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Patient Satisfaction in the IR Suite | Anesthesia, Nursing, and Technologists: Synergy of Three Teams for One Common Goal
Patient Satisfaction in the IR Suite | Anesthesia, Nursing, and Technologists: Synergy of Three Teams for One Common Goal
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Patient Safety in Radiology | Utilizing CO2 Angiography to Reduce the Incidence of Contrast-Induced Nephrotoxicity and Allergic Reaction
Patient Safety in Radiology | Utilizing CO2 Angiography to Reduce the Incidence of Contrast-Induced Nephrotoxicity and Allergic Reaction
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Nursing Considerations When Power Injecting CVAD | Preventing Extravasation: The Nursing Role in Power Injection and Access Selection
Nursing Considerations When Power Injecting CVAD | Preventing Extravasation: The Nursing Role in Power Injection and Access Selection
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Select and Secure Injection
Select and Secure Injection
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Risk Factors - Skill of the HCP | Preventing Extravasation: The Nursing Role in Power Injection and Access Selection
Risk Factors - Skill of the HCP | Preventing Extravasation: The Nursing Role in Power Injection and Access Selection
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Extravasation vs Infiltration - What is a Vesicant | Preventing Extravasation: The Nursing Role in Power Injection and Access Selection
Extravasation vs Infiltration - What is a Vesicant | Preventing Extravasation: The Nursing Role in Power Injection and Access Selection
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Causes and Management of Port Extravasation | Preventing Extravasation: The Nursing Role in Power Injection and Access Selection
Causes and Management of Port Extravasation | Preventing Extravasation: The Nursing Role in Power Injection and Access Selection
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Risk Factors and Comorbidities for Contrast Extravasation | Preventing Extravasation: The Nursing Role in Power Injection and Access Selection
Risk Factors and Comorbidities for Contrast Extravasation | Preventing Extravasation: The Nursing Role in Power Injection and Access Selection
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Importance of Fast IV Injection Rates - CT Scan Rates | Preventing Extravasation: The Nursing Role in Power Injection and Access Selection
Importance of Fast IV Injection Rates - CT Scan Rates | Preventing Extravasation: The Nursing Role in Power Injection and Access Selection
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Management of Contrast Extravasation | Preventing Extravasation: The Nursing Role in Power Injection and Access Selection
Management of Contrast Extravasation | Preventing Extravasation: The Nursing Role in Power Injection and Access Selection
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Incidence and Causes of Contrast Extravasation | Preventing Extravasation: The Nursing Role in Power Injection and Access Selection
Incidence and Causes of Contrast Extravasation | Preventing Extravasation: The Nursing Role in Power Injection and Access Selection
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Venous Symptoms Consensus (SYM Vein)
Venous Symptoms Consensus (SYM Vein)
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Contraindicated Sites for IV Insertion | Preventing Extravasation: The Nursing Role in Power Injection and Access Selection
Contraindicated Sites for IV Insertion | Preventing Extravasation: The Nursing Role in Power Injection and Access Selection
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Transcript

Another case of healthy 78 year-old female that her primary complaint which he had rib impingement there on the left when she stood and walked as well as significant stenosis. Close-up

view. Once again screws once you take the time to dissect the screws just go in perfectly and it's really dramatic how accurate the guides really are. So a few

So a couple of things. So we got this state back,

and it was important in IR suite, it's patient satisfaction. You know CG CAHPS, HCAHPS, that's very important for patients how they felt during a procedure, right. The other thing that's very important in IR right now is the opioid epidemic right, pain.

Prescription of opioids. And actually one of these, these two things anesthesiologists are good at.

Radiologic contrast agents have properties that categorize them as vesicants, and I would like to discuss two

of its clinically relevant properties. First is osmolality. Osmolality describes the concentration of a solution. It is the ratio of solute to solvent, and on the screen here, I am going to show you the osmolality of blood, of plasma,

as opposed to the osmolality of the contrast media. The reference range of serum osmolality is 275 to 295 milliosmoles per kilogram. And we have the high-osmolar contrast medias, which we know as the ionic contrast, has an osmolality

of 1,400 to 2,000 milliosmoles per kilogram, which is five to eight times more concentrated than that of plasma. We have our non-ionic contrast, or the LOCMs, which is 600 to 800 milliosmoles per kilogram. This is what we use at our institution.

It is two to three times greater than that of plasma. And we have the iso-osmolar, or the non-ionic dimers, which has approximately the same osmolality or concentration than that of plasma. Now when a solution is highly concentrated, it is thicker, which brings us to the next clinically relevant property

of contrast media, which is viscosity. Viscosity is the measure of the resistance of fluid. And I googled this, in simple terms, it is the measure of fluid's thickness. The thicker and more viscous a solution or a contrast media, the greater the force it will need

to be administered into the patient's body. It is almost like injecting syrup into the patient's veins. It is this viscosity that causes vein spasm and discomfort along the site of injection.

- I guess we can all agree that patient safety is paramount in the radiology department, in the vascular suite or otherwise. We're all very concerned about keeping the patient safe. That's why it's important to discuss

alternate contrast options. The use of contrast may present some safety concerns for certain patients, like the one we just talked about. Those with high risk for developing contrast-induced nephrotoxicity, and those who may have allergic reaction to contrast.

The American College of Radiology states in their manual on contrast media that patients who have had higher allergic- - [Audience Member] Can you speak into the microphone? - Sorry, is that better? - [Audience Member] Yeah.

- There's some background noise too. - According to the American College of Radiology, patients who have had a prior allergic or allergic-like reaction, or an unknown type of reaction, like those people who say that they're allergic to contrast but they can't articulate what that reaction may have been,

which I'm sure you have all run into, they're at a five times greater risk for having another reaction to contrast of the same type. So if they reacted to Omnipaque or Visipaque, something like that, they're at five times greater risk for reacting to contrast in the same category.

It's therefore conjectured that strategies to improve patient safety through the reduced risk of contrast-induced nephrotoxicity and anaphylactic reaction, while maintaining high quality images, includes the use of CO2 angiography.

So what happens in acute compartment syndrome?

We have multiple compartments in our arm, forearm, hands, and wrists, and these compartments have a relatively fixed volume. During large extravasations, the compartment pressure increases to accommodate the extravasated fluid,

and that will lead to increase in venous pressure. So when the venous pressure is greater than the capillary perfusion pressure, the capillaries would collapse, and that would lead to decrease in tissue perfusion. When the capillaries collapse,

there's no blood supply going to the muscles and nerves, and that would lead to muscle and nerve ischemia. So what are the signs and symptoms of compartment syndrome? First sign is usually pain, pain that is progressive, pain that is greater than the... Pain that is progressive,

and pain that is greater than the initial injury. Paresthesia and poikilothermia, poikilothermia refers to the change in the temperature, so the affected extremity feels cooler compared to the unaffected extremity. Paralysis, pallor, and pulselessness

are all considered late signs. This means that there's no blood circulation going to the nerves and muscles.

In case of severe contrast extravasation, we arrange for transfer to these patients to the emergency room for further monitoring and management.

And plastic or surgical consult is indicated in patients who has increased swelling or pain after two to four hours. Any evidence of altered tissue perfusion, and for all extravasation events, it needs to be documented.

So we have to document the medical team that was contacted, the interventions that we give to the patients, and the patient's response. And all extravasation events has to be entered into the patient reporting system.

So now we go to our nursing considerations when power-injecting central venous access devices. We have a lot of central venous access devices

already in the market that are power-injectable, such as our power-injectable PICC line catheters, our power-injectable Hickmans, and our power-injectable ports. So our first nursing consideration is to determine if this central venous access device

is power-injectable, so we can identify, if the device is power-injectable, by looking at the dictated procedure note, OR record, or outside facility documentation. The patient can also identify what type of device he or she has,

by showing us the implant identification card, ID bracelet, or key chain that was given to them after the procedure. Before accessing the central venous access device, documentation of a catheter tip location is required. So we can look for the catheter tip location in the chest x-ray or CT chest report.

For PICC lines inserted at that side using the 3CG device, we can look for the 3CG strip on the patient's chart. So what do we do in case the patient comes in with a non-power-injectable port for CT study? A risk versus benefit assessment has to made with the doctor.

We prefer inserting a peripheral IV, but if the patient doesn't really have good veins, then we can, with a doctor's order, and a verification of where the tip is located, we can use the port for a maximum rate of one ml per second. This would result in a lower image quality,

but we can use it in pediatric studies as well as studies that we can go at a rate of one ml per second. Prior to using the central venous access device, we also observe the head, neck, and thorax for any abnormalities. This is to rule out the presence of SVC syndrome

that is common in patients with malignancies. Clot-related SVC syndrome is directly associated in patients with central venous catheters. And also, prior to using the central venous access device, we inspect the catheter site for any signs of infection, such as if there's any redness, swelling,

or any drainage on the site, we do not proceed, we have to put in a peripheral IV. When using the port, we only use the power-injectable needle. It is designed to access the port to prevent coring the silicone septum.

And we aspirate for blood return for central venous access device. If there is no blood return, we cannot use it. And we vigorously flush it with 10 ml of saline, we note for any presence of pain, or if there's any signs of infiltration,

we do not proceed. While giving contrast media through the port, we closely observe the patient and the port site for any swelling or redness around the port or chest area. Any pain or burning sensation in chest, neck, or shoulder post-infusion,

those would indicate that there is port extravasation. After using the central venous access device for contrast media injection, we flush it per hospital policy, utilizing the push-pause method. We instill a third of the saline first,

pausing two to three seconds, we instill the second third of NS, pausing again two to three seconds, then we instill the remaining third. This is more effective in rinsing the catheter, preventing infection, and catheter disfunction

compared to the low-flow technique. And after using the PICC lines or Hickmans, we cover the needle-less connector with a disinfection cap to prevent infection.

Now we go to our nursing considerations when power-injecting through peripheral IV. First, we have to properly select the peripheral IV site, so Maria mentioned already earlier

regarding the high-risk sites, we avoid the dorsum of the hand, the wrist, for the risk of nerve damage, so we choose first the veins in the antecubital fossa. The catheter gauge, when selecting the catheter gauge, it is dependent on the patient's condition.

Elderly patients who have small veins, of course, we have to put in a smaller gauge. But sometimes, also dependent on the protocol, or the type of study. If it calls for a faster injection rate, of course, you have to put in a larger catheter.

We also ask, or allow input from patients, regarding which site is the best, because from previous experience, especially our cancer patients, they will be able to tell us which one is the best site for IV.

Next nursing consideration is to secure properly the site with transparent dressing to avoid premature catheter removal during injection, as well as to prevent dislodgement of the catheter, or any movement during injection. And we test inject it with normal saline

to verify patency, so note, if the patient complains of pain, if there's any evidence of infiltration or any swelling, you have to take that IV out right away and insert a new line.

In a perfect world,

this is how the veins of all our patients should look like when they come to us. The area of the triangle there, is the most commonly accessed site for contrast injection. (clears throat) Excuse me. And also in that triangle,

you can see the veins that are also the preferred veins for IV cannulation, which is the cephalic vein, the median cubital, and the basilic veins. Why are they the preferred veins? Because they are accessible, they are visible, they are stable,

and they are large enough to accommodate large-bore catheters, and strong enough and large enough to withstand high-speed and high-pressure injections. How many of you here catch yourself unconsciously checking out other people's veins?

(audience laughs) Thank you very much (chuckles). I do that all the time in the subway. I make up stories in my mind how I can access that vein without a tourniquet and things like that. And I have come to realize that at this stage in my life,

diagnostic radiology and veins have become my thing. (audience laughs)

I love this picture.

This illustration brings me to my third group of risk factors, which is, the healthcare professional's skills of IV insertion and assessment skills. Before I forget, I am so proud to be part of a group of nurses in my institution who are so good at what they do.

They cannot be here today, but they are so good at what they do. Now, this slide, what this slide means, is that the safe administration of contrast media depends on your skills as a nurse. In terms of your ability to identify the high-risk sites,

to choose the right location, to use the proper IV insertion techniques, and to assess previously placed IVs. Previously inserted IVs assessment should include the following: peripheral IV sites,

oops, sorry, peripheral IV sites that are greater than 24 hours of insertion. That IV site is at a greater risk for extravasation. Is the catheter power-injectable or not? Are there are multiple venipuncture sites

above, right above the site of injection? Are there dressings hiding the injection site, which prevents us from assessing the injection site before, during, and after the injection of contrast media. How many of you here have injected peripheral IV lines with contrast media which does not give us any blood return?

Anyone? We have a policy, not a policy but guidelines, for intravenous contrast administration via power-injection. It states that blood return is preferred but not essential, in the presence of an adequate flush, and a palpable thrill, because if there is a flush,

it flushes very well, and it has a palpable thrill, it is a good IV. And another thing I would like to mention. If you're assessing an IV site that does not have any blood return, it would be a good thing for you to inject that IV also.

Do not give it to your peers to inject and hope nothing happens. (audience laughs)

Before we give the contrast, we perform a pre-procedure verification process, this is essentially the timeout.

How many of you guys perform timeout prior to giving contrast? So not everyone, okay. In MSK, we do a timeout prior to giving contrast. We properly identify patient using two patient identifiers,

the MRN, medical record number of the patient, or the full name of the patient. We also review the protocol and order for the contrast to make sure that we have the correct study. We verify that we have the right contrast, we have the right amount of contrast,

and, of course, the right rate. This is our verification form. Again, we confirm the patient's identity using at least two identifiers, we confirm the radiologic procedure to be performed, and we confirm the contrast type, amount, and rate.

So if the patient comes in for a double study, we do a second verification, like a second timeout. Part of our nursing consideration is also patient education. Of course we have to tell the patient

what type of contrast they are getting, what is the normal side effects, because the feeling of warm feeling, that metallic taste, can be overwhelming for some patients. And also, we have to also educate them regarding the signs of contrast complications.

Like hey, if you feel itchy, if you get short of breath, you let us know right away so we can intervene.

What is extravasation,

and how does that differ from an infiltration? These are two words that are often used to describe the accidental leaking of an intravenous solution or medication into the surrounding tissue outside of the vein. The difference between the two,

is the type of solution that is leaked out of the vein into the surrounding tissue. When a non-vesicant solution is inadvertently administered into the surrounding tissue, it is called an infiltration. It is now an extravasation when a vesicant solution is administered into the surrounding tissues inadvertently.

What is a vesicant? A vesicant is an agent that has the ability to cause blistering, ulceration, and tissue necrosis. These are examples of some vesicants. We have chemotherapy and biotherapy agents, such as the vinca alkaloids and the anthracyclines.

We have some antibiotics and medications, such as nafcillin, vancomycin, propofol, sodium bicarb. And then we have parenteral nutrition solutions, we have vasodilators and vasopressors, such as epinephrin, Levophed, dopamine.

And last but not least, we have the radiologic contrast media, which is often referred to as a lesser known vesicants.

Now we go to causes of port extravasation. So, first is when the Huber needle

is not inserted completely. We have to insert the Huber needle straight and perpendicular to the port's septum. We have to utilize a steady pressure until the needle stops at the base of the reservoir. We also make sure that there's no gap

between the skin an consider inserting a shorter Huber needle. Another cause of port extravasation is a catheter fracture or separation. The first sign is a pinch-off syndrome,

we can see it in the x-ray that the catheter is compressed or is indented as it passes beneath the clavicle. The catheter fracture usually occurs in the space between the clavicle and the first rib because the greatest amount of friction occurs here.

Another cause of port extravasation is a backtracking of fluid by fibrin sheath. Fibrin sheath formation occurs in all catheters within one week of placement, and initial sign that the fibrin sheath is present is a withdrawal occlusion.

So this means that you have no problems injecting the port, but you do not get good blood return. Persistent withdrawal occlusion would lead to catheter disfunction, low flow rate, and contrast media extravasation. In rare instances,

the fibrin sheath can detach from the vein wall and can embolize the pulmonary circulation, causing thrombotic complications. So in case of port extravasation, we have to stop the infusion right away, and we have to notify the doctor,

and the doctor will have to arrange for the port evaluation and sometimes, removal.

Now, let's go to the risk factors of contrast extravasation. I've grouped them into three. First are the patient factors. In patient factors we have age,

the elderly and pediatric patients, because of their small, fragile veins, and their reduced ability to report symptoms. Then we have patients with altered mental status, because of their inability to communicate effectively. And, another is a history of extravasation.

This information is usually volunteered by the patient themselves, and believe me, they know exactly when it happened, which institution it happened, and even if the nurse did everything right and it was not her fault,

she is going to be the person responsible for the extravasation. Therefore, as clinicians, we should make every effort to try other sites first before that site of previous extravasation. And under patient factors,

we have comorbidities that further increase their risk. And first we have patients with vascular diseases such as Raynaud's, patients with diabetes, because of poor vascular circulation, and third, is very relevant to our institution, is cancer.

Memorial Sloan Kettering Cancer Center is a tertiary care cancer center. And the patients who come to us for cancer treatment require hospitalization, and surgeries with or without axillary node dissections. They also have to through multiple laboratory tests,

which equals multiple venipunctures. Frequent diagnostic radiology, diagnostic imaging studies, for diagnosing the extent of disease, or to evaluate the effectiveness of treatment. And that also equals multiple venipunctures

plus the injection of a vesicant, which is the radiologic contrast medias. They also go for radiation therapy and chemotherapy. Chemotherapy involves the administration of vesicant, sclerosing, and irritating agents through the patient's veins.

All of these factors result to what our patients love to call their chemo veins. What are chemo veins? Chemo veins are veins that are hard, they are scarred, they are sclerosed, and they move. And in very extreme circumstances,

you've got that vein but there's no blood return, nothing. Now let's go to the next group of risk factors that I love to call the contrast media factors. First is the type of contrast. Almost all contrast media are categorized as vesicants, and that goes for both iodinated contrast media

and the gadolinium-based contrast agents for MRI. We have the methods of administration, which is automated power injection, which allows for large volumes of extravasated contrast media in a short period of time. As opposed to a hand injection or a straight injection,

where the clinician injecting has absolute control over the administration of contrast. Third, larger volumes to be infused, and faster injection rates. These all contribute to increased risk of contrast media extravasation.

Having said that, iodinated contrast agents have a far greater risk of extravasation than that of gadolinium-based contrast agents. In terms of their method of administration which is power injection, the volume, which are larger volumes to be infused,

and the faster injection rates required within the protocol. So all of these factors are all associated to increased instances of contrast media extravasation.

Why are fast injection rates important? It is important because it allows for optimum enhancement of normal and abnormal structures in the body. It adds quality, value, and extent to the images.

At our institution, the maximum injection rate we currently use is 6 ml per second for CT angiographies. And when we are faced with the issue of image quality versus the risk of extravasation, I always remember what our favorite radiologist

always tells us: Maria, image quality is important, but patient safety comes first. There is a reason why we love him. But also, it depends on who you're talking to. Some radiologists would not even think of that. And here are studies that require fast injection rates

that we usually perform at our institution. And of all these studies, it is the liver and the pancreas studies that make up a large percentage of imaging that we perform at our institution. Now these are images of a CT of the chest

with IV contrast utilizing a one ml per second injection on your left, and a 2.5 ml injection on your right. You can see there is better enhancement, the blood vessels are clearer, the structures are clearer. And I have another slide

that will show us the CT of the abdomen with IV contrast utilizing a one ml per second injection versus a 2.5 ml per second injection. What can you see in the images on the right that you cannot see on the left? Blood vessels, yes, thank you.

You can see very clearly on the right, there are the normal structures, and you have the lesion on the liver, and there's something on the kidney that looks like maybe it's mets, or maybe it's just a cyst, hopefully.

And you see the spleen and the stomach, and there you can see, let me try this, right there, yay, okay, that is the main portal vein, and somewhere here is the hepatic artery, arteries. So having said that,

(laughs) I'm almost done. (Maria and audience laughing) Having said that, these images, oh, sorry, okay, these images clearly demonstrate that fast injection rates are essential

to achieve high quality diagnosis. However, as nurses, and as advocates for our patients, we should always remember that patient safety is still our priority.

Our next nursing consideration is our documentation of venous access site. We document the gauge and length of the catheter we use, and the location of the IV site.

We also document the attempts made by the nurse, because in our guideline, no more than two attempts should be made by one nurse, because multiple attempts would lead to delay in the study, it would give patients unnecessary pain, and of course, it limits the future venous access.

This is also the same documentation we use when we access Mediport for contrast media injection. We have to confirm the Mediport first, if it's power-injectable or not, and also we have to document the tip location. We also have to verify patency,

we have to make sure that the access flushes freely, the site is non-tender, and there's no signs of infiltration noted.

Following venous injection, CO2 is carried by the blood to the lungs and eliminated in a single pass. The cost of CO2 is much less expensive than iodinated contrast media. It's about 3 cents per 100 cc of CO2.

In conclusions, nurses play an important role in management of patients undergoing studies with power injection, extravasations can be prevented,

and that injury from extravasations should be minimal. Thank you, (speaks in foreign language).

So what do we do in case of contrast extravasation? First, of course, we have to assess the injection site. We have to note the amount of extravasated fluid,

we note the size of extravasation, as well as the patient's signs and symptoms. We elevate the affected extremity above the level of the heart, this reduces hydrostatic capillary pressure and promotes reabsorption of the extravasated fluid.

And of course, we have to notify the radiologist. We apply either hot or cold compress. There's no consensus as to which one is better, so cold compress promotes vasoconstriction, and helps with the pain and the inflammation, while the hot compress improves the blood flow

and also helps with the reabsorption of extravasated fluid. And we monitor patient closely for any complications, such as any sensory changes. Does the patient has any sensation of pins and needles in the affected extremity? Any motor changes,

can the patient move the affected extremity? Any vascular changes, such as decrease in capillary refill? Any change in the color or temperature of the affected extremity, or any presence of ulceration or blisters? And of course, we educate the patient

regarding signs and symptoms that would warrant further management. In case of severe contrast extravasation, we arrange for transfer to these patients to the emergency room for further monitoring and management.

And plastic or surgical consult is indicated in patients who has increased swelling or pain after two to four hours. Any evidence of altered tissue perfusion, and for all extravasation events, it needs to be documented.

So we have to document the medical team that was contacted, the interventions that we give to the patients, and the patient's response. And all extravasation events has to be entered into the patient reporting system. Because contrast media is considered a vesicant,

it has the potential to lead into blistering, ulceration, tissue necrosis, and acute compartment syndrome. So acute compartment syndrome is the serious complication that was directly associated with contrast media extravasation.

So now we go to nursing considerations when power-injecting contrast media.

First is assessment of patient's risk factors to contrast complications. We have to assess if patient is at risk for an allergic reaction, so for patients who had previous allergic reaction, we have to make sure that they are properly pre-medicated

before we give the contrast media. And for patients who have a diagnosis of active asthma, we have to be very vigilant when giving contrast media to these patients, because they can go into bronchiospasm. We also assess our patients,

if they are at risk for contrast-induced nephropathy, so for patients who are diagnosed with any kidney disease and diabetes, we have to check for their recent EGFR to make sure that their kidneys are functioning well before we give the contrast.

And of course, we have to assess our patients, if they are at risk for contrast extravasation. Maria already spoke to you earlier regarding the risk factors, patients who are elderly, patients who have history of contrast media extravasation,

and patients who have poor venous access, are all at risk for contrast extravasation.

According to the ACR 2017 manual, the incidence of contrast media extravasation

related to power injection has ranged from 0.1%, or that is one out of 1,000 patients, to 0.9%, which is one out of every 106 patients. Peripheral venous extravasations are usually caused by a dislodged or malpositioned venous catheter. It could also be caused by the leaking of contrast media

at the site of the injection, or a newly venipunctured site above that site of injection, and it could also be caused by a rupture of the vessel wall.

This is just a little history of CO2 as a contrast agent.

In 1895 x-rays were discovered. Not that long afterwards room air was used with radiographs to visualize abdominal contents. Again, fairly soon after that, CO2 was introduced as a contrast agent. It was initially introduced to insufflate

the retroperitoneaum and CV structures and evaluate for masses. Room air was eventually abandoned as a contrast media because it became problematic. People were suffering air emboli. But CO2 remained viable.

In the '50s and '60s CO2 was used to visualize the right atrium to diagnose pericardial effusion. During the same period of time, animal studies demonstrated that CO2 was safe for venous injections and was generally well tolerated.

In the late '60s, CO2 was reported safe for injection into the IVC. Fast forward to the '80s and the development of digital subtraction angiography, CO2 becomes useful as a contrast media for vascular procedures.

Okay, this slide, are radiographic images, of an extravasation in the dorsum of the hand on the left, on your left side,

and on the antecubital fossa on your right. The image on your left shows us a large volume of extravasated contrast media in a small space, in the hand, and the image on the right shows us, a large volume extravasation in a larger space. So when you look at these two images,

which of the two do you think would be at most risk for complications? Yes, perfect, thank you. This is a perfect example of how volume and location impact patient outcomes.

- Good morning. Thank you for the invitation. Dear moderators. I don't have disclosures for my presentation, and to understand the importance of venous symptoms, we must start from the beginning. And the beginning is to understand

the part of physiology of chronic venous disease and special the importance of the leukocyte-endothelium interaction and dysfunction with the release of inflammatory mediators. So this answer that it is the specific venous inflammation and consequently the abnormal permeability of capillaries

and this can be potential. The explanation for the venous symptoms as having this release of inflammatory mediators. This can activate the C noci receptors fibers and provoke this umbrella concerning the concept of venous pain,

that it is diffused, it is not localized and it is unpleasant and being unpleasant means that these have a huge impact on the quality of life. And we can measure that. We have scores to assess the impact on the quality of life

and that we'd like to remember the largest epidemiological study than until today. The vein consult program where using the CIVIQ-14, it was possible to assess, the impact on the quality of life due to the presence of each specific symptom. So, why we need a consensus on venous symptoms?

Because even in the middle of us, there is a frequent confusion between signs and symptoms and if you go into the literature, you can read that. The fact that venous symptoms are non-pathognomonic adds to this difficulty because linking these symptoms with their etiology and their cause

is still matter of debate. The severity of the signs and the results of investigations do not always correlate with the intensity of symptoms. The pathophysiology of the different venous symptoms has not been clearly established. And this is in particular important in those patients C0s.

And precise physiopathologic knowledge should lead to more targeted and specific treatment and this is quite important for example for venatic drugs. For all these reasons, the SYM VEIN group built a reference document with these five chapters: Definition and description of venous symptoms,

ascription of symptoms to chronic venous disorders, the pathophysiology of the different venous symptoms, how to score the symptoms, and how to investigate the symptoms. This group, it was an international group with 23 members from fourteen countries

that include not only vascular surgeons but also angiologists, dermatologists, a neurologist and even a healthcare economist. And you can see here the distribution per country and the distribution per chapter under the coordination of Michel Perrin and Bo Eklof.

Of course it is difficult in five minutes to highlight all the document. And you can read chapter by chapter, what means for example the definitions of the different symptoms. In the chapter concerning the ascription

of symptoms to chronic venous disorders. Those venous symptoms that should not be described as non specific and those that are poorly documented. Other developed items were that, venous symptoms does not mean symptoms of varicose veins.

Absence of physical signs of chronic venous disorders does not mean absence of chronic venous disease. Locomotion disorders does not necessarily rule out chronic venous disorders. And no abnormal test does not mean absence of venous dysfunction.

How to score the symptoms and the current available tools and how to investigate and this more important to investigate the microcirculation and this is quite important for example for C0s. We have new data that was published this year. You can read all the documented,

it was published 'International Angiology'. And to finalize. This is a provocative question to the audience and to the different speakers. Are symptoms, the different venous symptoms, predictive of disease progression?

This is a provocative question. Thank you.

And last but not least, in anesthesia we have these emergency manuals, cognitive aids. That when people know here when we actually have a crisis your cognitive, your attention span, right, decreases. We kind of learned that before.

So what do we do? We have these emergency manuals. And this is in our culture, in the operating room culture we have these emergency manuals ready, available. We put one in in every single IR room.

But we haven't actually educated the providers how to use it. We also haven't really had much work in terms of a crisis situation, of going over drills. And this is what we're doin', because again if the patient starts vomiting,

we need to be able to, everybody needs to know their roles. What does the nurse do? Who do they call for help? What's the tech do? What's their role?

Move the bed. Can they help us with mask ventilation? What's the IR fellow, or the IR attending, what's their role? Can they help us out as well? Because we are removed.

We don't have many hands on deck. But you guys are our first hand, you know first responders. And you should be able to know what we do to help the patient, because every second does count.

So I wanna just finish out by saying that, you know, the world is your oyster, and this is just a talk to motivate you, and tell you that you know, the future is here. That you need to collaborate with your anesthesia colleagues in terms of you know,

coming up with ideas of how to increase patient safety. You know don't be ashamed to ask them, hey, you know, what are you doin'? What's goin' on, how can I help you? And in your institutions, I say go back and maybe look at your practices

with anesthesia cases and you know, it's not just two different people comin' in. You're gonna see more and more of this. And I strongly believe that. And you know I hope by attending this talk you could be more cognizant of that.

And then maybe be a little bit more proactive in terms of you know, what's goin' on, and maybe preparing yourself. Thank you. (applause)

Before we give the contrast,

it's our responsibility to warn the patients to report any unusual sensations at the IV site immediately, such as if the patient complains of any pain, like stinging or burning pain, any feeling of tightness or pressure in the IV site, that would indicate contrast extravasation already.

During contrast injection, we have to observe the IV site for at least the first 10 to 20 seconds of injection. We have to look for any redness, any swelling, and you have to palpate the injection site. So a strong, palpable thrill

would indicate a good contrast delivery. And if there's any sign of extravasation, we have to stop the injection of contrast right away.

Now, we have high-risk sites, which is the back of the hand, the wrist, the foot, and the ankle.

And we also have contra-indicated sites, which are the extremities that have evidence of phlebitis or infection. We have extremities with AV fistula or AV graft, extremities with lymphedema, and those extremities

that have had axillary lymph node dissection. On the screen is an algorithm that is part of our intravenous line placement and medication administration in patients who have had axillary surgery. There are two very important things to determine

before you proceed. First would be the type of axillary surgery. Was it a sentinel node biopsy? Or was it an axillary node dissection? Sentinel node biopsy is defined as the, is defined by the removal of one to four lymph nodes

on any given side. If a patient has had a sentinel node biopsy, that side can still be used for IV access and medication administration, as long as there is no evidence of lymphedema. Axillary node dissection, though,

is the removal of five to 30 lymph nodes on any given side. That side should be avoided unless it is an extreme emergency. There is a discussion between the LIP and the radiology team about risks versus the benefits, and also, we need an LIP order to use,

as well as the absence of lymphedema. When there's a lymphedema, no, we cannot use it.

So what do we do in case the patient comes in with a non-power-injectable port for CT study? A risk versus benefit assessment has to made with the doctor.

We prefer inserting a peripheral IV, but if the patient doesn't really have good veins, then we can, with a doctor's order, and a verification of where the tip is located, we can use the port for a maximum rate of one ml per second. This would result in a lower image quality,

but we can use it in pediatric studies as well as studies that we can go at a rate of one ml per second.

so our story starts out at MGH, the IR, you know in grade two, where we do it. We have six rooms where we do anesthesia. Every room is actually outfitted with anesthesia equipment. So room four's our CT. Room six we do our anesthesia cases.

Room two we do our complex cases, CERTs, pre CERTs. Room one, neuro IR. So it's typical IR program I think. But I think a lot of special things happen. And although it doesn't seem like that at some point. But I believe that we're at the leading edge

of the contemporary trend that's coming. So IR at MGH our case growth has increased by 20% over the past year. From 2016 to 2017 we went from 1200 cases to 1400 cases with, this is IR anesthesia only. We're growin' pretty rapidly.

It's 20% growth. And I believe that we're gonna grow more this year just because, I'm not sure what's goin' on, put the patients just keep on getting sicker and sicker. And our services keep on getting more and more wanted, I suppose.

The top three cases that we do are G-tubes, tunneled line catheters, our fistulagrams. Our CT microwaves as well. So those are the top three, top four cases that you can see where general anesthesia is utilized. We do about 50-50% of inpatients and outpatients.

At MGH I believe we're special because we have, given this explosion we actually have had anesthesia full time in IR. So we reside there. We have a dedicated IR team. So there's no,

you know we kinda heard before, there's a stranger comin' in, and now you don't know, hey, anesthesia, you're on your cell phone. Now we actually attach names to people. We already know.

So actually that's one of the big cultural barriers I think, and misconceptions that we've kinda broken in. And you know I think a lot of people know each other by first names now. We run two to three rooms per day four times a week.

And again like I stated previously all rooms are outfitted with anesthesia. And the IR suite at MGH is the new IR anesthesia. This is the future. So it's no longer, you know, you go down, and before being assigned to IR,

as anesthesiologist it was a punishment. Oh my goodness I'm gonna have some sort of, you know, patient who's on death's end, and nobody knows a clue, and now I'll have to sedate 'em, or do general anesthesia.

I have no idea what's goin' on. That's no longer, you know, I'm just gonna give versed, fentanyl, or nothing, just hold hands. We're gonna use propofol, use a little sedation. That's long gone. I think my colleagues are kind of upset

that we've already broken the mold. That I'm gonna show you what we're doing at MGH, and this is coming to you, to your regional practices very soon.

Now we go to power injections of lower extremity. We really tend to avoid using the veins in the lower extremity for power injections because of the increased risk of thrombophlebitis,

tissue damage, and ulceration. However, if no other options exist, again, we need to talk to the doctor for a risk versus benefit discussion. We need a doctor's order prior to insertion. It is only restricted to medical and nursing staff.

Hand injection is preferred. Distal location should be attempted first, and that documentation of the site is important.

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