-abdominal biopsies bone lung

biopsies breast biopsies superficial biopsies paracentesis thoracentesis basically any fluid aspirations fine needle aspiration superficial drains and chest tube placements and now I'll have

thank you for joining me this morning as we talk about patient safety and risk management we're gonna touch on a number of different things but for starters can I see how many of bedside or procedural room nurses CTM our procedural room excellent okay all right okay all right

any leaders charge nurses directors awesome all right by chance are there any physicians in the crowd all right okay cool welcome thanks again for coming okay so just to note I have no financial or educational conflicts of

interests all right so today we're going to be talking about and discussing some key patient safety influencers in health care we're going to take a look at something that's called human factors engineering we're going to look at

educational and global human error reduction strategies and we're going to take a look at the just culture concept and its impact on patient safety Event Reporting so according to some statistics from this year for patient

safety week which was March 10th through March 16th so just a few days ago there are about that occur due to patient due to adverse events and 10 to 20% just to highlight a

few 10 to 20% during medical examiner cases they find that there have been some misdiagnosis during that so arriving at an accurate diagnosis is fundamental to the practice of medicine yet according to the 2015 Institute of

Medicine report most patients will experience at least one diagnostic err in their lifetime this report will also note that diagnostic errors contribute to about 10% of patient deaths and account for up

to 17% of adverse events during hospitalizations so currently we have about 41% of Americans who say that they've experienced a medical error either in their own care or that of a loved one or a friend and the National

Academy of Medicine and just a word about the National Academy of Medicine the IOM in July of 2015 changed their name to the National Academy of Medicine so this statistic comes post July of 2015 and they're

suggesting that 5% of US adults who seek care in outpatient settings experience a diagnostic error so that's the reason why we're here today so when we're

is my cap nog Rafi reading actually I want to back up a little bit here do I want to back up no I don't I don't want to back up so um let's look at the first

question why is my cap nog Rafi reading abnormal so let's first talk about physiology so a question I get a lot of times is sue the patient comes down for a procedure to the floor I put a sample line set on

them I plug them into the monitor and I'm getting a value of 28 29 30 why are my values abnormal anyone ever see this is anyone still awake okay so there's a few reasons the patients that we are dealing with generally aren't

healthy right I mean sometimes I go to work and I get chest pain I'm like can I just be in an ambulatory gallbladder room today because the patients that are coming from down to IR are sick what their physiology is sick too so we have

Krebs cycle we take oxygen in right it circulates to ourselves it participates in aerobic metabolism we get the byproducts of heat and energy and we get carbon dioxide as a by-product carbon dioxide really diffuse about diffuses

into our blood travels to the lungs and gets exhaled where we measure it so let's talk metabolism really quickly so if someone has a fever if their metabolism is ramped up you think they're gonna be producing more carbon

dioxide yes let's say they're a little hypothermic maybe they're gonna be producing a little bit less you see it for sure in the car patients who are cardiac arrest that are cool to status post cardiac

arrest right those values go way down normal physiology normal physiologic response somebody comes down and they're mildly hypoxic they've got pneumonia or some sort of VQ mismatch and they're hyperventilating to UM debeso

compensate for their hypoxia do you think there's co2 values gonna be a little lower at baseline yeah so these are the patients that you're seeing right so we have reasons that patients could be hyper cap neck like metabolism

right somebody who's in pain someone who's developing a fever early stages of sepsis they may actually have a little bit of a higher value somebody who's sedated or hypoventilating may have a higher value and when we talk about

perfusion is the blood moving round and round is that circulating co2 coming back to the core do we have increased cardiac output with continuous constant ventilation and certainly we can we're gonna look at equipment issues next and

the same goes true more probably in your cases of the hypocapnia patient so someone who is not fully exhaling someone who's in bronchospasm or a COPD or you're not getting that nice square waveform you're only getting some of the

mixed gas ventilation that they're exhaling rights and the conducting airway is mixing with the alveolar gases someone's a little hypothermic someone who's been NPO for 24 hours right it's the opposite of carb-loading right so

you kind of throw them into a little bit of like acidosis you know they're kind of not burning carbs for fuel are they gonna be producing as much carbon dioxide not so much right so when you're coming so when

patients come down to you and you put them on the monitor consider these things so ventilation perfusion gradients so we have what we call our VQ matches and our body is designed beautifully right so when everything is

working great it works great so the way we ventilate all of our lungs owns is very closely matched to the perfusion of all of our lungs ohms so by me standing up here I'd like to think I'm pretty healthy if you did a blood gas and you

put me on one of those filter line sets right now you would hopefully see a gradient that's very small the normal gradient between a PA co2 on a blood gas so the level of carbon dioxide on a blood gas in the arterial blood and what

you see when I fully exhale into the monitor should be between two and five millimeters so these are your patients come down healthy physiology you put them on and you get a value of like 32 then you

could assume that if they were healthy two to five millimeters okay their blood gas would probably like 35 for POC to everyone follow now does any of our patients read the physiology tech books textbooks no they typically don't so

when you have patients come down they may have shunt right so they may have we have our little airway here a and B you're out like picture them as lungs and lung a is blocked so we have no ventilation going to lung a but blood is

still chugging through right so blood is still going through the pulmonary circuit so we're gonna have Patapsco a dia depending on the size of the shunt is this the end of the world are we gonna cancel the case no but just being

aware of the patient's physiology would explain to you why I put this patient on this and I'm getting a value of 30 you follow and it's not the end of the world you document 30 and you monitor for trends as you're going along with your

sedation same thing goes through with dead space dead spaces were ventilating but we have an area of the lung that is not being perfused pulmonary emboli other circulations some medications hypovolemia shocky patients same thing

the VQ mismatch not the end of the world it's part of the patient's physiology maybe part of the reason why they're down there just being aware of these things though so the technology works right our equipment works if just amazed

it's picking up something that we don't connect all the dots on physiologically that sometimes confuses us a little bit so I hope that clears up part of it so when we're monitoring capnography certainly ventilation is what we think

of first and it's important co2 being expired by the lungs that's what we're looking for but if we back up and look at the physiology of carbon dioxide production in the body we are also inferring that

it's being metabolized and being created from Krebs cycle and aerobic metabolism and that we have perfusion occurring okay I'm sure if some of us have seen in our you know nursing careers patients who are kind of peri-arrest and

the capnography kind of drops off it's like a poor man's swan you're watching cardiac output drop in real time because carbon carbon dioxide is not being delivered to the lungs so when we're looking at our patients when

they first come down we first want to establish a baseline value we want to put on a monitor have a patient take some nice deep breaths full ventilations not just one but a few you want to you know have them take a few and look at

their other vital signs their mental baseline status and we're gonna look for trends in their carbon dioxide value so if someone starts off at twenty nine I don't care that they're not 35 to 45 which is textbook normal this person may

not have the stimulus to breathe if I let too much co2 accumulate so we're really looking for the trends okay now somebody will say well how much of you know how much should we look for 10 to 20 percent change from your baseline is

somewhere where you want to start paying attention to what's going on okay maybe like titrating your sedation or just being a little bit more cautious with how much more sedation but again it's more important to look at the trend

value behavior of your carbon dioxide than it is the absolute numbers themselves so first you having a problem let's consider the patient's physiology

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

going to open it up to any talks or questions great great question great question so

her question was do we share these guidelines with her inpatient nursing staff yes I did a clinical Grand Rounds where we kind of over viewed but no expecting them to remember this and understand it no but it is available

online within our my own Mayo Clinic intranet for them to refer to but then that also comes down to our nurses calling the flora nurse - because they're really screening these patients and then calling and having that

conversation with our floor nurses and then just prior to Kerri and I travelling here these guidelines are also being shared across our enterprise for enterprise conversion so Arizona Florida and Rochester the referring

clinician yes yes yes so that's why okay so that's why it's really important to have that physician to physician disgusting yes our radiologists are not putting through these orders to hold these medications

that's a very good point to make that is where our radiologists will be calling the ordering clinician and determining hey I really strongly encourage you to hold this medication on this patient if you disagree what are your objections

and then they discuss the plan going forward from there our microphone isn't working hello yes yep so you you want to take that yes we do have like I shared I would love to be

doing these phone calls a week in advance we have not gotten that far but that's something that we're looking to you can explain the company we run into this on a daily basis yes and you know with all the health systems and we have

so many people ordering these procedures that don't understand what we do what our coagulation guidelines are a lot of our physicians in the Health System and other parts of the clinic have access to that ask Mayo expert which which does

follow that guideline so it is available but a lot of times we are finding patients that are getting added a day or two before and the bulk of our pre procedure phone calls are done the night before the procedure so when that

happens and we call the patient and they say oh yeah I just had a stent placed in my Hospital in Montana a week ago then that's the point at which we have to turn it over to the radiologist and say can you look into this and we have

fellows often that will look into that the night before and the procedure may be rescheduled it may be delayed or it you know been depending on the patient condition they may have that risk-benefit conversation and decide to

proceed yes so yes and no so in our practice a lot of these patients are all patients strictly outpatients so a lot of these patients are not even sent to an AM admits they come directly to radiology

they report right to our desk but with the phone calls the we what we use epic how many of you guys use epic so scheduling we do have scheduling triage is yes so our scheduling triage right now

because I can't give them all these guidelines we've put in our big hitters we have them ask are you taking any new blood thinning medications do you take warfarin that's the one medication that we do call out so yes sorry

yep I've misunderstood what you're asking it does yeah yeah you know your exact yep so good point and when we first rolled these out I sat down with our scheduling supervisor and we updated all of our

triage is to reflect because we did have it in all of our procedures and then we removed it from some [Music] they need it for the semen we say Menards

yeah okay and you [Music] yeah mm-hm yeah it's so good what world

you know and I would like to add so what we're trying to do now that we have a Peck we've just recently rolled it out so we're trying to optimize it trying to create BPA so that it can pull these medications and give an alert to the

ordering clinicians boat and then you run into alert fatigue and things like that but that's that's our next step in this problem we do where you know we're fortunate so that yeah okay do you want to we share that we share

that tub so her question was when you have when you do identify in a patient's chart when you're doing a review that the patient is on one of these medications who has that conversation with the ordering clinician and we're a

little bit spoiled in that we typically have residents and fellows and so our staff radiologists might not want to have that conversation but we do tend to have a fellow who sort of triage is all those problems both in the late

afternoon and in the morning before we get started so they can call providers and have those conversations and if it's at the point where the patient is already there then it's too late for that conversation so then that becomes a

you know supervising radiologist and patient discussion all right yes I uh I'm full disclosure we do not get all of our pre-procedure phone calls done we do the best we can and we prioritize it and oftentimes we're doing

it up until eight o'clock at night and we are pretty selective about who we call we're not if we have a lot of cases we're not going to call low risk procedures we're not gonna call the repeat biopsies if they've had a biopsy

in the last few months yeah repeat procedure call and and and so that's where we differ - so in our practice we do not use moderate sedation for any of our ultrasound guided procedures or even our deep organ

biopsies shouldn't say any we yeah right never say any board's question but uh very rarely do we local only no blocks yeah but those are for our low-risk bleeding procedures or our deep organ kidney

livers pinks oh yeah oh all that's in there patient appointment guide also it's mailed to them but then also we have a Mayo Clinic app so they can just click where their

appointment is and the map we're spoiled because there's big infrastructure but if any of you guys have any questions please feel free to reach out to a carrier myself again it's in your handouts so thank you all

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

Kerry go into kind of a refresher from

this morning for you all this is a video from a liver biopsy and let's just start that no we actually don't know how to play this from the clicker okay

so this is just a short clip to show normal bleeding everybody bleeds and all the procedures that we do involve placing needle in the patient so we are going to have some amount of bleeding and it can range from seconds to minutes

and hopefully it's a fairly minimal amount of blood loss typically what happens is the needle is inserted into the patient the body detects the injury clotting mechanisms are activated hemostasis is restored which sounds

pretty simple but as you may remember from this morning there are a lot of different mechanisms involved that make that happen and we wanted to just provide a brief overview for those of us that have been out of nursing school for

a little while so we thought it would be helpful to start with just a brief generalized overview the first step obviously is the endothelial injury platelet plug forms the coagulation cascade starts we get a clot and then we

have the Ambo thrombotic control mechanisms and the fibrinolysis in our practice we're really just concerned with the first two we really just want to make sure that the patient has the ability to clot so here's a fairly

simplified version of the coagulation cascade the factors are the Roman numerals and to keep it simple we've just included a few of them so we have a wound occurring the endothelial cells release the tissue factor which combines

with some factors we get factor 10 release produces thrombin and eventually fibrin we also have this amplification loop that's happening at the same time so we need some of these factors we need the thrombin for this all to work

so at this point we have thrombin being generated by the pathways more being created by the amplification process and that thrombin then binds to these platelet para scepters up here and that initiates cofactors assembling on the

platelets which makes them sticky causing them to adhere to the site of injury when the platelets are activated we have the adenosine diphosphate molecule or ADP that's also binding to some receptors specifically I didn't

include the p2y on this but the p2 y 12 which then eventually winds up activating this molecule down here that molecule is normally this complex I should say is normally folded over but when the platelet is activated it

unfolds and it allows the fibrinogen to bind and then that secures the platelets to each other so with the medications that we run into in our in our practice one of the ones that you learned about this morning where the direct factor 10

inhibitors we typically see Xarelto and Eliquis the most in our practice and as you can see by the red stop signs there are two places that these inhibitors work here and here they bind to the thrombin while the while the drug is

circulating in the blood which essentially removes that factor Xa from the equation if we don't get thrombin we don't get a thrombus we don't have a plat no these things do have a relatively short half-life and in our

practice we do not monitor these with routine labs the direct thrombin inhibitors Pradaxa is the one that we see the most work one step further down the chain these are actually interfering with the power receptors so they bind to

those and that prevents the platelet activation and aggregation these can be monitored with a PTT although research tells us that it doesn't necessarily correlate with the actual levels circulating in the

blood and the different methods of sampling aren't consistent so this is not something that we routinely monitor with labs in our practice as well and I do have agents and clinical trials on here they were in trials I believe at

the time we started doing this research but as we learned this morning some of them are currently available and these do have a short half-life so their effect is relatively limited and they are reversible so the inhibitors that

work on this p2y twelve receptor are actually binding to that receptor and this is irreversible so this is going to affect the playlet for the life of the platelet seven to ten days and as we learned this morning there's a certain

amount of turnover happening all the time so there are always new platelets being produced so if we stop this we don't necessarily need to hold it for the entire seven to ten days but it is something that's going to take a while

for the patient's body to overcome and the thing that we wanted you to note about this this is an inhibitor it's an inhibitory effect so it's not necessarily captured that accurately by lab values the platelets are still there

they just don't work as well and so you can do a platelet count but it's not going to show you how well those platelets are functioning so again this is another medication that doesn't really get captured with lab values

sorry little operator error here on the remote control so the Cox inhibitors aspirin is the one that we're probably most familiar with same kind of thing aspirin is permanently affecting the platelet over its lifespan of seven to

ten days the ibuprofen the naproxen or Aleve the effect is much more limited for these medications so we're going to hold these again these are medication that will not necessarily be accurately reflected by a lab value so in our

practice we rely on oral confirmation of the last dose we literally ask the patient when was your last dose of advil when was your last dose of aspirin and we can compare it to our procedural guidelines

we also talked about these a little bit this morning we have the vitamin K antagonists warfarin is the one that you hear about you also hear about it called to mannan by the other name the liver is producing these clotting factors which

are reliant on a reaction that happens with vitamin K these things actually work by interfering with the vitamin K cycle now if you put more vitamin K in this reaction can still happen or if we add FFP that already has these factors

in it the patient has the ability to clot so this is reversible we can also choose to not reverse patients that are on warfarin Nikhil talked a little bit about the bridging that we sometimes do with patients that are on warfarin but

this is one that we still encounter pretty frequently and typically it is monitored with the pt/inr and we are currently screening for angiogenesis inhibitors in our practice these are used to treat different kinds of cancer

the one that we are primarily concerned with is the imbruvica the mechanism of action how this causes bleeding isn't fully understood but it's thought that since these inhibit the development of endothelial cells those cells aren't

available to release the factors needed to start the clotting cascade and especially if these are used in conjunction with anti platelets or anticoagulation they can really have a it can really have an effect on the

patient's bleeding risk and they can also cause thrombocytopenia thank you

okay second why is my camp nog raphy reading abnormal now let's look are you

measuring a true sample of the patients and tidal volume so again we have some of these campin ography waveforms here and in the yellow blocks I'm gonna play it again we're gonna play it again in the back we're gonna look at the

hypoventilation again nice square waveform but you tell the patient take a deep breath and all of a sudden you see the amplitude go up so just because we see little boxes yeah the patient's breathing but are they really taking a

full deep breath this is the patient that you got a baseline on and they were normal and now you started your procedure and now your values are like 28 29 guess what the value probably didn't drop in their blood

it's just a probably not exhaling as well did you flip them prone are they on their side you follow did you change something with their airway so now looking again at the classic hypoventilation okay this is somebody

who is taking deep breaths so we have our normal waveforms here on the top okay that would you hopefully you'd see before sedation and you know what you might see that drop off a little bit during your sedation is at the end of

the world no because you're watching trends every now and then you might tap them on and say okay take a deep breath but you know that they're still ventilating right but if we start to see examples of partial airway obstructions

or complete airway obstructions that's when we want to intervene on the bottom I included the hype optic hypoventilation this is what we see a lot of you see some squiggles and you're like okay airs moving in and out but how

come my numbers aren't adequate that's where you're like are they effectively exchanging are they emptying out their full tidal volume and you give them an Ambu bag breath or you stimulate them and you are you give them that chin lift

and they take that big deep breath and that's what you see is the actual waveform going up that's more of a representative sample and you got to be careful with that they get too much co2 retained again the sedation gets worse

and they may eventually stop breathing from that so look at this waveform here we have an amplitude of five we have us reading to five and a bunch of these square little boxes that's an example of somebody who is making some effort but

are they effectively ventilating not so much so this is the patient that you again you give a you know good breath open the airway stick an oral airway in or do something to stimulate them and then you see that you're like now I'm

ventilating appropriately so looking at another troubleshooting this is really common in the IR Suites from what I seen and I'm sure you guys have seen as well is co2 re breathing so patients are exhaling and what you're seeing here

notice how the baseline in that waveform is not returning to zero so patients are exhaling and then they're inhaling exhaling inhaling they're not clearing the carbon dioxide that they're exhaling out so how

is this happening well what do we do to pee like you guys are working in environments that are certainly not pristine we are flipping patients over there on their side they're draped so we have this beautiful little tent of

oxygen don't even get me started on the combustion cycle right but we have this beautiful Lake draping of a tent and patients are exhaling and where is that going so the last thing we want is somebody who's potentially going to be

hypoventilating then rien hailing carbon dioxide because not enough fresh gas flow so this is also patients who are just shallow breathing right they're inhaling exhaling and they're really exchanging

mostly dead space or this is someone that you put the oxygen mask or maybe you start with a nasal cannula and then you want to increase their fio2 so you put a mask on but you forget to plug the mask in instead of a nasal cannula it

happens right or the oxygen mask gets unplugged or the tubing gets runned over or the connection because it's like a mile away gets disconnected these things happen but if you see a waveform like that these are things to start to think

about right what's going on where my patient is rebreathing carbon dioxide so first we're gonna look at physiology do we understand the physiology of our patient and what our patient is trying to tell us second are we really

assessing an effective ventilation are we really assessing the adequacy of ventilation so instead of just skiing square bumps on our monitor are we seeing something that we saw the beginning of our case or are they

hypoventilating are they not effectively exchanging so that's the second thing we

interested okay let's look at the

literature so when we look at the AAA say they were the ones that you know they look at a lot of sedation claims and the close claims are what they look at the causative factors of adverse incidents and when they look at sedation

claims that occurred outside the o.r it's sometimes it's been referred to as the wild wild west of anesthesia yeah when you're outside the o.r environment and you're in remote locations the incidence of things going really wrong

increases significantly and I'm sure you guys are no stranger to that right but in remote locations a lot of the claims were judges being preventable thirty-two percent of the time versus eight percent of the times

that that happens in the operating room 62 percent of claims with over sedation as their cause could have been prevented by better monitoring and these are anesthesia providers that are looking at this right and we're seeing the

anesthesia providers have been using capnography and other advanced monitoring as their standard of care for a very long time certainly sedation and claims in monitored anesthesia care these are you

know cases where we're not into baiting the patient very common 21 percent in the specific claims related to Mac anesthesia and again the common denominator here was lack of monitoring or better monitoring could have improved

outcomes so when we look at the professional associations we have UAS a we have the European Society of anesthesiology the Society of gastroenterology nurses and then certainly your organization right the

association of radiology and imaging nursing and what your statement is with capnography it's a RN endorses the routine use of capnography for all patients who receive moderate sedation and analgesia during procedures in your

imaging environments right and and there's certainly there's their statements from many organizations that are all along these lines one of the questions I often get is - well how come we have these recommendations we have

these you know endorsements and such but we're not you know mandated to use it and a lot of that is political there's a lot of pushback from organizations that are gonna come out and say you must use this you know or else they could

strongly recommend things in the anesthesia world it is one of those things that but it's been a long time and I think in time you're gonna see the movement become more strong as far as recommendations go but for now that's

where a lot of the claims are strongly encouraged strongly recommend and such but that means that we should be doing it because the evidence is proven that that it is safer for patients so let's look back at our case study so later in

the procedure our patient develops the following pattern on the monitor you stimulate the patient and position the airway and you have no response what should your next step be nothing because the pulse oximetry is

normal hold additional sedation meds until breathing normalized supplement breathing with a BVM if if required to maintain acceptable and tidal co2 give a reversal agent or intubate the patient well the correct answer would be

to hold additional meds monitor the breathing and supplement the breathing with a BVM see if you can increase the ventilation to maintain acceptable levels well now we're further deteriorating so our same Jane Doe

patient is does not respond to your previous efforts and the end tidal co2 continues to rise followed by a sharp drop in our spo2 concentration despite being on oxygen then the following waveform appears what do we do nothing

decrease our oxygen give a reversal agent or intubate okay I heard some C's what do we want to immediately do she's kind of acutely dropping so yes C would've been correct maybe a slight ago you know before she's really started to

desaturate and certainly that would be correcting the problem but immediately before she decreases her SATs any further becomes any further hypoxic recommendation is to establish an airway

so I actually work mostly in

interventional radiology in CT and ultrasound which is actually on a different floor that where we have our cath lab and I our stuff upstairs so that I our doctors are each going between two floors and one of my biggest

concerns is when we're doing moderate sedation the nurses are down in CT and ultrasound it doesn't matter how many comorbidities the patients have the aasa' is always three or less because they want to justify doing it downstairs

with just one nurse and the procedure list and I just and then you have somebody who obviously needs to be having anesthesia involved and now the anesthesiologist or the nurse anesthetist they get a circulating nurse

with them and I'm just wondering is there a cut-off that anesthesiologists or nurse and necess use for saying okay the a SA when it's this you have to consult with an anesthesiologist before you proceed with a nurse just giving

sedation that's a great question and that's institution unfortunately that's one of those things that is like institution dependent policy and procedure politics finances you know sometimes you'll see patients who really

are in a sa three four or four and a half that are made to be an a sa to write you know so they could be done during off-hours without anesthesia unfortunately it's a symptom so the organization's ever sit together and say

let's look at this globally for the patient safety and if we're doing sedation in this scenario we should still have somebody there who's trained to do the backup for that person I can't speak to your organization's policies

because I don't know them I know that they recommend catalog' Rafi I do know that the avenues to look at would be the Joint Commission in the anesthesia patient safety foundation you know for guidelines and again guidelines are just

that they're guidelines they're not mandates especially you know when institutions develop policies procedures protocols and such I do know on the third bullet down is we have a whole implementation project that we've rolled

out so one of the questions in addition to technical questions we get is how do I go to my institution and kind of change practice a little bit and usually the question is like implementing capnography but it it's a three-part

series that we did on how to implement change in an organization who are the stakeholders who are the champions who can you really talk to that would create change and whether it's the chief of anesthesiology is the person who's your

roadblock or your best friend is it the VP in nursing is it the safety committee you know cuz it takes one adverse event one Sentinel event unfortunately sometimes to change culture it takes more than that I know I know we're

trying a little at a time though but think it was a great comment in question was just made in our institution anesthesia kind of hit at this because the nurses were concerned about what she was just saying and so they worked with

the directors of like IR cath lab the medical directors to you say let's come together and figure out you know if it's a four it doesn't mean that every four needs to be you know it can be given sedation can be given by nurses but at

least get an assessment or things like that and in our institution nurses are able to if they feel like they needed anesthesia consult they can do the anesthesia console it doesn't mean they're gonna have anesthesia but

anestis you can tell you what to give and what not to give mm-hmm but that's that's what they're trying to do they have done for cath they're doing it for IR too and that is I forget them term for it but that's a team collaboration

and so and I must said where we work we actually screen the charts ahead of time because we have some really remote places and some not as remote and it's like the litmus test you know somebody with a BMI 55 is not going to be done

down the street they're gonna be done where emergent resuscitation is right upstairs if needed and same thing holds true like in our institution like anybody can call a patient safety stop meaning like I don't

feel comfortable with this let's not go forward and and again the procedure lists are another list of those champions because procedure lists they care about their pain you know they don't want to see adverse outcomes and

they're so focused sometimes on what they're doing that they kind of black you blank out on some of the peripheral factors and no one wants to see something bad happen on their watch so the procedure lists can be

instrumental in getting better monitoring or advocating for advanced levels of care or at least support for the nurses to have there's another question in your experience are the waveforms the same as far as a

ventilated patient versus a non ventilated patients have you seen any discrepancy in the actual performance that waveform itself yes and no okay so so I'm ventilated patients somebody who's really hyper dynamic I mean I've

seen like you could see sometimes their heart beating you know like just some of the little fluctuations or oscillations for the most part no difference if the non-invasive ventilation patient is getting monitored really right where the

gas is being exhaled like right here you may see some other you know and somebody is intubated so if there's secretions you might see like a little you know blip and such but when things are perfectly working the way they should be

working in both the intubated patient or the patient with an artificial airway versus not the waveform should be spot-on but if you're not seeing that is it a COPD or is it somebody who's got you know bronchitis in there yeah if

you're not seeing that full square waveform the question should be why not is my equipment not working good question great questions did the sign-in sheet make its way I know the spiral bound notebook is over

here but please do make sure that you put your name your email address and you'll be emailed because so you could fill out an evaluation and make sure that you get c e for attending this opportunity today I hope you guys

enjoyed it I hope you took something out of it I hope this just wasn't the basics for you today I hope that there was some value added in to coming today please do hang around we'll be here we'll be in the exhibit hall I know that there's

going to be many more events that are have this afternoon but the rest of the team will be here and we really do look yeah I love working with nurses that are providing sedation's I feel like you're the you're my people you know but you're

the people that are doing this day in and day out and you really are that that patient safety advocate and I feel like when I speak to a roomful of people that you guys go out and teach your precept ease and create change that's going to

impact patient safety so thank you for your attention today and thank you for attending [Applause]

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

questions comments and accusations please hello this topic is very personal to me I've had it actually had a UFE so this is like one of my big things I work in the outpatient center as well as a

hospital where we perform you Effy's and frequently the radiologist will have me go in and talk to the patient it's from a personal perspective one of the issues which it may just have been from my situation was pain control post UFE

whether you normally tell your patients about pain control after the UFE someone say we are all struggling with this yeah oh it's not what's your question is going to be okay good I'm gonna get doctor Dora to answer Shawn the question

is what do you what do we do with this pain issue you know what are you doing for the home there at Emory there you know and a lot of practices we we don't rely on one magic bullet for pain control recently we've been doing

alternate procedures for two adjunctive procedures to help with pain control for example there are nerve blocks that you can do like a superior hypogastric nerve block there's there's Tylenol that can be given intravenously which is seems to

be a little more effective than by mouth there's there's a you know it and a lot of times it's it's a delicate balance right between pain post procedural pain because you can often get the pain well controlled with with narcotics opioid

with a pain pump but the problem is 12 hours later the patients is extremely nauseous and that's what keeps her in the hospital so it's a it's a balance between pain control and nausea you can you can hit the nausea

beforehand using a pain and scopolamine patch that that'll get built up in the system during the procedure and that kind of obviates the nausea issues like I said that the the nerve blocks the the tile and also there are some other

medicines that can can be used adjunctive leaf or for pain control in addition to to the to the opioids so the answer the question is there are multiple there multiple answers to the question there's not one magic bullet so

that helped it did one of the things that I tell the patients is that you know everyone is different and yet some people I've seen patients come out and they have no pain they're like perfect and then some come out and they are

writhing in the bed and they're hurting and they're rolling all around what and I always ask the acid docs are you telling them they could possibly have you know pain after the procedure because some have the expectation that

I'm going to be pain-free and that's not always the case so they have an unrealistic expectation that I'm gonna have the UFE but not have pain what I also tell them is that the pain it's kind of like an investment right and

this is easy for a guy to say that right but but it's it's an investment the worst part the worst pain you should be feeling is the first 12 12 hours or so every day I tell my patient you're gonna be getting better and better and better

with far as the pain as long as you is you follow our little cookbook of medicines that we give you on the way home and I want you to make sure that you fill these prescriptions on the way home or you have someone fill those

prescriptions for you before he or she picked you up in the hospital and lately we have been and I see that you're there as well lots of other little tricks that are out there right and again there are all

little tricks so ensure arterial lidocaine doctor there is near alluded to and if you're on si R Connect you may it may spill over on some of your chat rooms here people have been using like muscle relaxant like flexural or

robertson with some success but just know that we don't have any studies that tell us how that's supposed to do so when i have someone that is like writhing in pain i just use everything so i do it superior hypogastric nerve

vlog and i actually will do some intra-arterial lidocaine although not so much lately i have been using the muscle relaxant but i will warn you that i've had two patients with extreme anticholinergic effects where they are

now not able to pee from that so you know where we're doing that balance act I see that you're there can I take that question here first just so we're we're doing the same thing we're using the multimodal just throwing all these

things at people and we're trying the superior hypogastric blocks but we're collaborating with anesthesia to do that right now do you all do your own blocks or do you collaborate with anesthesia we do our own blocks okay it isn't it is

not that difficult I would tell you that but again it's kind of like you know you got to do if you start feeling better and then you're like we don't really need them we'll just do it on our own okay thank you again yes what's the

acceptable interval between UFE and for IBF oh that's a your question what is the interval between UFE and IVF so if you wanted to get pregnant yeah and can you have a you Fe and then have an IVF like how long would you have to wait

wait and tell you before you can have that the IBF it I guess it really depends on the age of the patient because we know that that the threshold for which patient tend to have that inability to conceive

is around 45 years old so you know it did below the you know below the age of 45 the risk of causing ovarian failure or or the inability to conceive is significantly less it's zero zero to three percent so I would say that you

know you probably want the effects of the fibroid embolization to two to take effect it takes around 12 months for these fibroids to shrink down to their most weight that they're gonna they're going to shrink down the most I wouldn't

say you need to wait 12 months to put our nine vitro fertilization there's no good there's no good literature out there I don't believe that's your next and so I would say just remember that if you came to my practice and you said you

wanted to get pregnant I will be sending you to talk to fertility specialists beforehand we do not perform embolization procedures as a way to become pregnant there's no data to support that but if you saw your

gynecologist and they said let's do this then I'm sure they'll be doing lots of adjunct things to figure out what would be an ideal time then to for you to have IVF and if I dove not having any data to inform me I would ask you to wait a year

and what will be the effect of those hormones that they gave you if for example a patient has existing fibroids what would be the effect of those hormones that IVF doctors prescribed their patients yeah so fibroids actually

can grow during pregnancy so I would say that most of those hormones are pro fertility hormones so I would expect that maybe you can see some of that effect as well yeah alright if you have any other questions you can grab me oh

you're I'm sorry go with it okay yes we we have time I don't want to keep anybody here for that so I have a two-fold question the first one is post-procedure can you use a diclofenac patch or a 12-hour pain

patch that is a an NSAID have you have any experience with that and your next question my second part of the question is there a patient profile or a psychological profile that tips you that the patient is not going to be able to

candidate because of their issues around pain so they're two separate but we have in success sending people home that first day so I'm looking to just make it better I haven't had experience with the Clos

phonetic patch it's in theory it seems ok you know these are all the these are they're all these are non-steroidal anti-inflammatory drugs so there are different potency levels for all of them they you know they range from very low

with with naproxen to to a little bit higher with toradol like that clover neck I think is somewhere in between so we found that at least I found that that q6 our our tour at all it tends to help a lot so with that said I I don't have

much experience with it with the patch in answer to your second question the only thing I can say is there there is a strong correlation between size of fibroids and the the amount of a post procedural pain and post embolization

syndrome so there really you know we often say we don't really care too much about the number of fibroids but the size of the fibroid is is is should be you know you should you should look at that on pre procedural imaging because

if it gets too big it may not be worth it for the patient because they may be in severe pain the more embolic you put into the blood supply's applying the the fibroid the the greater the pain post procedural pain

are there multiple other factors that would contribute to pain but that's that's one aspect you can you can look at post procedurally on imaging okay thank you very much yes ma'am hi what what kind of catheter do you use

to catheterize the fibroid artery when you pass by radio access yeah so over the last three years the companies have been really very good about that so there are a few things that I without endorsing one company or the other that

you need to make sure that the sheath that you're using is one of those radial sheets a company that makes a radio sheath you should not use a femoral sheath for radial access so no cheating where that's concern you may get away

with it once or twice but it will catch up to you and you need a catheter that is long enough to go from the radio to the to the groin so I'm looking for like a 120 or 125 centimeter kind of angled catheter whether it's hydrophilic the

whole way or just a hydrophilic tip or not at all you can you can choose which one in our practice most of us still tend to use a micro catheter through that catheter although if I'm using a for French and good glide calf and it

just flips into like a nice big juicy uterine artery then I may just go ahead and take that and do the embolization if the fellow is not scrubbed in as well so thanks a lot but they make they make many different kinds like that and more

of those are to come all right I'm you can please please please send us any other questions that you have thanks for your time and attention and enjoy the rest of the living

establish our guidelines this was something this was a question that we got when we did publish our journal article because you'll see when you do

see our guidelines we are not 100% in alignment with SAR that is because we used SAR in a detailed literature review and examined both of those sources but then we also have our own homegrown radiology database our nurses are

instrumental in collecting this data every biopsy patient we collect their medication list as well as their current lab values we've been doing this since 2002 and we currently have over 50 000 patients within that database so we pull

from that database to identify what is best what trends are we seeing what medications are we seeing that are causing issue in our practice so we're taking from our own clinical expertise and then we also have a great panel

within Mayo Clinic it's called ask me Oh expert this panel is made up of multiple physicians we have physicians from Department of Laboratory Medicine physicians from our anticoagulation practices we have our liver physicians

can need lots of different doctors we have two radiologists that also sit on that committee so it's a combined specialty panel so we take we took into consideration all of these factors to establish our guidelines our nurses use

these guidelines when they are performing pre-procedure phone calls so I love to the presentation yesterday from Johns Hopkins I believe where they're doing pre procedure phone calls but often times a whole week before we

don't have that yet but I would love to get to that point but right now our nurses are doing pre procedure phone calls within a few days prior to a patient's procedure and we are going through these guidelines to identify

what medication or risk factors these patients have and we're alerting our radiologists to see if there's any type of considerations that we may need to take if for example a patient has not stopped warfarin and

then they also look for if within our guidelines the patient needs lab values we determine if there's lot values ordered or if they have any within the medical record we want them within 30 days except for if the patient has known

or suspected liver disease we do want them more recently within 14 days or if a patient's on chemotherapy or one of those anti antagonists this is something I really need to stress to our nurses and I think I've gotten the point across

to you that these are guidelines only clinical decisions are made by the supervising radiologist so we've we've put this right in all of our guidelines in that yes these are guidelines that we can use those nurses to help triage our

patients and move and streamline our assessment process but sometimes it does further critical thinking and then discussion you want to go into what you

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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